femur and tibia fractures

Femur and Tibia Fractures

Kevin E. Coates, M.D., M.P.T.

Worker’s Compensation?

2

Femoral Neck Fractures

• Epidemiology• 250,000 Hip fractures annually– Expected to double by 2050

• At risk populations– Elderly: poor balance&vision, osteoporosis, inactivity,

medications, malnutrition• incidence doubles with each decade beyond age 50– higher in white population– Other factors: smokers, small body size, excessive

caffeine & ETOH – Young: high energy trauma

3

Classification

• Garden• I Valgus impacted or • incomplete• II Complete• Non-displaced• III Complete• Partial displacement• IV Complete• Full displacement• ** Portends risk of AVN and

Nonunion

4

I II

III IV

Treatment

• Goals– Improve outcome over natural history– Minimize risks and avoid complications– Return to pre-injury level of function– Provide cost-effective treatment

5

TreatmentDecision Making Variables

• Patient Characteristics– Young (arbitrary physiologic age < 65)

• High energy injuries– Often multi-trauma

– Elderly• Lower energy injury• Comorbidities• Pre-existing hip disease

6

TreatmentYoung Patients(Arbitrary physiologic age < 65)

– Non-displaced fractures• At risk for secondary displacement• Urgent ORIF recommended

– Displaced fractures• Patients native femoral head best• AVN related to duration and degree of displacement• Irreversible cell death after 6-12 hours• Emergent ORIF recommended

7

8

ORIF

Hemi

THR

Non-displaced Fractures

• ORIF standard of care• Predictable healing

– Nonunion < 5%• Minimal complications

– AVN < 8%– Infection < 5%

• Relatively quick procedure– Minimal blood loss

9

Displaced FracturesHemiarthroplasty vs. ORIF

• ORIF is an option in elderlySurgical emergency in young patients

•Complications• Nonunion 10 -33%• AVN 15 – 33%

• AVN related to displacement • Early ORIF no benefit

• Loss of reduction / fixation failure 16%

10

Displaced FracturesHemiarthroplasty vs. ORIF

• Hemi associated with• Lower reoperation rate (6-18% vs. 20-36%)• Improved functional scores• Less pain• More cost-effective• Slightly increased short term mortality

11

Femoral Neck Nonunion

• Definition: not healed by one year• 0-5% in Non-displaced fractures• 9-35% in Displaced fractures• Increased incidence with– Posterior comminution– Initial displacement– Inadequate reduction– Non-compressive fixation

12

Femoral Neck FracturesComplications

• Failure of Fixation– Inadequate / unstable reduction– Poor bone quality– Poor choice of implant

• Treatment– Elderly: Arthroplasty– Young: Repeat ORIF

Valgus-producing osteotmy Arthroplasty

13

Femoral Neck FracturesComplications

• Post-traumatic arthrosis• Joint penetration with hardware• AVN related

• Blood Transfusions– THR > Hemi > ORIF– Increased rate of post-op infection

• DVT / PE– Multiple prophylactic regimens exist

• One-year mortality 14-50%

14

Intertrochanteric Femur Fractures

• Intertrochanteric Femur – Extra-capsular

femoral neck – To inferior border of

the lesser trochanter

15

Etiology

• Osteoperosis

• Low energy fall– Common

• High Energy– Rare

16

Radiographs

• Plain Films– AP Pelvis– Cross Table Lateral

17

Goals of Treatment

• Obtain a Stable Reduction

• Internal Fixation

– Good Position

– Mechanically Adequate

• Permit Immediate Transfers & Early Ambulation

18

Rehabilitation

• Mobilize– Weight Bearing As Tolerated– Cognitive Intact Patients Auto Protect– Unstable Fractures = Less WB– Stable Fractures = More WB• No Difference @ 6 weeks Post op

19

Femoral Shaft Fractures

• Common injury due to major violent trauma• 1 femur fracture/ 10,000 people• More common in people < 25 yo or >65 yo• Femur fracture leads to reduced activity for 107 days• Motor vehicle, motorcycle, auto-pedestrian, aircraft,

and gunshot wound accidents are most frequent causes

20

Femur FractureManagement

• Initial traction with portable traction splint or transosseous pin and balanced suspension

• Evaluation of knee to determine pin placement• Timing of surgery is dependent on:– Resuscitation of patient– Other injuries - abdomen, chest, brain– Isolated femur fracture

21

Femur FractureManagement

• Antegrade nailing is still the gold standard• Antegrade nailing problems:– Varus alignment of proximal fractures– Trendelenburg gait– Can be difficult with obese or multiply injured patients

22

Femur FractureManagement

• Retrograde nailing has advantages– Easier in large patients to find starting point– Better for combined fracture patterns (ipsilateral

femoral neck, tibia,acetabulum)• Retrograde nailing has its problems:– Intra-articular starting point

