1. Femur and Tibia Fractures
Kevin E. Coates, M.D., M.P.T.

2. Worker’s Compensation?

3. Femoral Neck Fractures
Epidemiology
250,000 Hip fractures annually
Expected to double by 2050
At risk populations
Elderly: poor balance&vision, osteoporosis, inactivity, medications, malnutrition
incidence doubles with each decade beyond age 50
higher in white population
Other factors: smokers, small body size, excessive caffeine & ETOH
Young: high energy trauma

4. Classification I Valgus impacted or incomplete II Complete
Garden
I Valgus impacted or
incomplete
II Complete
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement
** Portends risk of AVN and Nonunion I II
III IV

5. Treatment Goals Improve outcome over natural history
Minimize risks and avoid complications
Return to pre-injury level of function
Provide cost-effective treatment

6. Treatment Decision Making Variables
Patient Characteristics
Young (arbitrary physiologic age < 65)
High energy injuries
Often multi-trauma
Elderly
Lower energy injury
Comorbidities
Pre-existing hip disease

7. Treatment Young Patients (Arbitrary physiologic age < 65)
Non-displaced fractures
At risk for secondary displacement
Urgent ORIF recommended
Displaced fractures
Patients native femoral head best
AVN related to duration and degree of displacement
Irreversible cell death after 6-12 hours
Emergent ORIF recommended

8. Hemi
ORIF
THR

9. Non-displaced Fractures
ORIF standard of care
Predictable healing
Nonunion < 5%
Minimal complications
AVN < 8%
Infection < 5%
Relatively quick procedure
Minimal blood loss

10. Displaced Fractures Hemiarthroplasty vs. ORIF
ORIF is an option in elderly
Surgical emergency in young patients
Complications
Nonunion %
AVN 15 – 33%
AVN related to displacement
Early ORIF no benefit
Loss of reduction / fixation failure 16%

11. Displaced Fractures Hemiarthroplasty vs. ORIF
Hemi associated with
Lower reoperation rate (6-18% vs %)
Improved functional scores
Less pain
More cost-effective
Slightly increased short term mortality

12. Femoral Neck Nonunion Definition: not healed by one year
0-5% in Non-displaced fractures
9-35% in Displaced fractures
Increased incidence with
Posterior comminution
Initial displacement
Inadequate reduction
Non-compressive fixation

13. Femoral Neck Fractures Complications
Failure of Fixation
Inadequate / unstable reduction
Poor bone quality
Poor choice of implant
Treatment
Elderly: Arthroplasty
Young: Repeat ORIF
Valgus-producing osteotmy
Arthroplasty

14. Femoral Neck Fractures Complications
Post-traumatic arthrosis
Joint penetration with hardware
AVN related
Blood Transfusions
THR > Hemi > ORIF
Increased rate of post-op infection
DVT / PE
Multiple prophylactic regimens exist
One-year mortality 14-50%

15. Intertrochanteric Femur Fractures
Extra-capsular femoral neck
To inferior border of the lesser trochanter

16. Etiology
Osteoperosis
Low energy fall
Common
High Energy
Rare

17. Radiographs
Plain Films
AP Pelvis
Cross Table Lateral

18. Goals of Treatment Obtain a Stable Reduction Internal Fixation
Good Position
Mechanically Adequate
Permit Immediate Transfers & Early Ambulation

19. Rehabilitation Mobilize Weight Bearing As Tolerated
Cognitive Intact Patients Auto Protect
Unstable Fractures = Less WB
Stable Fractures = More WB
No 6 weeks Post op

20. Femoral Shaft Fractures
Common injury due to major violent trauma
1 femur fracture/ 10,000 people
More common in people < 25 yo or >65 yo
Femur fracture leads to reduced activity for 107 days
Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most frequent causes

21. Femur Fracture Management
Initial traction with portable traction splint or transosseous pin and balanced suspension
Evaluation of knee to determine pin placement
Timing of surgery is dependent on:
Resuscitation of patient
Other injuries - abdomen, chest, brain
Isolated femur fracture

22. Femur Fracture Management
Antegrade nailing is still the gold standard
Antegrade nailing problems:
Varus alignment of proximal fractures
Trendelenburg gait
Can be difficult with obese or multiply injured patients

23. Femur Fracture Management
Retrograde nailing has advantages
Easier in large patients to find starting point
Better for combined fracture patterns (ipsilateral femoral neck, tibia,acetabulum)
Retrograde nailing has its problems:
Intra-articular starting point

24. Femur Fracture Complications
Hardware failure
Nonunion - less than 1-2%
Malunion - shortening, malrotation, angulation
Infection
Neurologic, vascular injury
Heterotopic ossification

