Fractures of the Femur, Tibia, and Fibula

Presented by:

Dr. Aric StorckOctober 2,

2002

Objectives Clinical evaluation Radiological diagnosis Emergency department management Will not discuss hip fractures (femoral

head, neck, trochanters) – discussed at pelvis/hip rounds

Will not discuss distal tib/fib fractures -discussed during ankle rounds

Femur Fractures

Femur FracturesFemoral Shaft Fractures

High-energy trauma – MVC, bicycle, falls Tensile strain usually produced

transverse fractures Comminution with higher forces Open fractures uncommon – generally

penetrating trauma Pathologic fractures – result from

torsional stress causing spiral fracture

Femoral Shaft FractureClassification

No generally accepted system Describe based on characteristics

Location Geometry Transverse, oblique, spiral, wedge,

comminution

Femoral Shaft Fractures

Femoral Shaft FracturesClinical Features

Obvious deformity 50% have ligamentous instability of the knee Neurovascular injuries rare in closed

fractures Fracture of Proximal 2/3

Proximal fragment abducted, flexed, and externally rotated due to pull of gluteal and iliopsoas muscles of trochanters

Fracture of Distal 1/3 Hyperextension of distal fragment due to pull of

gastrocnemius

Femoral Shaft FracturesED Management

Cross and type for at least 2 units PRBC Assess and treat neurovascular status D/C traction (NV damage more likely

from traction than from fracture) Immobilize without traction Analgesia (im/iv or femoral nerve block

with bupivicaine after careful neurological exam)

Femoral Shaft Fractures Definitive Management

Traction no longer commonly employed

External fixation especially open and comminuted

fractures Intramedullary rods

Operation of choice for most fractures Has been shown to decrease

hospitalization and total disability

Femoral Shaft FracturesDefinitive Treatment

Callus formation 3 weeks post IM nail

Bridging trabeculae 5 weeks post IM nail

Femoral Shaft FracturesComplications

Outcome generally good with close to 100% union rate. Potential complications include… Malunion Fat embolism

2-23% of isolated femoral shaft fractures Fever, tachycardia, ALOC, resp distress, petechiae

ARDS Hemorrhage (average 1-1.5 litres) Concurrent multisystem trauma Limb-length discrepancy Compartment syndrome of the thigh - rare

Knee Fractures Distal Femur

Supracondylar Intracondylar Condylar

Patella Proximal Tibia

Tibial plateau Tibial spine

Ottawa Knee Rules X-ray knees with knee injury and one

or more of:1. Blunt knee trauma in a patient >55 years

old2. Tenderness to palpation of head of fibula3. Isolated tenderness of patella4. Inability to flex knee to 90 degrees5. Inability to bear weight both immediately

and inability to take four steps in ED

Exclusion criteria Isolated skin injuries Referred patients from another ED or clinic Injury >7 days old Patient returning for re-evaluation Distracting injuries Altered mental status Age < 18 years old Pregnant patients Paraplegia

Ottawa Ankle Rules Derived from study of 1047 adult

ankle injuries 100% sensitive 54% specific Reduced radiography from 69% –

49% Reduced time in ER by 39 minutesStiell IG, Greenberg GH, Wells GA, et al: Prospective

validation of a decision rule for the use of radiography in acute knee injuries. JAMA 275:611-615, 1996

Stiell IG, Wells GA, Hoag RH, et al: Implementation of the Ottawa knee rule for the use of radiography in acute knee injuries. JAMA 278:2075-2079, 1997

Knee Injuries If Ottawa criteria are met x-ray:

AP / Lateral “sunrise” view for patients with patellar

tenderness Oblique view / plateau view for patients

unable to bear weight provides better view of femoral condyles, tibial

tuberosity, medial/lateral patellar margins Tunnel view for patients with suspected

ACL injury and tibial spine fracture

Pittsburgh Rules for Knee Radiographs

Pittsburgh Rules for Knee RadiographsExclusion criteria

• Injury >6 days old

• Isolated skin injuries

• History of knee fracture or surgery

• Repeat visit for same injury

Pittsburgh vs Ottawa rules More specific than Ottawa rules

(60-80% vs 27-49%) Comparable sensitivity (99% vs

97%) One study found the Pittsburgh

rules decreased knee radiography by 52% with one missed fracture vs 23% with three missed fracturesSeaberg DC, Yealy DM, Lukens T, et al: Multicenter comparison of two clinical

decision rules for the use of radiography in acute, high-risk knee injuries. Ann Emerg Med 32:8-13, 1998

