Transcript 06- LLF.ppt

lower limb fractures &
Dislocations
DR. Khalid Bakarman
Pediatric & trauma orthopedic
consultant
Topics
• Ace tabular fractures.
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Pelvic Fractures.
Hip Dislocations.
Proximal femoral fracture.
Femoral Shaft Fractures.
Fracture tibial plateau.
Tibial shaft Fractures.
Ankle fractures.
Mechanism of fractures
• Lower limb fracture is a result of a high
energy trauma except in elderly people or
diseased bones
• Types of fracture are depend on position of
limb during impaction and magnitude of
forces applied.
Management
• The proper way to treat a patient with high
energy trauma is to look at the patient as
whole ,not to injured limb alone!
• So the aim to treat such patient is to save life
first, then save limb ,finally to save function.
• A.B.C.D
Pelvic Fractures
• Pelvic fracture is a high energy trauma , as a
result of MVA, fall .
• Classifications. ( Tile)
Type A. Stable
A 1. fractures of the pelvic not involving the
Ring.
A 2 . Stable , minimally displaced fracture of
the Ring .
Type A stable fracture the SP not
disturbed
• Type B. Rotationally Unstable ,Vertically
Stable.
B1. Open Book
B2 . Lateral Compression : Ipsilateral
B3. Lateral Compression :Contra lateral
Type B open book fracture Diasthesis of SP more
than 2cm
• Type C. Rotationally and Vertically Unstable
C1 . Unilateral
C2 . Bilateral
C3 . Associated with Acetabular Fracture
Type c fracture there is diasethsis of SP & vertical shear
& SIJ involvement
MANEGEMENT
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Aggressive treatment . By A.B.C.D.
Obtain X-Ray: AP pelvic, Inlet ,outlet ,Ct Scan.
Think in systemic approach.
Specific treatment:
type A . symptomatic treatment
type B .ORIF with plates& screws ,External Fix.
Type C . ORIF with plates & screws. Both AP.
Type A stable Fracture of superior & inferior pubic remi
& no diasthesis of SP
AP showing pelvic inlet in normal
person
Surgical correction of type B open book fracture by
anterior plating [ ORIF ]
CT give you clear idea about bony & soft tissues you
can asses the degree of distrubtion
coronal CT here showing distrubtion in anterior &
posterior of LT SIJ
Surgical correction of type C fracture by percutanous
screw & plating of SP anterior[ ORIF ]
Acetabular fracture
• Usually it is a result of high- energy trauma .
• The acetabulum is divided into 4 segments—
an anterior column and wall (rim) and a
posterior column and wall (rim). Fractures of
the acetabulum are classified based on their
involvement of these structures .
classification Letournel and Judet
Investigation
• AP pelvis.
• Judat views ( Internal Oblique,Obturator view)
• C T scan .
Ilioisheal line
AP \ Patient with complex fracture of acetabulum
AP isn’t a good view for showing acetabular fractures
Iliopectineal
line
Anterior
line of
acetabul
um
Tear drop
Posteri
or line
of
acetab
ulum
Obturator view \ by put ! Pt 45 to ! Normal side
can show us anti.column & post. Wall fracture
Post.wall
fracture
Intact
iliopecte
neal line
Your
guide ;p
Internal iliac ( internal oblique) view show us pos column &
anti.wall
post.
column
fracture
Intact
ant.w
all
CT
CT can show us :
1\ ! Amount of post. Wall
fracture ( more than 40 %50% )
2\ intra-articular fragments
3\ impaction on post. Wall
4\ sublaxation of ! joint or
dislocation
All these are indications for
operation ( ORIF )
3D give you an idea about ! Fracture
in ! Post. element fraction ( post.column)
TREATMENT
• Indications for Nonoperative Treatment
1. Nondisplaced and Minimally Displaced
Fractures.
2. Fractures with Significant Displacement but in
Which the Region of the Joint Involved Is Judged
To Be Unimportant Prognostically
• 3.Secondary Congruence in Displaced BothColumn Fractures
• Medical Contraindications to Surgery
• Local Soft Tissue Problems, Such as Infection,
Wounds, and Soft Tissue Lesions from Blunt
Trauma.
• Elderly Patients with Osteoporotic Bone in
Whom Open Reduction May Not Be Feasible.
• skeletal traction for 4-6 weeks. And then start
physiotherapy in bed , PWP ,FWBAT.
