Fracture lower extremities Part II

Subtrochanteric fracture

-       Anatomy

  • To 5 cms below lesser trochanter

-       Mechanism

  • High-energy mechanism
  • Low-energy mechanism
    • metastatic tumor

-       Clinical Feature

  • Pain
  • Swelling
  • Deformity
  • Shortening
  • External rotation

-       Classification: Seinsheimer, Russell-Taylor

-       Investigation

-       Treatment

  • Emergency management
  • ATLS
  • Skin traction
  • Definite treatment
  • cephalomedullary nail, proximal femoral locking plate

-       Complications

  • Malunion: shortening, rotation
  • Nonunion

 

Femoral shaft fracture

-       Anatomy

-       Mechanism

  • High-energy mechanism
  • spiral, transverse, oblique, comminuted
  • Low-energy mechanism
    • Elderly : osteoporosis
    • Child   : Abuse

-       Clinical Feature

  • Pain
  • Swelling
  • Deformity
  • Shortening
  • 10% Ipsilateral femoral neck fracture

-       Classification: Winquist classification

  • Type 0 : no comminution
  • Type I   : Smallcortical fragment
  • Type II : butterfly fragment < 50% femur
  • Type III : butterfly fragment > 50% femur
  • Type IV :severe comminution, segmental fracture

-       Investigation

-       Treatment

  • Emergency management
    • ATLS protocol
    • Resuscitation
    • Immobilization ด้วยThomas’ splint หรือvacuum splint
  • Definite treatment
    • Intramedullary nail
    • Plate and screws
    • External fixator
      • high-grade open fracture

-       Complications

  • Early complications
    • Hypovolemic shock
    • Fat embolism & ARDS
    • Venous thromboembolism
    • Infection
  • Late complications
    • Delayed union & non-union
    • Malunion
    • Joint stiffness
    • Implant failure & re-fracture

Distal femoral fracture

-       Anatomy : 10-15 cms distal

-       Mechanism

  • High-energy mechanism
  • Low-energy mechanism

-       Clinical Feature

-       Neurovascular injury(Popliteal artery)

-       Classification: AO

  • Extra-articular fracture
    • Type A: supracondylar fracture
  • Intra-articular fracture
    • Type B: uni-condylar fracture
    • Type C: bi-condylar fracture

-       Investigation

  • Plain X-ray
  • CT
    • Complex intra-articular fracture
  • MRI
    • Ligament, Meniscus

-       Treatment

  • Non-operative treatment : malunion ,joint stiffness
  • Operative treatment
    • Retrograde intramedullary nail
    • Plate and screw
    • External fixation

-       Complications

  • Early
    • Arterial injury
  • Late
    • Joint stiffness
    • Malunion & non-union
    • Post-traumatic arthritis

Patella fracture

-       Anatomy

  • Largest sesamoid bone
  • Extensor mechanism

-       Mechanism

  • Indirect injury
    • avulsion fracture
    • Transverse fracture
  • Direct injury
    • abrasion ,laceration wound
    • incomplete,stellate ,comminuted pattern

-       Clinical Feature

  • Active knee extension

-       Classification

-       Investigation

  • Plain X-ray (Knee AP, Lateral)
  • CT
    • Complex fracture
  • MRI
    • Chondral fracture

-       Treatment

  • Non-operative treatment
    • cylinder cast in full extension for 4-6 weeks
  • Operative treatment( ORIF with TBW, Screw)
    • Articular stepping > 2 mm
    • Fracture gap > 3 mm
    • Loss of extensor mechanism
    • Open fracture

-       Complications

  • Early: Fixation failure, non-union, joint stiffness
  • Late: Patello-femoral arthritis

Proximal tibia fracture

-       Anatomy

-       Mechanism

  • Axial load with Varus or Valgus.

-       Clinical Feature

  • Pain
  • Swelling
  • Deformity
  • Neurovascular injury
  • Popliteal artery
  • Peroneal nerve 

-       Investigation

  • Plain X-ray
  • CT

-       Classification: Schatzker classification

  • Type I-III : Lateral condyle fracture , low-energy trauma
  • Type 4: Medial condyle fracture
  • Type Bicondylar fracture , high-energy

-       Treatment

  • Non displace: Hinge knee brace, NWB 3 weeks, PWB 8 weeks
  • Minimal displaced(<5 mms): Traction then Immobilization
  • Displaced fracture(>5 mms): Internal fixation

-       Complications

  • Malunion
  • Joint stiffness

Tibial Shaft Fracture

-       Anatomy

-       Mechanism

  • Indirect injury
    • Low energy
    • Spiral oblique
    • avulsion fracture
    • Transverse fracture
  • Direct injury
    • abrasion ,laceration wound
    • High energy
    • Comminuted
    • segmental

-       Clinical Feature

  • Pain
  • Swelling
  • Deformity
  • Soft tissue injury
    • Compartment syndrome

-       Investigation

  • Plain X-ray
  • CT

-       Classification

  • Close fracture
    • Tscherne]s classification
  • Open fracture
    • Gustilo’s classification

-       Treatment

  • Initial treatment
    • Temporary reduction & immobilization
    • Wound debridement & antibiotic administration(open fracture)
    • Definite treatment
      • Non operative treatment( NON OR MINIMAL DISPLACED)
        • long-leg cast 4-6 wks., SLC until 12 wks.
  • Operative treatment( DISPLACED)
    • Intramedullary nail
    • Plate-screw fixation
    • External fixator

-       Complications

  • Vascular injury
  • Compartment syndrome
  • Infection
  • Malunion
  • Delayed union & non-union
  • Joint stiffness
  • Disuse osteoporosis

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