1sthospitalofXinjiangMedicalUniversityLowerExtremity

FractureFractureofproximalpartoffemurAnatomyreviewBloodsupply4groups1.Extracapsulararterialring2.Ascendingcervicalbranches3.Subsynovialintracapsularring(Chung)4.ArteryoftheligteresCoronalSectionBonystructureAPHipLateralHipTheneckshaftangleWhenitis>127o,

collumvalgum.Thenormalneckshaftangleis127o.Whenitis<127o,coxavara.ThefemoralanterersionangleEpidemiology

1.increasedfreqwith

age

dementia

malignancy

chronicillness,osteoporosis2.decreasedfreqwith

longtermphysicalactivity

supplementalVitD3andCainelderlywomen

HRT

CausesThemajorityoffemoralneckfracturesaretheresultoflow-energytraumasuchasasimplefallintheelderpopulationFemoralneckfacturesinyoungadultsaregenerallyassociatedwithhigh-energytraumasuchasmotorvehicleaccidents

MechanismofinjuryIngeneral,mechanismofinjuryisdescribedasaindirectblow,oftenassociatedwithforcedexternalrotationoftheextremity

ClassificationThereareseveralclassificationschemesforfemoralneckfracturesThemostcommonlyusedclassificationisthatproposedbyGarden

TheGardenclassificationThisclassificationisbasedonthedegreeofdisplacementshownontheanteroposterior(AP)radiographTheGardenclassificationisofprognosticvaluefortheincidenceofavascularnecrosis,thehighertheGardennumber,thehighertheincidenceTheGardenclassification(GradeⅠ)Valgusimpactionofthefemoralhead

TheGardenclassification(GradeⅡ)Completebutnon-displacedVarusdisplacementofthefemoralheadTheGardenclassification(GradeⅢ)TheGardenclassification(GradeⅣ)CompletelossofcontinuitybetweenbothfragmentsOtherclassificationschemesClassificationaccordingtofractureintra-orextra-capcularClassificationaccordingtoPauwell’sangleClassificationaccordingtofracturelineIntraIntra-capsularExtra-capsularClassificationaccordingtoPauwells’anglePauwells’angle<30oisabductionfracture,whichisahorizontalandstablefracturethathasthelowestriskofnonunionClassificationaccordingtoPauwells’anglePauwells’angle>50oisadductionfracture,whichisamoreverticalandunstablefracturethatproducesahighriskofunionNeckofFemurfractures

Pipkin

FractureFractureoffemoralheadinassociationwithposteriordislocationofhipTheclinicalpresentationsPainonstressingthehipjointSwellingandbruisingaroundthefractureImpairedfunctionDisplacedfractureattheupperendofthefemurShortingandexternalrotationoftheleg,usuallyexternalrotationdegree40°~60°ThetypicaldeformityDiagnosisHistoryPhysicalexaminationRadiographsDifferentialdiagnosesTheintertrochantericfracture1,veryunstable2,mal-unionisalmostinevitableunlesstheyarefixedinternally3,usuallyexternalrotationdegree>90°TheintertrochantericdislocationTheprinciplesoftherapybasedonptageandgradeoffracture

Ptlessthan65anddonothaveachronicillness,poorlifeexpectancyORIF

Ptbetween65and75thosewithhighfunctionaldemandORIF

thosewithlowdemand,chronicillnessarthroplasty

Ptmorethan75arthroplastyMethodsoftreatmentInternalfixation1,multiplepins2,crossedscrew-nails3,compressionwithdynamicscrewandplateArthroplastyAMPforptsmorethan70

THRforptslessthan70multiplepinsDynamicscrewandplateComplications

1.AVN(avascularnecrosis)undisplacedfracture~10%

displacedfractureupto~80%eitherpartialorcomplete(variablereporting)

latesegmentalcollapseoccursin~10%undisplacedfracture

~30%displacedfracture2.FailureoffixationNonunionrareinundisplacedfracture

~30%indisplacedfracture

treatwitheitheravalgusosteotomyoranarthroplasty

DVT/PE(deepveinthrombosis)DVT~40%

lowdosewarfarininptswhojustifyriskofanticoagulationNonunionFractureofFemoralshaftAnatomyreviewPoplitealarteryandveinSciaticNervePosteriorViewCausesusuallyhighenergytraumaClassificationbylocation,fracturepattern,comminution,softtissueinjury,mechanism

