Fractures at the Tibia and Fibula

P/s: As usual, I did not owe this note. Credit should be given to Appley and Netter’s Concise Orthopaedic and of course my lecturers 😉

1. Patella #
Most important is to look at the extensor mechanism, is it intact or not.

Extensor mechanism comprises of:
➡ Quadriceps
➡ Patella
➡ Patella tendon

How to test?
Ask the patient to lift up the leg.

MOI
1. Direct injury to patella. Usually result in undisplaced and comminuted fracture (stellate #). Extensor mechanism usually intact.
2. Avulsion #. Sudden forceful contraction of the extensors. Usually result in displace transverse # with involvement of the extensor mechanism.

Management:
Huge hemarthrosis
➡ requires aspiration as it can damage the articular surface, however this may cause it to become an open #.
➡ aspiration is done using an aseptic technique, hence no need to treat as open #.
➡ small hemarthrosis usually resolves spontaneously

Definitive Management
🔴 Undisplaced # – knee brace/casting for 6 weeks + exercise to prevent joint stiffness.
🔴 Comminuted, displaced, with intact extensor mechanism – partial or full patellectomy.
🔴 Displaced with involvement of extensor mechanism – ORIF (tension bands wire) and repair of extensor mechanism.

Complications:
Patellofemoral OA
Decreased ROM

2. Patella Dislocation
MOI:
Direct force to patella – rare.
Sudden forceful contraction of the extensors muscle – more common MOI  esp in sports

Clinical features:
Usually patella has reduced spontaneously or else, obvious deformity.
Bruises and swelling.
Fluid aspiration, may contain blood. If contain fat meaning that there is osteochondral #.

Management:
💟 Closed reduction. Usually did not need anaesthesia.
After that, put in braces for 2-3 weeks followed by 2-3 months exercise of the extensors.
💟 Intraarticular dislocation usually need operative treatment.
💟 Severe bruising indicates severe soft tissue injury. It requires surgical exploration and repoir of the damaged structures.

Complications:
Recurrent dislocation

♠Recurrent Dislocation♠
2x in a year.
It may follows patella dislocation or can be due to other factors such as ligamentous laxity, underdeveloped femoral condyle or underdeveloped patella.

Dislocation occurs unexpectedly when the quadriceps muscle is contracted with the knee in flexion. Painful.

Dislocation usually reduce spontaneously.
Positive apprehension test – patient worried that dislocation happened again.

♣ Habitual Dislocation ♣
Dislocates even with sitting to standing position. It is painless.

Long term, patella may permanently dislocate.

3. Tibial Spine #
MOI:
Varus or valgus stress, or twisting injury damage the ligamentsband caused # of the tibial spine.

Usually in paeds and is a traction injury.

Management:
Close reduction under anaesthesia.
If failed, OR & IF (screw)
Post reduction, casting for 6 weeks.

4. Tibial Plateau #
MOI:
Varus or valgus force combined with axial loading (intact femoral condyle hit the tibial plateau).
It will result in tibial plateau fracture, meniscus injury, with/without ligament tear.

Classification:
Schatzker
Type 1 ➡ lateral plateau #
Type 2 ➡ lateral plateau # with depression #
Type 3 ➡ depression #
Type 4 ➡ medial plateau #
Type 5 ➡ bicondylar plateau #
Type 6 ➡ # with metaphyseal and diaphyseal seperation

CT scan will visualize the # clearer.

Management:
🔘 Aspirate the hemarthrosis
🔘 Undisplaced ➡ casting for 6-8 weeks. NWB until # unites
🔘 Displaced ➡ IF (Buttress plating)
🔘 Depression # (type 2&3) ➡ Bone graft/rafting using screws
🔘 Severe swelling ➡ use ex-fix to stabalize until swelling subsides before IF
🔘 Ligamentotaxis ➡ using traction to achieve close reduction.
🔘 Old and frail ➡ conservative mx

🔱 later ligaments and meniscus repair

Complications:
1. Compartment syndrome (esp Type 4 onwards due to severe bleeding)
2. Joint stiffness (multiple op and prolonged immobilization)
3. OA
4. Popliteal artery injury
5. Common peroneal nerve or tibial nerve injury.
6. Deformity

5. # of Tibia and Fibula
MOI:
Twisting force ➡ spiral #
Angulatory force ➡ transverse or oblique #
Low energy usually caused by indirect injury.
High energy may cause open # and comminution.
Why open #?
Tibia is located very superficial.
Hence, evaluation of surrounding soft tissue is very important.

Risk of non-union is high due to poor blood supply.
Risk of compartment syndrome is also high owing to the presence of a lot of compartments in a small space.

