Fracture both bones leg class ug

1. Fracture both bones leg. Dr.Sarthy.V Dept Of Orthopaedics SSSMCRI

2. Break in the structural continuity of bone Fracture

3. Injury Repetitive Stress Pathological Causes

4. Direct force. Indirect force Twisting. Bending. Compression. Tension. Fatigue / Stress Fractures Pathological Fracture. Mechanism

5. Types Of Fracture Complete InComplete Transverse. Oblique. Spiral. Impacted. Comminuted. Compression. Green Stick. Plastic Deformation.

6. Why we need them? Classifications

7. OPEN FRACTURE

8. Translation. Angulation. Rotation. Shortening. Lengthening. Displacement

9. Stage of Hematoma Stage of Inflammation Stage of repair Stage of remodeling Fracture Healing

10. Stage of Hematoma Stage of Inflammation Stage of repair Stage of remodeling

11. Fracture Healing Healing By Callus Direct Union

12. Alleviate pain. To ensure union in good position. Permit early movement of the limb & return of function. Role of splinting.

13. Fracture. Types. Causes. Healing. LEG? Fractures Of Leg.

14. ANATOMY

15. Each Compartment has Specific Innervation Ant Comp - Deep Peroneal N. Lateral - Sup Peroneal N. Deep Post. - Tibial N. Sup Post. - Sural N.

16. Anterior Compartment Dorsiflexes ankle Tib ant, EDL, EHL, and peroneus tertius muscles Anterior tibial a./v. deep peroneal n. 1 st webspace sensation

17. Lateral Compartment Everts the foot Peroneus brevis and longus muscles Superficial peroneal n. dorsal foot sensation

18. Superficial Posterior Compartment Plantarflexes ankle Gastrocnemius, soleus, popliteus, and plantaris muscles Sural nerve Lateral heel sensation Greater and lesser saphenous veins

19. Deep Posterior Compartment Plantarflexion and inversion of foot FDL, FHL, Tib post muscles Post tibial vessels, peroneal a. tibial nerve Plantar foot sensation

20. Mechanism of injury High Enregy Low Energy .

21. Classification Numerous classification systems Important variables Pattern of fracture location of fracture comminution associated fibula fracture degree of soft tissue injury

22. 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

23. Henley’s Classification Applies Winquist & Hansen grading of femur to fractures of the tibia

24. 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

25. 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

26. Physical Exam Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself Repeated exam to follow compartment swelling

27. Radiographic Evaluation AP and Lateral views of entire tibia from knee to ankle Oblique views can be helpful in follow-up to assess healing

28. 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, 3r d Ed

29. Associated Injuries Ipsilateral femur fx, “floating knee” Neuro/vascular injury less common than in proximal tibia fx or knee dislocation Foot and ankle injury

30. Compartment Sydrome Common with high energy tibia fractures Treatment is 4 compartment fasciotomies

31. Compartment Syndrome 5-15% HISTORY Hi-Energy Crush 4 leg compartments

32. 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

33. Depends on the type of fracture. Open / Closed High Energy / Low Energy Management

34. Closed Fractures.

35. Closed Tibial Shaft Fractures Broad Spectrum of Injures w/ many treatments Nonsurgical management Intramedullary nails Plates External Fixation

36. 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

37. 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

38. 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)

39. Surgical Options Intramedullary nail ORIF with plate External Fixation

40. 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

41. 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

42. Plating of Tibial Fractures Narrow 4.5mm DCP plate can be used for shaft fractures Newer periarticular plates available for metaphyseal fractures

43. 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

44. 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

45. External Fixation Generally reserved for open tibia fractures or periarticular fractures

46. 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

47. Advantages of External Fixator Can be applied quickly in polytrauma patient Allows easy monitoring of soft tissues and compartments

48. Outcomes of External Fixation Anderson et al. Clin Orthop 1974 Edge 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

49. Conclusions Common fracture w/ several treatment options. Closed stable fxs . can be treated in a cast. Unstable fxs . often best treated by intramedullary nail

50. Open Fracture.

51. Objectives Prevent Infection Soft tissue coverage Union Function Often requires staged treatment over several months

52. 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

53. 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

54. 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

55. 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

56. Fracture Stabilization Reduces risk of infection External Fixation uniplane vs. multiplane provisional vs. definitive tx Intramedullary nail Plate fixation

57. Advantages of External Fixator Can be applied quickly in polytrauma patient Allows easy monitoring of soft tissues and compartments

58. Technique of External Fixation

59. Outcomes of External Fixation Anderson et al. Clin Orthop 1974 Edge 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

60. Advantages of IM Nail Less malunion and shortening Earlier weight bearing Early ankle and knee motion Reduced time to union -Shannon, J. Trauma 2002

61. Infection 1-5% Union >90% Knee Pain 56% w/ kneeling 90% w/ running 56% at rest 33% Complications Court-Brown, JOT 1996

62. Plating of Tibial Fractures Narrow 4.5mm DCP plate can be used for shaft fractures Periarticular plates available Plate through open wound

63. Subcutaneous Tibial Plating Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture

64. Disadvantages of Plating Increased risk of infection 13% deep infection -Bach, CORR 1989

65. 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

66. 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

67. 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

68. 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

69. 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

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

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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

77. Limb Salvage vs. Amputation Saving a functional limb versus saving the patient

78. M angled E xtremity S everity S core 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

79. 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

80. Fracture. Leg. Types Of Fracture. Clinical Features. Red Flags. Management Conservative. Surgical. When? How? Pros & Cons…. To Summarise .

81. Thank You