LOWER LIMB FRACTURES in adults, mva.pptx

Limb

1. LOWER LIMB FRACTURES PART I DR BRIAN RAMASUVHA DEPT OF ORTHOPAEDIC SURGERY TRAUMA UNIT : DGMAH MEDUNSA

2. PELVIC FRACTURES High energy trauma in young patients Retroperitoneal haematoma Life-threatening

3. INITIAL MANAGEMENT Principles of Advanced Trauma Life Support (ATLS) AB C DE Mx should start at the scene of accident Larrey’s manoeuvre A belt / a sheet wrap using the Seattle technique

4. Management of Urogenital injuries Corresponds to the letter D of the ATLS procedure to manage deficits. Meatal bleeding Urinary retention Dysuria High-riding prostate Cystogram Catheterisation ( ? Supra-pubic)

5. Open fractures of the pelvic ring Life-threatening risk of pelvic fracture is doubled Morrel-Lavallee lesion Anorectal lesion Inguinal lesion

6. Multiple trauma patients present with SIRS, which begins after the 1 st day and ends after approx. 4 days later. After 10 days CARS develops, reducing the patient’s immunity against surgery. Thus the patient should undergo surgery before the first day or between the 4 th and 10 th days. Early Total Care VS Damage Control Orthopaedics

7. The 2 commonest used classifications used are the Young and Burgess and Marvin Tile classifications. Tile Classification Type A Stable A1 #s not involving the pelvic ring A2 Iliac wing #s or min displaced ant. arch #s A3 stable, T/V #s of the sacrum or Cx Type B Vertically stable – rotationally unstable B1 ‘Open-book’ injury B2 LC injury – ipsilateral B3 LC injury – bilateral Type C Vertically and rotationally unstable C1 Unilateral injury C2 Bilateral injuries C3 Assoc. hip dislocation CLASSIFICATION OF PELVIC FRACTURES

8. ALGORITHM OF ACUTE MX & RX OF PATIENTS WITH PELVIC RING #S

9. ‘WE COME TO THIS WORLD UNDER THE BRIM OF THE PELVIS AND LEAVE THROUGH THE NECK OF THE FEMUR’ FEMORAL NECK FRACTURES

10. Femoral neck #s are intracapsular and typically occur in a bimodal age distribution The incidence increases with age Co-morbidities – prior hip pain ambulatory status functional and mental capacity INTRODUCTION

11. CLASSIFICATION Garden classification Pauwel classification Anatomical classification

12. BLOOD SUPPLY TO THE FEMORAL HEAD

13. There is very limited options for conservative treatment. AGE TREATMENT 60yrs and younger ORIF Above 60yrs THR/Hemi- arthroplasty In younger patients ORIF has to be done in less than 6 -24hrs to reduce the risk of AVN. Cognitive impairment is the number one killer in these patients. N.B Problems associated with prolonged bed rest. TREATMENT OPTIONS

14. TREATMENT OPTIONS Neck of femur # treated with Cannulated screws

15. TREATMENT OPTIONS NECK OF FEMUR FRACTURE TREATED WITH THA

16. INTERTROCHANTERIC FEMUR FRACTURES These are #s in the proximal femur between the greater and the lesser trochanter. Usually in the elderly with co-morbidities. Most classifications of IT #s have poor reliability and reproducibility.

17. It is important to distinguish between Stable & Unstable fractures. Unstable fractures : 1. Posteromedial cortex comminution 2. Reverse obliquity 3. Subtrochanteric extension INTRODUCTION

18. UNSTABLE FRACTURES

19. Nonsurgical treatment usually reserved for patients with comorbidities. Unacceptable risk from anaesthesia, the surgical procedure, or both. Mortality from surgical treatment typically results from cardiopulmonary complics, TE, and sepsis. Early mobilisation out of bed to chair in patients treated non-surgically is recommended. NONSURGICAL VS SURGICAL TREATMENT OF IT #S

20. EXTRAMEDULLARY FIXATION SURGICAL TREATMENT OF IT FEMUR FRACTURES INTRAMEDULLARY FIXATION

21. No significant difference in wound complications, fracture union, mortality, or functional outcomes. SHS or IM implant for stable fractures. IM device (unstable #s) aids in early mobilisation and results in decreased blood loss and reduced surgical time. INTRAMEDULLARY VS EXTRAMEDULLARY FIXATION IN IT #S

22. Intramedullary nailing is the method of choice for treating fractures of the femoral shaft. Traction (Thomas splint) is reserved for children. FEMORAL SHAFT FRACTURES

23. Multitrauma patient - damage control orthopaedics - to ream or not to ream - use of an external fixator/ unreamed retrograde nail Open fractures - less common than of the tibia - wound debridement and immediate IM nailing mostly Vascular and Neurologic injury - bony stabilisation (external fixator or retrograde IMN) followed by neurovascular repair - convert to definitive IMN within 2 weeks if there is no sepsis Obese patients - retrograde IMN provides advantage of reduced radiation exposure and surgical time. SPECIAL SITUATIONS

24. These fractures are usually comminuted and intra-articular, and they often involve osteoporotic bone, hence they are difficult to treat. DISTAL FEMORAL FRACTURES

25. ANATOMY

26. AO Classification CLASSIFICATION

27. Requires maintenance or restoration of distal femoral alignment to preserve the function of the extremity Butt et al reported good or excellent results in 53% of patient’s treated surgically and in 31% of patients treated nonsurgically in the elderly The nonsurgical group had a higher rate of complications MANAGEMENT

28. Reserved for stable, minimally displaced #s Restricted weight bearing in a hinged knee brace Early R.O.M Splinting/Bracing/Traction Also for medically unfit patients Complications of prolonged bedrest NONSURGICAL MX

29. ATLS Treat co-morbidities SURGICAL MX

30. FIXED-ANGLE BLADE PLATE

31. DCS

32. LOCKING PLATES

33. IM NAILS

34. EXTERNAL FIXATOR

35. ATLS principles of resuscitation Must include mx of Osteoporosis in the elderly Early mobilization CONCLUSION

36. THANK YOU