Fracture both bones leg.

Dr.Sarthy.VDept Of Orthopaedics

SSSMCRI

Break in the structural continuity of bone

Fracture

Injury

Repetitive Stress

Pathological

Causes

Direct force. Indirect force

Twisting. Bending. Compression. Tension.

Fatigue / Stress Fractures Pathological Fracture.

Mechanism

Types Of Fracture

Complete InComplete

◦ Transverse.◦ Oblique.◦ Spiral.◦ Impacted.◦ Comminuted.◦ Compression.

◦ Green Stick.◦ Plastic Deformation.

Why we need them?

Classifications

OPEN FRACTURE

Translation.

Angulation.

Rotation.

Shortening.

Lengthening.

Displacement

• Stage of Hematoma

• Stage of

Inflammation

• Stage of repair

• Stage of remodeling

Fracture Healing

Stage of Hematoma Stage of Inflammation

Stage of repair Stage of remodeling

Fracture Healing

Healing By Callus Direct Union

Alleviate pain.

To ensure union in good position.

Permit early movement of the limb & return

of function.

Role of splinting.

Fracture. Types. Causes. Healing.

LEG?

Fractures Of Leg.

ANATOMY

Each Compartmenthas Specific Innervation

Ant Comp - Deep

Peroneal N.

Lateral - Sup Peroneal

N.

Deep Post. - Tibial N.

Sup Post. - Sural N.

Anterior Compartment

• Dorsiflexes ankle

• Tib ant, EDL, EHL, and peroneus tertius muscles

• Anterior tibial a./v.• deep peroneal n.

1st webspace sensation

Lateral Compartment

• Everts the foot

• Peroneus brevis and longus muscles

• Superficial peroneal n.dorsal foot

sensation

Superficial Posterior Compartment

• Plantarflexes ankle

• Gastrocnemius, soleus, popliteus, and plantaris muscles

• Sural nerveLateral heel sensation

• Greater and lesser saphenous veins

Deep Posterior Compartment

• Plantarflexion and inversion of foot

• FDL, FHL, Tib post muscles

• Post tibial vessels, peroneal a.

• tibial nervePlantar foot sensation

Mechanism of injury

High Enregy Low Energy.

Classification• Numerous classification systems

• Important variablesPattern of fracture

location of fracture

comminution

associated fibula fracture

degree of soft tissue injury

OTA Classification• Follows Johner &

Wruh system

• Relationship between fracture pattern and mechanism

• Comminution is prognostic for time

to union Johner and Wruhs, Clin Orthop 1983

Henley’s Classification

• Applies Winquist & Hansen grading of femur to fractures of the tibia

Tscherne Classification of Soft Tissue Injury

• Grade 0- negligible soft tissue injury• Grade 1- superficial abrasion or contusion• Grade 2- deep contusion from direct trauma• Grade 3- Extensive contusion and crush injury

with possible severe muscle injury, compartment syndrome

History & Physical

• Pain, inability to bear weight, and deformity

• Local swelling and edema variable

• Careful inspection of soft tissue envelope, including compartment swelling

• Thorough neurovascular assessment including motor/sensory exam and distal pulses

Physical Exam

• Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself

• Repeated exam to follow compartment swelling

Radiographic Evaluation

AP and Lateral views of entire tibia from knee to ankle

Oblique views can be helpful in follow-up to assess healing

Associated Injuries• Up to 30% of patients

with tibial fractures have multiple injuries

• Ipsilateral fibula fracture common

• Ligamentous injury of knee with high energy tibia fractures

Browner and Jupiter, Skeletal Trauma, 3rd Ed

Associated Injuries

• Ipsilateral femur fx, “floating knee”

• Neuro/vascular injury less common than in proximal tibia fx or knee dislocation

• Foot and ankle injury

Compartment Sydrome

Common with high energy tibia fractures

Treatment is 4 compartment fasciotomies

Compartment Syndrome

5-15% HISTORY

◦Hi-Energy◦ Crush

4 leg compartments

Limit soft tissue damage.

Preserve or restore soft tissue cover.

Prevent or recognize & treat Compartment

Syndrome.

To obtain & hold fracture alignment.

Early weight bearing.

To start joint movements as early as possible.

Management - Objectives

Depends on the type of fracture.

◦ Open / Closed

◦ High Energy / Low Energy

Management

Closed Fractures.

