fracture both bones leg class ug
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Fracture both bones leg.
Dr.Sarthy.VDept Of Orthopaedics
SSSMCRI
Break in the structural continuity of bone
Fracture
Injury
Repetitive Stress
Pathological
Causes
Direct force. Indirect force
Twisting. Bending. Compression. Tension.
Fatigue / Stress Fractures Pathological Fracture.
Mechanism
Types Of Fracture
Complete InComplete
◦ Transverse.◦ Oblique.◦ Spiral.◦ Impacted.◦ Comminuted.◦ Compression.
◦ Green Stick.◦ Plastic Deformation.
Why we need them?
Classifications
OPEN FRACTURE
Translation.
Angulation.
Rotation.
Shortening.
Lengthening.
Displacement
• Stage of Hematoma
• Stage of
Inflammation
• Stage of repair
• Stage of remodeling
Fracture Healing
Stage of Hematoma Stage of Inflammation
Stage of repair Stage of remodeling
Fracture Healing
Healing By Callus Direct Union
Alleviate pain.
To ensure union in good position.
Permit early movement of the limb & return
of function.
Role of splinting.
Fracture. Types. Causes. Healing.
LEG?
Fractures Of Leg.
ANATOMY
Each Compartmenthas Specific Innervation
Ant Comp - Deep
Peroneal N.
Lateral - Sup Peroneal
N.
Deep Post. - Tibial N.
Sup Post. - Sural N.
Anterior Compartment
• Dorsiflexes ankle
• Tib ant, EDL, EHL, and peroneus tertius muscles
• Anterior tibial a./v.• deep peroneal n.
1st webspace sensation
Lateral Compartment
• Everts the foot
• Peroneus brevis and longus muscles
• Superficial peroneal n.dorsal foot
sensation
Superficial Posterior Compartment
• Plantarflexes ankle
• Gastrocnemius, soleus, popliteus, and plantaris muscles
• Sural nerveLateral heel sensation
• Greater and lesser saphenous veins
Deep Posterior Compartment
• Plantarflexion and inversion of foot
• FDL, FHL, Tib post muscles
• Post tibial vessels, peroneal a.
• tibial nervePlantar foot sensation
Mechanism of injury
High Enregy Low Energy.
Classification• Numerous classification systems
• Important variablesPattern of fracture
location of fracture
comminution
associated fibula fracture
degree of soft tissue injury
OTA Classification• Follows Johner &
Wruh system
• Relationship between fracture pattern and mechanism
• Comminution is prognostic for time
to union Johner and Wruhs, Clin Orthop 1983
Henley’s Classification
• Applies Winquist & Hansen grading of femur to fractures of the tibia
Tscherne Classification of Soft Tissue Injury
• Grade 0- negligible soft tissue injury• Grade 1- superficial abrasion or contusion• Grade 2- deep contusion from direct trauma• Grade 3- Extensive contusion and crush injury
with possible severe muscle injury, compartment syndrome
History & Physical
• Pain, inability to bear weight, and deformity
• Local swelling and edema variable
• Careful inspection of soft tissue envelope, including compartment swelling
• Thorough neurovascular assessment including motor/sensory exam and distal pulses
Physical Exam
• Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself
• Repeated exam to follow compartment swelling
Radiographic Evaluation
AP and Lateral views of entire tibia from knee to ankle
Oblique views can be helpful in follow-up to assess healing
Associated Injuries• Up to 30% of patients
with tibial fractures have multiple injuries
• Ipsilateral fibula fracture common
• Ligamentous injury of knee with high energy tibia fractures
Browner and Jupiter, Skeletal Trauma, 3rd Ed
Associated Injuries
• Ipsilateral femur fx, “floating knee”
• Neuro/vascular injury less common than in proximal tibia fx or knee dislocation
• Foot and ankle injury
Compartment Sydrome
Common with high energy tibia fractures
Treatment is 4 compartment fasciotomies
Compartment Syndrome
5-15% HISTORY
◦Hi-Energy◦ Crush
4 leg compartments
Limit soft tissue damage.
Preserve or restore soft tissue cover.
Prevent or recognize & treat Compartment
Syndrome.
To obtain & hold fracture alignment.
Early weight bearing.
To start joint movements as early as possible.
Management - Objectives
Depends on the type of fracture.
◦ Open / Closed
◦ High Energy / Low Energy
Management
Closed Fractures.