Distal Femoral Fractures

Distal femur fractures Uncommon Result from high velocity trauma

(MVC) Hyperabduction Adduction Hyperextension Axial loading

Extensive soft tissue injuries Compartment syndrome - rare

Distal femur fractures Examination

Knee pain deformity hemarthrosis Supracondylar fractures

Shortened and externally rotated thigh Quadriceps pull proximal fragment

forwards Gastrocnemius pulls distal fragment back

Femur fractures - imaging AP Lateral Also don’t forget …

AP pelvis AP/lateral hip

Distal Femur Fractures Anatomy

Vascular close to femoral/popliteal vessels Assess distal pulses Palpate for hematoma in popliteal fossa

Neurological Tibial nerve – gastrocnemius, plantaris Peroneal/Deep Peroneal nerves

Supplies anterior compartment (dorsiflexion) Sensory to first dorsal interosseus cleft

Distal Femur Fractures Supracondylar

Extra-articular No hemarthrosis

Intracondylar Intra-articular

Condylar Intra-articular

Distal Femur Fractures

Distal Femur Fractures No definitive classification system Evaluate based on

Displacement Comminution Soft-tissue injury Neurovascular status Joint involvement Intra vs extra-articular Open vs closed

Distal Femur Fractures Complications – similar to femoral shaft

dvt fat embolism delayed union / malunion valgus/varus deformities chronic arthritis compartment syndrome growth disturbances in adolescents (65% of

leg growth from distal femoral epiphysis!!)

Distal Femur Fractures Management

assess & manage neurovascular status analgesia (consider femoral nerve block) immobilization appropriate fluid management orthopedic referral

definitive treatment (ORIF vs conservative)

Distal Femur Fractures

Distal Femur Fractures

Distal Femur Fractures

Distal Femur Fractures

Transcondylar fracture 10 months post ORIF

Distal Femur Fractures

Patellar Fractures Largest sesamoid bone in body Acts to increase mechanical advantage

during knee extension 1% of all adult fractures 27% occur during MVC’s – knee to dash Most patellar fractures are intra-articular Search for concomitant injuries

Knee/acetabular dislocations Acetabular fractures Femur fractures

Patellar fractures - mechanism Indirect trauma

Forceful knee flexion against contracted quadriceps

Horizontal fractures common Direct trauma

Direct blow / fall on knee comminution

Patellar fractures

Patellar fractures - Px Pain Hemarthrosis Crepitus Disruption of extensor mechanism

(must be able to fully extend knee against gravity)

Patellar fractures Imaging

AP Lateral Sunrise

Tangential view across 45 degree flexed knee

Shows small vertical fractures of patella

Transverse Patellar Fracture

Patellar fractures - Management

Nondisplaced with intact extensor mechanism immobilize knee in extension with partial

weight bearing x 3 weeks Repeat x-ray in 3 weeks Wear another 3 weeks for horizontal

fractures, less for vertical fractures

Patellar Fractures Management

Displaced (>3mm bony separation or > 2mm articular surface disruption) Orthopedic referral Tension band / K-wires Possible patellectomy – surgical

connection of quadriceps and patellar tendons

Patellar Fractures

58 year old dashboard injury and comminution of patella

Patellar Fractures

After total patellectomy and repair of the extensor mechanism

Tibial Fractures Major load-bearing structure of

lower leg Thin overlying tissues

open fractures common Easily fractured by direct trauma

Tibial Plateau Fractures aka tibial condylar fracture Mechanism - can be almost any …

axial compression rotation direct trauma varus/valgus stress Trivial mechanism in osteoporotic

individuals Very common after pedestrian vs

automobile – due to valgus/varus stress

Tibial Plateau Fractures Examination

Unable to weight bear knee slightly flexed knee effusion Joint line pain possible varus/valgus deformity (esp. with

depressed fractures) associated ligamentous and meniscal

injuries assess neurovascular status

Tibial Plateau Fractures Imaging

if meets Ottawa rules AP lateral (medial condyle concave, lateral

condyle convex) if patient unable to weight bear 4 steps

oblique views tibial plateau view (AP with 15 deg vertical

orientation)

Schatzker Classification of tibial plateau fractures

I. 1. Lateral plateau fracture without articular depression

II. 2. Lateral plateau fracture with articular depression

III. 3. Isolated areas of lateral plateau depression

NB: 60% are lateral plateau fractures (types I-III)

Tibial Plateau FracturesSchatzker Classification

Schatzker Classification 4. Medial plateau fracture (15%)

Schatzker Classification5. Bicondylar

NB: 25% of fractures bicondylar (types V-VI)

Schatzker Classification6. Bicondylar & tibial shaft

NB: 25% of fractures bicondylar (types V-VI)

Tibial Plateau Fracture. Type?

