Pelvic Fractures and Dislocations
- Pelvic fractures are potentially life-threatening injuries with high mortality rates.
- Most are caused by MVAs and falls from height.
- A multidisciplinary approach is necessary to reduce mortality and disability.
- Pelvic ring fractures account for 3% of all fractures.
Four patterns of injury are responsible for pelvic fractures. Anteroposterior compression results in external rotation of the hemipelvis and rupture of the pelvic floor and anterior sacroiliac ligaments. Lateral compression creates compression fractures of the sacrum and disruption of the posterior sacroiliac ligament complex. The sacrospinous and sacrotuberous ligaments remain intact, limiting the instability. In high-energy lateral compression injuries, the contralateral hemipelvis can be pushed in external rotation, as seen in rollover or crush injuries. Combined external rotation-abduction is common in motorcycle accidents, and the deforming forces are transmitted through the femur. The fourth pattern is a shear force vector resulting from fall from heights, where the grade of translational instability is variable.
Knowledge of the injury mechanism is of prime importance to estimate the outcomes; the physical examination includes inspection of the skin, perineum, and rectum. Closed degloving injuries (Morel-Lavallée) should be properly identified. Palpation of the pelvic bony landmarks, including posterior palpation of the sacrum and sacroiliac joint, should be done, but anteroposterior and lateral iliac wing compression maneuvers to assess stability should be performed only once or avoided in hemodynamically unstable patients because excessive manipulation can increase bleeding by mobilizing the initial clotting. Rectovaginal examination is mandatory in all cases to identify open fractures. Bony spikes protruding through the mucosa contaminate the fracture hematoma. Associated injuries should also be systematically sought: lower urinary tract injuries, distal vascular status, and a thorough recorded neurologic examination.
An initial AP pelvic radiograph as per ATLS protocol is examined to evaluate the pelvic ring as a possible cause of shock. Following successful resuscitation, AP pelvis radiography should be obtained. When the patient is hemodynamically stabilized, inlet and outlet views and, if acetabular fractures are suspected, obturator or iliac oblique views should be ordered. Actual displacement of the symphysis pubis can also be evaluated by stress views under general anesthesia. CT scan is essential to further define the fracture pattern. Vascular and urologic imaging may also be required.
Most pelvis fractures treated by orthopedic surgeons are stable injuries, and management of these low-energy fractures generally requires nonsurgical treatment. On the contrary, management of unstable pelvic injuries requires a systemic approach in a multidisciplinary manner. Thus, in the hemodynamically unstable patient, the ATLS protocol should be followed. Hemorrhage and shock are the primary causes of death due to pelvic fracture. The cornerstones of successful treatment include identification of a significant pelvic injury; rapid resuscitation; hemorrhage control (using angiography or pelvic packing); assessment and treatment of associated injuries; and mechanical stabilization in selected cases. Initial resuscitation started with 2 L of crystalloid should be followed by packed blood cells, fresh frozen plasma, and platelets in a 1:1:4 ratio. A pelvic binder or sheet can be used to stabilize the unstable pelvis temporarily. After ruling out other sources of bleeding by chest and spine radiography and focused abdominal sonography for trauma (FAST), an external fixation device (pelvic clamp and/or anterior external fixator) should be applied. Pelvic packing and/or arterial angiography should be executed according to the protocol of the trauma center. If the patient's hemodynamic status stabilizes, the need for definitive versus temporizing mechanical fixation of the pelvis should be determined. Anterior fixation may involve anterior plating of the pubic symphysis or maintaining the external fixation device in place, which does not provide posterior stability and can potentially increase displacement of the fractured pelvis in vertical unstable fracture configuration. It usually resists stresses imposed by sitting but not those from weight bearing, and further internal fixation is often required at a later stage. Posterior fixation (either surgical or CT-guided percutaneous fixation) is usually deferred until a later time.
In open pelvic fractures, which account for 2–4% of all pelvic fractures, early surgical intervention using a multidisciplinary approach should be undertaken. Seventy-two percent of open pelvic fractures are grade III open wounds and should be appropriately treated. The definitive method of stabilization of open pelvic fractures remains controversial. Internal fixation can be done when no gross contamination is present. Otherwise, external fixation is preferred when fecal or environmental contamination is present. If the fecal content contacts the open wound, colostomy is indicated.