23

Femur FractureComplications

• Hardware failure• Nonunion - less than 1-2%• Malunion - shortening, malrotation, angulation• Infection• Neurologic, vascular injury• Heterotopic ossification

24

Ipsilateral Femoral Neck & Shaft Fractures

• Optimum fixation of the femoral neck should be the goal

• Varus malunion of the femoral neck is not uncommon, osteotomies can lead to poor results

• Vertical femoral neck fracture seen in 26-59% of cases• Rate of avascular necrosis is low, 3%, even when

missed

25

Tibial Plateau Fractures

26

• Mechanism of Injury• Mean age in most series of tibial plateau

fractures is about 55 years– Large percentage over age 60

• Elderly population is increasing in numbers

Mechanism of Injury

27

• Mechanism of injury is fall from standing height in most patients– MVA is increasing as % of fractures

• Most common fracture pattern is split-depressed fracture of lateral tibial plateau (80% of fractures)

Physical Exam

28

• Neurologic exam– peroneal nerve!

• Vascular exam– popliteal artery and medial plateau injuries– beware the of the knee dislocation posing as a

fracture– beware of posteriorly displaced fracture

fragments– ABI <0.9 urgent arterial study

Physical Exam

29

• Compartment syndrome• KNEE STABILITY

– varus/valgus in full extension– may require premedication

• aspiration of knee effusion/hematoma• replace with lidocaine+marcaine

Evaluation of Soft Tissues

• Proximal and distal tibia subcutaneous

• Soft tissue remains compromised for at least 7 days

• Early ORIF risks wound sloughexposed hardware

30

AP and Lateral Radiographs

31

32

Pre-traction

Post-traction

33

Computed Tomography

• Indications– Fracture in an active patient for which you are

considering nonsurgical care– Complex fracture– To aid surgical planning of approach, technique,

screw position, etc.

34

Computed Tomography

35

Computed Tomography

36

Classification:Schatzker

37

I

II

III

Classification:Schatzker

38

IV

VVI

Surgical Indicatons

• Open Fracture – I&D, spanning ex-fix• Extensive soft tissue contusion – spanning ex-fix• Closed fracture– Varus/valgus instability of the knee– Varus or valgus tilt of the proximal tibia– Meniscal injury/previous mensicectomy– Articular displacement or gapping???

39

Angular Malalignment of the Proximal Tibia

– Incidence of arthrosis:• Valgus < 10o 14%• Valgus > 10o 79%

• Any amount of varus angulation was bad• Independent of articular congruity

40

Meniscectomy

– Higher rate of arthrosis in patients who had undergone meniscectomy at surgery

– 70% arthrosis in patients who had undergone meniscectomy

– results independent of the amount of articular incongruity

41

Postoperative Management

• Immediate PROM/AROM of knee• Routine Pin site care (if ex-fix)• TDWB for 8-12 weeks

42

Outcomes

• Outcome depends on:– Varus valgus stability of the knee– Varus/valgus alignment of the proximal tibia– Presence of an intact meniscus– Articular congruity (to a lesser extent)

43

Treatment Goals

• Focus on restoring stability and proximal tibial alignment to the knee, rather than restoring anatomic alignment of the articular surface at all costs

• Use minimally invasive techniques, when possible• Other techniques are preferable to hybrid ex-fix• MOVE THE KNEE EARLY IN ALL PATIENTS!

44

Tibial Shaft Fractures

Mechanism of Injury●Can occur in lower energy, torsional type injury (eg, skiing)

●More common with higher energy direct force (eg car bumper)

45

Physical Exam

46

• Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself

• Repeated exam often necessary to follow compartment swelling

Associated Injuries

47

• Up to 30% of patients with tibial fractures have multiple injuries*

• Fracture of the ipsilateral fibula common

• Ligamentous injury of knee common in high energy tibia fractures

Associated Injuries

48

• Ipsilateral femur fx, so called “floating knee”, seen in high energy injuries

• Neuro/vascular injury less common than in proximal tibia fx or knee dislocation

• Foot and ankle injury should be assessed on physical exam and x-ray if needed

Compartment Syndrome

• 5-15%• History of high energy or

crush injury

49

Nerve is the Tissue most Sensitive to Ischemia

• PAIN first Symptom• PAIN with Passive Stretch first Sign

50

Each Compartmenthas Specific Innervation

• Ant Comp Deep- - Peroneal• Lateral -Sup Peroneal N.• Deep Post. - Tibial N.• Sup Post. - Sural N.

