4Fracture of the femur Two types Extra capsular Extracapsular IntracapsularExtra capsularTrochantericSubtrochanteric
5Trochanteric (Evan’s classification) Stable # configuration – Type A & BUnstable # configuration – Type C & DType C – lateral cortex is intactType D – lateral cortex is violatedType E – Reverse obliquityFractures parallel to neck axis &traverse lat. cortex
7Subtrochanteric Three types- Simple, Wedge , Complex All unstable due to relatively small contact area
8Intra capsular Classification (Low energy) Fracture site- subcapitus, transcervical, basicervicalInclination of the # -Pauwel’s classificationType I – 30 degreeType II – 50Type III – 70
9Relation of # fragment Garden classification Type I – incomplete & impactedType II – Complete & undisplacedType III – Complete & partially displaced(intact post.retinacular ligament)Type IV – completely displaced(disruption of reti.vessels)
10Classification (High Enegy) Type I - undisplaced neck #Type II – simple displaced neck #Type III – Comminuted displaced neck #Type IV – FON + # of acetabulum or shaft of the femurType V – Neck # that occur or recognized during antegrade nailing of shaft
11First aid Safe place Reassure the person Have the victim lie flat and rest.Ask for helpCPRIf there is a wound remove the clothesIf there is bleeding apply direct pressure to the wound to stop the bleeding.Cover the wounded area with a clean cloth or dressing.Continue to apply pressure as long as the wound bleeds. Add new dressings over existing ones.
12Immobilize the injured area Immobilize the injured area. A splint is a good way to immobilize the affected area, reduce pain and prevent shock.Effective splints can be made. The general rule is to splint a joint above and below the fracture.Or, lightly tape or tie an injured leg to the uninjured one, putting padding between the legs, if possible.
17Check the pulse in the limb with the splint Check the pulse in the limb with the splint. If you cannot find it, the splint is too tight and must be loosened at once. Check for swelling, numbness, tingling or a blue tinge to the skin. Any of these signs indicate the splint is too tight and must be loosened right away to prevent permanent injuryKeep her fastingInform relativesMove to hospital
19Care of Injury – 4 Stages Prevention Pre-hospital care Hospital care Rehabilitation“Manage the patient, Not the fracture”
20Initial assessment and resuscitation A = AirwayB = BreathingC = CirculationD = Disability of CNSE = Exposure of the patientF = Foley catheter
21Airway and BreathingAt risk in all unconscious patients.
22CirculationBlood loss is greater than the NOF fracture and trochanteric fracture. Large volume of blood can accumulate in the thigh.Skin: cold , pale ,sweatingPulse: rate, volume, rhythmBlood PressureJVPAdequate fluid resuscitation.
23Disability of CNS- AVPU Head injuryExamination: Level of consciousnessExternal woundsPupils- dilated, unequalCT scan of the brain
24Damage to cervical spine Suspected in all unconscious and head injured patients.In line bimanual immobilizationSemi rigid collarX-ray cervical spine
26Differential Diagnosis- Generalized bone diseasesPaget’s disease of bonePrimary hyperparathyroidismOsteomalaciaOsteoporosis
27Differential Diagnosis- Localized bone diseasesMetastases from carcinoma breast, lung, kidney, and thyroid.Multiple myelomaPrimary bone tumorsMalignant-OsteosarcomaChondrosarcomaBenignOsteoclastomaBone cyst
28History 1.Name- (for identification purposes) 2.Age-important to identify the disease since most of the diseases have an age distributioneg:- osteoporosis -over 50 yrsosteosarcoma yrsosteoma 40-50yrsParosteal osteosarcoma yrs-imporatant to take decisions on surgicalfitness
293.Sex- Osteoporosis is more common in females 4.Occupation-exposure to radioactive radium and thorium dioxide increases the risk of development of osteosarcoma5.P/C-What has happen-(circumstance)?accident/?deliberate harmAt what time?After math-LOC/Numbness/Bleeding/Inability to walkTime of the last meal?Intoxication?(alcohol/drugs)
30Early fractures or any prolong immobilisation? Suffering from any illness?Wt loss (CA/TB)Change in Ht?Hx of renal stones?6.PMHx-DM,HT,AsthmaCushing’s,Hyperthyroidism,AcromegalyCVA,fainting attack,epilepsy,hypoglysemia7.PDHx- Corticosteroids8.PSHx-Any previous trauma,any Sx and complications
319. Menstual Hx- 10. Allergies- 11. Immunisation-eg tetanus 12 9.Menstual Hx- 10.Allergies- 11.Immunisation-eg tetanus 12.Family Hx-eg-osteogenesis imperfecta osteopetrosis 13.Personal Hx-smoking,alcohol,lifestyle family life (?assault) 14.Dietary Hx-?protein and Vit deficiency? Inadequate Ca intake
32Examination General Examination 2.Examination of the Hip Joint 3. Special Examination of systems4. Radiographical Examination
33General Examination Patient is in pain Unable to stand Limb is shortened and lies in external rotationSkin wounds or obvious deformity
34Mental and Emotional state Physical attitude Gait Physique Face Skin Hands Feet Neck – lymph nodes, thyroid gland Breast Axillae T Pulse Respiration Odours
36Examination of the Hip Joint InspectionSkin changes- Redness, swellingShapePositionScarsWasting of gluteal and thigh musclesPalpationTemperature, tenderness over the jointSkin, soft tissue, muscles, boneMovementsVoluntary, involuntary , crepitusFlexion- measured with knee bent. Opposite thigh must remain in neutral position. Flex the knee as the hip flexes.Abduction- measured from a line that forms an angle of 90 degrees with a line joining the ASISs .AdductionRotation in flexionRotation in extensionExtension- attempt to extend the hip with the patient lying in the lateral or prone position
37Haematoma or bruit over the area suggest arterial damage . Look for,Shortening in External rotation of the involved extremityPalpation below the ingunum elicits painInability to move
38Additional examinations of hip joint : Measurement of True and apparent shortening
