“Look, Feel, Move” Pain, tenderness Swelling… bruising Loss of function Crepitus Signs of blood loss Injury to other structures
History Examination X-ray Isotope Bone Scan Specialised Imaging C.T. M.R.I.
Two planes Two joints Two occasions Two limbs Two opinions
Two planes Two joints Two occasions Two limbs Two opinions AP and Lateral +/- special views e.g. scaphoid
Two planes Two joints Two occasions Two limbs Two opinions Joint above and below for shaft fractures
Two planes Two joints Two occasions Two limbs Two opinions Repeat X-rays after an interval may show a fracture e.g. scaphoid, hip
Two planes Two joints Two occasions Two limbs Two opinions Comparative views of opposite limb e.g. elbow injuries in children
Two planes Two joints Two occasions Two limbs Two opinions Ask a radiologist or senior colleague!
haematoma inflammatory exudate new blood vessels (2-3 days) bone forming cells bridge of callus (cartilage, bone, fibrous tissue) framework for bridging the gap replaced by woven bone remodelling along lines of stress
callus is the response to movement at fracture site callus does not develop if the fracture is rigidly fixed with no movement: primary bone healing
Depends on many factors age bone type of fracture infection nutrition stimulation
Full assessment Reduction Immobilisation Maintenance of reduction Rehabilitation
problem: infection prophylactic antibiotics appropriate to the injury anti-tetanus cover irrigation “the solution to pollution is dilution” debridement: remove all dead tissue skin cover
Initial treatment – splinting and analgesia. Compound injuries – Antibiotic cover (usually cephalosporin +/- aminoglycoside if contaminated). -Tetanus cover.
Compound injuries must be debrided ASAP, should be within 6 hours. Bone should be covered with tissue to prevent dessication. Delayed primary closure of the wound, or “second look” procedure.
Aims – obtain union, maintain relative positions of knee and ankle joints. Treatment options include: Conservative. Open Reduction and Internal Fixation. Intra medullary nailing. External fixation.
Casting may be considered if: Isolated tibial fracture (fibula not involved). >50% cortical overlap at # site. Closed reduction of displaced #’s and casting leads to significant incidence of non- union. Less than 2cm initial shortening.
Usually used for intra–articular #’s involving knee or ankle rather than shaft #’s. Periosteal stripping required. Fracture site must be opened. May be useful in Rx of non-union +/- bone grafting.
Probably preferred Rx of closed displaced tibial shaft fractures. Union rates of near 100% for closed injuries. Fracture site not opened during the procedure, reduced chance of infection. More difficult in proximal shaft fractures.
Compartment syndrome. Pressure in muscular compartments rises above capillary pressure, ischaemia of tissues in affected compartment. Patients complain of pain unrelieved by splinting and analgesia.
Pain on passive stretching is classic physical sign. Normal distal pulses and neurology DO NOT exclude compartment syndrome. Incidence NOT reduced in compound fractures (up to 9%). ? May complicate nailing of fracture.
Union delayed union non-union atrophic hypertrophic infected mal-union
Subcapital Femoral Fracture. Over 100,000/year in the UK
Common in osteoporotic bone. Majority of blood supply to head comes from the neck. Elderly. Almost 90% occur in >65 years. Almost 75% occur in females.
The fibres are reflected back along the neck of the femur to the articular margin of the femoral head. The reflected part constitutes the retinacular fibres, which bind down the nutrient arteries from the trochanteric anastomosis, along the neck to supply the head.
The head and intracapsular part of the neck receive blood from the trochanteric anastomosis. Formed by descending superior gluteal artery with ascending branches of the medial and lateral circumflex femoral arteries. Branches pass along the femoral neck with the retinacular fibres of the capsule.
Blood supply lost through thrombosis or interrossoeus hypertension. Marrow of head is replaced by fat, bone dies. Zone of revascularisation, incomplete if large avascular area. Zone of reossification – joint may collapse. May -> secondary arthritis.
X-rays – may appear normal. Radioisotope – dead area of femoral head surrounded by hyperaemic area of revascularisation. MRI – one or more avascular areas.
Age and displacement Co-Morbidity Undisplaced (Garden 1 & 2): 1. Cannulated Hip Screws. 2. DHS. 3. Hemi-Arthroplasty Displaced (Garden 3 & 4): 1. Hemi-Arthroplasty. 2. Total Hip Replacement occasionally if pre-existing OA.
