2. INJURIES TO THE LOWER LIMB ( 2 )
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
2
3. FEMORAL NECK FRACTURES
Epidemiology
increasingly common due to aging
population
women > men
whites > blacks
most expensive fracture to treat
Mechanism
high energy in young patients
low energy falls in older patients
Healing potential
femoral neck is intracapsular, bathed in
synovial fluid
lacks periosteal layer
callus formation limited, which affects healing
3
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
4. Blood supply to femoral head
major contributor is medial femoral circumflex (lateral epiphyseal
artery)
some contribution to anterior and inferior head from lateral femoral
circumflex
some contribution from inferior gluteal artery
small and insignificant supply from artery of ligamentum teres
displacement of femoral neck fracture will disrupt the blood supply and
cause an intracapsular hematoma
4
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
5. FEMORAL NECK FRACTURES
Symptoms
impacted and stress fractures
slight pain in the groin or pain referred
along the medial side of the thigh and
knee
displaced fractures
pain in the entire hip region
Physical exam
impacted fractures
no obvious clinical deformity
minor discomfort with active or passive
hip range of motion, muscle spasms at
extremes of motion
pain with percussion over greater
trochanter
displaced fractures
leg in external rotation and abduction,
with shortening
5
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
6. FEMORAL NECK FRACTURES
Treatment
Nonoperative
observation alone
may be considered in some patients who
are non-ambulators, have minimal pain,
and who are at high risk for surgical
intervention
Operative
ORIF
Cannulated screw fixation (<50 yo)
Sliding hip screw
Hemiarthroplasty (for elders )
total hip arthoplasty (for active elders ) 6
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
8. FEMORAL NECK FRACTURES
Prognosis
mortality
~25-30% at one year (higher than vertebral compression
fractures)
predictors of mortality
pre-injury mobility is the most significant determinant for
post-operative survival
in patients with chronic renal failure, rates of mortality at
2 years postoperatively, are close to 45%
8
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
9. INTERTROCHANTERIC FRACTURES
Extracapsular fractures of the proximal femur between the
greater and lesser trochanters
Female : male ratio between 2:1 and 8:1
typically older age than patients with femoral neck fractures
Risk factors: osteoporosis, prior hip fracture, risk of
falls
More common than femoral neck fracture in patients
with preexisting hip arthritis
In contrast to intracapsular fractures, extracapsular trochanteric
fractures unite quite easily and seldom cause avascular
necrosis
Physical Exam : painful, shortened, externally rotated lower
extremity 9
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
11. INTERTROCHANTERIC FRACTURES
Treatment
Nonoperative
nonweightbearing with early out of bed to chair
Operative
Intertrochanteric fractures are almost always treated by early
internal fixatio because :
to obtain the best possible position And
to get the patient up and walking as soon as possible and
thereby reduce the complications associated with prolonged
recumbency
sliding hip compression screw
intramedullary hip screw
arthroplasty
11
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
12. INTERTROCHANTERIC FRACTURES
Complications
Implant failure and cutout
most common complication
usually occurs within first 3 months
Nonunion <2%
treatment
revision ORIF with bone grafting
proximal femoral replacement
Malunion
12
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
13. FEMORAL SHAFT FRACTURES
high energy injury that is associated with life-threating conditions
Fracture patterns
transverse
spiral
oblique
segmental
comminuted
Blood loss in closed femoral shaft fractures is 1000-1500ml
Must record and document distal neurovascular status
13
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
14. FEMORAL SHAFT FRACTURES
Treatment
Nonoperative
long leg cast or hip spica cast
nondisplaced femoral shaft fractures in patients with
multiple medical comorbidities
pediatric patients
Operative
antegrade intramedullary nail ( gold standard for
treatment of diaphyseal femur fractures )
retrograde intramedullary nail
external fixation with conversion to intramedullary nail
within 2-3 weeks
open reduction internal fixation with plate
14
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
16. FEMORAL SHAFT FRACTURES
Complications
Heterotopic ossification 25%
Pudendal nerve injury
Femoral artery or nerve injury
Malunion and rotational
malalignment
Delayed union
Nonunion
Infection
Fat embolism
16
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
Heterotopic ossification
17. DISTAL FEMUR FRACTURE
Distal femur fractures are fractures extending from
the distal metaphyseal-diaphyseal junction of the femur
to the articular surface of the femoral condyles.
They occur both in younger patients (as the result of high
energy trauma) or in older patients (from low energy
trauma as a pathological fracture secondary to
osteoporosis or malignancy).
The classification is commonly used to classify distal
femur fractures into
extra-articular (type A),
partial articular (type B),
and complete articular (type C). 17
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
19. DISTAL FEMUR FRACTURE
The majority of distal femur fractures are managed
surgically.
retrograde nailing or open reduction internal
fixation (ORIF).
