Second lecture lower limbs injuries
Dr.Alaa A.H. Al-algawy
FEMORAL FRACTURES - SHAFT
Fractures of the shaft of the femur are frequently associated with major
trauma. As high-energy injuries, femoral fractures can be life-threatening from open wounds, fat embolism and respiratory compromise . By definition, a shaft fracture is >2.5 cm below the lesser trochanter and >8 cm above the knee joint.
Classification
Shaft fractures are described by the anatomical site (mid-shaft, junction of upper
and middle thirds, etc.) and fracture configuration (transverse, short oblique,
multi-fragmentary, etc.).
Fractures are often classified by the A0 classification
(32-A, 32-B or 32-C fort he femur), with various subtypes to describe the morphological pattern.
Associated injuries :
In 2 – 5 % of femoral shaft fractures have associated ipsilateral neck
fractures, and hip X-rays are therefore mandatory.
Less than 2% have associated condylar fractures. Ipsilateral ligament injuries are reported in
7 -9 % of fractures, most commonly the anterior cruciate. Meniscal damage is reported in
25-50% of fractures. Neurovascular injuries are surprisingly uncommon.
Treatment :
1. Traction may be used for initial management, or rarely as definitive treatment
with balanced skeletal traction in a Thomas splint. A traction force of 7-10 kg is
used and the patient’s hip and knee are mobilized in bed. When the fracture shows
signs of union at 6-8 weeks, the patient is mobilized partially weight-bearing, often
in a cast brace. Traction is occasionally advocated where co-morbidity prevents
surgical stabilization.
2. Internal fixation with an IM nail, inserted by a closed technique with interlocking screws, is treatment of choice for the majority of femoral shaft fractures,
with predictable healing rates. Stability of the knee should be assessed under anaesthetic at the end of the procedure. Infection is seen in less than 1% of cases and non-union is rare even with static interlocking screws. Reconstruction nails, with screws inserted along the femoral neck into the head, are used for ipsilateral femoral neck fractures.
For open fractures. It may be better to use an external fixator for IIIB and IIIC fractures.
Fixation should be performed within 2 4 hours of a closed fracture. I M nailing
has the advantage of achieving accurate fracture reduction and stabilization, with-
out extensive soft tissue dissection, and early patient mobilization. With rigid
fixation and a stable fracture configuration, full weight-bearing is safe at an early
stage.
3. External fixation is rarely required for the adult, even with open fractures unless major soft tissue maceration or loss.
4. Dynamic compression plate (DCP) fixation is seldom indicated. A broad DCP should be employed and with the advent of excellent intramedullary techniques,
the only real indication in the adult for DCP fixation is an associated ipsilateral
pelvic or acetabular fracture .
5. Paediatric femoral fractures are commonly treated by skin or skeletal traction
in a Thomas splint to allow fracture union, before mobilization in a suitable cast.
For the young infant, and in some centers, children up to the age of 10, early immobilization in a hip spica is favored , obviating the need for prolonged hospital
treatment. In the polytraumatized child, plate fixation is indicated, or an external
fixator can be used with less disturbance of the soft tissues.
IM nailing beyond the age of 12 years, avoiding violation of the distal epiphysis, is considered safe practice.
Complications
Fat embolus: 1%.
Infection: 5% after open nailing.
Infection: <l% after closed nailing.
Delayed union: 6- 9 % (defined as6 months).
Non-union: 2%.
Shortening: up to 1.5 cm is compatible with good function.
External rotation of up to1 5 degrees is seen in 20 % of patients and well tolerated.
FEMORAL FRACTURES – DISTAL
Distal or supracondylar femoral fractures are difficult to treat. .
Epidemiology
Distal femoral fractures represent 7% of all femoral fractures. 50% per cent are
extra-articular supracondylar fractures and 50% have an intra-articular extension.
Twenty five per cent of all fractures are open. Associated neurovascular or ligamentous injuries are relatively rare and present in <15% of cases.
There is a bimodal age distribution for supracondylar fractures. A younger,
predominantly male, group is affected following high-energy polytrauma. An
elderly, predominantly female, osteoporotic group is affected following minimal
trauma.
Fracture classification
Various classifications have been described, from simple extra and- intra-articular
classifications, to the detailed A0 classification (33-A, 33-B and 33-C, depending
on site, intra-articular involvement and extent of comminution).
Non-operative management
Non-operative management of these fractures in, a long leg cast or skeletal traction,
has proved difficult. The deforming force of the Gastrocnemius muscle attachment
causes a hyperextension deformity of the distal segment, making accurate reduction
difficult. Reduction can be achieved by 90/90 traction, but this is difficult to
maintain over a protracted period and subsequent knee stiffness is a problem.
Malunion and non-union are common.
Non-operative management is therefore reserved for the minimally displaced
fracture, or the elderly, low-mobility patient, particularly if unfit for anaesthesia.
Conservative treatment in the 1960s was reported to give a satisfactory outcome
in 67-84% of cases.
Operative management
Operative management is appropriate for open and most displaced fractures. The
aims are anatomical reduction of the articular surface, stable fixation and early
mobilization, achieved with minimal disruption to the soft tissue envelope and
blood supply to the bone. Several techniques are available and all have an application:
1- Plate and screws.
2- IM nails - rigid and flexible.
3- External fixation - monolateral, circular and hybrid.
As there is a wide range of injury patterns, it is important to appreciate that one
particular technique is not applicable to all fractures.
1. Screw fixation alone may be appropriate for partial articular or unicondylar
fractures , followed by early mobilization in a cast brace.
2- plate fixation takes the form of a blade plate, a dynamic condylar screw (DCS),
or a condylar buttress plate, after lag screw fixation for any intercondylar extension.
Plate fixation is usually through a lateral approach. Bone grafting is advisable for
comminuted fractures, especially in the elderly, or when the comminution is on the
medial side.
The disadvantages of this technique include the wide exposure necessary to
insert the plate, the extensive soft tissue damage and resultant damage to the blood
supply, as well as load sparing, or stress shielding by the plate itself. A DCS is
preferable to a blade plate, as it allows more flexibility in plate positioning on the
femur.
3.Intramedullary devices inserted in a retrograde fashion are becoming
increasingly popular.
Newer intramedullary devices, inserted through the roof of the intercondylar
notch adjacent to the posterior cruciate ligament (PCL) attachment, have
significant advantages. This type of device allows load sharing by virtue of the
intramedullary placement, as well as controlling length and rotation by interlocking
screw fixation.. Infection rates are low and union rates approaching 100% have been reported.
4. External fixation is usually reserved for more severe injuries,and open fractures. An anterior bridging fixator is used to stabilize the limb for soft tissue and vascular reconstruction. Minimal open reduction and percutaneous screw or wire fixation may be supported by circular frame stabilization. These techniques minimize soft tissue stripping, yet give adequate fixation for early
movement.
Complications
1. Ear/y. Vascular compromise, infection, malreduction and fixation failure.
2. Late. Malunion, non-union (particularly with a fracture above a stiff knee),
implant failure and knee stiffness.
SOFT-TISSUE KNEE INJURIES
Sporting and occupational injuries account for the majority of soft tissue knee problems. A history of the actual event often yields information useful to make a provisional diagnosis. For patients who present with ongoing knee problems, four mechanical symptoms should be asked about: pain, locking, swelling and instability. If there has been an acute injury then the history of the actual accident, and the speed and degree of swelling are useful in making a diagnosis. If the knee became swollen immediately or within a few hours it strongly suggests the development of a haemarthrosis. The presence of an acute haemarthrosis is associated with a complete anterior cruciate ligament (ACL) tear in 70% of cases.
Swelling developing, for example, at 24 h or later, suggests a synovial effusion, which is much less specific, but it makes an acute ACL tear very unlikely. The most common soft-tissue injuries are ligament sprains or tears, meniscal tears and patellar instability.
Ligament injury
ACL and medial collateral ligament (MCL) tears are the most common knee ligament injuries and often occur in combination. Isolated MCL sprains are frequent. Posterior cruciate ligament (PCL) and lateral ligament complex injuries are rare by comparison. Collateral ligament injuries alone rarely require surgery as they heal spontaneously. They are usually treated by 6 weeks in a hinged knee brace and a programme of knee rehabilitation. Cruciate ligament injuries do not heal and are frequently associated with development of instability of the knee. ACL tears are 20 times more common than PCL tears. If symptomatic instability occurs it can be treated by ACL reconstruction using hamstring tendons or the middle third of the patellar tendon. The operation is successful in 90% of patients in restoring normal or near normal stability to the knee. The main complications are stiffness (up to 10%) and graft failure (5-10%).
Meniscal tears
These are very common, but frequently present without a history of acute injury. Medial meniscal tears are more common than lateral meniscal tears. Degenerate flap tears involving the posterior third of the medial meniscus are more common in older patients (>35 years). They are often the result of minor twisting injuries. Bucket-handle tears of the meniscus are more common in younger patients. They are often associated with ACL tears, but the ACL tear occurs first. The instability of the knee as a consequence of the ACL tear allows the bucket-handle tear of the meniscus to occur. Diagnosis may not always be obvious on clinical examination. In doubtful cases, MRI scanning will confirm the diagnosis. The appropriate treatment is arthroscopic meniscectomy or meniscal repair. Resection of a large amount of meniscus in younger patients is associated with an increased risk of osteoarthritis. Meniscal repair is, therefore, often considered for these patients with large bucket-handle tears.
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