Tibial Plateau Fracture. Type?

Tibial Plateau Fracture - Type?

Tibial Plateau Fractures Management

I-III can be managed by experienced primary care physician

Splint in extension Non-weight bearing x 4-6 weeks

III-VI require orthopedic assessment Decision to operated based on:

Ligament/fracture stability Displacement >3mm Comminution Fracture location age

Tibial Plateau Fractures Complications

decreased ROM degenerative arthritis angular deformity of knee associated ligamentous injuries neurovascular compromise early and

late (compartment syndrome)

Neurovascular compromise

in action

Popliteal artery occlusion following high energy bicondylar tibial plateau fracture

Schatzker type II and proximal fibular fracture

Tibial Spine Injuries aka intercondyle eminence Same mechanism as ACL rupture

(hyperextension, rotation, ab/adduction) In young patients ACL stronger than tibial

spine – thus tibial spine injury Suspect with ACL-like presentation

(positive Lachman, etc.) AND inability to weight bear

Tibial Spine Injuries Type I

Incomplete avulsion with no displacement

Type II incomplete avulsion with

displacement Type III

Completely avulsed fragment

Tibial Spine Injury

Type II tibial spine avulsion fracture

Tibial Spine Injuries Treatment

Orthopedic referral for all Type I/II

Attempt closed reduction with hyperextension

Immobilize x 4-6 weeks in extension Type III

ORIF

Tibial Tuberosity Fractures Forced flexion vs. contracted

quadriceps Uncommon after apophysis closure

Tibial Tuberosity Fractures Type I

Distal fragment displaced proximally and anteriorly

Type II Fragments hinged at proximal portion Large fragment extending into physis

Type III Extension into articular surface

Tibial tuberosity fractures

Type II tibial tuberosity fracture

Tibial Tuberosity Fractures Treatment

Type I Immobilization in extension x 6 weeks

Type II/III Orthopedic referral for ORIF

Tibial Shaft Fracture Most commonly fractured long bone Commonly open (1/3 of surface

area just subcutaneous) Precarious blood supply Hinge joints at knee and ankle are

unforgiving of post-reduction deformity

Tibial Shaft FracturesClassification

No universally accepted classification scheme. Describe the following Location (prox, middle, distal third) Configuration (transverse, spiral,

comminuted) Displacement Angulation Length rotation

Tibial Shaft Fracture

Closed distal third comminuted fracture of left tibia

Nondisplaced as <5% angulation, no rotation

Tibial Shaft FractureED Treatment

Manage neurovascular status Carefully inspect any soft tissue

defect for open fracture Splint in long-leg, padded,

posterior splint Beware of compartment syndrome

Tibial Shaft FractureDefinitive Management

Orthopedic referral No consensus exists re: definitive

treatment Multifactorial decision Possible management

ORIF Intramedullary rod Cast immobilization

Early progressive weight bearing after two weeks

Tib/Fib Fractures

Fibular Fractures Not significantly involved in weight

bearing Usually associated with tibial fractures Important in stability of knee/ankle Proximal fibula = attachment site of LCL

and biceps femoris Beware of peroneal nerve injuries Patients can often walk on isolated fibular

fractures

Fibular Shaft Fractures Direct force

Blow to leg Transverse or comminuted fracture

Indirect force Rotational – oblique fracture Varus stress – avulsion injury

Fibular Shaft FracturesImaging

AP / lateral – generally sufficient Always order knee / ankle x-rays NB: common association with tibial

plateau fractures (type II)

Fibular Shaft fracturesTreatment

Immobilization in posterior splint Non-weight bearing until follow-up visit.

Weight bearing afterwards NB: always generously pad fibular head

during casting to avoid peroneal nerve injury

Treatment of tibial fracture generally treats fibular fracture as well

ORIF generally reserved for stabilization of complex concurrent tibial injuries