25. Ipsilateral Femoral Neck & Shaft Fractures
Optimum fixation of the femoral neck should be the goal
Varus malunion of the femoral neck is not uncommon, osteotomies can lead to poor results
Vertical femoral neck fracture seen in 26-59% of cases
Rate of avascular necrosis is low, 3%, even when missed

26. Tibial Plateau Fractures
Mechanism of Injury
Mean age in most series of tibial plateau fractures is about 55 years
Large percentage over age 60
Elderly population is increasing in numbers

27. Mechanism of Injury
Mechanism of injury is fall from standing height in most patients
MVA is increasing as % of fractures
Most common fracture pattern is split- depressed fracture of lateral tibial plateau (80% of fractures)

28. Physical Exam Neurologic exam Vascular exam peroneal nerve!
popliteal artery and medial plateau injuries
beware the of the knee dislocation posing as a fracture
beware of posteriorly displaced fracture fragments
ABI <0.9 urgent arterial study

29. Physical Exam Compartment syndrome KNEE STABILITY
varus/valgus in full extension
may require premedication
aspiration of knee effusion/hematoma
replace with lidocaine+marcaine

30. Evaluation of Soft Tissues
Proximal and distal tibia subcutaneous
Soft tissue remains compromised for at least 7 days
Early ORIF risks wound sloughexposed hardware

31. AP and Lateral Radiographs

32. Pre-traction

33. Post-traction

34. Computed Tomography Indications
Fracture in an active patient for which you are considering nonsurgical care
Complex fracture
To aid surgical planning of approach, technique, screw position, etc.

35. Computed Tomography

36. Computed Tomography

37. Classification: Schatzker
III II

38. Classification: SchatzkerIV VI V

39. Surgical Indicatons Open Fracture – I&D, spanning ex-fix
Extensive soft tissue contusion – spanning ex-fix
Closed fracture
Varus/valgus instability of the knee
Varus or valgus tilt of the proximal tibia
Meniscal injury/previous mensicectomy
Articular displacement or gapping???

40. Angular Malalignment of the Proximal Tibia
Incidence of arthrosis:
Valgus < 10o 14%
Valgus > 10o 79%
Any amount of varus angulation was bad
Independent of articular congruity

41. Meniscectomy
Higher rate of arthrosis in patients who had undergone meniscectomy at surgery
70% arthrosis in patients who had undergone meniscectomy
results independent of the amount of articular incongruity

42. Postoperative Management
Immediate PROM/AROM of knee
Routine Pin site care (if ex-fix)
TDWB for 8-12 weeks

43. Outcomes Outcome depends on: Varus valgus stability of the knee
Varus/valgus alignment of the proximal tibia
Presence of an intact meniscus
Articular congruity (to a lesser extent)

44. Treatment Goals
Focus on restoring stability and proximal tibial alignment to the knee, rather than restoring anatomic alignment of the articular surface at all costs
Use minimally invasive techniques, when possible
Other techniques are preferable to hybrid ex-fix
MOVE THE KNEE EARLY IN ALL PATIENTS!

45. Tibial Shaft Fractures
Mechanism of Injury
Can occur in lower energy, torsional type injury (eg, skiing)
More common with higher energy direct force (eg car bumper)

46. Physical Exam
Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself
Repeated exam often necessary to follow compartment swelling

47. Associated Injuries
Up to 30% of patients with tibial fractures have multiple injuries*
Fracture of the ipsilateral fibula common
Ligamentous injury of knee common in high energy tibia fractures

48. Associated Injuries
Ipsilateral femur fx, so called “floating knee”, seen in high energy injuries
Neuro/vascular injury less common than in proximal tibia fx or knee dislocation
Foot and ankle injury should be assessed on physical exam and x-ray if needed

49. Compartment Syndrome
5-15%
History of high energy or crush injury

50. Nerve is the Tissue most Sensitive to Ischemia
PAIN first Symptom
PAIN with Passive Stretch first Sign

51. Each Compartment has Specific Innervation
Ant Comp Deep- - Peroneal
Lateral -Sup Peroneal N.
Deep Post. - Tibial N.
Sup Post. - Sural N.