39Circulatory system Neurological Examination Musculoskeletal System Special ExaminationCirculatory systemNeurological ExaminationMusculoskeletal System
40Inspection Palpation Percussion Auscultation 1. Circulatory System why? 1) Cardiovascular syncopy or initial stroke could have caused the fall 2) Detect other cardiovascular problemsInspectionPalpationPercussionAuscultation
42Peripheral pulses- absent means major vessel injury
433. Musculoskeletal System Examination of Associated InjuriesWrist #Head injuryMost frequently associated injuries are due to patient’s osteoporosis in other areas of the body.They are sustained at the same time as the trochanteric fracture
44Radiographic Examination AP Radiograph of the distal PelvisAP and Lateral Radiographs of the hip jointFemurKnee joint^
45INVESTIGATIONS To Diagnose Fracture To Find Aetiology Preoperative AssessmentPostoperative evaluation
46Diagnose Fracture X-Ray Hip Rule of 2s Rule of As 2views2joints2limbs2timesRule of AsAnatomyArticularvAlignmentAngulationApexAppositionCT Scan-Not indicated in routine evaluation
47Find Aetiology X-ray- Osteoporosis Paget’s Disease Chondrosarcoma Lytic lesion Involves the inferior aspectof the neck and the medialintertrochanteric area.
48Ewing sarcoma. Entire proximal part of the femur is filled with mottled scleroticdensities indicative of a diffusepathological process.
49CXR , X-ray pelvis, Bone scan - Metastasis Serum Ca –HyperparathyroidismOsteomalaciaT3,T HyperthyroidismBone marrow biopsy- Multiple myeloma
53Definitive MANAGEMENT OF THE FRACTURE Management of fracture can be considered as,Operative treatmentNon operative treatmentIndications for Non operative TreatmentAn elderly person whose medical condition carries an excessively high risk of mortality from anaesthesia and surgeryNon ambulatory patient who has minimal discomfort following fracture
54Non operative management Skeletal traction is the most common method used to control and reduce painIn subtrochanteric fracture most common method to reduce the fracture is by skeletal traction with a transcondylar Steinmann pin90 degree flexion is used to relax the iliopsoas: correct the flexion and external rotational deformitiesperiod of traction ranges from 12 to 16 weeksshould be monitored with regular radiological imagingEarly removal of skeletal traction may be followed by bracing with a hip spica cast when early callus is seen in x-ray films.Maintenance exercise must be administered regularly to maintain the mobility of joints and muscle strengthHare traction, Buck's traction
55Position of patient in treating subtrochanteric fractures with skeletal traction
56ComplicationsIn elderly patients, this approach was associated with high complication ratestypical problems included decubiti, urinary tract infection, joint contractures, pneumonia, and thromboembolic complications, resulting in a high mortality rate.In addition, fracture healing was generally accompanied by varus deformity and shortening because of the inability of traction to effectively counteract the deforming muscular forces
57Surgical treatment Surgical stabilization is the standard of care Internal fixation of fractured end is widely performed.Intramedullary nail fixation is the preferred treatmentTwo methodsOpen MethodClosed Method
58Open Methodpossible in fractures with minimal comminution but it demands an extensive dissectionweight-bearing may not be possible until the fracture healsdisadvantage of the open technique is extensive soft tissue dissectiontemporarily fixed with reduction forceps or Kirschner wire (K-wire) fixation; then fixed with lag screwsplate is fixed proximally to the femoral head and neck for maximal stability
60Closed Method closed reduction and internal fixation Closed reduction is usually performed with the use of a fracture traction table with a transcondylar Steinmann pinfixation can be carried out with percutaneous implant insertionmost common implant used is the intramedullary locked naildoes not disturb the fracture hematomaminimum soft tissue dissectionneed to use fluoroscopy and the difficulty in performing distal locking are potential disadvantages
61Sliding hip screwThis device is indicated only for very proximal fractures.The sliding of the screw allows medialization of the distal fragment, which reduces bending moment on fracture and implant
62Other treatmentHence this was pathological fracture we have to find the cause and treat for that.metastatic tumours are the most common types of tumour deposits in this regionSo other metastatic sites should also be investigated before definitive fixation of the fracture is performed.In the case of primary, investigate for secondaries and follow chemotherapy / Radiation therapy
64Pre operative measures Assessment of the patientCormobid factorsSurgical fitnessRisk for anesthesiaPre operative templating - for proximal comminution the use of a fixed angle device with the proper blade and compression screw length
65Normal side femur length When an intramedullary device is chosen, templating for length, canal diameter is necessary for proper planning.c)MeasurementsNormal side femur length
66open reduction and internal fixation Extra medullary implants Surgerymain techniques:external fixationopen reduction and internal fixationExtra medullary implantsIntra medullary implants
67Extra medullary devices 1.)Sliding compression screw plate2.)Dynamic hip screw(DHS) e.g:-DCSIndications:-Fractures with stable configurationsUnstable fractures with an intact lateral cortex
68Intra medulary devices 1)Intra medullary hip screw(IMHS)Cephalomedullary nailsReconstruction nails(centromedullary)Indications:-Shorter nail-If fracture line doesn’t extend more than 1 to 2cm distal to lesser trochanterLonger nail-unstable fractures
70External fixation-Rarely used but is indicated in severe open fractures.For most patients, external fixation is temporary, and conversion to internal fixation can be made if and when the soft tissues have healed sufficiently.
