Fracture lower extremities Part I

 

 

Pelvic fracture

-       Anatomy of pelvic ring

  • Bone
  • Joint
  • Ligament

-       Clinical Features

  • Asso injury
    • massive hemorrhage
    • Intraabdominal injury
    • Lower limb injury

-       PE

  • Pelvic compression test
  • Perineum and genital examination

-       Classification

  • AP compression
  • Lateral compression
  • Vertical shear

-       Investigation

  • Plain film
    • Pelvis (AP, Inlet, outlet)
  • CT scan

-       Treatment

  • Emergency management
    • ATLS protocol
    • pelvic binder ,external fixation
    • angiographic embolization
  • Definite treatment
    • Minimal displace fracture
      • bed rest
      • AP compression
        • external fixator, Anterior plate and screw
      • Lateral compression
        • external fixation, plate fixation ,scroilliac screw
      • Open pelvic fracture
        • diversion colostomy

-       Complications

  • Urologic complication
  • Sciatic nerve injury
  • Thromboembolism

Acetabular fracture

-       Anatomy of pelvic ring

  • Anterior column (iliopubic component)
  • Posterior column (ilioischial component)
  • Acetabular roof

-       Clinical Features

-       Classification

  • Letournel and Judet
    • Simple หรือelementary fractures
      • anterior posterior column fracture
      • anterior posterior wall fracture
      • transverse fracture
      • Complex fractures
        • Combination

-       Investigation

  • Plain X-ray
    • pelvis AP
    • Judet views
      • Iliac oblique
  • Special imaging: CT scan

-       Treatment

  • Emergency management
    • Volume/fluid resuscitation
    • Close reduction
    • skeletal traction
  • Definite treatment
    • Conservative treatment (skeletal traction 6-8 weeks)
    • Non-displaced และ minimally displaced (< 2mm)
    • Non-weight bearing zone
    • Both column fracture with secondary joint congruence
  • Operative treatment โดยใช้reconstruction plate-screw
    • Displaced fracture (   2mm) in wt. bearing
    • Posterior wall fracture(>50%)
    • Incarcerated fragment

-       Complications

  • Iliofemoral venous thrombosis
  • Sciatic nerve injury
  • Heterotopic bone formation
  • Avascular necrosis
  • Post-traumatic osteoarthritis

 

Hip fracture

-      Osteoporosis

-      trivial trauma

-       Clinical Features

  • Falling
  • Shortening
  • External rotation
  • Ecchymosis
  • Rolling test
  • Anvil test

-       Investigation

  • Plain X-ray
    • Hips (AP , Lateral)
  • Special imaging: CT scan

Classifications

-       Femoral neck fracture

  • Garden Classification(I-IV)
  • Anatomical classification
    • Sub-capital fracture
    • Mid-cervical fracture
    • Basilar neck fracture

-       Intertrochanteric fracture

  • Boyd & Griffin classification
    • Type I-IV
  • Evan classification
    • Stable VS unstable

Treatment

-Initial treatment : Skin traction

-       Femoral neck fracture

  • Internal fixation non-displaced fracture (Garden I และ
  • Prosthetic replacement displaced fracture (Garden III และ
    • Hemiarthroplasty
    • Total hip replacement

-       Intertrochanteric fracture

  • Internal fixation( sliding hip screw-plate short cephalomedullary nail)
  • Prosthetic replacement

-       Complications

  • Venous thromboembolism (deep vein thrombosis ,pulmonary embolism)
  • Decubitus ulcer (bedsores)
  • Urinary tract infection
  • Pulmonary complication : pneumonia, atelectasis
  • Non-union
  • AVN
  • Malunion
  • Fixation failure

-       Post-operative care

  • Early ambulation
  • Osteoporosis treatment

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