Lower limb fractures and dislocation DR. MOHAMAD KHAIRUDDIN BIN ABDUL WAHAB M.B.B.S (Univ. Malaya), MS Ortho (UKM) ORTHOPAEDIC SURGEON FACULTY OF MEDICINE CUCMS

Learning outcome: The student should be able to: Discuss on the mechanism, clinical presentation, classification, radiological findings, and its complications of fractures and joint dislocation Derive treatment option of the common lower limb fractures and joint dislocation

Contents: FRACTURE NECK OF FEMUR INTERTROCHANTERIC FRACTURE HIP JOINT DISLOCATION FEMUR SHAFT FRACTURE DISTAL FEMUR FRACTURE KNEE JOINT DISLOCATION PATELLA FRACTURE TIBIAL PLATEAU FRACTURE

CONT’: TIBIA SHAFT FRACTURE MALLEOLI FRACTURE TALUS FRACTURE CALCANEUM FRACTURE

Fracture neck of femur Common in elderly following fall (osteoporosis) Young adult is due to high energy impact such as road traffic accident May accompanied hip joint dislocation (high impact injury) Demonstrated radiological (AP view of hip joint) as: Loss of Shenton’s line Disruption of proximal femur trabecula

Classification: Garden’s classification (4 stages) for femur neck fracture Help to determine the management and predict the prognosis on complication (avascular necrosis of the femoral head)

Garden’s classification Stage I Incomplete # (impacted) Stage II Complete and undisplaced Stage III Complete and moderately displaced Stage IV Severely displaced

Anatomical classification: Also can describe the pattern of neck fracture Subcapital region Transcervical region Basal region Prognosis for AVN worsen in subcapital and transverse fracture

Radiological features of neck of femur fracture Shenton’s line

Complication: Avascular necrosis of the femur head Non-union of the fracture General complications following prolong bedridden for conservative treatment (bedsore, DVT, pneumonia, stiffness)

Treatment: Depend on the age of the patient, patient’s health and fracture stages & duration Non-operative reserve for: Poor health (unfit for surgery) patient Require on Traction for 3 – 6 weeks then start ambulate

Cont’: Operative treatment is the main goal: Younger age group with acute # and elderly with impacted # (preserved the head) usage of fracture fixation devices eg. Screw fixation, Dynamic Hip Screw Elderly patient with displaced # or chronic # subjected to hip replacement (hemiarthroplasty or total arthroplasty of the hip joint)

Intertrochanteric fracture Commonly occur in elderly patient (osteoporosis) following trivial fall Extension to subtrochanteric region May presented as comminuted fracture pattern

Radiograph shows intertrochanteric fracture of the femur

Complications: Mal-union of the fracture Failure in fixation for the fracture due to osteoporotic bone General complications following prolong bedridden

Treatment Operative is the main goal except unfit patient for anaesthesia or extreme osteoporotic bone Choices of implant for fracture fixation: Dynamic Hip Screw Proximal femoral nail (PFN)

Fixation of fracture intertrochanteric fracture

Hip joint dislocation Direction: posterior is more common than anterior Mechanism: ‘dash-board’ injury Limb attitude: Posterior dislocation (flexed, adducted, internally rotated, short limb) Anterior dislocation (flexed, externally rotated, abducted) Association with acetebular fractures of femoral head fractures

Left side Radiograph shows left hip dislocation

Complications: Sciatic nerve injury leading muscle paralysis and loss of sensory below the knee Prolong dislocation can also result in avascular necrosis of the femoral head

Treatment Emergency CMR under sedation Failure in CMR  open reduction Failure in CMR to obtain acceptable reduction is due to: Inverted limbus of the acetebular rim Intra-articular fracture fragment

Femoral shaft fractures Area that is well padded with muscles leading to fracture displacement and difficulty in CMR and maintain the reduction Associated with soft tissue injury due to high-energy injury risk of getting compartment syndrome Long bones – segmental # Occasionally associated with # neck of femur

Radiographs show femur shaft fractures Distal 1/3 supracondyalar Proximal 1/3

Complication Vascular injury (femoral artery) Fat embolism Delayed and non-union of the fracture Mal-union of the fracture Joint stiffness (knee)

Treatment Less preference for non-operative treatment (as the bone is weight bearing region) in adult Operative fracture fixation used : Intramedullary-Locking-Nail Plating (DCP)

Intramedullary locking nail

Distal femur #: Supracondylar & intercondylar Supracondylar # can be isolated or combination with intercondylar # Result from high energy force Risk of vascular injury (femoral artery) Intercondylar extension may involved articular region of the knee

Complications Joint stiffness and arthrosis if involve the articular region Risk of femoral artery injury

Treatment Open Reduction Internal Fixation is a goal standard treatment Fixation devices: Angled blade plate CDS (condylar dynamic screw) Supracondylar inter-locking nail Buttress plating (locking plate)

Angled blade plate for fixation of supracondylar fracture of the femur

Knee joint dislocation Result from violence injury force Involve more than two of knee ligaments injury Can presented as ‘self-reduction’ joint dislocation Associated with popliteal vessel injury and common peroneal nerve injury Urgent attention for vascular assessment

Radiographs show anterior dislocation of the knee

Risk of vascular injury Transected or thrombosis (following intimal injury) Vascular assessment or surveillance Angiogram as indicated

Directions of dislocation Reference to the position of tibia Anteromedial dislocation (risk of associated intimal injury of popliteal artery) Posterolateral dislocation (highly associated with transected popliteal artery)

artery

Complications Neurovascular injury Knee ligaments injury (result in joint instability) Stiffness of the joint Arthrosis formation following cartilage damage