71Post operative period.1.)Following intramedullary nailing if the bone quality and cortical contact is adequate, 50% partial weight bearing can be allowed immediately.With less stability, patients can perform touchdown weight bearing.Following OR and plate fixation, minimal protected weight bearing can begin immediately but is advanced slowly beginning approximately 4 weeks after surgery, with full weight bearing anticipated at 8-12 weeks.Elderly patients may have difficulty with compliance with weight bearing restrictions.
722.) Check for proper union 3.) Prevent infections4.) Wound care ) Nutrition- high protein diet
73Complications Acute complications Long term complications Damage to nerves and blood vesselsHaemorrhageOther soft tissue damageLong term complicationsFailure of fixation-screws may cut out of the bone if reduction is poor or if the fixation device is incorrectly positioned. Reduction and fixation may have to be re-done.
74-only complication that is frequent Malunion-only complication that is frequent-may occur through bending or breakage of a nail plate or simply through compression of the soft cancellous bone with metal.-causes union with a slightly reduced neck-shaft angle- coxa vara
75-If neglected, Treatment May unite with marked lateral rotation of the shaft.May develop severe coxa vera associated with shortenig.TreatmentIn most cases, can be accepted without treatment.In severe deformities,-the bone is divided in the trochanteric region and the fragments are secured in the correct position by a compressive screw plate or other appropriate device(as in a fresh fracture.
76complications due to treatments casts-pressure ulcers-thermal burns-thrombophlebitisInternal fixation-infections-neurological and vascular injury-thromboembolic events-avascular necrosis-posttraumatic arthritis
77Complications of immobilization Bed soresHypostatic pneumoniaOsteoporosisHypercalcaemiaHypercaliuriaUrolithiasisUTIsMuscle wastingJoint stiffnessDVTPulmonary embolismPsychological depression
79Follow-Up Close follow-up is required following fixation DKAFollow-UpClose follow-up is required following fixation50% PWB can be allowed immediatelyWound is checked for proper healing 7-14 days post operatively
80Quadriceps rehab to be started within 02 weeks post operatively DKAPatient should have monthly clinical evaluations and radiographs to monitor healing.Quadriceps rehab to be started within 02 weeks post operativelyMost patients will have significant disability for 4-6 months
81DKAImpact activities may be possible after 06 months (Should wait 01 year before returning to full contact sports)
82Rehabilitation Rehabilitation involves: * Ankle pumps (to prevent DVT) DKARehabilitationRehabilitation involves:* Ankle pumps (to prevent DVT)* Chest Physiotherapy (Airway clearance)* Exercises : Quadriceps, Hamstrings and Glutei (Isometrics)Heel Slides (in supine lying)Strengthening Ex to Upper Limbs (Before prescription of walking aids)
86DKAMobility and weight bearing * Increase bed mobility (Supine to Sitting) * Increase ambulation with appropriate weight bearing (TDWB with walker -> PWB with walker) * Perform SLR (up to 6” from the bed level in supine lying) * Mini Squats
89Within 1-2 Weeks * Reinforce good posture DKAWithin 1-2 Weeks* Reinforce good posture* Add standing hip abduction, adduction, extension and flexion with hip and knee flexion exercises
90Discharge Criteria Gets out of bed independently. DKADischarge CriteriaGets out of bed independently.Able to ambulate 50 feet independently in a hall with assistive device.In and out of bathroom independently.
91After discharge Advice to the patient on: DKAAfter dischargeAdvice to the patient on:Changes to the home environmentLifestyle changesPrevention