52. Advantages of IM Nail
Advantages include less malunion and less shortening than closed treatment or ex-fix
Earlier weight bearing may be allowed with insertion large nail

53. Proximal Fractrues are technically more challenging
Prone to Valgus & Pro-curvatum deformities

55. Complications
Infection 1-5%
Union >90%
Knee Pain
Common

56. Knee Pain Severe 9% Kneeling 92% Moderate 22% Running 57% Mild 68%
Rest 37%

57. Nail Removal
Resolved 27%
No - 20%

58. Disadvantages of IM Nail
Disadvantages include anterior knee pain (up to 56.2% *), risk of infection

59. External Fixator
External fixation generally reserved for open tibia fractures or periarticular fractures

60. Disadvantages of External Fixator
Increased incidence of malunion compared to IM nail
Risk of pin tract infection, cellulitis

61. Outcomes of External Fixation
95% union rate has been reported for group of closed and open tibia fractures, but 20% malunion rate*
Most common complications are pin track infections and malunion
Loss of reduction associated with removing frame prior to union

62. Open Tibia Fractures
Open fractures of the tibia are more common than in any other long bone
Rate of tibial diaphysis fractures reported from 2 per 1000 population to 2 per 10,000 and of these approximately one fourth are open tibia fractures*

63. Associated Injuries
Neurovascular structures require repeated assessment
Foot fractures also common
Compartment syndrome must be looked for

64. Gustilo and Anderson Classification
Grade 1- skin opening of 1cm or less, minimal muscle contusion, usually inside out mechanism
Grade 2- skin laceration 1-10cm, extensive soft tissue damage
Grade 3a- extensive soft tissue laceration(10cm) but adequate bone coverage
Grade 3b- extensive soft tissue injury with periosteal stripping requiring flap advancement or free flap
Grade 3c- vascular injury requiring repair

65. Objectives
Prevent Sepsis
Union
Function

66. Soft Tissue Coverage
Definitive coverage should be performed within 7 days if possible
Most type 1 wounds will heal by secondary intent or can be closed primarily
Delayed primary closure usually feasible for type 2 and type 3a fractures

67. Soft Tissue Coverage
Type 3b fractures require either local advancement or rotation flap, split-thickness skin graft, or free flap
STSG suitable for coverage of large defects with underlying viable muscle

68. Soft Tissue Coverage
Proximal third tibia fractures can be covered with gastrocnemius rotation flap
Middle third tibia fractures can be covered with soleus rotation flap
Distal third fractures usually require free flap for coverage

69. Amputation
In general amputation performed when limb salvage poses significant risk to patient survival, when functional result would be better with a prosthesis, and when duration and course of treatment would cause intolerable psychological disturbance

70. Complications Nonunion Malunion Infection- deep and superficial
Compartment syndrome
Fatigue fractures
Hardware failure

71. Nonunion Time limits vary from 6 months to one year
Fracture shows no radiologic progress toward union over 3 month period
Important to rule out infection

72. Malunion In general varus malunion more of a problem than valgus
For symptomatic patients with significant deformity treatment is osteotomy

73. Deep Infection
Often presents with increasing pain, wound drainage, or sinus formation
Treatment involves debridement, stabilization (often with ex-fix), coverage with healthy tissue including muscle flap if needed, IV antibiotics, delayed bone graft of defect if needed

74. Superficial Infection
Most superficial infections respond to elevation of extremity and appropriate antibiotics (typically gram + cocci coverage)
If uncertain whether infection extends deeper and/or it fails to respond to antibiotic treatment, then surgical debridement with tissue cultures necessary

75. Hardware Failure Usually due to delayed union or nonunion
Important to rule out infection as cause of delayed healing
Treatment depends on type of failure- plate or nail breakage requires revision, whereas breakage of locking screw in nail may not require operative intervention

76. Outcomes
Outcome most affected by severity of soft tissue and neurovascular injury
Most studies show major change in results between type 3a and 3b/c fractures
For type 3b and 3c fractures early soft tissue coverage gives best results

77. Tibial Plafond Fractures
Terrible Injuries
“Excellent Results” rarely achieved
Fair to Good Results are the Norm
Outcomes are Impossible to Predict
Avoid Treatment Complications

78. Treatment Principles Delay Until Definitive Surgery
Spanning External Fixation
Pecutaneous and Limited Approaches
Plating Fibula

85. Surgical Delay with External Fixation
Maintains Length and Aligment
Better Imaging Studies
Allows Mobilization
Pre-Operative Planning
Allows Soft Tissue Recovery

86. Plating of Fibula Fracture
Fibular length
Articular reconstruction
Early motion

87. Outcomes Most Have Some Pain Most Return to Work
Detectable Arthritis in 50%

88. Outcomes - Pain
50% Minimal
35% Pain with WB
15% Continuous

89. Long Term Outcome 5 - 11 Years Most Have Some Degree of Ankle Pain
Most Cannot Run or Play Sports
70% with Moderate to Severe Arthritis
Most Rate Their Outcome as Good

90. Summary Bad Injuries with Unpredictable Outcomes
Complications in 10% or Less
Results Generally not Great but not Bad if no Complications