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Lower extremity xray rounds

Lower extremity xray rounds. Heather Patterson PGY3 August 23, 2007. Objectives. Classification of fractures Practice, practice, practice! This will NOT be: Clinical exam Management. Hip. Classification: Intracapsular Femoral head neck Extracapsular Intertrochanteric

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Lower extremity xray rounds

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  1. Lower extremity xray rounds Heather Patterson PGY3 August 23, 2007

  2. Objectives • Classification of fractures • Practice, practice, practice! • This will NOT be: • Clinical exam • Management

  3. Hip • Classification: • Intracapsular • Femoral head • neck • Extracapsular • Intertrochanteric • Subtrochanteric • Greater/lesser trochanter

  4. Hip • AVN: • Injuries to medal and lateral femoral circumflex arteries • After fracture the synovial fluid will lyse blood clots and prevent capillary formation needed for new bone formation/repair

  5. Approach • Shenton’s Line • Obturator foramen to medial surface of the proximal femur

  6. Approach • Normal and Reverse S • Medial and lateral margins of the fem head and neck

  7. Approach • Trabecular groups • Follow the groups starting at the femoral head

  8. Avulsion • Often in young athletes • Rapid accel/decel • Snap/pop • Locations: • ASIS: sartorius • AIIS: rectus femoris • Isch tuberosity: hamstring

  9. Name this fracture

  10. Femoral Neck Fractures • Classification: • Transcervical vs subcapital • Displaced vs nondisplaced

  11. Femoral Neck Fractures • Displaced (80%) • Shortened, rotated • Vascular structures disrupted • Nondisplaced (20%) • Subtle fractures • Must use lines/trabec to see • May be impacted – increased subcapital density

  12. Name this fracture

  13. Intertrochanteric fractures • Fracture runs between greater and lesser trochanter • Excellent blood supply • Often will be in internal rotation • Int rotators attached to distal femur • Ext rotators attached to proximal fragment

  14. Intertrochanteric fractures • Classification: • 2 part

  15. Intertrochanteric fractures • Classification • 3 part:

  16. Intertrochanteric fractures • Classification • 4 part:

  17. Trochanter fractures • Isolated fractures are rare • From direct force with fall or avulsion from iliopsoas

  18. Name this fracture

  19. Subtrochanteric fractures • Location: • Btwn lesser trochanter and proximal 5cm of femoral shaft • Often comminuted • Hemodynamic instability is seen with this fracture type

  20. Subtrochanteric fractures • Classification: • Short oblique • Short oblique + commin. • Long oblique • Long oblique + commin. • High transverse • Low transverse

  21. Stress fractures • Need high index of suspicion • Symptoms: • A.M. stiffness, aching with first steps after rest, increasing pain with exercise • Pain in groin or medial thigh to knee • Antalgic gait, min pain with ROM except at extremes

  22. Dislocations • High force • Classification: • Posterior • Anterior • Obturator • Inferior • Central

  23. Fracture dislocations • Positioning: • Posterior: FDI • flexed aDducted internal rotation • shortened and greater troch/buttock unusually prominent • Anterior: FBE • flexed aBducted, externally rotated

  24. Dislocations • Posterior: • Lesser trochanter superimposed on femoral shaft • Small femoral head

  25. Dislocations • Anterior: • Lesser trochanter in profile • Large femoral head

  26. Practise

  27. Practise

  28. Practise

  29. Practise

  30. Practise

  31. Practise

  32. Practise

  33. Practise

  34. Practise

  35. Practise

  36. Practise

  37. Practise

  38. Practise

  39. Name this fracture

  40. Ottawa Knee rules • X-ray knees with knee injury and one or more of: • >55 years old • Tenderness to palpation of head of fibula • Isolated tenderness of patella • Inability to flex knee to 90 degrees • Inability to bear weight both immediately and inability to take four steps in ED

  41. Ottawa Knee rules • Exclusion criteria: • Isolated skin injuries • Referred patients from another ED or clinic • Injury >7 days old • Patient returning for re-evaluation • Distracting injuries • Altered mental status • Age < 18 years old • Pregnant patients • Paraplegia

  42. Distal femur fracture • Anatomy: • Vascular • close to femoral & popliteal vessels

  43. Distal femur fracture • Anatomy: • Neuro • Tibial nerve • gastrocnemius, plantaris • Peroneal/Deep Peroneal nerves • Supplies anterior compartment (dorsiflexion) • Sensory to first dorsal interosseus cleft

  44. Distal femur fracture

  45. Distal femur fracture • Supracondylar • Extra-articular • No hemarthrosis • Intracondylar • Intra-articular • Condylar • Intra-articular

  46. Name this fracture

  47. Tibial Plateau Fractures • Anatomy • Vascular • High incidence of popliteal A damage • Neuro • Perineal N damage • Ligaments • 25% have associated ligamentous injury

  48. Tibial Plateau Fractures • Plateau slopes 10 degrees from A  P • May not appear to be at same level • Lateral plateau slightly convex upward • Medial plateau slightly concave upwards

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