Management
🌞 Tibia/fibula # less than 7 cm from ankle joint, treat as intraarticular #, hence need anatomical reduction.
🌞 Undisplaced # ➡ casting for about 8 weeks.
Start with above knee POP, when # unite can gradually change to below knee POP.
🌞 Displaced ➡ close reduction followed by casting.
Few precautions:
1. Angulation allowed for AP is only up to 5°. Why? May predispose to secondary OA of knee joint due to unequal force exerted to the knee joint.
For lateral, up to 15°. Why? Because it is in the axis of movement.
2. Reduced # may displaced back ofter reduction once swelling subsides➡ need to check the x-ray frequently.
3. Compartment syndrome.

That is why tibial # seldom treated close in adult.

🌞 The best choice of IF will be ILN.
🌞 Plating still indicated in metaphysial tibial # where nailing is difficult.
🌞 Unstable # (high comminution or segmental # need early stabalization)

Complications:
1. Malunion
2. Delayed/non-union
3. Compartment syndrome
4. Osteoporosis (distal part. To avoid, allow early weight bearing)
5. Joint stiffness due to prolong immobilization
6. Vascular injury ➡ popliteal vessels

Fracture of the tibia alone
🔶 Low energy trauma
🔶 Reduction is harder due to intact fibula
🔶 Rate of non-union is higher also due to intact fibula.
🔶 Otherwise, management remain the same.

6. Fracture of the Malleoli
MOI:
Low energy injury, usually due to twisting force (ankle goes into inversion)

Classification:
Denis-Weber classification (Classify according to fibular # in relation to the syndesmotic joint)
✳ A: Transverse fibular # below the syndesmotic joint.
MOI: Adduction injury.
Usually results in oblique or vertical # of medial malleolus.
✳ B: Oblique fibular # at the syndesmotic joint.
Usually result in deltoid ligament and anterior tibiofibular ligament injury.
MOI: External rotation injury.
✳ C: Fibular # above syndesmotic joint ➡ part if the syndesmotic joint and tibiofibular ligament are torn.
MOI: Abduction injury
Associated injury: Avulsion # of the medial malleolus, a posterior malleolar # and diastasis of the tibiofibular joint.

Other classification is Lauge Hansen. Classification is based on MOI and foot position.

Intraarticular injuries❗
Hence need perfect reduction.
Post CR, check X-ray needed. Must meet 4 criterias:
1. Normal length of fibula restored.
2. Thalus sit squarely on the mortise.
3. Normal width of medial joint line.
4. No tibiofibular diastasis

# often unstable, hence frequent checking of the x-ray.

Management:
Dislocated joint ➡ need to reduce immediately.
Check X-ray.
Undisplaced joint ➡ Casting for 4-6 weeks.
Except:
🔵 Type B if involve the tibiofibular ligament
🔵 Type C often unstable. Hence better fix earlier.
Unstable/Displaced # ➡ ORIF. Aim for restoration of fibular length. Add syndesmosis fixation if unstable syndesmosis

7. Pilon Fracture
MOI:
High energy axial loading. Fall from height.
Thalus drives upwards towards the tibial plafond.

Slow to heal.

Injury:
1. Comminuted # of the metaphysis of tibia.
2. Severe soft tissue injury ➡ # blisters. This may lead to complication (soft tissue cannot tolerate, predispose to wound breakdown and infection) with early open treatment.
3. Seperation of malleoli and fibula #
4. Compression of articular surface of tibia.

Classification (Reudi/Allgower)
Type 1 ➡ non or minimally displaced
Type 2 ➡ displaced, articular surface incongruous
Type 3 ➡ comminuted articular surface

CT needed to clearly visualize # site.

Management (staged treatment)
1. Elevate the ankle & put ex-fix to hold the # until swelling subsides.
2. May plan IF. Usually ORIF (plating KIV bone graft)
However, severe injury might need indirect reduction using legamentotaxis.
3. Post fixation, elevation and early mobilization reduce edema.

Complications
1. Joint stiffness
2. Secondary OA (degree of cartilage injury plays and important role)

Femur Fracture

P/s: This note is not entirely mine. Credit should be given entirely to the Appley textbook, Netter’s concise Orthopaedic anatomy and of course what my beloved lecturers told me during the teachings in the ward ☺

1. Neck of Femur #
MOI
Elderly: usually after trivial trauma.
Young age: high velocity injury (MVA or fall)

Classification:
➡Garden
➡ Anatomical (subcapital, transcervical, and base cervical)
✳ subcapital & transcervical is intracapsular.
Why it’s important?
Healing problem.
1. Less blood supply
2. Synovium wash the hematoma (initial stage for # healing)
3. No contact with soft tissue hence callus etc cannot form.
✳ transcervical higher risk for AVN

Tx:
Young ➡ head preserving as much as possible. IF (cannulated screw as soon as possible). Closely reduce the # and IF.
Why head preserving?
1. Younger age, hence can withstand revision surgery (if any).
2. Risk of implant wear and tear.

