2. Definition:_
Fracture:_ is a break in the structural continuity of bone.
Dislocation: means that the joint surfaces are completely displaced and are no
longer in contact.
Subluxation: a lesser degree of displacement, such that the articular surfaces are
still partly apposed
Types of displacement:_
1.Translation(shfit): sideways ,forward ,or backward.
2.Angulation(tilt): malaligment lead to deformity.
3.Rotation(twist):end up with rotational deformity.
4.Shortening: Proximal migration of the distal fracture component results in
shortening of the overall bone length.
4. Hip Dislocation: Mechanism of Injury
Almost always due to high-energy trauma.
Most commonly involve unrestrained occupants in
RTAs.
Can also occur in falls from heights, industrial
accidents and sporting injuries
5. Classification
Simple vs complex
Complex associated with fractures.
3 main patterns in relation to acetabulum
Posterior, Anterior, Central
7. Posterior dislocation
Mostly posterior dislocation (80-90% of dislocations)
Occurs with axial load on femur, typically with hip flexed and
adducted. Dashboard Injury is an example of axial load on
flexed hip.
9. Diagnosis
1.X_ray: AP view show the femoral head out of its sockets&above acetabulum
asegment ofacetabular rim or femoral head may broken &displaced so do obligue
view to see the size of fragment.
2.CT-scan: best way to see the acetabular #.
*Thomas and Epstein Classification
of Posterior Hip Dislocations:
Type Description
I with or without a minor fracture
II with a large single fracture of the posterior acetabular rim
III with comminution of the acetabular ring
IV with a fracture of the acetabular floor
V with a fracture of the femoral head
10. TREATMENT
Closed reduction under G.A
Immobilization : by skeletal traction through a pin applied in
femoral condyles for 3-6 weeks .
Rehabilitation: active exercise & gradual wt. b. by using
crutches.
11. This x-ray, taken from the front,
shows a patient with a posterior dislocation
of the left hip.
Normal alignment after the hip
has been reduced.
12. COMPLICATION
Early Complications :-
1.Sciatic n. injury ; occur in 10_20% of cases but usually recovers ,so nerve
function should tested before reduction;if after reduction is diagnosed
,then. should be explored.
2.Vascular injury;(superior gluteal A.) is torn & bleeding may be profuse
Arteriogram should performed ; Treated by ligation
3.Associated # :of femoral shaft when occur at the same time the
dislocation is missed (it should be a rule with every femoral shaft # by X-
ray)
Treatment : by OR. Of dislocation then IF. Of #.
13. Late Complication:-
1.Avascular Necrosis of femoral head:
occur in 10% of traumatic dislocation & if reduction delay more than 12 hrs the
% increase more than 40%
;DX ,by MR I& isotope bone scan.
X-ray show increase density of f. head
Tx ;small necrotic segment treated by realignment ; Bif extensive collapse treated by
joint replacement.
2.Myositis ossificans:_its un common ;related to severity of injury ;so the period
of rest &non wt. bearing need to be prolonged.
3. POST TRAUMATIC O.A: 2nd OA not un common due to ;
A) Cartilage damage at time of dislocation. B)presence of retained fracture
In the joint. C)Ischemic necrosis of femoral head
4. STIFFNESS.
15. Anterior Dislocation
Femoral head situated anterior to acetabulum
Hyperextension force against an abducted leg that levers
head out of acetabulum.
Also force against posterior femoral head or neck can
produce dislocation
10 % to 15% of traumatic hip dislocation
20. FRACTURE OF FEMORAL NECK
It is intracapsular # of elderly osteoporotic individual ; majority occur in
Caucasian women in 7th &8th decades of life.
Other risk factor: bone losing or bone weakening dis. As osteomalacia ,
stroke, alcoholism,& chronic debilitating dis.
It result from simple fall in elderly.
fall from height or blow in RTA in young .
stress # in runners &military personnel.