51

Advantages of IM Nail

52

• Advantages include less malunion and less shortening than closed treatment or ex-fix

• Earlier weight bearing may be allowed with insertion large nail

• Proximal Fractrues are technically more challenging• Prone to Valgus & Pro-curvatum deformities

53

54

Complications

• Infection 1-5%• Union >90%• Knee Pain

Common

55

Knee Pain

• Severe 9%• Moderate 22%• Mild 68%

56

• Kneeling 92%• Running 57%• Rest 37%

Nail Removal

• Resolved 27% • No - 20%

57

Disadvantages of IM Nail

58

• Disadvantages include anterior knee pain (up to 56.2% *), risk of infection

External Fixator

59

• External fixation generally reserved for open tibia fractures or periarticular fractures

Disadvantages of External Fixator

60

• Increased incidence of malunion compared to IM nail

• Risk of pin tract infection, cellulitis

Outcomes of External Fixation

61

• 95% union rate has been reported for group of closed and open tibia fractures, but 20% malunion rate*

• Most common complications are pin track infections and malunion

• Loss of reduction associated with removing frame prior to union

Open Tibia Fractures● Open fractures of the tibia

are more common than in any other long bone

● Rate of tibial diaphysis fractures reported from 2 per 1000 population to 2 per 10,000 and of these approximately one fourth are open tibia fractures*

62

Associated Injuries

● Neurovascular structures require repeated assessment

● Foot fractures also common

● Compartment syndrome must be looked for

63

Gustilo and Anderson Classification

● Grade 1- skin opening of 1cm or less, minimal muscle contusion, usually inside out mechanism

● Grade 2- skin laceration 1-10cm, extensive soft tissue damage

● Grade 3a- extensive soft tissue laceration(10cm) but adequate bone coverage

● Grade 3b- extensive soft tissue injury with periosteal stripping requiring flap advancement or free flap

● Grade 3c- vascular injury requiring repair

64

Objectives

65

Prevent Sepsis Union Function

Soft Tissue Coverage

● Definitive coverage should be performed within 7 days if possible

●Most type 1 wounds will heal by secondary intent or can be closed primarily

● Delayed primary closure usually feasible for type 2 and type 3a fractures

66

Soft Tissue Coverage● Type 3b fractures require

either local advancement or rotation flap, split-thickness skin graft, or free flap

● STSG suitable for coverage of large defects with underlying viable muscle

67

Soft Tissue Coverage● Proximal third tibia fractures

can be covered with gastrocnemius rotation flap

● Middle third tibia fractures can be covered with soleus rotation flap

● Distal third fractures usually require free flap for coverage

68

Amputation

● In general amputation performed when limb salvage poses significant risk to patient survival, when functional result would be better with a prosthesis, and when duration and course of treatment would cause intolerable psychological disturbance

69

Complications

● Nonunion●Malunion● Infection- deep and superficial● Compartment syndrome● Fatigue fractures● Hardware failure

70

Nonunion● Time limits vary from 6

months to one year● Fracture shows no radiologic

progress toward union over 3 month period

● Important to rule out infection

71

Malunion● In general varus malunion

more of a problem than valgus

● For symptomatic patients with significant deformity treatment is osteotomy

72

Deep Infection● Often presents with

increasing pain, wound drainage, or sinus formation

● Treatment involves debridement, stabilization (often with ex-fix), coverage with healthy tissue including muscle flap if needed, IV antibiotics, delayed bone graft of defect if needed

73

Superficial Infection

●Most superficial infections respond to elevation of extremity and appropriate antibiotics (typically gram + cocci coverage)

● If uncertain whether infection extends deeper and/or it fails to respond to antibiotic treatment, then surgical debridement with tissue cultures necessary

74

Hardware Failure● Usually due to delayed union

or nonunion● Important to rule out

infection as cause of delayed healing

● Treatment depends on type of failure- plate or nail breakage requires revision, whereas breakage of locking screw in nail may not require operative intervention

75

Outcomes

● Outcome most affected by severity of soft tissue and neurovascular injury

●Most studies show major change in results between type 3a and 3b/c fractures

● For type 3b and 3c fractures early soft tissue coverage gives best results

76

Tibial Plafond Fractures• Terrible Injuries• “Excellent Results” rarely achieved• Fair to Good Results are the Norm• Outcomes are Impossible to Predict• Avoid Treatment Complications

77

Treatment Principles

• Delay Until Definitive Surgery• Spanning External Fixation• Pecutaneous and Limited Approaches• Plating Fibula

78

79

80

81

82

83

84

Surgical Delay with External Fixation

• Maintains Length and Aligment• Better Imaging Studies• Allows Mobilization• Pre-Operative Planning• Allows Soft Tissue Recovery

85

Plating of Fibula Fracture

• Fibular length• Articular reconstruction• Early motion

86

Outcomes

• Most Have Some Pain• Most Return to Work• Detectable Arthritis in 50%

87

Outcomes - Pain

• 50% Minimal• 35% Pain with WB• 15% Continuous

88

Long Term Outcome

• 5 - 11 Years• Most Have Some Degree of Ankle Pain• Most Cannot Run or Play Sports• 70% with Moderate to Severe Arthritis• Most Rate Their Outcome as Good

89

Summary

• Bad Injuries with Unpredictable Outcomes• Complications in 10% or Less• Results Generally not Great but not Bad if no

Complications

90