Proximal(5cmbelowlessertrochanter=

Subtrochanteric)MidshaftDistal(9cmabovekneejoint=Supracondylar)Transverse

Oblique

Spiral

Multifragmentary(comminuted)Butterflysegment

SegmentalTranslationShorteningAngulationRotation

DescriptiveanimationTypicaldisplacementrealitivetothedifferentlocationofthefracture1.proximal1/3rdfracture2.Middle

1/3rdfracture3.Distal1/3rdfracture

proximal1/3rdfractureM.adductorM.gluteusmediusM.iliopsoasMiddle

1/3rdfractureM.adductorM.iliopsoasM.gluteusmediusDistal1/3rdfractureM.becepsfemorisM.gastrocnemiiA.popliteaandV.popliteaWinquist1980classificationI-Verysmallfragment,notaffectingfracturestabilityII-Atleast50%corticalcontact,preventingtranslationandshortening.

III-Lessthan50%corticalcontact,orpoorpurchaseofnailoncortexi.e.Proximalordistalfemoralfractures

IV-CircumferentiallossofstablecorticalcontactTheclinicalpresentationsPainonstressingthehipjointSwellingandbruisingaroundthefractureImpairedfunctionCrepitusorgratingbetweenthefracturesitesCertainmanifestationscausedbyneurovasculardamageDiagnosisHistoryPhysicalexaminationRadiographsDonotmissRelatedinjuriesTheprinciplesoftherapy

PrioritytorelatedinjuriesI.ClosedreductionandspicacastimmobilizationII.SkeletaltractionIII.FemoralcastbraceIV.ExternalfixationFromCampbell'sOperativeOrthopaedic9theditionchapter47:FracturesofLowerExtremityV.InternalfixationA.Intramedullarynail1.Opentechnique2.ClosedtechniqueB.Interlockingintramedullarynail1.Reamed2.UnreamedC.PlatefixationWinquist-HansenclassificationofcomminutionComplicationsEarlycomplicationsLatecomplicationsEarlycomplications1.Vascularcomplications?Hypovolaemicshock?Bloodvesseldamage?Compartmentsyndrome2.NeurologicalcomplicationsNeuropraxiaandaxonotmesis3.Infection?Osteomyelitis?Tetanus?Gasgangrene4.Posttraumaticsyndrome(fatembolism)

Latecomplications1.Complicationsofprolongedimmobilization?Bronchopneumonia?Deepveinthrombosisandpulmonarythrombo-embolism?Urinaryretentionandinfection?Decubitusulcers?Contracturesandjointstiffnessentswithstiffknees.2.Delayedunionandnon-union

?Delayedunion—poorbloodsupply,infection,inadequateimmobilisationandexcessivetraction.3.Mal-union4.Limblengthinequality5.Articularcomplications

?Stiffness,painandswelling

?Osteoarthritis6.Myositisossificans

Casereport1----StreettechniqueA,Nailisbeinginsertedintomedullarycanalofproximalfragment.B,Nailisbeingdriventhroughbaseoffemoralneck.C,Nailisbeingextractedproximallyuntilitsendislevelwithfracture.D,Fracturehasbeenreducedandnaildrivendistallyuntilseated.InjuryofMenisciAnatomyreviewSuperiorview

Lateralmeniscusissmallerindiameter,thickeraboutitsperiphery,widerinbody,andmoremobile;posteriorlyitisattachedtomedialfemoralcondylebyeitheranteriororposteriormeniscofemoralligament,dependingonwhichispresent,andtopopliteusmuscle.PosteriorviewPosteriorly,lateralmeniscusisattachedtoeitheranteriororposteriormeniscofemoralligament,dependingonwhichispresent,andtopopliteusmuscle.

PhysiologyofthemenisciThemenisciactasajointfiller,compensatingforgrossincongruitybetweenfemoralandtibialarticulatingsurfacesThemeniscipreventcapsularandsynovialimpingementduringflexion-extensionmovementsAjointlubricationfunctionandaidingthenutritionofthearticularcartilagethesmoothtransmissionfromapurehingetoaglidingorrotarymotionasthekneemovesfromflexiontoextension.Pathogenesis?Meniscalinjuriesusuallyoccurwhenatwistingforce

isappliedtoaweight-bearingknee.?Degenerativemenisci

—Inthesecasesanytypeofstrainmaycauseatear.?‘Buckethandle’tear

—Thismayresultindisplacementofthemedialpartofthemeniscusbetweenthefemoralcondylesandcause‘locking’oftheknee.ThemechanismofmenisciinjuryDiagnosisHistorySynovialeffusion—InameniscustearthismaytakeseveralhourstoformHaemarthrosisLockingofthekneeMcMurray’stestArthroscopyNotes:Roentgenographicexamination

Ordinaryroentgenogramswillnotmakethediagnosisofatornmeniscusbutareessentialtoexclude

osteocartilaginousloosebodies,osteochondritisdissecans,andotherinternalderangementsthatcanmimicatornmeniscus.

