Femur and Tibia Fractures

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

Worker’s Compensation?

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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

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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

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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

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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

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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

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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

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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%

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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

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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

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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

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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%

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Intertrochanteric Femur Fractures

• Intertrochanteric Femur – Extra-capsular

femoral neck – To inferior border of

the lesser trochanter

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Etiology

• Osteoperosis

• Low energy fall– Common

• High Energy– Rare

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Radiographs

• Plain Films– AP Pelvis– Cross Table Lateral

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Goals of Treatment

• Obtain a Stable Reduction

• Internal Fixation

– Good Position

– Mechanically Adequate

• Permit Immediate Transfers & Early Ambulation

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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

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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

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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

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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

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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

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Femur FractureComplications

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

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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

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Tibial Plateau Fractures

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• 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

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• 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

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• 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

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• 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

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AP and Lateral Radiographs

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Pre-traction

Post-traction

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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.

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Computed Tomography

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Computed Tomography

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Classification:Schatzker

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I

II

III

Classification:Schatzker

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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???

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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

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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

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Postoperative Management

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

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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)

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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!

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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)

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Physical Exam

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• 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

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• 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

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• 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

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Nerve is the Tissue most Sensitive to Ischemia

• PAIN first Symptom• PAIN with Passive Stretch first Sign

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Each Compartmenthas Specific Innervation

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

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Advantages of IM Nail

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• 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

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Complications

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

Common

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Knee Pain

• Severe 9%• Moderate 22%• Mild 68%

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• Kneeling 92%• Running 57%• Rest 37%

Nail Removal

• Resolved 27% • No - 20%

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Disadvantages of IM Nail

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

External Fixator

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

Disadvantages of External Fixator

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• Increased incidence of malunion compared to IM nail

• Risk of pin tract infection, cellulitis

Outcomes of External Fixation

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• 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*

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Associated Injuries

● Neurovascular structures require repeated assessment

● Foot fractures also common

● Compartment syndrome must be looked for

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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

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Objectives

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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

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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

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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

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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

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Complications

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

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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

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Malunion● In general varus malunion

more of a problem than valgus

● For symptomatic patients with significant deformity treatment is osteotomy

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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

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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

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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

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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

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

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Treatment Principles

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

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Surgical Delay with External Fixation

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

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Plating of Fibula Fracture

• Fibular length• Articular reconstruction• Early motion

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Outcomes

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

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Outcomes - Pain

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

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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

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Summary

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

Complications

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