Fractures at the Tibia and Fibula

November 26, 2015 at 11:35 pm | Posted in Uncategorized | Leave a comment

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 😉

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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)

Fractures of the Upper Limb

November 26, 2015 at 2:05 pm | Posted in Life as a Medical Student, Notes | Leave a comment
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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 😉

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1. Proximal humerus # in adult (elderly and osteoporotic)

Management depends on parts. (Neer Classification – head, GT, LT, shaft)
🔵 Undisplaced/minimally displaced: sling
🔵 2 fragments: closed reduction & splint.
🔵 3 fragments: operative
🔵 4 fragments: ORIF in young, may consider hemiarthroplasty in elderly.

Complications:
Shoulder stiffness
Brachial plexus injury
AVN (Anatomical neck #)
Nonunion

2. Shaft #
🐛Management:

Usually treated close (CMR + casting) as humerus heal readily. Complications following operative management higher.

ORIF (either plating/nailing) is still indicated in open #, severe comminuted #, polytrauma, unstable #.

🐛Humerus can accept more angulation due to presence of both elbow and shoulder joints.
Can accept up to <3cm shortening <20°AP angulation and <40° lateral angulation.

🐛Complications:
Distal 3rd #, radial nerve palsy, however mostly are neuropraxia. Why? Radial nerve in spiral groove, can become trapped easily. 

3. Distal Humerus #
🐞In adults, mostly intraarticular, either bicondylar or unicondylar.
Extraarticular (supracondylar) but very rare.

🐞Management, as usual:
Undisplaced, treated close.
Displaced, need anatomical reduction, hence ORIF.

🐞Complications:
1. Ulnar nerve palsy. (Ulnar is situated posterior to medial epicondyle).
2. Median nerve palsy. (enters forearm at biceps aponeurosis)
3. Elbow stiffness
4. HO

4. Supracondylar # in children
:idea:Most common, extension type (posterior displacement), Gartland classification.

:idea:X ray: Fat pad sign. Fat pad at coronoid and olecranon fossa is displaced.

:idea:Management:
Gartland 1: casting
Gartland 2 & 3: CMR and k wire.
Children has good remodelling and thick cortex. K wire itself sufficent.

Rarely need ORIF. Still indicated for unreduced #, vascular involvement.

:idea:Complications:
1. Nerves injury
– Radial (between brachialis and BR @ posterior elbow)
– Median (jaggered fragments poke the median nerve/AIN)
– Ulnar
2. Vascular injury – brachial artery (same mechanism as median nerve injury)
3. Malunion – cubitus varus. Usually due to angulation.

5. Elbow dislocation
🌼Simple or Complex (with fractures of the surrounding structures). Posterior dislocation commonest.

🌼Terrible triad: Dislocation with radial head & coronoid #.

🌼Tx.
Simple – simply by closed reduction, then splint (collar and cuff for 1 week, start exercise after that, off by 3rd week)
Complex – settle the # first.

🌼Complications:
1. Nerve injury.
-Ulnar nerve (in cubital tunnel)
-Median nerve in Ligament of Struthers)
Both can become compressed
2. Vascular injury – Brachial artery
3. Elbow stiffness and instability.

➡ Recurrent dislocation very rare

6. Fractures of the Radius and Ulnar
Manage like an intraarticular #, needs anatomical reduction. Why? Presence of supinator and pronator muscle. Not easy to maintain reduction.

👉Both bone #
Paeds, closed reduction and casting. Remodelling is very good.
Adult, ORIF (plating)

👉Single bone #
Monteggia: Prox ulnar # with PRUJ disruption (radial head dislocation due to shortening force @ ulnar)
Mx: ORIF. Dislocation will reduce when # has been managed

Galleazi: Distal 1/3 radial # with DRUJ disruption
Mx: ORIF, DRUJ closed reduction.

7. Distal End Radius #
MOI: Axial force, FOOSH
Common, esp in osteoporotic pt.

✴ Colles #, dinner fork deformity ( dorsal displacement)
✴ Smith #, reverse Colles

Classification:
Frykman for Colles (joint involvement)
Even number – ulnar styloid #
1&2 Extraarticular
3&4 RC joint
5&6 RU joint
7&8 Both RC and RU involved

Management:
Undisplaced: cast
Displaced:
Extraarticular (close reduction, check X-Ray, Rule of 11). If unstable, ORIF
Intraarticular, need ORIF.

Old and osteoporotic ➡ allow more conservative mx as use the joint less.

Complications:
-malunion
-stiffness
-median nerve injury (carpal tunnel)
-TFCC injury (important for stability)

😇TFCC
Triangular fibrocartilage complex
-between distal ulnar and ulnar prox carpal row (triquetrium)
-Ligaments – central disc, dorsal radioulnar, palmar radioulnar.

8. Scaphoid #
Tenderness @ snuffbox region.

🔺Mx:
70% of scaphoid covered by articular cartilage, hence mx line intraarticular #.
Displace # need anatomical reduction (headless screw compression)

🔺Complications:
– AVN esp if injury at proximal part.
Blood vessel enters in a nonarticular ridge on the dorsal surface. Prox part supplied by retrograde blood flow.
– Non-union

Femur Fracture

November 26, 2015 at 11:00 am | Posted in Uncategorized | Leave a comment

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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.

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