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Femur and Tibia Fractures

Femur and Tibia Fractures. Kevin E. Coates, M.D., M.P.T. Worker’s Compensation?. Femoral Neck Fractures. Epidemiology 250,000 Hip fractures annually Expected to double by 2050 At risk populations Elderly: poor balance&vision, osteoporosis, inactivity, medications, malnutrition

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Femur and Tibia Fractures

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  1. Femur and Tibia Fractures Kevin E. Coates, M.D., M.P.T.

  2. Worker’s Compensation?

  3. Femoral Neck Fractures • Epidemiology • 250,000 Hip fractures annually • Expected to double by 2050 • At risk populations • Elderly: poor balance&vision, osteoporosis, inactivity, medications, malnutrition • incidence doubles with each decade beyond age 50 • higher in white population • Other factors: smokers, small body size, excessive caffeine & ETOH • Young: high energy trauma

  4. Classification • Garden • I Valgus impacted or • incomplete • II Complete • Non-displaced • III Complete • Partial displacement • IV Complete • Full displacement • ** Portends risk of AVN and Nonunion I II III IV

  5. Treatment • Goals • Improve outcome over natural history • Minimize risks and avoid complications • Return to pre-injury level of function • Provide cost-effective treatment

  6. TreatmentDecision Making Variables • Patient Characteristics • Young (arbitrary physiologic age < 65) • High energy injuries • Often multi-trauma • Elderly • Lower energy injury • Comorbidities • Pre-existing hip disease

  7. TreatmentYoung Patients(Arbitrary physiologic age < 65) • Non-displaced fractures • At risk for secondary displacement • Urgent ORIF recommended • Displaced fractures • Patients native femoral head best • AVN related to duration and degree of displacement • Irreversible cell death after 6-12 hours • Emergent ORIF recommended

  8. Hemi ORIF THR

  9. Non-displaced Fractures • ORIF standard of care • Predictable healing • Nonunion < 5% • Minimal complications • AVN < 8% • Infection < 5% • Relatively quick procedure • Minimal blood loss

  10. Displaced FracturesHemiarthroplasty vs. ORIF • ORIF is an option in elderly Surgical emergency in young patients • Complications • Nonunion 10 -33% • AVN 15 – 33% • AVN related to displacement • Early ORIF no benefit • Loss of reduction / fixation failure 16%

  11. Displaced FracturesHemiarthroplasty vs. ORIF • Hemi associated with • Lower reoperation rate (6-18% vs. 20-36%) • Improved functional scores • Less pain • More cost-effective • Slightly increased short term mortality

  12. Femoral Neck Nonunion • Definition: not healed by one year • 0-5% in Non-displaced fractures • 9-35% in Displaced fractures • Increased incidence with • Posterior comminution • Initial displacement • Inadequate reduction • Non-compressive fixation

  13. Femoral Neck FracturesComplications • Failure of Fixation • Inadequate / unstable reduction • Poor bone quality • Poor choice of implant • Treatment • Elderly: Arthroplasty • Young: Repeat ORIF Valgus-producing osteotmy Arthroplasty

  14. Femoral Neck FracturesComplications • Post-traumatic arthrosis • Joint penetration with hardware • AVN related • Blood Transfusions • THR > Hemi > ORIF • Increased rate of post-op infection • DVT / PE • Multiple prophylactic regimens exist • One-year mortality 14-50%

  15. Intertrochanteric Femur Fractures • Intertrochanteric Femur • Extra-capsular femoral neck • To inferior border of the lesser trochanter

  16. Etiology • Osteoperosis • Low energy fall • Common • High Energy • Rare

  17. Radiographs • Plain Films • AP Pelvis • Cross Table Lateral

  18. Goals of Treatment • Obtain a Stable Reduction • Internal Fixation • Good Position • Mechanically Adequate • Permit Immediate Transfers & Early Ambulation

  19. Rehabilitation • Mobilize • Weight Bearing As Tolerated • Cognitive Intact Patients Auto Protect • Unstable Fractures = Less WB • Stable Fractures = More WB • No Difference @ 6 weeks Post op

  20. Femoral Shaft Fractures • Common injury due to major violent trauma • 1 femur fracture/ 10,000 people • More common in people < 25 yo or >65 yo • Femur fracture leads to reduced activity for 107 days • Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most frequent causes

  21. Femur FractureManagement • Initial traction with portable traction splint or transosseous pin and balanced suspension • Evaluation of knee to determine pin placement • Timing of surgery is dependent on: • Resuscitation of patient • Other injuries - abdomen, chest, brain • Isolated femur fracture