23. Anatomical Classification
Subcapital region
Transcervical region
Basal region
Diagnosis:
1.Stress #:_in elderly with unexplained pain in hip also in athletes &
military personnel(X-ray is normal& MRI show the lesion.
2.Undisplaced #: impacted difficult to see on X-ray but MRI & bone
scan show the lesion.
24. 3.Painless #:_in bed ridden pt. develop silent #.
4.Multiple #:_pt. with f. shaft # may have hip #.
Treatment:
Pain relieving measure
Simple splintage of the limb.
25. DEFENTIVE treatment:_
Garden type I&II : treated by closed reduction.
Garden type III&IV: operation is almost mandatory &done urgently either closed
R. under GA then hold by screw & side plate through lat. Incision then do X-ray
if failed or pt. under 60 years old ;OR is indicated.
In pt. older than 70 yrs. Do prosthetic replacement .
THR indicated only in case of (a)Tx have been delayed for some wks.
(b) in pt with metastatic dis. Or pagets dis.
Post op.: exercise & early mobility are important.
26.
27. COMPLICATION
1.General complication:_DVT , pulmunary Embolism, pneumonia, bed sore.
2.Avascular necrosis :_occur in 30 % of displaced&10% of undisplaced ..Dx by
isotope .
C.F :pain &progressive loss of function.
Tx :by THR in pt. more than 45 yrs. &arthrodesis or realignment osteotomy in young.
3.Nonuonin : occur in more than 30 % of all neck # in severly displaced #
C. F : pain ,shortening, difficulty with walking.
X-ray show # line.
4.Osteoarithritis: treated by THR.
30. Intertrochanteric Hip Fractures
The intertrochanteric area of the femur is distal to the femoral neck and
proximal to the femoral shaft; it is the area of the femoral trochanters, the
lesser and the greater trochanters .
31. Caused by:_
1. fall directly onto the greater trochanter
2.or by an indirect twisting injury.
Divided in to stable & unstable.
C.F: pt. is old, unable to stand , more shorter &externally rotated than with trans
cervical ,& can not lift hisher leg.
32.
33. TREATMENT
Intertrochanteric fractures are almost always treated by early
internal fixation. (a) to obtain the best possible positionand
(b) to get the patient up and walking as soon as possible and
thereby reduce the complications associated with prolonged
recumbency.
Most intertrochanteric fractures are managed with either a
compression hip screw or an intramedullary nail
34. COMPLICATION:
EARLY:
DVT , pneumonia ,bed sore….
LATE:_
1.Failed fixation: Screws may cut out of the osteoporotic bone
if reduction is poor or if the fixation device is incorrectly
positioned. In either event, reduction and fixation may have to
be re-done
2. Malunion : Varus and external rotation deformities are
common.
3.Nonunion :rarely occur , if healing delayed beyond 6
months…..Treated by OR&IF with bone graft.
35. Subtrochanteric Fractures:
Subtrochanteric typically defined as area from lesser trochanter to 5cm
distaly:
usually in younger patients with a high-energy mechanism
may occur in elderly
patients from a low-energy mechanism
36. CLINICAL FEATURES &DIAGNOSIS
The leg lies in neutral or external rotation and looks short; the thigh is
markedly swollen, Movement is very painful.
In X-ray the # may be transverse , oblique or spiral.
37. Treatment
Non operative:
observation with pain management
Operative:
.OR&IF is the treatment of choice.
Two main type of implant are used:
1.Intramedullary nail with proximal interlocking screw.
2.95 degree hip screw & side plate.
39. Complication:
1. Nonunion :
can be treated with plating, , good fixation & bone graft.
2, malunion:
Rotational & varus are common prevented by accurate reduction ,if it
cause symptoms…. op.is indicated.
41. FEMORAL SHAFT RRACTURE
High energy injuries frequently associated with life-threatening conditions.
most common in younger population
low-energy:
More common in elderly.
