Trauma Lec 7

Truma Of The Lower
limb
Lec. 7
1-Hip dislocation
mechanism is usually with high energy trauma
Hip joint inherently stable due to
1)bony anatomy (ball-and-socket configuration between femoral
head with the acetabulum)
2)soft tissue constraints including
. labrum (deepen the acetabulum and increase the stability of
the joint).
. capsule (iliofemoral, pubofemoral, and ischiofemoral ligaments)
. ligamentum teres
Classification
. Simple vs. Complex
o simple (pure dislocation)
ocomplex (dislocation associated with fracture of acetabulum or
proximal femur)
. Anatomic classification
o posterior dislocation (90%)
. occur with axial load on femur, typically
with hip flexed
and adducted
. axial load through flexed knee (dashboard injury)
o anterior dislocation
. occurs with the hip in abduction and external rotation
Presentation
-acute pain, inability to bear weight, deformity
-posterior dislocation (90%)
hip and leg in slight flexion, adduction,
and internal rotation
-anterior dislocation
hip and leg in flexion, abduction,
and external rotation
Treatment
1)emergent closed reduction within 6 hours
-perform with patient supine and apply traction in line with
deformity regardless of direction of dislocation
-adequate sedation and muscular relaxation to perform
reduction
-assess hip stability after reduction
-post reduction CT scan required to rule out
1)femoral head fractures
2)intra-articular loose bodies/incarcerated fragments
3)acetabular fractures
-protected weight bearing for 4-6 weeks
. contraindications (ipsilateral displaced or non-displaced
femoral neck fracture )
2)open reduction and/or removal of incarcerated fragments
. irreducible dislocation
. radiographic evidence of incarcerated fragment
. delayed presentation
. non-concentric reduction
3)ORIF
. associated fractures of (acetabulum, femoral head, femoral
neck)
Complications
. Post-traumatic arthritis
. Femoral head osteonecrosis
. Sciatic nerve injury : 8-20% incidence
. Recurrent dislocations :
2. Femoral Neck Fractures
-increasingly common in older population
Mechanism
o high energy in young patients
o low energy falls in older patients
Low healing potential
. femoral neck is intracapsular, bathed in synovial fluid
. lacks periosteal layer
vascular supply
Mainly lateral and medial circumflex arteries (a and b)
form a vascular ring (c) Fromr this, retinacular vessels
run on the surface of the femoral neck to penetrate the
head (d).
Classification (Garden Classification)
Garden 1: incomplete fracture
Garden 2: complete undisplaced
fracture
Garden 3: Complete partially
displaced fracture
Garden 4: Complete fully displaced fracture
Management
1)cannulated screw fixation -sliding hip screw
displaced fractures in young or physiologically young patients
(most pts <65 years of age)
2)arthroplasty
3. Intertrochanteric Fractures
Extracapsular fractures of the proximal femur
between the greater and lesser trochanters
Classification
1)stable : intact posteromedial cortex
2)unstable: comminution of the posteromedial
cortex
Treatment
1)non-weightbearing with early out of bed to chair
1)nonambulatory patients
2)patients unfit for operation
2)sliding hip compression screw(DHS)
stable intertrochanteric fractures
3)intramedullary hip screw
(gamma nail)
stable and unstable fracture patterns
4. Subtrochanteric Fractures
Subtrochanteric typically defined as area from lesser trochanter to
5cm distal
Classification(Russell-Taylor)
Type I:
Fractures with an intact
piriformis fossa in which:
Type II:
Fractures that extend into the piriformis fossa
Treatment
1)observation with pain
management
1)nonambulatory patients
2)patients unfit for operation
2)intramedullary nailing
3)fixed angle plate
5. Femoral Shaft Fractures
• fracture of the femoral diaphysis occurring between 5 cm distal to
the lesser trochanter and 5 cm proximal to the adductor tubercle
Treatment
1)intramedullary nail
-gold standard for treatment of
diaphyseal femur fractures
2)ORIF with plate
1)ipsilateral neck fracture requiring screw fixation
2)fracture at distal metaphyseal-diaphyseal junction
3)inability to access medullary canal
3)external fixation with conversion to intramedullary nail within 2-
3 weeks
-unstable polytrauma patient
-vascular injury
-severe open fracture
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Truma Of The Lower

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