Non-operative management requires a long period of
immobilisation and non-weight bearing, however is
sometimes indicated for fractures with minimal
displacement in a non-ambulatory or very co-
morbid patient.
19
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
20. PATELLA FRACTURE
A patella (kneecap) fracture is a traumatic injury caused by
direct trauma or rapid contracture of the quadriceps with a
flexed knee
most fractures occur in 20-50 year olds
male to female 2:1
Mechanism of injury
direct impact injury occurs from fall or dashboard injury
indirect eccentric contraction occurs from rapid knee
flexion against contracted quads muscle
Osteology
patella is largest sesamoid bone in body
superior 3/4 of posterior surface covered by articular cartilage
articular cartilage thickest in body (up to 1cm)
posterior articular surface comprised of medial and lateral
facets
lateral facet is larger
facets separated by vertical ridge 20
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
22. PATELLA FRACTURE
Treatment
Nonoperative
knee immobilized in extension (brace or cylinder cast) and full weight
bearing
Operative :depending on displacement and knee extension
function
ORIF
partial patellectomy
total patellectomy
22
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
23. DISLOCATION OF THE PATELLA
Anatomy
Static stability
medial patellofemoral ligament
(MPFL)
is primary restraint in first 20
degrees of knee flexion
patellar-femoral bony structures
account for stability in deeper
knee flexion
trochlear groove morphology,
patella height, patellar
tracking
Dynamic stability
provided by vastus medialis
23
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
24. DISLOCATION OF THE PATELLA
The patella can be dislocated by a sharp twisting movement of
the knee in very slight flexion
It is common in adolescents, particularly girls with loose
ligament
On examination soon after a dislocation, the knee will be
swollen because of the haemarthrosis and there will be
tenderness on the medial side of the patella because the medial
structures are torn (medial patella femoral ligament)
Treatment
All blood should be aspirated to help reduce pain.
Immobilization of the knee and early rehabilitation
If the patella has dislocated more than three times a
stabilizing operation will probably be required
24
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
26. DISLOCATION OF THE PATELLA
Recurrent dislocation of patella :
In over 70% of cases an underlying abnormality is found.
These include joint hypermobility, patella alta, patella maltracking and
axial malalignments
Anatomical factors
patella alta :causes patella to not articulate with sulcus, losing its
constraint effects
trochlear dysplasia
excessive lateral patellar tilt (measured in extension)
lateral femoral condyle hypoplasia
Treatment
Nonoperative
NSAIDS, activity modification, and physical therapy
Operative
Medial retinaculum and ligament repair
26
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
27. KNEE DISLOCATION
Complete separation of the tibia from the femur requires enough
trauma to tear at least two of the four major ligaments.
Both vascular and neurological functions must be assessed carefully
and recorded so that any deterioration will be noticed.
Damage to the popliteal vessels occurs in 50% of cases and an
angiogram is mandatory if there is doubt about the peripheral
vascularity.
Exploration of the popliteal artery and repair should be performed as
an emergency as there is a high chance of an amputation if this is
delayed more than 6 hours from the time of the injury
Types :
Anterior (30-50%) (most common)
Posterior (30-40%)
Lateral
Medial
Rotational
Treatment :
Emergent reduction followed by vascular assessment/consult
27
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
29. TIBIAL PLATEAU FRACTURES
Fractures of the tibial plateau are caused by a varus or valgus force
combined with axial loading (a pure valgus force is more likely to rupture
the ligaments).
Associated conditions
meniscal tears
ACL injuries
compartment syndrome
vascular injury
Radiology :
X-ray
CT scan
important to identify articular depression and comminution
Treatment :
Undisplaced fractures can be treated conservatively (splint).
Displaced fractures need open reduction and internal fixation +/- bone
graft .
29
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
31. TIBIAL SHAFT FRACTURES
Most common long bone fracture
account for 4% of all fracture seen in the Medicare population
Mechanism of injury
Indirect force: (low energy)
Twisting: spiral fractures of both bones
Angulation: oblique fractures with butterfly segment.
Direct force:
Transverse (low energy) or comminuted (high energy) fractures usually with skin and
soft tissue damage.
Treatment
Closed reduction / cast immobilization
indications
closed low energy fractures with acceptable alignment
< 5 degrees varus-valgus angulation
< 10 degrees anterior/posterior angulation
> 50% cortical apposition
< 1 cm shortening
No rotational malalignment
Open reduction internal fixation ( plate , IM nail)
External fixation ( mostly for open fractures )
31
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
33. TIBIAL SHAFT FRACTURES
Complications :
Knee pain
Malunion
Nonunion
Malrotation
Compartment syndrome
can occur in both
closed and open tibia
shaft fractures
Soft tissue damage.
Skin loss
33
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
34. DISTAL TIBIAL FRACTURES
These fractures occur at the distal end of the
tibia.