42. Classification:
Winquist and Hansen Classification:
Type 0 • No comminution
Type I • Insignificant amount of comminution
Type II • Greater than 50% cortical contact
Type III • Less than 50% cortical contact
Type IV • Segmental fracture with no contact between proximal and
distal fragment
43. Presentation
Initial evaluation
Advanced Trauma Life Support (ATLS) should be initiated
Symptoms
pain in thigh.
There is swelling, deformity of the limb & movement is painful, bleeding is
sever, more than 1 liter may be lost in the soft tissue
, one must exclude neurovascular injury & other lower limb or pelvic #. # of
the femoral shaft & tibial shaft on the same side produce floating knee.
44. X ray:
Determine # pattern, one must x ray the hip & knee as well as
base line chest x ray because of the risk of ARDS in those with
multiple injuries.
45. Treatment
Emergency treatment: 1- treat the shock. 2- splint the #either by tying the limb
to the other leg. Or by the use of
Thomas splint, this will control pain, reduce bleeding & make transfer
easier.
* Definitive treatment: to reduce the systemic complications the # must be stabilized
either by:
(1)- Traction& bracing:
Traction can reduce & hold most #s. in reasonable alignment except those in the
upper 1/3 of the femur
46. (2)- Intramedullary nailing :
Is the method of choice for most femoral shaft #, if locking
screw used it will control even subtrocanteric & distal 1/3 #
(3)- External fixation: indicated for:
1- sever open injury. 2- multiple injury. 3- deal with bone loss.
47. Complications of femoral shaft #:
Early:
1- shock: 1-2 liters of blood can be lost even in closed #.
2- fat embolism & ARDS: because # through large marrow filled cavity
result in small shower of fat emboli being swept to the lung.
3- thromboembolism: prolong traction in bed predispose to thrombosis.
4- infection: risk occur in open injury & follow internal fixation & should
be treated as for acute osteomyelitis.
48. Late:
1- delayed & nonunion: when union delayed > 3-4 months & this should
be treated by rigid fixation & bone graft.
2- malunion: no more than 15 degree angulation should be accepted & if
shortening occur can be accommodated by building up the shoe.
3- joint stiffness: may be caused by soft tissue adhesion or the joint
injured at the same time of initial trauma.
4- refracture.
50. SUPRACONDYLAR FRACTURES OF
THE FEMUR
It needs sever trauma to happen in young adult, or miner trauma in osteoporotic
bone in elderly.
It happen from a fall from height
The fracture line just above the condyle and may extend in between either in form
of Y or T shape fracture.
The most dangerous acute complication is popliteal A. injury.
C.F :the knee is swollen ,movement is painful ,tibial pulses should always
checked. X-Ray: The fracture line above condyle ,either TV or comminuted, there is
shift and tilt back –ward due to gasterocnimous origin.
51. Classification of supracondylar #
Type A: # not involve the joint surface.
Type B: # involve the joint surface(one condyle)but leave the supracondylar region
intact.
Type C: # have supracondylar&condylar component.
52. Treatment
1. Reduction by manipulation under general anasthesia &2. skeletal traction with
semi flex knee to counteract muscle.
3.Immobilization: By the same traction with 9 Kgms for 12 wks.
4.Check X-ray after 2-3 days.
Failure of conservative R indicate open reduction and I.F .
Complication:
Early—skin damage and arterial damage
Late---knee stiffness, non-union & malunion
54. Knee joint dislocation
Result from violence injury force
Involve more than two of knee ligaments injury
Associated with popliteal vessel injury and common peroneal nerve injury
Urgent attention for vascular assessment.
55. Directions of dislocation:
Reference to the position of tibia
Anteromedial dislocation (risk of associated intimal injury of popliteal artery)
Posterolateral dislocation (highly associated with transected popliteal artery)
56. Treatment
1. Immediate reduction and immobilization
2. Artery exploration and repair in the evidence of arterial injury
3. Immobilization in cast (POP) or external fixation for 12wks.
4. Ligaments repair or reconstruction for multiple ligaments injury in
instability
Complications:
1. Stiffness : is most common complication (38%), more common with
delayed mobilization.