Most of the bleeding associated with pelvic ring fractures usually comes from the small to medium-sized veins in the surrounding soft tissues and from the bone itself. Arterial injuries causing significant bleeding occur only in about 10% of pelvic fractures. After blunt trauma, the most common pelvic arteries injured are the superior gluteal and internal pudendal arteries. CT scans can be used to detect arterial bleeding before angiography but should be postponed until the patient is hemodynamically stable for transfer. Embolization can be used to prevent arterial bleeding. Pelvic packing helps tamponade the bleeding by increasing the intrapelvic pressure. Surgery for repair or bypass is urgently required if there is a distal ischemia.
Pelvic fractures increase the risk of venous thromboembolic problems in trauma patients. DVT is seen not only in distal calf veins, but also in pelvic venous plexus. Magnetic venous venography is more advantageous than duplex color ultrasound to detect pelvic thrombosis. Guidelines for prophylaxis are controversial, and one should consider the benefits, risks, and cost of different treatment options. Early administration of low-molecular-weight heparin (LMWH) may decrease the incidence of symptomatic pulmonary emboli. More trauma centers now use intermittent pneumatic compression after trauma and temporary vena cava filters in severely traumatized patients with contradictions to pharmacologic prophylaxis (heparin, warfarin, or LMWH).
Neurologic injuries are common, and the frequency increases with complexity of the fractures. Up to 40% of unstable pelvic injuries may have neurologic injuries. After unstable vertical shear sacral fractures, the incidence rises to 50%. L5 and S1 are the most common affected roots. It is of paramount importance that a thorough neurologic examination is performed and recorded as soon as possible, searching for sensory or motor deficits in the distribution of sciatic, femoral, obturator, pudendal, or superior gluteal nerves. Peripheral nerve injuries have, overall, a better prognosis than root injuries. Partial nerve injuries also have a better outcome than complete ones. Most of the lesions are of the neurapraxia type, with favorable outcome. It is still accepted that nearly 10% have clinically significant permanent neurologic sequelae.
Urogenital injuries are common and occur in as many as 24% of adults with pelvic fractures. Males have twice the urethral injury incidence than females because of the anatomic disadvantage. In males, these injuries should be suspected in a patient who is unable to void, who has gross hematuria at the meatus, swelling or hematoma of the perineum or penis, or a “high-riding” or “floating” prostate at digital rectal examination.
Additionally in female patients, vaginal bleeding, labial edema, blood at the meatus, and urinary leak per rectum can be clinical signs of possible urethral injury. Blind insertion of a Foley catheter may cause extension of a partial tear into a complete tear, may increase the extent of a hemorrhage, or may introduce an infectious agent into a previously sterile hematoma, so a retrograde (ascending) urethrogram should be obtained before insertion. When a partial or complete urethral disruption is diagnosed, a suprapubic cystotomy should be performed.
Injuries to the Pelvic Ring (ICD-9:808.41-42-43-49, 808-2)
Injuries that are stable do not deform under normal physiologic forces, whereas unstable injuries are characterized by their type of displacement, such as vertically unstable or horizontally unstable.
From the anatomic standpoint, the posterior sacroiliac ligamentous complex is the single most important structure for pelvic stability. Injuries involving the pelvic ring in two or more sites create an unstable segment. The integrity of the posterior sacroiliac ligamentous complex will determine the degree of instability. Inlet and outlet views and CT scanning are necessary imaging techniques to make this determination. When intact, the hemipelvis will be rotationally unstable but vertically stable. When disrupted, the hemipelvis will be both rotationally and vertically unstable.
Classification and Treatment
Tile devised a dynamic classification system based on the mechanism of injury and residual instability (Table 2–5).
Table 2–5. The Tile Classification of Pelvic Ring Disruptions. ||Download (.pdf)
Table 2–5. The Tile Classification of Pelvic Ring Disruptions.
