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