2. Arthrosis formation following cartilage damage.
3. Knee ligaments injury (result in joint instability)
4. Neurovascular injury.
58. Tibial plateau fractures:
Mechanism of trauma by fall from height, the # and its
degree depend upon the state of knee during trauma.
Presentation: haemathrosis, instability, associated
neurovascular injure.
59. Classification:
Type 1: a vertical split of the lateral condyle.
Type 2: a vertical split of the lateral condyle combined with
depressionof an adjacent loadbearing part of the condyle
Type 3: depression of the articular surface with an intact
condylar rim.
Type4: fracture of the medial tibial condyle.
Type 5: fracture of both condyles.
Type 6: combined condylar and subcondylar fractures.
61. Treatment:
*by Reduction for most of the # especially with minimal displacement.
*Hold with same traction for 12 wks, the exercises started.
*Failure of conservative R. is an indication of open reduction I.F.
SURGICAL TREATMENT:
*1st &4th with marked displacement treated by I.F with Buttress plate or
by screw.
*3rd treated surgically by elevation of articular surface &B.G.
*5TH treated either by screws or buttress plate.
*6th reduction by manipulation & immobilization for 12 weeks.
64. Patella fractures:
Direct injury (dash board, direct fall onto the knee) produced
‘stellate’ fracture
Indirect injury (forced flexion knee) produce avulsion type or
simple transverse pattern
Loss of extensor mechanism
Haemathrosis
X-Ray: 1.one or more line of # is seen by x-ray.
2.multiple # line with irregular displacement.
65. Treatment:
Undisplaced fracture
Cylinder cast immobilization for 6 weeks
Displaced fracture
ORIF (tension band wiring)
Severely comminuted
Cerclage wiring or patellectomy
68. Ligaments injuries of knee joint:
The knee joint is synovial hinge j.
The stability depend on the tendons&ligments.
There are 4important ligements and 2 accissories:_
1.Med. Collatral lig.:give stability to med. Compartment.
2.Lat. Collatral lig.:give inassociation with fascia lata&poplitus m. insertion
stability to lat. Compartment
3.Ant. Cruciate lig.:its injury giveway anteriorly
4.Post. Cruciate lig.:its important in stability of post. Aspect.
Accissory lig.(aricuate&oblique):helps the post. Cruciate in stability of
med.&lat. Condyles of tibia.
69.
70. Ligaments injury ;cont.
Divided into:_
A)Acute B)Chronic
Mechanism of injury:
1.Trauma.
2.Atheletes injury.
Presentation:
Acute can be divided into a)partial b)compelet.
Partial: 1.more hemoarthrosis 2.sever pain 3.pt. can walk normally.
Compelet: 1.less hemoarthrosis 2.less or no pain at all
3.pt. can not walk (give way).
71. Diagnosis
1.X-ray.
2.MRI.
Treatment
Partial: a)aspiration oh hemoarthrosis b)double bandage of knee then
backslab for short period.
Complete: almost always surgery by
a)re-attachment b)re-inforcement c)replacement
72. Meniscus Tears
The meniscus is a rubbery, C-shaped disc that cushions your knee. The
menisci keep your knee steady By balancing your weight across the knee.
A meniscus tear is usually caused by twisting or turning quickly, often
during sport. There are three types of meniscus tears:
minor tear, you may have slight pain and swelling.
moderate tear can cause pain at the side or center of your knee. Swelling
slowly gets worse over 2 or 3 days
severe tears, pieces of the torn meniscus can move into the joint space.
This can make your knee catch or lock. Your knee may feel give way. It
may swell and become stiff right after the injury or within 2 or 3 days.
73. (3) IMPORTANT TESTS:
1. the McMurray test. Is a pathognomonic test..the doctor will bend your knee, then
straighten and rotate it. This puts tension on a torn meniscus. If you have a
meniscus tear, this movement will cause a clicking sound.