TreatmentConservativemanagementIfimmediateoperativemanagementisnotpossibleIfthisisthefirstepisode

oflockingAcylinderplaster

inabout20°flexion

for3weeksOperativemanagementofmeniscalinjuriesInyoungpatients

withalockedkneeImmediatepartialmeniscectomyRepair

ofaperipheraltearbyarthroscopyInotherpatients,ifthekneelocksagainorgivessignificantsymptoms,arthroscopicmeniscectomy

shouldbecarriedout,aslateosteoarthritismayotherwiseoccur.ComplicationsofkneeinjuriesQuadricepswastingKneestiffnessLateosteoarthritisMiscellaneouscomplications‘Locking’,‘clicking’and‘givingway’UnstablekneesVasculardamageNervedamageArthroscopicMeniscectomyTibiaandFibulashaftFractureAnatomyreviewClassificationSiteFracturepatternDisplacementProximal

Transverse

Translation

Middle

Oblique

Shortening

Distal1/3rd

Spiral

Angulation

Comminuted

Rotation

Open(Compound)orClosedGeneralprinciplesofTreatmentNonoperativeLow-energyfractures

Minimalsoft-tissueinjury

Stablefracturepattern

Coronalangulationof<5°

Sagittalangulationof<10°

Rotationof<5°

Shorteningof<1cm

Abletoweightbear2.OperativeHigh-energyfracture

severesoft-tissueinjury

Unstablefracturepattern

Coronalangulationof>5°

Sagittalangulationof>10°

Rotationof>5°

Shorteningof>1cm

Openfracture

Compartmentsyndrome

Ipsilateralfemoralfracture

Inabilitytomaintainreduction

Intactfibula(relative)

TreatmentOptionsCasttreatment

Theadvantagesofcastimmobilizationoverintramedullarynailfixationincludeanegligibleriskofinfection,fewproblemswithkneepain,andnoneedforhardwareremoval.Intramedullarynailing

ReamedUnreamed

OpenreductionandinternalFixation(Platefixation)

Generallyreservedforproximalmetaphysealfracturesnow.Problemsbeinginfectionandwoundhealing.ExternalfixationOpenfracturesnotamenabletointramedullarynailing,verythinmedullarycanals,children,orcomplexperiarticularfractures(treatedwithfinewireframes)ComplicationsEarlycomplication

Pressuresores

NeurovasculardamageCompartmentsyndrome2.

Latecomplications?Angulation?

Lateraloverlap?

Non-union

—Non-unionofthetibiaiscommonatthejunctionoftheproximal2/3anddistal1/3duetothepoor

bloodsupplyatthissite.Infectionandincomplete

immobilisationofthefracturesiteareothercauses.?

Osteomyelitis?

Kneeandanklestiffness?

OsteoarthritisofthekneeandankleCasereportSpiralfracture,Extra-articulardistalmetaphysisinanadolscentPostopenreduction&internalfixation

InjuryofAnkle

AnatomyreviewAPviewFibulasitsslightlyposteriortoTibiathereforeonApviewnolateralclearspacevisible.Medialclearspacewithin1-2mmofsuperiorclearspace.MortiseViewTakenwithfoot/ankle15Degreesofinternalrotation,nowseelateralclearspace.AllowsyoutoassesscongruenceofmortiseandlookforevidenceofTalarshiftLateralViewLookatposteriormalleolusClassificationLauge-HansenclassificationSupination-adduction(sa)Supination-everson(externalrotation)(ser)Pronation-abduction(pa)Pronation-everson(externalrotation)(per)Pronation-dorsiflexion(pd)WeberclassificationTypeA—AdductionTypeB—ExternalrotationTypeC—AbductionClinicaldiagnosisPainonstressingthehipjointSwellingandbruisingaroundthefractureImpairedfunctionCrepitusorgratingbetweenthefracturesitesX-rayshelpstodifferentiateligamentinjures(AP/lat/mortiseviews)

TreatmentNonoperativeIndications

forundisplacedorstablefracturesfordisplacedfra