Elderly ➡ Garden 1 & 2 go for IF. Why? Risk of revision surgery is lower. Undisplaced should always be treated as it can easily go to Garden 4.
Garden 3 & 4 Thompson hemiarthroplasty.
Why? No need for revision surgery and risk of wear and tear is lower.
However, drawback is longer surgery time, more blood loss and higher risk of infection.
✴ there’s even argument that for all NOF # in elderly go for hemiarthroplasty.

Complications
1. AVN
– must treat fast if head preserving (preferably less than 12 hrs)
– why AVN? Anatomy of the blood supply.
⏩ median and lateral circumflex artery (retrograde blood flow, easily interrupted when #)
⏩ interamedullary artery (always interrupted in #)
⏩ arteries of the ligamentum teres (in elderly aboyt 20% is not existence)
– can only discharge patient from follow up after 2 years.
– risk of AVN (Apply) 10% in non-displaced # and 30% in displaced #.
2. General complication of bed ridden.
3. Secondary OA
4. Non-union

Additional notes:
🔵 off CBD prior to hemiarthroplasty as it can predispose to UTI. Urine should be sterile prior to op. Check with UFEME.
🔵 implant life span about 20 years. Life expectancy in Malaysia, Male 70 years old, Female 73 years old. Hence mx using prosthesis is for those who are 60 y/o and above.

2. Intertrochanteric #
Usually in osteoporotic bone. Shortening more marked than NOF # and easier to heal.
Why? Because it is extracapsular.

Classification: Evans (degree on displacement & comminution, where it will interfere with stability. Less stability, harder surgery, easier to get malunion)
Type 1: Not displaced
Type 2: 2 parts
Type 3: 3 parts (maybe GT or LT segment)
Type 4: 4 parts (severely comminuted)

Tx:
CRIF (proximal femoral nail PFN, IM nail with proximal locking screw), esp if # involve LT as plate cannot be placed properly.
OR in the case of fail CR
Medically unsuitable for surgery ➡ non-operative

Complications:
1. General complications of bed ridden
2. Malunion (however usually didn’t interfere with function)

3. Subtrochanteric #
Subtrochanteric area: Area between LT and 5 cm distal to it.

Blood loss maybe higher than in NOF or intertroc # as higher blood supply (lateral and medial circumflex artery from profunda femoris artery)

# may extend to the intertrochanteric area (influence management)

MOI:
Elderly ➡ trivial fall (osteoporosis)
Young ➡ high velocity trauma
Maybe pathologic # secondary to mets etc…

Tx:
ORIF (anatomical reduction will get best contact between fragments)
Dynamic hip screw

4. Shaft #
MOI:
Usually high energy trauma.
In elderly with trivial trauma, pathological until proven otherwise.
In child less than 4 y/o, suspect child abuse.

How to predict the displacement and angulation?
➡ Proximal shaft #, proximal part tend to be in abduction, flexion and externally rotated.
Why? effect of the gluteus and illiopsoas muscle.
➡ Midshaft #, less abduction
➡ Distal shaft #, distal fragments in adduction, proximal tilted due to gastrocnemius pull.

It’s an emergency 🆘
Why? Risk of hypovolumic shock. Bleeding can be up to 2 litres from the profunda femoris arteries.

Classification (Winquist – according to the degree of comminution and stability)
Type 1: Comminution less than 25%
Type 2: <50%
Type 3: <75%
Type 4: more than 75%
It influences the management.
Only type 1 can be managed with plating.

X-Ray ➡ AP and Lateral with knee and hip x-ray.
Why?
1. High energy injury. Usually can cause injury to knee and hip.
2. Deformity following # can mask hip dislocation.
3. Avoid missed # (NOF #, or else patient will develop AVN)

Tx:
Initially at ED:
Splinting, analgesia, adequate hydration (6 pint NS), put on traction.

All requires CRIF. OR in certain cases.
💟 IM nail – the best implant, weight sharing, not rigid hence promote callus formation (healing by secondary intention)
💟 Plating – previously a rigid fixation, load sparing, may cause osteoporosis of bone underneath the plate due to disuse of bone.
Now, MIPO technique (Minimally invasive plate osteogenesis)
➡ put at the submuscular plane, hence less rigid. Allow healing by secondary intention.
➡ less scar, less risk of infection.
Plating is indicated in:
1. Peadiatric patient
2. # with vascular injury
3. # at distal part of femur
4. # with FES. (Faster, and plating didn’t need reaming, decrease the likelihood of worsening the FES)
💟 External fixator – in open fracture, LRS.