Type A: Stable, posterior arch intact
- A1: Posterior arch intact, fracture of innominate bone (avulsion)
- A1.1 Iliac spine
- A1.2 Iliac crest
- A1.3 Ischial tuberosity
- A2: Posterior arch intact, fracture of innominate bone (direct blow)
- A2.1 Iliac wing fractures
- A2.2 Unilateral fracture of anterior arch
- A2.3 Bifocal fracture of anterior arch
- A3: Posterior arch intact, transverse fracture of sacrum caudal to S2
- A3.1 Sacrococcygeal dislocation
- A3.2 Sacrum undisplaced
- A3.3 Sacrum displaced
Type B: Incomplete disruption of posterior arch, partially stable, rotation
- B1: External rotation instability, open-book injury, unilateral
- B1.1 Sacroiliac joint, anterior disruption
- B1.2 Sacral fracture
- B2: Incomplete disruption of posterior arch, unilateral, internal rotation (lateral compression)
- B2.1 Anterior compression fracture, sacrum
- B2.2 Partial sacroiliac joint fracture, subluxation
- B2.3 Incomplete posterior iliac fracture
- B3: Incomplete disruption of posterior arch, bilateral
- B3.1 Bilateral open-book
- B3.2 Open-book, lateral compression
- B3.3 Bilateral lateral compression
Type C: Complete disruption of posterior arch, unstable
- C1: Complete disruption of posterior arch, unilateral
- C1.1 Fracture through ilium
- C1.2 Sacroiliac dislocation and/or fracture dislocation
- C1.3 Sacral fracture
- C2: Bilateral injury, one side rotationally unstable, one side vertically unstable
- C3: Bilateral injury, both sides completely unstable
- Type A: Fractures that involve the pelvic ring in only one place and are stable.
- Type A1: Avulsion fractures of the pelvis that usually occur at muscle origins (eg, the anterosuperior iliac spine [sartorius], anteroinferior iliac spine [direct head of the rectus femoris], and ischial apophysis [hamstring muscles]). These fractures occur most often in the adolescent, and conservative treatment is usually sufficient. On rare occasions, symptomatic nonunion occurs and is best dealt with surgically.
- Type A2: Stable fractures with minimal displacement. Isolated fractures of the iliac wing without intraarticular extension usually result from direct trauma. Even with significant displacement, bony healing is to be expected, and therefore, treatment is symptomatic. On rare occasions, the soft-tissue injury and accompanying hematoma may heal with significant heterotopic ossification.
- Type A3: Obturator fractures. Isolated fractures of the pubic or ischial rami are usually minimally displaced. The posterior sacroiliac complex is intact, and the pelvis is stable. Treatment is symptomatic, with bed rest and analgesia, early ambulation, and weight bearing as tolerated.
- Type B: Fractures that involve the pelvic ring in two or more sites. They create a segment that is rotationally unstable but vertically stable.
- Type B1: Open-book fractures occur from anteroposterior compression. Unless the anterior separation of the pubic symphysis is severe (>6 cm), the posterior sacroiliac complex is usually intact and the pelvis relatively stable. Significant injury to perineal and urogenital structures is often present and should always be looked for. One should remember that fragment displacement at the time of injury might have been significantly more than what is apparent on radiograph. For minimally displaced symphysis injuries, only symptomatic treatment is needed. The same applies for the so-called straddle (four rami) fracture. For more displaced fracture-dislocations, reduction is done by lateral compression using the intact posterior sacroiliac complex as the hinge on which “the book is closed.” Reduction can be maintained by external or internal fixation. “Closing the book” decreases the space available for hemorrhage. It also increases patient comfort, facilitates nursing care, and allows earlier mobilization, which is beneficial to the polytrauma patient.
- Type B2 and B3: Lateral compression fractures. A lateral force applied to the pelvis causes inward displacement of the hemipelvis through the sacroiliac complex and the ipsilateral (B2) or, more often, contralateral pubic rami (B3, bucket-handle type). The degree of involvement of the posterior sacroiliac ligaments will determine the degree of instability. The posterior lesion may be impacted in its displaced portion, affording some relative stability. The hemipelvis is infolded, with overlapping of the symphysis. Major displacement requires manipulation under general anesthesia. This should be done soon after injury because disimpaction becomes difficult and hazardous after the first few days. Reduction can be maintained with external or internal fixation, or both. External fixation alone decreases pain and makes nursing care easier but is not strong enough for ambulation if the fracture is unstable posteriorly.