  22. Femur FractureManagement • Antegrade nailing is still the gold standard • Antegrade nailing problems: • Varus alignment of proximal fractures • Trendelenburg gait • Can be difficult with obese or multiply injured patients

  23. Femur FractureManagement • Retrograde nailing has advantages • Easier in large patients to find starting point • Better for combined fracture patterns (ipsilateral femoral neck, tibia,acetabulum) • Retrograde nailing has its problems: • Intra-articular starting point

  24. Femur FractureComplications • Hardware failure • Nonunion - less than 1-2% • Malunion - shortening, malrotation, angulation • Infection • Neurologic, vascular injury • Heterotopic ossification

  25. Ipsilateral Femoral Neck & Shaft Fractures • Optimum fixation of the femoral neck should be the goal • Varus malunion of the femoral neck is not uncommon, osteotomies can lead to poor results • Vertical femoral neck fracture seen in 26-59% of cases • Rate of avascular necrosis is low, 3%, even when missed

  26. Tibial Plateau Fractures • Mechanism of Injury • Mean age in most series of tibial plateau fractures is about 55 years • Large percentage over age 60 • Elderly population is increasing in numbers

  27. Mechanism of Injury • Mechanism of injury is fall from standing height in most patients • MVA is increasing as % of fractures • Most common fracture pattern is split-depressed fracture of lateral tibial plateau (80% of fractures)

  28. Physical Exam • Neurologic exam • peroneal nerve! • Vascular exam • popliteal artery and medial plateau injuries • beware the of the knee dislocation posing as a fracture • beware of posteriorly displaced fracture fragments • ABI <0.9 urgent arterial study

  29. Physical Exam • Compartment syndrome • KNEE STABILITY • varus/valgus in full extension • may require premedication • aspiration of knee effusion/hematoma • replace with lidocaine+marcaine

  30. Evaluation of Soft Tissues • Proximal and distal tibia subcutaneous • Soft tissue remains compromised for at least 7 days • Early ORIF risks wound sloughexposed hardware

  31. AP and Lateral Radiographs

  32. Pre-traction

  33. Post-traction

  34. Computed Tomography • Indications • Fracture in an active patient for which you are considering nonsurgical care • Complex fracture • To aid surgical planning of approach, technique, screw position, etc.

  35. Computed Tomography

  36. Computed Tomography

  37. Classification:Schatzker I III II

  38. Classification:Schatzker IV VI V

  39. Surgical Indicatons • Open Fracture – I&D, spanning ex-fix • Extensive soft tissue contusion – spanning ex-fix • Closed fracture • Varus/valgus instability of the knee • Varus or valgus tilt of the proximal tibia • Meniscal injury/previous mensicectomy • Articular displacement or gapping???

  40. Angular Malalignment of the Proximal Tibia • Incidence of arthrosis: • Valgus < 10o 14% • Valgus > 10o 79% • Any amount of varus angulation was bad • Independent of articular congruity

  41. Meniscectomy • Higher rate of arthrosis in patients who had undergone meniscectomy at surgery • 70% arthrosis in patients who had undergone meniscectomy • results independent of the amount of articular incongruity

  42. Postoperative Management • Immediate PROM/AROM of knee • Routine Pin site care (if ex-fix) • TDWB for 8-12 weeks

  43. Outcomes • Outcome depends on: • Varus valgus stability of the knee • Varus/valgus alignment of the proximal tibia • Presence of an intact meniscus • Articular congruity (to a lesser extent)

  44. Treatment Goals • Focus on restoring stability and proximal tibial alignment to the knee, rather than restoring anatomic alignment of the articular surface at all costs • Use minimally invasive techniques, when possible • Other techniques are preferable to hybrid ex-fix • MOVE THE KNEE EARLY IN ALL PATIENTS!

  45. Tibial Shaft Fractures Mechanism of Injury • Can occur in lower energy, torsional type injury (eg, skiing) • More common with higher energy direct force (eg car bumper)

  46. Physical Exam • Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself • Repeated exam often necessary to follow compartment swelling

  47. Associated Injuries • Up to 30% of patients with tibial fractures have multiple injuries* • Fracture of the ipsilateral fibula common • Ligamentous injury of knee common in high energy tibia fractures

  48. Associated Injuries • Ipsilateral femur fx, so called “floating knee”, seen in high energy injuries • Neuro/vascular injury less common than in proximal tibia fx or knee dislocation • Foot and ankle injury should be assessed on physical exam and x-ray if needed

  49. Compartment Syndrome • 5-15% • History of high energy or crush injury

  50. Nerve is the Tissue most Sensitive to Ischemia • PAIN first Symptom • PAIN with Passive Stretch first Sign

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