lower limb fractures & DislocationsDr Guido Cabrera LTraumatologa y OrtopediaCiruga Reconstructiva Extremidad Superior.Servicio de Urgencia Clnica Las Condes

TopicsAce tabular fractures.Pelvic Fractures.Hip Dislocations.Proximal femoral fracture.Femoral Shaft Fractures.Fracture tibial plateau.Tibial shaft Fractures.Ankle fractures.

Mechanism of fracturesLower limb fracture is a result of a high energy trauma except in elderly people or diseased bonesTypes of fracture are depend on position of limb during impaction and magnitude of forces applied.

ManagementThe 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 FracturesPelvic 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 B. Rotationally Unstable ,Vertically Stable. B1. Open Book

B2 . Lateral Compression : Ipsilateral

B3. Lateral Compression :Contra lateral

Type C. Rotationally and Vertically Unstable

C1 . Unilateral

C2 . Bilateral

C3 . Associated with Acetabular Fracture

MANEGEMENTAggressive treatment .

Obtain X-Ray: AP pelvic, Inlet ,outlet ,Ct Scan.

TreatmentAggressive 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.

Emergency treatment

Protect primary blood clot by early pelvic splintage and prevention of exessive movement

IV fluids, early blood transfusion, early fresh frozen plasma, platelets, cryoprecipitate

Prevent hypothermia and acidosis

Stop other bleeding sites

Stabilize pelvis

complications Hemorrhage life threateningBladder/bowel injuriesNeurological damageObstetrical difficultiesPersistent Sacro-iliac joint painPost traumatic arthritis of the hip with acetabular fractures

Acetabular fractureUsually it is a result of high- energy trauma .The acetabulum is divided into four segmentsan 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 .

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 Both-Column Fractures

Medical Contraindications to SurgeryLocal 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 TreatmentIndications 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.

complicationsposttraumatic 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

Complicationpost traumatic arthritisFemoral head injury with risk of AVN (100% if the dislocation last >12 H)Sciatic nerve palsy 25% ( 10 % permanent)Femoral shaft /neck fracture knee injury

Treatmentneck 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.