Closed Tibial Shaft Fractures Broad Spectrum of
Injures w/ many treatments
Nonsurgical management
Intramedullary nails
Plates External Fixation
Nonoperative Treatment Indications
Minimal soft tissue damage
Stable fracture pattern < 5° varus/valgus
< 10° pro/recurvatum
< 1 cm shortening
Ability to bear weight in cast or fx brace
Frequent follow-up
Schmidt, et.al., ICL 52, 2003
Fracture Brace
Closed Functional Treatment◦ 1,000 Tibial Fractures
60% Lost to F/u All < 1.5cm shortening Only 5% more than 8° varus
Average 3.7wks in long leg cast, then◦ Functional fracture brace
Sarmiento, JBJS 1984
Natural History
Long-term angular deformities may be well
tolerated without associated knee or ankle
arthrosis
Kristensen F/U: 20-29 yr
All patients >10 degree deformity
Merchant & Dietz F/U: 29 yrs.
◦ Outcome not associated with ang., site, immob.
(37/108 patients)
Surgical Options
• Intramedullary nail
• ORIF with plate
• External Fixation
Advantages of IM Nail
• Less malunion and shortening
• Earlier weight bearing• Early ankle and knee
motion• Possibly cheaper than
casting if time off work included
Tovainen, Ann Chir Gynaecol, 2000
Disadvantages of IM Nail
*Court-Brown et al. JOT 96
Anterior knee pain (up to 56.2%)
Risk of infection Increased
hardware failure with unreamed nails
Plating of Tibial Fractures
• Narrow 4.5mm DCP plate can be used for shaft fractures
• Newer periarticular plates available for metaphyseal fractures
Advantages of Plating
Anatomic reduction usually obtained
In low energy fractures 97% very good/good results have been reported
Ruedi et al. Injury vol 7
Disadvantages of Plating
• Increased risk of infection and soft tissue problems, especially in high energy fractures
• Higher rate hardware failure than IM nail
Johner and Wruhs, Clin Orthop 1983
External Fixation
• Generally reserved for open tibia fractures or periarticular fractures
Technique of External Fixation
• Unilateral frame with half pins • 5mm half pins (‘near-near and
far-far’)• Pre-drilling of pins
recommended• Fracture held reduced while
clamps and connecting bar applied
Advantages of External Fixator
• Can be applied quickly in polytrauma patient
• Allows easy monitoring of soft tissues and compartments
Outcomes of External Fixation
Anderson et al. Clin Orthop 1974Edge and Denham JBJS[Br] 1981
95% union rate for group of closed and open tibia fractures
20% malunion rate Loss of reduction
associated with removing frame prior to union
Risk of pin track infection
Conclusions
Common fracture w/ several treatment
options.
Closed stable fxs. can be treated in a cast.
Unstable fxs. often best treated by
intramedullary nail
Open Fracture.
Objectives Prevent Infection Soft tissue
coverage Union Function
Often requires staged treatment over several months
Timing of Surgical Debridement
Controversial issue◦ Classically <6hrs◦ Currently urgent, not emergent
Early antibiotics may be more critical More wound contamination requires more
urgency and more frequency
-Bosse, JAAOS, 2002-Skaggs, JBJS 2005
Treatment of Soft Tissue Injury Meticulous debridement Explore/Extend wound Deliver bone ends for full exposure Excise all foreign material, necrotic muscle,
unattached bone fragments, exposed fat and fascia◦ Infection 21% vs 9% w/ improved debridement
Fasciotomy as indicated
-Edwards, CORR 1988-Patzakis, JAAOS 2003
Role of Irrigation D & I “Debridement & Irrigation” No consensus on volume required
Pulse lavage◦ May remove debris vs. harmful to osteoblasts
Antibiotics vs. Soap
-Anglen, JBJS 2005
Bead Pouches
Tobra 1.2g per packet of PMMA
Seal wound to create antibiotic-laden seroma
Reduced risk of infection◦ 12% vs 4%
Reduced aminoglycoside toxicity
-Ostermann, JBJS-B 1995
Fracture Stabilization
Reduces risk of infection
External Fixation◦ uniplane vs. multiplane◦ provisional vs.