2. GRINDING TEST.
3. DESTRUCTION TEST.
Treatment may include:
Rest, ice, wrapping the knee with an elastic bandage, and propping up the leg on
pillows.
Physical therapy.
Surgery to repair the meniscus.
Surgery to remove part of the meniscus.
74. FRACTURES OF TIBIA AND FIBULA
Because of its subcutaneous position, the tibia is more commonly
fractured, and more often sustains an open fracture, than any other long
bone.
Mechanism of injury
Indirect injury is usually low energy; with a spiral or long oblique#.
Direct injury crushes or splits the skin over the fracture;
this is usually a high-energy injury and the most common cause is a
motorcycle. It is either compound #(open) or close #.
75. CLOSED FRACTURE
*# of both bone is the important one & usually associated with
displacement in form of shift, tilt or twist.
*The radiological findings are in form of T.V ,,butterfly ,oblique or spiral #.
76. TREATMENT
1. Reduction by MUA after examination of pulse .
2. Immobilization by above knee back slab then check x-ray.
3. If the # acceptable, change POP slab to cast for 10-12 wks.
4. Removal the cast & recheck x-ray, if consolidation is seen.
5. Exercise is proceed with active & passive exercise.
6. If conservative R. failed, open reduction & I.F is applied.
77. COMPOUND # (0PEN):
It always contaminated.
The grading depend on the severity of soft tissue injury, described by Gustilo
classification :
78. Treatment:
• antibiotics
• debridement
• stabilization
• prompt soft-tissue cover
• rehabilitation.
Wound toilet by mechanical washing to remove the foreign bodies.
Urgent wound excision: it is done systematically. skin, fascia, muscles.
nerve & tendon then bones.
Fixation of # by external fixation & it is contraindicated to internal fixation
80. MALLEOLAR FRACTURES OF THE
ANKLE
Fractures and fracture dislocations of the ankle are common.
Most are low-energy fractures of one or both malleoli, usually
caused by a twisting mechanism. The patient usually presents
with a history of a twisting injury, usually with the ankle going
into inversion, followed by immediate pain, swelling and
difficulty weight bearing. Bruising often comes out soon after
injury.
81. Classification
Danis & Weber:
Type A: # below the tibiofibular syndesmosis
,Perhaps associated with an oblique or vertical fracture of the medial
malleolus; this is almost certainly an adduction (or adduction and internal
rotation) injury.
82. Classification cont.
Type B:_ is an oblique fracture of the fibula in the sagittal plane at the level
of the syndesmosis;
This is an external rotation injury and it may be associated with a tear of
the anterior tibiofibular ligament
83. Classification cont.
Type C:_ is a more severe injury, above the level
of the syndesmosis, which means that the tibiofibular
ligament and part of the interosseous membrane must
have been torn. This is due to severe abduction or a
combination of abduction and external rotation
84. Treatment:
Undisplaced # :
Cast immobilization (boot POP)
Displaced # with or without
subluxation :
ORIF (fibular plating, screw fixation
of medial malleoli , syndesmotic
screw).
86. FRACTURES OF THE CALCANEUM
Result from axial loading
Traction through Achilles tendon lead to avulsion fracture
Can be extra-articular or intra-articular fracture (referring to
subtalar joint)
Result in loss of foot arch lead to flat foot
87. FRACTURES OF THE CALCANEUM
Extra_articular # of calcenum
Intra_articular # of calcenum
88. Treatment
Extra-articular fractures or undisplaced fractures may require bandaging for
1 week then followed by boot POP cast for 5 weeks
No weight bearing is allowed
Displaced intra-articular # or avulsion of Achilles insertion: ORIF screw or
recon plate
89. Complications
EARLY
1. Swelling and blistering
2. Compartment syndrome
LATE
1. Malunion
2. Peroneal tendon impingement
3. Insufficiency of the tendo Achillis
4. Talocalcaneal stiffness and osteoarthritis