- Type C: Fractures that are both rotationally and vertically unstable. They often result from a vertical shear mechanism, like a fall from a height. Anteriorly, the injury may fracture the pubic rami or disrupt the symphysis pubis. Posteriorly, the sacroiliac joint may be dislocated, or there may be a fracture in the sacrum or in the ilium immediately adjacent to the sacroiliac joint, but there is always loss of the functional integrity of the posterior sacroiliac ligamentous complex. The hemipelvis is completely unstable. Three-dimensional displacement is possible, particularly proximal migration. Massive hemorrhage and injury to the lumbosacral nerve plexus are common. Indirect radiologic clues of pelvic instability should be looked for such as avulsion of the sciatic spine or fracture of the ipsilateral L5 transverse process. Reduction is relatively easy, with longitudinal skeletal traction through the distal femur or the proximal tibia. If chosen as definitive treatment, traction should be maintained for 8–12 weeks. Bony injuries heal quicker than ligamentous injuries. External fixation alone is insufficient to maintain reduction in highly unstable fractures, but it may help control bleeding and eases nursing care. ORIF is often required. The surgical technique is demanding, and there is a significant risk of complications. It is best left to experienced pelvic surgeons.
Long-term complications of unstable pelvic ring disruptions are more frequent and disabling than once thought. If anatomic restoration of anatomic bony alignment cannot be achieved and maintained, complications such as pain, leg-length discrepancy, and residual gait abnormalities can be seen. The overall nonunion rate is around 3%. Chronic low back pain and sacroiliac pain are frequent and seen in up to 50% of cases on long-term follow-up. Changes in voiding pattern, altered defecation, and sexual dysfunction are common after sacral fractures or sacroiliac dislocations.
Fractures of the Acetabulum (ICD-9:808.0)
The acetabulum results from the closure of the Y or triradiate cartilage and is covered with hyaline cartilage.
Fractures of the acetabulum occur through direct trauma on the trochanteric region or indirect axial loading through the lower limb. The position of the limb at the time of impact (rotation, flexion, abduction, or adduction) will determine the pattern of injury. Comminution is common.
The acetabulum appears to be contained within an arch. It is supported by the confluence of two columns and enhanced by two walls. The posterior column is the strongest one and where more space is available for fixation. It begins at the dense bone of the greater sciatic notch and extends distally through the center of the acetabulum to include the ischial spine and ischial tuberosity. The inner surface forms the posterior wall, and the anterior surface forms the posterior articular surface of the acetabulum. The anterior column extends from the iliac crest to the symphysis pubis. The anterior column rotates 90 degrees just above the acetabulum as it descends. The medial part of the anterior column is the true pelvic brim. The quadrilateral plate is the medial structure preventing medial displacement of the hip and is an independent structure between the two columns. The acetabular dome or weight-bearing area extends from the bone posterior to the anterior inferior iliac spine to the posterior column.
Letournel has classified acetabular fractures based on the involved column. Fractures may involve one or both columns in a simple or complex pattern.
Proper fracture classification requires good-quality radiographs. Two oblique views (Judet views) taken 45 degrees toward and away from the involved side complement the standard AP view of the pelvis. The obturator (internal) oblique view is obtained by elevating the fractured hip 45 degrees from the horizontal. This view shows the anterior column (iliopectineal line) and the posterior lip of the acetabulum, and the iliac wing is perpendicular to its broad surface. In this view, the spur sign can be identified in 95% of cases of both-column fractures (type C), and it corresponds to the area of the iliac wing above the acetabular roof. The iliac (external) oblique view is obtained by elevating the nonfractured hip 45 degrees. This view best shows the posterior column (ilioischial line), including the ischial spine, the anterior wall of the acetabulum, and the full expanse of the iliac wing. In addition, inlet and outlet pelvic views can be complementary if any doubt about pelvic ring compromise is present.
CT scanning gives further information on the fracture pattern, the presence of free intraarticular fragments, and the status of the femoral head and the rest of the pelvic ring.
Letournel has classified acetabular fractures into 10 different types: five simple patterns (one fracture line) and five complex patterns (the association of two or more simple patterns) (Figure 2–16). This is the most widely used classification system, as it allows the surgeon to choose the appropriate surgical approach.
Letournel classification of acetabular fractures. (Reproduced, with permission, from Canale ST, ed: Campbell's Operative Orthopaedics, 9th ed. Philadelphia: Lippincott; 1998. http://lww.com)
The goal of treatment is to attain a spherical congruency between the femoral head and the weight-bearing acetabular dome and to maintain it until bones are healed. As with other pelvic fractures, acetabular fractures are frequently associated with abdominal, urogenital, and neurologic injuries, which should be systematically sought and treated. Significant bleeding can be present and should be addressed as soon as possible. Examination of the knee ligaments and vascular status of the extremities is mandatory. A careful neurologic examination is necessary. Sciatic nerve compromise occurs in 20% of cases. The peroneal branch is often involved. The femoral nerve and superior gluteal nerve are also susceptible to injury during trauma or surgery. Prophylaxis and surveillance for DVT should be started soon after trauma.
The stabilized patient should be put in longitudinal skeletal traction through a distal femoral or proximal tibial pin pulling axially in neutral position. A trochanteric screw for lateral traction is contraindicated, because it will create a contaminated pin tract and thus preclude possible further surgical treatment. Postreduction radiographs are obtained. In general, a displaced acetabular fracture is rarely reduced adequately by closed methods. If the reduction is judged acceptable, traction is maintained for 6–8 weeks until bone healing is evident. Another 6–8 weeks is necessary before full weight bearing can be attempted. Surgical indications include intraarticular displacement of 2 mm or more, an incongruous hip reduction, marginal impaction of more than 2 mm, or intraarticular debris. The choice of approach is of primary importance, and sometimes more than one approach will prove necessary. Acetabular surgery uses extensile approaches and sophisticated reduction and fixation techniques and is best performed by trained pelvic surgeons. Other surgical indications include free osteochondral fragments, femoral head fractures, irreducible dislocations, or unstable reductions.
Complications inherent to the injury include posttraumatic degenerative joint disease, heterotopic ossification, femoral head osteonecrosis, DVT, and other complications related to conservative treatment. Surgery is performed to prevent or delay osteoarthritis but increases the possibility of complications such as infection, iatrogenic neurovascular injury, and heterotopic ossification. When the reduction is stable and fixation is solid, the patient can be mobilized after a few days with non–weight-bearing ambulation, and weight bearing may begin as early as 6 weeks. Most pelvic surgeons now routinely use postoperative prophylactic anticoagulation and heterotopic bone formation prophylaxis with irradiation or indomethacin, or both.
American College of Surgeons, Committee on Trauma: Advanced Trauma Life Support for Doctors: Student Course Manual, 7th ed. Chicago: American College of Surgeons; 2008.
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Hip Fractures and Dislocations
- Globally, 6.3 million hip fractures are estimated by year 2050.
- Primarily occur in older patients over 55 years.
- Fall from standing height is the main cause of injury.
- Almost all hip fractures are treated surgically.
- One-year mortality after femoral neck and intertrochanteric fracture exceeds 14–36%.
Anatomy and Biomechanical Principles
The hip joint is the articulation between the acetabulum and the femoral head. The trabecular pattern of the femoral head and neck, and that of the acetabulum, is oriented to optimally accept the forces crossing the joint. Calcar femorale is the dense bone oriented in posteromedial portion of the femoral shaft under the lesser trochanter that supports the force transfer from the neck to the shaft.
The total force acting across the joint is 2.5 times body weight when standing on one leg and five times body weight when running. Using a cane in the opposite hand reduces the force to body weight when standing on that leg.
Femoral Neck Fractures (ICD-9:820.0)
Femoral neck fractures occur in the intracapsular region between the trochanters distally and the head proximally. Main arterial blood supply of the neck comes from an extracapsular ring of vessels formed by the ascending branch of the lateral circumflex artery anteriorly and medial circumflex artery posteriorly. These fractures are classified as subcapital, transcervical, and basicervical. The latter acts more like an intertrochanteric fracture. These fractures are generally low-energy injuries in the elderly population; however, they are more often seen as high-energy injuries at young ages. The typical patient is a female who had a falling incident and presents with a painful hip, with shortened and externally rotated extremity on physical examination. Stress fractures of the femoral neck can also occur and should be excluded in young athletes. These fractures may be difficult to diagnose. Physical examination, as well as the initial radiographs, may be normal. Repeat radiographs, radionuclide imaging, and MRI may be necessary to confirm the diagnosis. Plain AP view and a cross-table lateral view of the involved hip are indicated to diagnose and classify the fracture. Bone scans can be false negative in the acute phase.