Closed Tibial Shaft Fractures Broad Spectrum of

Injures w/ many treatments

Nonsurgical management

Intramedullary nails

Plates External Fixation

Nonoperative Treatment Indications

Minimal soft tissue damage

Stable fracture pattern < 5° varus/valgus

< 10° pro/recurvatum

< 1 cm shortening

Ability to bear weight in cast or fx brace

Frequent follow-up

Schmidt, et.al., ICL 52, 2003

Fracture Brace

Closed Functional Treatment◦ 1,000 Tibial Fractures

60% Lost to F/u All < 1.5cm shortening Only 5% more than 8° varus

Average 3.7wks in long leg cast, then◦ Functional fracture brace

Sarmiento, JBJS 1984

Natural History

Long-term angular deformities may be well

tolerated without associated knee or ankle

arthrosis

Kristensen F/U: 20-29 yr

All patients >10 degree deformity

Merchant & Dietz F/U: 29 yrs.

◦ Outcome not associated with ang., site, immob.

(37/108 patients)

Surgical Options

• Intramedullary nail

• ORIF with plate

• External Fixation

Advantages of IM Nail

• Less malunion and shortening

• Earlier weight bearing• Early ankle and knee

motion• Possibly cheaper than

casting if time off work included

Tovainen, Ann Chir Gynaecol, 2000

Disadvantages of IM Nail

*Court-Brown et al. JOT 96

Anterior knee pain (up to 56.2%)

Risk of infection Increased

hardware failure with unreamed nails

Plating of Tibial Fractures

• Narrow 4.5mm DCP plate can be used for shaft fractures

• Newer periarticular plates available for metaphyseal fractures

Advantages of Plating

Anatomic reduction usually obtained

In low energy fractures 97% very good/good results have been reported

Ruedi et al. Injury vol 7

Disadvantages of Plating

• Increased risk of infection and soft tissue problems, especially in high energy fractures

• Higher rate hardware failure than IM nail

Johner and Wruhs, Clin Orthop 1983

External Fixation

• Generally reserved for open tibia fractures or periarticular fractures

Technique of External Fixation

• Unilateral frame with half pins • 5mm half pins (‘near-near and

far-far’)• Pre-drilling of pins

recommended• Fracture held reduced while

clamps and connecting bar applied

Advantages of External Fixator

• Can be applied quickly in polytrauma patient

• Allows easy monitoring of soft tissues and compartments

Outcomes of External Fixation

Anderson et al. Clin Orthop 1974Edge and Denham JBJS[Br] 1981

95% union rate for group of closed and open tibia fractures

20% malunion rate Loss of reduction

associated with removing frame prior to union

Risk of pin track infection

Conclusions

Common fracture w/ several treatment

options.

Closed stable fxs. can be treated in a cast.

Unstable fxs. often best treated by

intramedullary nail

Open Fracture.

Objectives Prevent Infection Soft tissue

coverage Union Function

Often requires staged treatment over several months

Timing of Surgical Debridement

Controversial issue◦ Classically <6hrs◦ Currently urgent, not emergent

Early antibiotics may be more critical More wound contamination requires more

urgency and more frequency

-Bosse, JAAOS, 2002-Skaggs, JBJS 2005

Treatment of Soft Tissue Injury Meticulous debridement Explore/Extend wound Deliver bone ends for full exposure Excise all foreign material, necrotic muscle,

unattached bone fragments, exposed fat and fascia◦ Infection 21% vs 9% w/ improved debridement

Fasciotomy as indicated

-Edwards, CORR 1988-Patzakis, JAAOS 2003

Role of Irrigation D & I “Debridement & Irrigation” No consensus on volume required

Pulse lavage◦ May remove debris vs. harmful to osteoblasts

Antibiotics vs. Soap

-Anglen, JBJS 2005

Bead Pouches

Tobra 1.2g per packet of PMMA

Seal wound to create antibiotic-laden seroma

Reduced risk of infection◦ 12% vs 4%

Reduced aminoglycoside toxicity

-Ostermann, JBJS-B 1995

Fracture Stabilization

Reduces risk of infection

External Fixation◦ uniplane vs. multiplane◦ provisional vs.

