FRACTURES OF

THE HIP AND ANKLEJames M. Steinberg, D.O.

Garden City Hospital

HIP FRACTURES

More than 250,000 hip fractures in the U.S. each year, expected to double by year 2050

Falls are the most common cause of fracture in the elderly

High energy trauma is the most common cause in young adults

Femoral head has a very fragile blood supply

Femoral Head Fractures Usually a result of hip dislocations, 10% of posterior hip

dislocations Most are shear or cleavage type fractures Radiographic evaluation must include an AP and Judet

views of the pelvis Blood supply to the femoral head:

-medial femoral circumflex artery (majority)

-lateral femoral circumflex

-artery of the ligamentum teres

Pipkin Classification

Type I:

-Hip dislocation with fracture of the femoral head caudad to the fovea capitis femoris

Type II:

- Hip Dislocation with fracture of the femoral head cephalad to the fovea capitis femoris

Pipkin Classification

Type III:

-Type I or II injury associated with fracture of the femoral neck

Type IV:

-Type I or II injury associated with fracture of the acetabular rim

Treatment of Femoral Head Fractures

Pipkin Type I:

-If < 1mm step-off closed treatment, four weeks of traction and four weeks of toe-touch weight bearing

-If > 1mm step-off, ORIF with small cancellous screws or herbert screws

-In young patients immediate ORIF recommended to allow for early mobilization and prevention of AVN

Treatment of Femoral Head Fractures

Pipkin Type II:

-For nonoperative care an anatomic reduction must be achieved

-ORIF is the treatment of choice utilizing screw fixation

Treatment of Femoral Head Fractures

Pipkin Type III:

-ORIF of the femoral head followed by screw fixation of the femoral neck

-In young patients, emergent ORIF

-Prognosis for this fracture is poor and depends on the degree of displacement of the femoral fracture

Treatment of Femoral Head Fractures

Pipkin Type IV:

-Fracture must be treated in tandem with its associated acetabular fracture

-Surgical approach dictated by acetabular fracture

-Femoral head should be fixed internally even if nondisplaced

Complications of Femoral Head Fractures

AVN Degenerative arthritis Sciatic nerve palsy Heterotopic ossification Wound infection Chronic instability

Femoral Neck Fractures

Low energy trauma (older patients) :

-Fall onto the greater trochanter or forced external rotation of the lower extremity

High energy trauma (younger patients): -MVA or fall from significant height

Cyclical loading/stress fractures (athletes)

Evaluation of Femoral Neck Fractures

Physical exam:

-Weight bearing status

-Shortening and external rotation

-Pain with provocative movements Imaging:

-AP in internal rotation and cross-table lateral

-MRI if x-rays are negative with a high index of suspicion (first 48 hours)

-Bone scan 48 hours after injury

Classification of Femoral Neck Fractures

Anatomic:

-Subcapital

-Transcervical

-Basicervical Pauwel:

-Based on angle of fracture from horizontal

-Type I: 30 degrees; Type II: 50 degrees; Type III: 70 degrees

Garden Classification of Femoral Neck Fractures

Based on degree of valgus displacement

-Type I: incomplete/impacted

-Type II: complete nondisplaced

-Type III: complete with partial displacement (trabecular pattern does not line up)

-Type IV: completely displaced (trabecular pattern in a parallel orientation)

Treatment of Femoral Neck Fractures

Fatigue/stress fractures:

-Tension: in situ screw fixation

-Compression: crutch ambulation Impacted/nondisplaced fractures:

-In situ fixation with three cancellous screws except in pathologic fractures, severe OA/RA and Paget’s disease (prosthetic replacement)

Treatment of Femoral Neck Fractures

Displaced fractures: ORIF and capsulotomy

-25% incidence of AVN within 12 hours

-30% within 12-24 hours

-40% within 24-48 hours

-In young patients, treat as a surgical emergency

Operative Techniques of Femoral Neck Fractures

Multiple screw fixation:

-Favored technique

-Threads should cross the fracture site to allow for compression

-Three parallel screws yield the best fixation Sliding screw devices

-Not recommended

-If used, second pin should be inserted superiority to control rotation

Hemiarthroplasty of Femoral Neck Fractures

Allows for immediate weight bearing Indications: comminuted fractures, pathologic

fractures, nonambulatory status, and neurological conditions

Contraindications: young active patients, active sepsis, and acetabular disease

Bipolar: reduces acetabular erosion (young patients)