The Garden classification for acute fractures is the most widely used system:
- Type 1: Valgus impaction of the femoral head
- Type 2: Complete but nondisplaced
- Type 3: Complete fracture, displaced less than 50%
- Type 4: Complete fracture displaced more than 50%
This classification is of prognostic value for the incidence of avascular necrosis: The higher the Garden number, the higher the incidence. The benefits of either skeletal or skin traction are unclear prior to definitive treatment. Traction may offer comfort in some patients but does not improve overall outcome.
Stable Femoral Neck Fractures
These include stress fractures and Garden type 1 and 2 fractures. Nonsurgical treatment should be reserved for patients with extreme medical risks for surgery.
The Garden type 1 fracture is impacted in valgus position and is usually stable. Impaction must be demonstrated on both AP and lateral views. The risk of displacement is nevertheless significant; most surgeons recommend prophylactic internal fixation with screws or sliding hip screw to maintain reduction and allow earlier ambulation and weight bearing.
Unstable Femoral Neck Fractures
Treatment is directed toward preservation of life and restoration of hip function, with early mobilization. This is best attained by rigid internal fixation or primary arthroplasty as soon as the patient is medically prepared for surgery. In general, the younger the patient, the greater the effort is justified to save the femoral head. More studies are in favor of an urgent intervention in a young patient to protect the head viability. Necessity of a capsulotomy to decompress the joint is controversial. In the elderly patient, surgical options are either ORIF or primary arthroplasty. Gjertsen et al showed that hemiarthoplasty for displaced femoral neck fractures in the elderly resulted in fewer reoperations, less pain, and higher satisfaction rates than internal screw fixation in 4335 patients from the Norwegian Hip Fracture Register.
The fracture is reduced under fluoroscopic imaging as anatomically accurately as possible. Gentle manipulation is usually sufficient. Rarely, open reduction may be necessary before fixation. Open reduction, if performed, should be approached anteriorly because this results in less disruption of blood supply than a posterior approach. The most accepted method is fixation with three screws (in an inverted triangle manner with one screw in the posteroinferior of the neck). Sliding hip screw or plate should be placed with center-apex distance within 25 mm. An additional screw is inserted superior or posteroinferior in order to control the rotational forces. The patient can usually be mobilized the following day, and weight bearing is allowed according to the stability of the construct.
Arthroplasty is reserved for elderly displaced fractures, particularly for Garden type 4 fractures, in which avascular necrosis is highly probable, and for Garden type 3 fractures that cannot be satisfactorily reduced or for femoral heads with preexisting disease. Recent studies indicate that a lower rate of reoperations and better outcomes are expected after total hip arthroplasty versus hemiarthroplasty.
The most common sequelae of femoral neck fractures are loss of reduction with or without hardware failure, nonunions or malunions, and avascular necrosis of the femoral head. This latter complication can appear as late as 2 years after injury. According to different series, the incidence of avascular necrosis varies from 0 to 15% for Garden type 1 fractures, 10 to 25% for type 2 fractures, 25 to 50% for type 3 fractures, and 50 to 100% for type 4 fractures. Secondary degenerative joint disease appears somewhat later. The most disabling complication, infection, is fortunately rare.
Trochanteric Fractures (ICD-9:820.2)
Lesser Trochanter Fracture (ICD-9:820.20)
Isolated fracture of the lesser trochanter is rare. When it occurs, it is the result of the avulsion force of the iliopsoas muscle. Rarely, a symptomatic nonunion may require fragment fixation or excision.
Greater Trochanter Fracture (ICD-9:820.20)
Isolated fracture of the greater trochanter may be caused by direct injury or may occur indirectly as a result of the activity of the gluteus medius and gluteus minimus muscles. It occurs most commonly as a component of intertrochanteric fracture.
If displacement of the isolated fracture fragment is less than 1 cm and there is no tendency to further displacement (as determined by repeated radiographic examinations), treatment may be bed rest until acute pain subsides. As rapidly as symptoms permit, activity can increase gradually to protected weight bearing with crutches. Full weight bearing is permitted as soon as healing is apparent, usually in 6–8 weeks. If displacement is greater than 1 cm and increases on adduction of the thigh, extensive tearing of surrounding soft tissues may be assumed, and ORIF is indicated. Tension band wiring is the preferred technique.
Intertrochanteric Fractures (ICD-9:820.21)
- Approximately 50% of all hip fractures.
- Older age, female gender, osteoporosis, history of fall, and gait abnormalities are risk factors.