definitive tx Intramedullary nail Plate fixation

Advantages of External Fixator

Can be applied quickly in polytrauma patient

Allows easy monitoring of soft tissues and compartments

Technique of External Fixation

Outcomes of External Fixation

Anderson et al. Clin Orthop 1974Edge and Denham JBJS[Br] 1981

95% union rate for group of closed and open tibia fractures

20% malunion rate Loss of reduction

associated with removing frame prior to union

Risk of pin track infection

Advantages of IM Nail

Less malunion and shortening

Earlier weight bearing

Early ankle and knee motion

Reduced time to union

-Shannon, J. Trauma 2002

Infection 1-5% Union >90% Knee Pain 56%

w/ kneeling 90%w/ running 56%at rest 33%

Complications

Court-Brown, JOT 1996

Plating of Tibial Fractures Narrow 4.5mm DCP

plate can be used for shaft fractures

Periarticular plates available

Plate through open wound

Subcutaneous Tibial Plating

Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture

Disadvantages of Plating

Increased risk of infection

13% deep infection

-Bach, CORR 1989

Wound Closure Primary closure controversial

◦ Surgical judgement gained with experience◦ If in doubt, repeat debridement 24-72hrs

Type I and some Type II wounds can be closed primarily or after repeat I+D

Type II and Type IIIa can be closed after repeat debridement if clean

-Bosse, JAAOS 2002

Soft Tissue Coverage Type IIIB fractures

require local rotation flap, split-thickness skin graft, or free flap◦ “reconstructive ladder”◦ within 7 days◦ <72 hrs may be better

Reduced need for complex flaps with negative pressure wound therapy -Parrett, Plast & Recon Surg, 2006

-Gopal, JBJS-B, 2000

Soft Tissue Coverage

Proximal third tibia fractures - gastrocnemius rotation flap

Middle third tibia fractures - soleus rotation flap

Distal third fractures - free flap or reverse sural rotation flap

Bone Grafting Typically no acute bone grafting due to risk

of infection Bone graft substitutes BMP-2, OP-1

◦ BESST trial w/ BMP-2 in open fxs◦ Safe, fewer infections, faster fracture healing◦ Unknown cost effectiveness

-Govender, et.al. JBJS 2002

Gunshot Wounds

Low energy missiles rarely require debridement and can often be treated like closed injuries

Fractures due to high energy missiles (eg assault rifle or close range shot gun) treated as standard open injuries

Complications Nonunion Malunion Infection- deep and superficial Fatigue fractures Hardware failure

Nonunion

Definition varies from 3 months to one year

Rule out infection

Treatment options:◦ onlay bone grafts◦ Bone graft substitutes◦ free vascularized bone

grafts◦ reamed exchange

nailing◦ compression plating◦ Ilizarov ring fixator

Malunion Varus malunion more of a

problem than valgus

May not be symptomatic

For symptomatic patients with significant deformity treatment is osteotomy

-Kristensen et al. Acta Orthop Scand 1989

Superficial Infection Ex-fix pin tracts

Should respond to elevation and appropriate antibiotics (typically gram + cocci coverage)

High index of suspicion for deep infection with repeat debridement required

Deep Infection

Pain, erythema,wound drainage, or sinus formation

Multiple staged treatment◦ Radical Debridement◦ Hardware removal◦ Cultures◦ Antibiotic beads/nail◦ Soft tissue coverage◦ IV antibiotics◦ Delayed bone

reconstruction-Patzakis, JAAOS 2005

Associated Fatigue Fractures Sometimes seen during rehab after

prolonged non-weight bearing

Can present with localized tenderness in metatarsal, calcaneus, or distal fibula

Bone scan or MRI may be required to make diagnosis as plain radiographs often normal

Treatment is temporary reduction in weight bearing

Hardware Failure

Usually due to delayed union or nonunion

Rule out infection Treatment depends on

type of failure: plate or nail breakage often requires revision

locking screw in nail may not require operative intervention

Limb Salvage vs. Amputation

Saving a functional limb versus saving

the patient

Mangled Extremity Severity Score An attempt to

help guide between primary amputation vs. limb salvage

Score of 7 or higher was predictive of amputation

-Johansen et al. J Trauma 1991

Limb Salvage vs. Amputation Host factors

◦ Type A – healthy◦ Type B – minimal

comorbidities◦ Type C – Multiple

comorbidites, tobacco use, poor social support

The four “D’s”◦ Disabled◦ Destitute◦ Drunk◦ Divorced

Fracture. Leg. Types Of Fracture. Clinical Features. Red Flags. Management

◦ Conservative.◦ Surgical.

When? How? Pros & Cons….

To Summarise.

Thank You