Unipolar: less active patients

Total Hip Arthroplasty of Femoral Neck Fractures

Indications:

-Contralateral hip disease

-Ipsilateral acetabular metastatic disease

-Preexisting degenerative disease

Complications of Femoral Neck Fractures

Nonunion Osteonecrosis:

-10% of nondisplaced fractures

-27% of displaced fractures Fixation failure Infection Thromboemboli

Intertrochanteric Hip Fractures Fracture between the greater and lesser trochanters Extracapsular fracture Musculature produces shortening, external rotation

and varus position at the fracture site:

-Abductors displace the greater troch.

-Iliopsoas displaces the lesser troch.

-Hip flexors, extensors, and adductors pull the shaft proximally

Evaluation of Intertrochanteric Hip Fractures

Typically fractures result from a fall, direct blow to the greater troch.

Imaging:

-AP and cross-table lateral

-Bone scan or MRI may be useful in nondisplaced or occult fractures

Classification of Intertrochanteric Hip Fractures Kyle:

-Type I: nondisplaced, stable

-Type II: displaced into varus with a small lesser troch. fragment

-Type III: displaced into varus, posteromedial comminution and greater troch. fracture

-Type IV: Type III with subtrochanteric extension

Other classifications: Boyd and Griffin, Evans, and Zuckerman

Treatment of Intertrochanteric Hip Fractures

Nonoperative: only for patients who are an extreme risk for surgery

Sliding hip screw (130 degrees-150 degrees)

-Screw placement should be within 1cm of subchondral bone

-Screw should be located slightly posterioinferior or centrally in the femoral head

Treatment of Intertrochanteric Hip Fractures

Prosthetic replacement

-For patients with failed ORIF

-Calcar replacement hemiarthroplasty or bipolar endoprosthesis

Cephalomedullary nails for reverse obliquity fracture pattern

Greater troch. displacement should be fixed with tension banding

Large posteriomedial fragments should be fixed with a lag screw or cerclage wires

Complications of Intertrochanteric Hip Fractures

Fixation failure Malunion Nonunion Infection Acetabular penetration Pressure sores

Subtrochanteric Hip Fractures

Fracture between the lesser troch. and a point 5 cm distal to the lesser troch.

Closed reduction difficult because straight femoral traction does not neutralize deforming muscle forces

-Proximal Fragment: Abduction (gluteus), External Rotation (short rotators), Flexion (psoas)

-Distal Fragment: Varus (adductors)

Subtrochanteric Hip Fractures

Frequent site for pathological fractures, 17-35% of all subtroch. fractures

Mechanism of injury:

-High energy trauma in younger patients with normal bone

-Minor fall in older patients with weakened bone

Seinsheimer Classification

Type I: nondisplaced fracture or any fracture with <2mm of displacement of the fracture fragments

Type II: -A: two-part transverse femoral fracture

-B: two-part spiral fracture with the lesser troch. attached to the proximal fragment

-C: two-part spiral fracture with the lesser troch. attached to the distal fragment

Seinsheimer Classification

Type III: -A: three part spiral fracture in which the lesser troch. is

part of the 3rd fragment

-B: three part spiral fracture of the proximal third of the femur, with the 3rd part a butterfly fragment

Seinsheimer Classification

Type IV: Comminuted fracture with four or more fragments

Type V: Subtroch-intertroch fracture, any subtroch. fracture with extension into the greater troch.

Other Classifications:

-Fielding: based on location of primary fracture line in relation to lesser troch.

-AO: based on comminution of fracture

Nonoperative Treatment of Subtrochanteric Hip Fractures

Reserved for poor operative candidates Skeletal traction in the 90/90 position

followed by spica casting or cast bracing

Associated with increased morbidity and mortality

Operative Treatment of Subtrochanteric Hip Fractures

Choice of fixation dependent on the involvement of the trochanters

-Intact greater and lesser trochs.: conventional locked IM nail

-Intact greater troch., fractured lesser troch.: recon nail (2nd gen. IM device)

-Fractured greater and lesser trochs. 95 degree blade plate or dynamic compression screw