By definition, these fractures usually occur along a line between the greater and the lesser trochanter. They typically occur at a later age than do femoral neck fractures. They are most often extracapsular and occur through cancellous bone. Bone healing within 8–12 weeks is the usual outcome, regardless of the treatment. Nonunion and avascular necroses of the femoral head are not significant problems.
Clinically, the involved extremity is usually shortened and can be internally or externally rotated. If there is comminution in the calcar (posteromedial cortex) or the fracture line extends through the subtrochanteric region, the fracture is considered unstable. Reverse oblique fractures, where the course fracture line is proximal-medial to distal-lateral, are extremely unstable. A wide spectrum of fracture patterns is possible, from the nondisplaced fissure fracture to the highly comminuted fracture with four major fragments (head and neck, greater trochanter, lesser trochanter, and femoral shaft). The Muller/AO system is useful in classifying intertrochanteric femur fractures and has gained more popularity in recent years (Figure 2–17).
Muller/AO system for intertrochanteric femur fracture classification. (Reproduced, with permission, from Browner BD, Levine A, Jupiter J, et al, eds: Skeletal Trauma, 2nd ed. New York: WB Saunders; 1998.)
The selection of definitive treatment depends on the general condition of the patient and the fracture pattern. Rates of illness and death are lower when the fracture is internally fixed, allowing early mobilization. Operative treatment is indicated as soon as the patient is medically able to tolerate surgery. Overall mortality decreases if surgery can be performed within 48 hours. Initial treatment in the hospital should be by gentle skin traction to minimize pain and further displacement. Skeletal traction as the definitive treatment is rarely indicated and is fraught with complications such as pressure sores, DVT and PE, deterioration of mental status, and varus malunion. When surgery is contraindicated, it may be preferable to mobilize the patient as soon as pain permits and accept the eventual malunion or nonunion.
The great majority of these fractures are amenable to surgery. The goal is to obtain a fixation secure enough to allow early mobilization and provide an environment for sound fracture healing in a good position. Reduction of the fracture is usually accomplished by closed methods, using traction on the fracture table, and monitored using fluoroscopic imaging. Internal fixation can be obtained by dynamic hip screw (DHS), intramedullary (IM) nail, and side plate. Fixation with IM nail has biomechanical advantages over DHS, especially for the unstable fracture patterns. Early full weight bearing, return to preinjury activity, decrease in blood loss, insertion through small incision, and shorter surgery time also make IM nailing favorable. While inserting the hip screw, the screw should be centrally positioned in the head, and the distance of the lag screw to the apex of the femoral head on both AP and lateral radiographic views should be within 25 mm. Reverse oblique fractures should be treated as subtrochanteric fractures. Although generally it is not the primary option for fixation, calcar replacement arthroplasty may be an option for patients with preexisting arthritic change who have poor bone quality or for salvage procedures. General complications include infection, hardware failure, loss of reduction, nonunion, irritation bursitis over the tip of the sliding screw, and dislocation for prosthetic implants.
Traumatic Dislocation of the Hip Joint
- Usually results from a high-energy trauma.
- Occurs with or without acetabular fracture.
- Eighty-five percent are posterior dislocations.
- Concomitant femur, knee, and patella fractures are common.
Posterior Hip Dislocation (ICD-9:835.01)
Usually the head of the femur is dislocated posterior to the acetabulum when the thigh is flexed, for example, as may occur in a head-on automobile collision when the knee is driven violently against the dashboard. Posterior dislocation is also a complication of hip arthroplasty, especially with the posterior approach.
The significant clinical findings are shortening, adduction, and internal rotation of the extremity. Anteroposterior, lateral, and, if fracture of the acetabulum is demonstrated, oblique radiographic projections (Judet views) are required. Common associated injuries include fractures of the acetabulum or the femoral head or shaft and sciatic nerve injury. The head of the femur may be displaced through a tear in the posterior hip joint capsule. The short external rotator muscles of the femur are commonly lacerated. Fracture of the posterior margin of the acetabulum can create instability.
If the acetabulum is not fractured or if the fragment is small, reduction by closed manipulation is indicated. Reduction should be achieved as soon as possible, under general anesthesia with maximum muscle relaxation, preferably within the first few hours after injury. The incidence of avascular necrosis of the femoral head increases with time until reduction. The main feature of reduction is traction in the line of deformity followed by gentle flexion of the hip to 90 degrees with stabilization of the pelvis by an assistant. While manual traction is continued, the hip is gently rotated into internal and then external rotation to obtain reduction (Allis method).