definitive tx Intramedullary nail Plate fixation
Advantages of External Fixator
Can be applied quickly in polytrauma patient
Allows easy monitoring of soft tissues and compartments
Technique of External Fixation
Outcomes of External Fixation
Anderson et al. Clin Orthop 1974Edge and Denham JBJS[Br] 1981
95% union rate for group of closed and open tibia fractures
20% malunion rate Loss of reduction
associated with removing frame prior to union
Risk of pin track infection
Advantages of IM Nail
Less malunion and shortening
Earlier weight bearing
Early ankle and knee motion
Reduced time to union
-Shannon, J. Trauma 2002
Infection 1-5% Union >90% Knee Pain 56%
w/ kneeling 90%w/ running 56%at rest 33%
Complications
Court-Brown, JOT 1996
Plating of Tibial Fractures Narrow 4.5mm DCP
plate can be used for shaft fractures
Periarticular plates available
Plate through open wound
Subcutaneous Tibial Plating
Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture
Disadvantages of Plating
Increased risk of infection
13% deep infection
-Bach, CORR 1989
Wound Closure Primary closure controversial
◦ Surgical judgement gained with experience◦ If in doubt, repeat debridement 24-72hrs
Type I and some Type II wounds can be closed primarily or after repeat I+D
Type II and Type IIIa can be closed after repeat debridement if clean
-Bosse, JAAOS 2002
Soft Tissue Coverage Type IIIB fractures
require local rotation flap, split-thickness skin graft, or free flap◦ “reconstructive ladder”◦ within 7 days◦ <72 hrs may be better
Reduced need for complex flaps with negative pressure wound therapy -Parrett, Plast & Recon Surg, 2006
-Gopal, JBJS-B, 2000
Soft Tissue Coverage
Proximal third tibia fractures - gastrocnemius rotation flap
Middle third tibia fractures - soleus rotation flap
Distal third fractures - free flap or reverse sural rotation flap
Bone Grafting Typically no acute bone grafting due to risk
of infection Bone graft substitutes BMP-2, OP-1
◦ BESST trial w/ BMP-2 in open fxs◦ Safe, fewer infections, faster fracture healing◦ Unknown cost effectiveness
-Govender, et.al. JBJS 2002
Gunshot Wounds
Low energy missiles rarely require debridement and can often be treated like closed injuries
Fractures due to high energy missiles (eg assault rifle or close range shot gun) treated as standard open injuries
Complications Nonunion Malunion Infection- deep and superficial Fatigue fractures Hardware failure
Nonunion
Definition varies from 3 months to one year
Rule out infection
Treatment options:◦ onlay bone grafts◦ Bone graft substitutes◦ free vascularized bone
grafts◦ reamed exchange
nailing◦ compression plating◦ Ilizarov ring fixator
Malunion Varus malunion more of a
problem than valgus
May not be symptomatic
For symptomatic patients with significant deformity treatment is osteotomy
-Kristensen et al. Acta Orthop Scand 1989
Superficial Infection Ex-fix pin tracts
Should respond to elevation and appropriate antibiotics (typically gram + cocci coverage)
High index of suspicion for deep infection with repeat debridement required
Deep Infection
Pain, erythema,wound drainage, or sinus formation
Multiple staged treatment◦ Radical Debridement◦ Hardware removal◦ Cultures◦ Antibiotic beads/nail◦ Soft tissue coverage◦ IV antibiotics◦ Delayed bone
reconstruction-Patzakis, JAAOS 2005
Associated Fatigue Fractures Sometimes seen during rehab after
prolonged non-weight bearing
Can present with localized tenderness in metatarsal, calcaneus, or distal fibula
Bone scan or MRI may be required to make diagnosis as plain radiographs often normal
Treatment is temporary reduction in weight bearing
Hardware Failure
Usually due to delayed union or nonunion
Rule out infection Treatment depends on
type of failure: plate or nail breakage often requires revision
locking screw in nail may not require operative intervention
Limb Salvage vs. Amputation
Saving a functional limb versus saving
the patient
Mangled Extremity Severity Score An attempt to
help guide between primary amputation vs. limb salvage
Score of 7 or higher was predictive of amputation
-Johansen et al. J Trauma 1991
Limb Salvage vs. Amputation Host factors
◦ Type A – healthy◦ Type B – minimal
comorbidities◦ Type C – Multiple
comorbidites, tobacco use, poor social support
The four “D’s”◦ Disabled◦ Destitute◦ Drunk◦ Divorced
Fracture. Leg. Types Of Fracture. Clinical Features. Red Flags. Management
◦ Conservative.◦ Surgical.
When? How? Pros & Cons….
To Summarise.
Thank You
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