Complications of Subtrochanteric Hip Fractures

Malunion Nonunion Loss of fixation Technical difficulty of fixation device

Ankle Fractures

The most common type of fracture treated by orthopedic surgeons

Only slight variation from normal is compatible with good joint function

Imaging: AP, lateral, and mortise views

Ankle Anatomy Complex hinge joint with articulations with the fibula, tibia, and

talus Ligaments:

-Deltoid ligament: superficial and deep

-ATFL

-PTFL

-Calcaneofibular

-Syndesmosis: anterior and posterior inferior tibiofibular ligaments, inferior transverse ligament, and interosseous ligament

Lauge-Hansen: Supination-Adduction

10-20% of malleolar fractures Stage I: transverse/avulsion fracture of the

distal fibula or a rupture of the lateral collateral ligaments

Stage II: vertical fracture of the medial malleolus

Lauge-Hansen: Supination-External Rotation

Most common malleolar fracture Stage I: disruption of the ATFL with or without

an avulsion fracture at its attachment Stage II: spiral fracture of the distal fibula Stage III: disruption of the PTFL or a fracture of

the posterior malleolus Stage IV: transverse/avulsion fracture of the

medial malleolus or a rupture of the deltoid ligament

Lauge-Hansen: Pronation-Abduction

Stage I: transverse fracture of the medial malleolus of rupture of the deltoid ligament

Stage II: rupture of the syndesmotic ligaments or an avulsion fracture at their insertions

Stage III: transverse or short oblique fracture of the distal fibula at or above the level of the syndesmosis

Lauge-Hansen: Pronation-External Rotation

Stage I: transverse fracture of the medial malleolus or rupture of the deltoid ligament

Stage II: disruption of the ATFL with or without avulsion fracture at its insertion sites

Stage III: spiral fracture of the distal fibula at or above the level of the syndesmosis

Stage IV: rupture of the PTFL or avulsion fracture of the posteriolateral tibia

Weber Classification

Based on the level of the fibular fracture Type A: fracture below the level of the

syndesmosis Type B: oblique or spiral fracture at the

level of the syndesmosis Type C: fracture above the level of the

syndesmosis

Fracture Variants

Maisonneuve fx: ankle injury with a fracture of the proximal third of the fibula, PER

Curbstone fx: avulsion fracture of the posterior tibia

LeForte-Wagstaffe fx: anterior fibular tubercle avulsion by ATFL, SER

Tillaux-Chaput fx: avulsion of anterior tibia by ATFL

Treatment of Ankle Fractures Reduce dislocated ankles prior to x-rays Cover open fractures with sterile, saline soap

dressing, antibiotics, tetanus, etc. Nonoperative(closed reduction): reserved for stable

fracture patterns with an intact syndesmosis Operative treatment required when closed reduction

requires forced abnormal positioning of the foot, unstable fractures, open fractures, and widening of the mortise (1-2mm)

Operative Treatment of Ankle Fractures Key to reduction is restoration of fibular length: lag screw

and 1/3 tubular plate Medial malleolus can be held with 2 cancellous screws

perpendicular to the fracture line Posterior malleolus should be fixed if there is >2mm of

displacement or involvement of >25% of the articular surface

Syndesmotic screw for fibula fractures above the syndesmosis, placed 1.5-2cm above the joint line from the fibula to the tibia

Complications of Ankle Fractures

Nonunion Malunion Infection Posttraumatic arthritis Compartment Syndrome Reflex sympathetic dystrophy Tibiofibular synostosis

Pilon Fractures

Mechanism of injury:

-Axial compression force through the talus

-Shear: rotation combined with a varus or valgus stress

Etiology: mva, fall from height, direct crush injury, and sporting injuries (ski boot)

Imaging: AP, lateral, and oblique x-rays; CT scan for articular surface

Ruedi and Allgower Classification

Based on the severity of comminution and displacement of the articular surface

Type I: nondisplaced with splitting fracture lines Type II: articular surface displaced; split fracture

types Type III: significant comminution and

displacement of articular surface Other classifications: AO, Mast, and Ovadia and

Beale

Treatment of Pilon Fractures

ORIF of the fibula with 1/3 tubular plate Reconstruction of tibial joint surface with K-

wires Bone graft metaphyseal deficits Plate tibia (medial malleolus), cloverleaf plate Fractures with metaphyseal comminution and

severe soft-tissue injury consider external fixation

Complications of Pilon Fractures

Skin slough Infection Nonunion Malunion Posttraumatic arthritis Joint stiffness