Operative Treatment
• Indications for Operative Treatment.
1. An acetabular fracture with 2 mm or more
displacement in the dome of the acetabulum.
2. any subluxation of the femoral head from a
displaced acetabular fracture noted on any of
the three standard roentgen graphic views
• More than 50% involvement of the articular
surface of the posterior wall or clinical
instability with hip flexion to 90 degrees in
posterior wall fractures .
• Incarcerated Fragments in the Acetabulum
after Closed Reduction of a Hip Dislocation.
Post.wall transverse acetabular
fracture
RT acetabular fracture & central
dislocation
Ct \ assess ! Amount of fracture
All anti & post.
Wall fractures
Unstable
Post, wall #
more than
50% indication
for
operation
see ! Femoral head , same distance b\t it & both anti & post . Wall
--- congruency
Post.wall & column # \\
Rx by ORIF plate & screw
Myosistis\
Heterotopic
ossifIcans
Central dislocation , post.column & wall , transverse # , loose
body , joint sublaxation Rx by ORIF
ORIF
complications
• posttraumatic arthritis in 17%.
• a vascular necrosis after posterior dislocation
was 7.5%.
• Infections are reported to occur in 1% to 5%
• Sciatic nerve palsies as a result of the initial
injury occur in approximately 10% to 15%.
• Heterotopic ossification (HO) occurs after
most extensile approaches
HIP Dislocations
Bilateral post. dislocation
Post.dislocation of
RT hip for pt with
THR
Proximal femoral fracture.
• Fractures of the proximal femur are classified
first according to their anatomical location.
• Femoral neck fractures and intertrochanteric
fractures occur with about the same
frequency.
• They are both more common in women than
in men by a margin of three to one.
• it is a result of MVA, Fall,
Position of ! Limb flexed ,
adducted & Internal
rotation of pt with neck
femur #
A cross table lateral
view
Non displaced
neck femur #
4 fragments
Treatment
neck of femur
• Nondisplaced fracture of neck of femur can
be treat with canulated screws.
• Displaced fracture ----------DHS in patient less
than 60 years.
• > than 65 years look for.
. Level of activities.
. Status of the acetabulum.
then chose THR vs. hemi arthoplasty.
Treatment
• Intertrochantaric fracture-------DHS . DCP.
• Subtrochantaric fracture---------DHS.ABP.DCP.
• Combination of both------- IM Nail with
Canulated srews.
Bipolar hemi-arthroplasty
Fracture w\t scelerosis
MRI showing # ,
intratrochantric &
subtrochantric extension
Rx IM nail with canulated
screw
IM nail
Dynamic hip screw
As 77
# mid shaft of ! Femur Rx by IM
nail
# mid shaft of femur Rx
by plate & screw
Extra articular ( supra
condylar ) # \\ AP & lat
view Rx by ORIF with
plate
Uni condylar # Rx by ORIF
with plate & screw our aim to
restore the articular surface
Retrograde nail with
screw
angel plate nail
allow early ROM &
WB tolerate
Dynamic
condyler plate
allow early ROM
& WB tolerate
Locked plate &
screw
Copra plate
Angeled plate
X ray # patella to 3
parts comminuting
Transverse fracture
reduced by 2 tension band
wire & figure of 8 wire
Patellar
dislocation
Patella in ! Lat aspect
Post.dislocation on ! knee
Type 2 tibial
plateau #
Type 1 tibial
plateau #
Ct with 3D till you exactly ! type
depression #
ORIF for tibial plateau #
Type 6 comminuted # Rx by
external fixator
lesarouf
Spiral # of
distal tibia \\
twisting injury
Transverse # of distal
tibia caused more
sever inj. To soft
tissues due to direct
trauma
IM nail is ! Best Rx of tibial
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Lesarouf external fixator in
case of comminuted tibial #
Spiral # Rx by screw
Comminuted # Rx by
… special ring
K wire
plates
Type b trans-syndosmotic #
Type b[ # of medial
mal.+syndosmosis
Sublaxation of ankle joint coz of
post, mal. # Rx ORIF
Maisonneuve #
# med.mal & rotation
Rx by ORIF
Med . Mall # by canulated screw ,
screw w\t neutralized k wire or
tension band , .. screw
complications
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Post traumatic arthritis .
Stiffness.
Skin necrosis.
Malunion or nonunion.
Wound infection.
Regional complex pain syndrome.