Tibial plafond fractures (Also known
as pilon fractures) are caused by high energy
axial load (motor vehicle accidents, falls from
height) and often characterized by articular
impaction and comminution with soft tissue
injury
Check Dorsalis Pedis and Posterior Tibial pulses
Ct scan is very important in planning for surgery
Treatment :
Undisplaced stable fractures can be treated
conservatively .
Displaced fractures need
open reduction and internal fixation (ORIF)
+/- bone graft .
External fixation and delayed ORIF
34
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
37. ANKLE FRACTURES
Typically a low-energy mechanism of injury, rotational as opposed to
axial load
Must always evaluate for deltoid or syndesmosis injury
injury patterns
isolated medial malleolus fracture
isolated lateral malleolus fracture
bimalleolar fractures
posterior malleolus fractures
syndesmotic injury
Radiographs recommended views
AP
lateral
Mortise (the leg internally rotated 15 degree ) for syndesmosis
37
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
39. ANKLE FRACTURES
Treatment
Nonoperative
short leg walking cast or cast boot for
nondisplaced stable fracture and tip
avulsions
Operative
ORIF for displaced unstable fractures
Complications
Wound problems surgery
Deep infections
up to 20% in diabetic patients
Malunion
Post-operative stiffness
Post-traumatic arthritis
39
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
40. ANKLE LIGAMENT INJURIES
ankle sprains involve an injury to the
Anterior Talo-Fibular Ligament (ATFL)
and calcaneofibular ligament (CFL)
and are the most common reason for
missed athletic participation
Types:
Stretching of the ligament.
Partial tear: healing restores full
function.
Complete tear: joint instability.
Usually involves lateral ankle
ligaments (ant. Talofibular lig.,
talocalcaneal lig., and post. Talofibular
lig.).
Medial calcaneal lig. (deltoid lig.) can
result from abduction or eversion
injury.
40
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
41. ANKLE LIGAMENT INJURIES
Clinical features:
Bruising, swelling, tenderness (usually distal
and anterior to lat. Malleolus in anterior
talofebular lig. Injury).
Treatment
Partial tears: RICE , elastic bandage and
gentle active exercise.
Complete tears: cast immobilization from
below knee to toes for 6 wks then
physiotherapy. if this regime fails; operative
repair is done.
Complications:
Recurrent sprains.
Recurrent giving way or instability.
41
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
42. FRACTURES OF TALUS
Rare and usually due to fall from
height , car accidents,…
May involve the body, neck, head
or dislocation of the talus.
Clinical features
Pain, swelling, deformity.
Radiology :
X-ray: difficult to diagnose.
May need to repeat several
days later to see the fracture.
CT in difficult cases.
42
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
43. FRACTURES OF TALUS
Treatment
Undisplaced : Below knee plaster
with knee plantigrade for 6-8 wks.
Displaced fractures or fracture
dislocations: urgent reduction by
closed manipulation; if fails,
ORIF
Complications
Non-union.
Avascular necrosis of body after
fracture of neck.
Secondary osteoarthritis. 43
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
44. CALCANEAL FRACTURES
Usually seen after fall from height .
Lover's fracture, also known as Casanova fracture is a type of calcaneal
fracture
Associated injuries: spine, pelvis, hip or base of skull.
Types: ( CT scan is important )
Extra-articular fractures: need closed treatment. Have good prognosis.
Intra-articular fractures: involve superior articular surface.
May be comminuted.
Special features
The foot swollen, bruised and the heel look broad. Movement is painful.
Signs of compartment syndrome: intense pain and diminished sensation.
Necessary to X-ray the knees, spine, and pelvis.
44
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
45. CALCANEAL FRACTURES
Treatment
Admit to hospital, elevate the leg
and apply ice-packs until swelling
subside.
Undisplaced fractures: closed
treatment.
Displaced fractures: ORIF with
screws or calcaneal plate and
screws.
Complications
Broadening of the heel
Stiffness
Osteoarthritis
Compartment syndrome 45
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
46. METATARSAL FRACTURES
Mechanism of injury:
Direct trauma, Twisting, Repetitive stress.
Treatment:
Walking plaster for 3 weeks.
Displaced fractures; Kirschner wire fixation.
46
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
47. 5TH METATARSAL BASE FRACTURE
5th metatarsal base fractures are among the most common
fractures of the foot.
Some fractures may be predisposed to poor healing due to the
limited blood supply to the specific areas of the 5th metatarsal base.
Treatment can include protected weight bearing, immobilization or
surgery depending on location of fracture, degree of displacement,
and athletic level of patient.
47
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
48. 5TH METATARSAL BASE FRACTURE
Jones fracture :is a zone 2 fracture (a transverse fracture at the base of
the fifth metatarsal, 1.5 to 3 cm distal to the proximal tuberosity )
represents a vascular watershed area, making these fractures prone
to nonunion
zone 2 (Jones fracture) in elite or competitive athletes treated
surgically to minimizes possibility of nonunion or prolonged restriction
from activity
48
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali