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Fractures of the Femur, Tibia, and Fibula
Presented by:
Dr. Aric StorckOctober 2,
2002
Objectives Clinical evaluation Radiological diagnosis Emergency department management Will not discuss hip fractures (femoral
head, neck, trochanters) – discussed at pelvis/hip rounds
Will not discuss distal tib/fib fractures -discussed during ankle rounds
Femur Fractures
Femur FracturesFemoral Shaft Fractures
High-energy trauma – MVC, bicycle, falls Tensile strain usually produced
transverse fractures Comminution with higher forces Open fractures uncommon – generally
penetrating trauma Pathologic fractures – result from
torsional stress causing spiral fracture
Femoral Shaft FractureClassification
No generally accepted system Describe based on characteristics
Location Geometry Transverse, oblique, spiral, wedge,
comminution
Femoral Shaft Fractures
Femoral Shaft FracturesClinical Features
Obvious deformity 50% have ligamentous instability of the knee Neurovascular injuries rare in closed
fractures Fracture of Proximal 2/3
Proximal fragment abducted, flexed, and externally rotated due to pull of gluteal and iliopsoas muscles of trochanters
Fracture of Distal 1/3 Hyperextension of distal fragment due to pull of
gastrocnemius
Femoral Shaft FracturesED Management
Cross and type for at least 2 units PRBC Assess and treat neurovascular status D/C traction (NV damage more likely
from traction than from fracture) Immobilize without traction Analgesia (im/iv or femoral nerve block
with bupivicaine after careful neurological exam)
Femoral Shaft Fractures Definitive Management
Traction no longer commonly employed
External fixation especially open and comminuted
fractures Intramedullary rods
Operation of choice for most fractures Has been shown to decrease
hospitalization and total disability
Femoral Shaft FracturesDefinitive Treatment
Callus formation 3 weeks post IM nail
Bridging trabeculae 5 weeks post IM nail
Femoral Shaft FracturesComplications
Outcome generally good with close to 100% union rate. Potential complications include… Malunion Fat embolism
2-23% of isolated femoral shaft fractures Fever, tachycardia, ALOC, resp distress, petechiae
ARDS Hemorrhage (average 1-1.5 litres) Concurrent multisystem trauma Limb-length discrepancy Compartment syndrome of the thigh - rare
Knee Fractures Distal Femur
Supracondylar Intracondylar Condylar
Patella Proximal Tibia
Tibial plateau Tibial spine
Ottawa Knee Rules X-ray knees with knee injury and one
or more of:1. Blunt knee trauma in a patient >55 years
old2. Tenderness to palpation of head of fibula3. Isolated tenderness of patella4. Inability to flex knee to 90 degrees5. Inability to bear weight both immediately
and inability to take four steps in ED
Exclusion criteria Isolated skin injuries Referred patients from another ED or clinic Injury >7 days old Patient returning for re-evaluation Distracting injuries Altered mental status Age < 18 years old Pregnant patients Paraplegia
Ottawa Ankle Rules Derived from study of 1047 adult
ankle injuries 100% sensitive 54% specific Reduced radiography from 69% –
49% Reduced time in ER by 39 minutesStiell IG, Greenberg GH, Wells GA, et al: Prospective
validation of a decision rule for the use of radiography in acute knee injuries. JAMA 275:611-615, 1996
Stiell IG, Wells GA, Hoag RH, et al: Implementation of the Ottawa knee rule for the use of radiography in acute knee injuries. JAMA 278:2075-2079, 1997
Knee Injuries If Ottawa criteria are met x-ray:
AP / Lateral “sunrise” view for patients with patellar
tenderness Oblique view / plateau view for patients
unable to bear weight provides better view of femoral condyles, tibial
tuberosity, medial/lateral patellar margins Tunnel view for patients with suspected
ACL injury and tibial spine fracture
Pittsburgh Rules for Knee Radiographs
Pittsburgh Rules for Knee RadiographsExclusion criteria
• Injury >6 days old
• Isolated skin injuries
• History of knee fracture or surgery
• Repeat visit for same injury
Pittsburgh vs Ottawa rules More specific than Ottawa rules
(60-80% vs 27-49%) Comparable sensitivity (99% vs
97%) One study found the Pittsburgh
rules decreased knee radiography by 52% with one missed fracture vs 23% with three missed fracturesSeaberg DC, Yealy DM, Lukens T, et al: Multicenter comparison of two clinical
decision rules for the use of radiography in acute, high-risk knee injuries. Ann Emerg Med 32:8-13, 1998
Distal Femoral Fractures
Distal femur fractures Uncommon Result from high velocity trauma
(MVC) Hyperabduction Adduction Hyperextension Axial loading
Extensive soft tissue injuries Compartment syndrome - rare
Distal femur fractures Examination
Knee pain deformity hemarthrosis Supracondylar fractures
Shortened and externally rotated thigh Quadriceps pull proximal fragment
forwards Gastrocnemius pulls distal fragment back
Femur fractures - imaging AP Lateral Also don’t forget …
AP pelvis AP/lateral hip
Distal Femur Fractures Anatomy
Vascular close to femoral/popliteal vessels Assess distal pulses Palpate for hematoma in popliteal fossa
Neurological Tibial nerve – gastrocnemius, plantaris Peroneal/Deep Peroneal nerves
Supplies anterior compartment (dorsiflexion) Sensory to first dorsal interosseus cleft
Distal Femur Fractures Supracondylar
Extra-articular No hemarthrosis
Intracondylar Intra-articular
Condylar Intra-articular
Distal Femur Fractures
Distal Femur Fractures No definitive classification system Evaluate based on
Displacement Comminution Soft-tissue injury Neurovascular status Joint involvement Intra vs extra-articular Open vs closed
Distal Femur Fractures Complications – similar to femoral shaft
dvt fat embolism delayed union / malunion valgus/varus deformities chronic arthritis compartment syndrome growth disturbances in adolescents (65% of
leg growth from distal femoral epiphysis!!)
Distal Femur Fractures Management
assess & manage neurovascular status analgesia (consider femoral nerve block) immobilization appropriate fluid management orthopedic referral
definitive treatment (ORIF vs conservative)
Distal Femur Fractures
Distal Femur Fractures
Distal Femur Fractures
Distal Femur Fractures
Transcondylar fracture 10 months post ORIF
Distal Femur Fractures
Patellar Fractures Largest sesamoid bone in body Acts to increase mechanical advantage
during knee extension 1% of all adult fractures 27% occur during MVC’s – knee to dash Most patellar fractures are intra-articular Search for concomitant injuries
Knee/acetabular dislocations Acetabular fractures Femur fractures
Patellar fractures - mechanism Indirect trauma
Forceful knee flexion against contracted quadriceps
Horizontal fractures common Direct trauma
Direct blow / fall on knee comminution
Patellar fractures
Patellar fractures - Px Pain Hemarthrosis Crepitus Disruption of extensor mechanism
(must be able to fully extend knee against gravity)
Patellar fractures Imaging
AP Lateral Sunrise
Tangential view across 45 degree flexed knee
Shows small vertical fractures of patella
Transverse Patellar Fracture
Patellar fractures - Management
Nondisplaced with intact extensor mechanism immobilize knee in extension with partial
weight bearing x 3 weeks Repeat x-ray in 3 weeks Wear another 3 weeks for horizontal
fractures, less for vertical fractures
Patellar Fractures Management
Displaced (>3mm bony separation or > 2mm articular surface disruption) Orthopedic referral Tension band / K-wires Possible patellectomy – surgical
connection of quadriceps and patellar tendons
Patellar Fractures
58 year old dashboard injury and comminution of patella
Patellar Fractures
After total patellectomy and repair of the extensor mechanism
Tibial Fractures Major load-bearing structure of
lower leg Thin overlying tissues
open fractures common Easily fractured by direct trauma
Tibial Plateau Fractures aka tibial condylar fracture Mechanism - can be almost any …
axial compression rotation direct trauma varus/valgus stress Trivial mechanism in osteoporotic
individuals Very common after pedestrian vs
automobile – due to valgus/varus stress
Tibial Plateau Fractures Examination
Unable to weight bear knee slightly flexed knee effusion Joint line pain possible varus/valgus deformity (esp. with
depressed fractures) associated ligamentous and meniscal
injuries assess neurovascular status
Tibial Plateau Fractures Imaging
if meets Ottawa rules AP lateral (medial condyle concave, lateral
condyle convex) if patient unable to weight bear 4 steps
oblique views tibial plateau view (AP with 15 deg vertical
orientation)
Schatzker Classification of tibial plateau fractures
I. 1. Lateral plateau fracture without articular depression
II. 2. Lateral plateau fracture with articular depression
III. 3. Isolated areas of lateral plateau depression
NB: 60% are lateral plateau fractures (types I-III)
Tibial Plateau FracturesSchatzker Classification
Schatzker Classification 4. Medial plateau fracture (15%)
Schatzker Classification5. Bicondylar
NB: 25% of fractures bicondylar (types V-VI)
Schatzker Classification6. Bicondylar & tibial shaft
NB: 25% of fractures bicondylar (types V-VI)
Tibial Plateau Fracture. Type?
Tibial Plateau Fracture. Type?
Tibial Plateau Fracture - Type?
Tibial Plateau Fractures Management
I-III can be managed by experienced primary care physician
Splint in extension Non-weight bearing x 4-6 weeks
III-VI require orthopedic assessment Decision to operated based on:
Ligament/fracture stability Displacement >3mm Comminution Fracture location age
Tibial Plateau Fractures Complications
decreased ROM degenerative arthritis angular deformity of knee associated ligamentous injuries neurovascular compromise early and
late (compartment syndrome)
Neurovascular compromise
in action
Popliteal artery occlusion following high energy bicondylar tibial plateau fracture
Schatzker type II and proximal fibular fracture
Tibial Spine Injuries aka intercondyle eminence Same mechanism as ACL rupture
(hyperextension, rotation, ab/adduction) In young patients ACL stronger than tibial
spine – thus tibial spine injury Suspect with ACL-like presentation
(positive Lachman, etc.) AND inability to weight bear
Tibial Spine Injuries Type I
Incomplete avulsion with no displacement
Type II incomplete avulsion with
displacement Type III
Completely avulsed fragment
Tibial Spine Injury
Type II tibial spine avulsion fracture
Tibial Spine Injuries Treatment
Orthopedic referral for all Type I/II
Attempt closed reduction with hyperextension
Immobilize x 4-6 weeks in extension Type III
ORIF
Tibial Tuberosity Fractures Forced flexion vs. contracted
quadriceps Uncommon after apophysis closure
Tibial Tuberosity Fractures Type I
Distal fragment displaced proximally and anteriorly
Type II Fragments hinged at proximal portion Large fragment extending into physis
Type III Extension into articular surface
Tibial tuberosity fractures
Type II tibial tuberosity fracture
Tibial Tuberosity Fractures Treatment
Type I Immobilization in extension x 6 weeks
Type II/III Orthopedic referral for ORIF
Tibial Shaft Fracture Most commonly fractured long bone Commonly open (1/3 of surface
area just subcutaneous) Precarious blood supply Hinge joints at knee and ankle are
unforgiving of post-reduction deformity
Tibial Shaft FracturesClassification
No universally accepted classification scheme. Describe the following Location (prox, middle, distal third) Configuration (transverse, spiral,
comminuted) Displacement Angulation Length rotation
Tibial Shaft Fracture
Closed distal third comminuted fracture of left tibia
Nondisplaced as <5% angulation, no rotation
Tibial Shaft FractureED Treatment
Manage neurovascular status Carefully inspect any soft tissue
defect for open fracture Splint in long-leg, padded,
posterior splint Beware of compartment syndrome
Tibial Shaft FractureDefinitive Management
Orthopedic referral No consensus exists re: definitive
treatment Multifactorial decision Possible management
ORIF Intramedullary rod Cast immobilization
Early progressive weight bearing after two weeks
Tib/Fib Fractures
Fibular Fractures Not significantly involved in weight
bearing Usually associated with tibial fractures Important in stability of knee/ankle Proximal fibula = attachment site of LCL
and biceps femoris Beware of peroneal nerve injuries Patients can often walk on isolated fibular
fractures
Fibular Shaft Fractures Direct force
Blow to leg Transverse or comminuted fracture
Indirect force Rotational – oblique fracture Varus stress – avulsion injury
Fibular Shaft FracturesImaging
AP / lateral – generally sufficient Always order knee / ankle x-rays NB: common association with tibial
plateau fractures (type II)
Fibular Shaft fracturesTreatment
Immobilization in posterior splint Non-weight bearing until follow-up visit.
Weight bearing afterwards NB: always generously pad fibular head
during casting to avoid peroneal nerve injury
Treatment of tibial fracture generally treats fibular fracture as well
ORIF generally reserved for stabilization of complex concurrent tibial injuries
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