AO Screws to hold femoral head in position Indications for Closed Reduction and Fixation: Physiologically young patient: age < 65, working patient, good bone stock; Demented elderly patient that requires total care; Adequate closed reduction with no comminution or femoral neck defects; Patient should be aware that with an inadequate closed reduction, then an open reduction or hemiarthroplasty will be required
Older patients – Hemiarthroplasty Especially in Life Expectancy<5 years One definitive operation. Fractures may progressively displace.
Undisplaced Garden 1+2 – no vascular disruption Lateral Approach X-ray control First part is a heavy plate fixed to lateral cortex of femur with cortical screws. Second part is a rod which passes into the femoral head. The threaded end crosses the fracture line to engage and hold the fracture line. As the patient weight bears on the healing fracture the broken ends of the bone collapse into each other and compress the fracture. The sliding-rod mechanism allows this to happen without the hip falling into varus.
Femoral Head survival unlikely. Under fifty – reduce and pin immediately. Older:<65 THR >65 Hemiarthroplasty
Austin Talley Moore, MD South Carolina 1899-1963 In September 1940, Austin Tally Moore and Harold Ray Bohlman, replaced the proximal 12 inches of a femur destroyed by a recurrent giant cell tumor with a custom-made prosthesis, Dr. Moore was encouraged to develop a new femoral head with a short stem for intramedullary fixation, and, the now legendary Austin Moore Hip was introduced in 1950. Cemented Frederick Roeck Thompson, MD Texas 1907-1983 Son of the renowned reconstructive surgeon Dr. James E. Thompson of the University of Texas Medical Branch, Frederick R. Thompson, MD, designed - one of the first metal hips for use in hip fractures and salvage arthroplasties. The first F.R. Thompson Hip was implanted in January 1951, and is still in worldwide use today. Uncemented
Poor general health that would prevent a second operation; pathologic hip fractures Parkinson's disease, hemiplegia, or other neurological disease; Physiologic age > 70 yrs; Severe osteoporosis without loss of primary trabeclae in femoral head Inadequate closed reduction; Displaced fracture which is several days old; Pre-existing hip disease (DJD, RA, AVN); Contraindications: Pre-existing sepsis Young patient Failure of internal fixation devices; Pre-existing disease of the acetabulum; Even without normal preoperative cartilagenous space, many patients will become symptomatic at 5 years due to metal induced degradation;
Mortality - mortality after hemiarthroplasty is 10 to 40% Fracture of the Femur: 4.5% almost all fractures occur when surgeon attempts to reduce prosthesis; most are non displaced and involve either greater trochanter or neck; with femoral shaft fracture consider methy methacrylate combined with a long stem prosthesis; Post-op: sepsis: 2% to 20% more common w/ posterior surgical approach; infections may be superficial or deep Loosening and migration presence of a radiolucent zone around the prosthesis; if clinical signs and symptoms are present and loosening or migration is present, then consider revision to THR;erosion tends to occur in active pts with cemented Thompson hemiarthroplasty;
Dislocation less than 10%. more common with too much anteversion or retroversion, posterior capuslectomy, & excessive postoperative flexion or rotation with hip adducted
Mobility: 41% of elderly walk as well as pre-injury (Koval, Clin Orthop 1995). Mortality: 3% to 27% in first 3 months. 15-30% die within 1 year of fracture.
The goal of operative treatment is Strong,stable fixation of the fracture fragments.
Dynamic Hip Screw: Shorter plate (e.g 2-hole) can be used for some undisplaced intra- capsular #s. Varying angles to suit angle atfemoral neck. Sliding compression screw device allows collapse into position of stability.
Dynamic Condylar Screw (95 °): Used in (paticularly) sub- troch #s. In certain inter-trochanteric #s.
Other Complications: Pressure sores. Nerve palsies. Prosthesis Dislocation. Failure to mobilise & death.
Mobility: 41% of elderly walk as well as pre-injury (Koval, Clin Orthop 1995). Mortality: 3% to 27% in first 3 months. 15-20% die within 1 year of fracture. Mortality risk over age-matched controls for up to 1 year post injury. Inter-trochanteric #s associated with greater morbidity & mortality.
May be Primary due to intrnsic defect (mechanical,immune, vascular, cartilage) Secondary - trauma, infection, congenital disorders. Get loss of the bearing surface, followed by development of osteophytes and breakdown of the osteochondral junction
Subchondral cysts ( from microfractures) Osteophyte formation Joint space narrowing Sclerotic bone formation
Joint space narrowing Subchondral cysts Sclerosis
Pain is the main + best indication Degenerative joint disease – OA 1 o or 2 o Rheumatoid Arthritis Intractable pain Stiffness Deteriorating function