Treatment Immediate reduction and immobilization Artery exploration and repair in the evidence of arterial injury Immobilization in cast (FLPOP) or external fixation Ligaments repair or reconstruction for multiple ligaments injury resulting in instability

Tibial plateau fractures Mechanism: varus or valgus force combined with axial loading Also known as ‘bumper fracture’ Tibial condyle can be crushed or split Presentation: haemathrosis, instability, associated neurovascular injury

Types of TP # Simple split lateral condyle Depressed, comminuted lateral condyle Crushed comminuted lateral condyle Split medial condyle Bicondylar fractures Bicondylar and subcondylar

Complications Compartment syndrome Joint stiffness Deformity arthrosis

Treatment Undisplaced or minimally displaced Traction until swelling subsided, apply cast immobilization Displaced and depressed Open reduction and internal fixation (buttress plate, inter-fragmentary screw) May need bone grafting in depressed fractures

Patella fractures Direct injury (dash board, direct fall onto the knee) produced ‘stellate’ fracture Indirect injury (forced flexion knee) produce avulsion type or simple transverse pattern Loss of extensor mechanism Haemathrosis

Complications Joint stiffness Patellofemoral arthrosis reduced knee extensor mechanism

Treatment Undisplaced fracture Cylinder cast immobilization for 6 weeks Displaced fracture ORIF (tension band wiring) Severely comminuted Cerclage wiring or patellectomy

Tibial shaft fractures Proximal, middle, distal region Compartment syndrome (proximal 1/3) Affecting union (distal 1/3) Spiral, oblique (indirect force) Transverse, comminuted (direct force) With or without fibular shaft #

Radiographs show tibial shaft fracture

Complications Compartment syndrome Malunion (leading to shortening and arthrosis) Nonunion

Treatment Acceptable displacement with less comminuted (stable) Apply Full Length POP immobilization for 6 weeks Comminuted, segmental (unstable reduction alignment) Internal fixation (ILN, Plating)

Intramedullary Locking nail for Tibia shaft fracture

Malleoli fractures Forces to the ankle region External rotation, abduction, adduction, Ankle joint dislocation or subluxation Ankle ligaments injury including syndesmosis

Classification Danis & Weber (Muller et al 1991): Type A: # below the tibiofibular syndesmosis abduction or adduction force Medial malleolus may #ed or rupture of deltoid ligament

Cont’: Type B: # level with syndesmosis Oblique fibular # External rotation force Disrupted medial structures Syndesmosis intact

Cont’: Type C: # above the syndesmosis Abduction alone or combination of abduction and external rotation force Disruption of syndesmosis and interosseous membrane (widened mortise) Unstable tibiofibular region

Fracture of lateral malleolus

Complications Dislocated or subluxated ankle joint Stiffness Arthrosis of ankle joint Ankle instability Nonunion fracture (displaced medial malleolus) Malunion of the fracture

Treatment Undisplaced # Cast immobization (boot POP) Displaced # with or without subluxation joint or loss of normal ankle mortise ORIF (fibular plating, screw fixation of medial malleoli, syndesmotic screw)

Plating of the lateral malleolus fracture with 1/3 tubular plate

Talus fractures Rare injury Violence injury (following inversion force or axial loading) +/- dislocation of the ankle joint or subtalar joint Regions affected: head, neck, body, and lateral process Risk of developing avascular necrosis of talus dome

Talus fractures Dome of talus fracture showed Through CT-scan Neck of talus fracture

Complications Skin damage or necrosis due to pressure from the underling bone Nonunion of the fracture AVN following fracture at the neck region Arthrosis (ankle and subtalar)

Treatment Undisplaced #: cast immobilization (boot POP) Displaced # +/- dislocation: ORIF screw fixation If AVN developed later may consider arthrodesis of the ankle joint

Screw fixation of the talus fracture at the neck region

Calcaneum fractures Result from axial loading Traction through Achilles tendon lead to avulsion fracture Can be extra-articular or intra-articular fracture (referring to subtalar joint) Result in loss of foot arch (Bohler’s angle: 25 –40 degrees) lead to flat foot

Extra-articular fracture of calcaneum

Complications Skin necrosis (intense swelling) Malunion of the fracture Peroneal tendon impingement Flat and broad foot (shoe fitting) Subtalar arthrosis

Treatment Extra-articular fractures or undisplaced intra-articular fractures may require Robert-Jones bandaging for 1 week then followed by boot POP cast for 5 weeks No weight bearing is allowed Displaced intra-articular # or avulsion of Achilles insertion: ORIF screw or recon plate

Exercise for student: After reviewing the lecture notes, you are require to do some exercises. The answers to the exercise need to be submitted via e-mail (address: mkhairuddin@salam.uitm.edu.com.my)

Questions: Briefly discuss on the classification used to describe neck of femur fracture. With regards to dislocated knee, describe the direction of dislocation in relation to vascular injury pattern. Briefly discuss on the complications following calcaneum fracture.

Reference for further reading: Orthopaedic Surgery Essential: Trauma; Charles Court-Brown, Lippincott Williams & Wilkins; 2005 Turek’s Orthopaedics: Principles & their application; Stuart L. Wienstein, Joseph A. Backwalter: 5th Edition Lippincott Williams & Wilkins 2005 Practical Fracture Treatment; Ronald McRae, Max Esser; 4th Edition, Churchill Livingstone 2002

Enjoy reading….. For further questions or enquiry , please contact through: Handphone: 012-8976094 Email : mkhairuddin@slam.uitm.edu.com.my