Complications:
1. FES
2. Compartment syndrome
3. Hypovolumic shock
4. Complications of prolong immobilization.

Late ➡ malunion, non-union, infection (in open #)

5. Distal Femur #/Supracondylar #
Distal part will usually be pulled by the gastrocnemius muscle (become extended, hence can injure the popliteal vessels)

MOI:
Young ➡ high energy injury
Elderly ➡ osteoporotic bone

Classification (AO)
Type A: Extraarticular (purely supracondylar #)
Type B: Unicondylar #
Type C: Supracondylar + intercondylar fissure

Mx
Extraarticular – plating or nailing.
Intraarticular – anatomical reduction + locking plate.

Undisplaced can be treated conservative, however risk of prolong bed rest, hence IF is still the treatment of choice.

Patient, Itulah Guruku

Aku menyeluruhi wajah patient yang berada di depanku ini. Wajah itu kelihatan tidak bermaya. Mata & kulit beliau jelas berwarna kuning. Tubuh beliau kelihatan sangat kurus, tampak pada ototnya yang menggelambir.

“Encik, saya pelajar perubatan tahun 3 UIA. kalau saya nak tanya-tanya sikit boleh?” Aku berbasa basi memulakan bicara.

“Ermm, takpe lah Encik. Saya mintak izin nak tengok fail tu.” Sekelip mata aku berubah fikiran. Sungguh tak patut untuk aku “clerk” beliau sedang beliau dalam keletihan.

“Tanya apa dik? Saya memang tak larat harini. Nanti lah dik. Adik bacalah pada fail ni. Kalau ada yang tak jelas baru tanya.”

Aku hanya tersenyum sambil meminta maaf, menyedari bahawa aku tak patut menganggu beliau yang sedang dalam kesakitan.

Aku lalu membuka fail yang maha tebal tersebut. Mengalahkan buku teks Burkitt Surgery.

Meneliti satu persatu catatan Specialist, MOs dan HOs, lab results dan imaging yang ada pada fail tersebut, juga cuba memahami history, findings dalam physical examination, investigations dan management yang disusun untuk beliau.

Daripada beliau, aku belajar mengenai gastric outlet obstruction, tube feeding, total parenteral nutrition, PTBD, dan banyak lagi yang tidak mampu ku nukilkan semuanya. Paling bermakna, aku belajar bahawa jangan sesekali meremehkan kebaikan-kebaikan kecil, kerna kita tak tahu amal kita yang mana yang diterima.

Malam sebelum aku pulang daripada oncall kami (oncall student untuk surgery setakat pukul 10), aku bertanya kepada seorang HO, “akak kenapa patient M tu (sambil tanganku menuding pada beliau) pakai branula kat chest wall?”

“Entahlah akak pun tak pasti.”

“Sebab nak masukkan morphine. Memang pasang kat situ.” Jawab patient tersebut. Tersekat-sekat suara beliau memberitahu kami. Sungguh, malam tersebut kesihatan beliau makin merosot. Batuk-batuk, demam, dan muntah. Perut beliau juga sudah semakin membusung.

Aku sungguh terharu melihat kesungguhan beliau melayan kami. Sungguh, beliau dan ramai lagi patient-patient lain merupakan guruku! Mereka berkongsi dengan kami tanpa mengharapkan apa-apa pulangan, tanpa diberi sebarang ganjaran, walaupun kala itu mereka dalam kesakitan dan kesulitan. Semoga Allah merahmati kalian. Hakikatnya, di sebalik seorang doktor yang cekap itu, ada ribuan makcik pakcik penghuni wad dan klinik yang telah berkorban untuknya.

Rupa-rupanya itulah kali terakhir kami berjumpa. Dua hari selepas itu, aku mencari beliau di wad namun tidak berjumpa. Rupa-rupanya, beliau telah pulang menghadap penciptanya, juga pencipta kami semua.

Semoga Allah merahmati beliau.

Allahummaghfirlahu warhamhu wa’afihi wa’fuanhu.

******

16 Mei.

Hari Guru.

Mak, Abah, Adik, pakcik makcik, Murrobiah, Muallimah, Ustaz, Cikgu, Pak Guard, Makcik Kantin, Lecturers, makcik pakcik & adik-adik yang menghuni ward, consultant specialist MOs HOs MAs and akak-akak nurse.

Tidak ada kata-kata yang mampu kuucapkan melainkan setinggi-tinggi penghargaan buat semua yang bergelar guru-guruku.

Hanya Allah yang layak mengganjari kalian.