The stability of the reduction is evaluated clinically by ranging the extended hip in abduction and adduction and internal and external rotation. If stable, the same movements are repeated in 90 degrees of hip flexion. The point of redislocation is noted, the hip is reduced, and an AP radiograph of the pelvis is obtained. Soft-tissue or bone fragment interposition will be manifested by widening of the joint space as compared to the contralateral side. Irreducible dislocations, nonconcentric reductions, open dislocations, dislocations with ipsilateral femoral neck fractures, and dislocations that redislocate after reduction despite hip extension and external rotation (usually because of associated posterior wall fracture of the acetabulum) are indications for immediate ORIF if necessary. Most authors agree that a widened joint space on radiograph, despite a stable reduction, is also an indication for immediate arthrotomy. Others prefer obtaining a CT scan first to further delineate the incarcerated fragments and associated injuries before surgery. Recent studies support the use of hip arthroscopy as a safer alternative to arthrotomy for managing loose bodies.
Minor fragments of the posterior margin of the acetabulum may be disregarded, but larger displaced fragments are not usually successfully reduced by closed methods. ORIF with screws or plates is indicated.
Postreduction treatment will vary according to the type of initial surgery and the extent of the injury. Some period of skin or skeletal traction may be beneficial after strictly soft-tissue injury with a stable concentric reduction. Gradual weight bearing starting with crutch ambulation follows this period, progressing to full weight bearing at 6 weeks. Securely fixed fractures are treated as soft-tissue injuries, but weight bearing is allowed when radiologic signs of bone healing are present. When fixation is tenuous, skeletal traction for 4–6 weeks or hip spica immobilization may be necessary.
Complications include infection, avascular necrosis of the femoral head, malunion, posttraumatic degenerative joint disease, recurrent dislocation, and sciatic nerve injury. Avascular necrosis occurs because of the disruption of the retinacular arteries providing blood to the femoral head. Its incidence increases with the duration of the dislocation. It can occur as late as 2 years after the injury. MRI studies enabling early diagnosis and protected weight bearing until revascularization has occurred are recommended. Sciatic nerve injury is present in 10–20% of patients with posterior hip dislocation. Although usually of the neurapraxia type, these lesions leave permanent sequelae in about 20% of cases. The rare patient who is neurologically intact before reduction but has a deficit after reduction should be explored surgically to see if the nerve has been entrapped in the joint. Associated injuries also, on rare occasions, include fracture of the femoral head. Small fragments or those involving the non–weight-bearing surface should be ignored if they do not disturb hip mechanics; otherwise, they should be excised. Large fragments of the weight-bearing portion of the femoral head should be reduced and fixed if at all possible.
Anterior Hip Dislocation (ICD-9:835.03)
- Accounts for 10–15% of hip fracture dislocations.
- Occurs when the hip is extended and externally rotated at the time of impact.
Usually, the femoral head remains lateral to the obturator externus muscle but can be found rarely beneath it (obturator dislocation) or under the iliopsoas muscle in contact with the superior pubic ramus (pubic dislocation).
The hip is classically flexed, abducted, and externally rotated. The femoral head is palpable anteriorly below the inguinal flexion crease. AP and transpelvic lateral radiographic projections are usually diagnostic.
Closed reduction under general anesthesia is generally successful. Here also the surgeon must ensure a concentric reduction, comparing both hip joints on the postreduction AP radiograph. The patient starts mobilization within a few days when pain is tolerable. Active and passive hip motion, excluding external rotation, is encouraged, and the patient is usually fully weight bearing by 4–6 weeks. Skeletal traction or spica casting may rarely be useful for uncooperative patients.
Rehabilitation of Hip Fracture Patients
There has been an increased interest in the psychosocial outcomes of patients with hip fractures. The goal of rehabilitation after hip injuries is to return the patient as rapidly as possible to the preinjury functional level. Factors influencing rehabilitation potential include age, mental status, associated injuries, previous medical status, myocardial function, upper extremity strength, balance, and motivation.
For the rare patient treated conservatively, rehabilitation focuses early on preventing stiffness and weakness of the other extremities and, eventually, on mobilizing the patient out of bed when pain is tolerable. Because the great majority of these injuries are now treated with internal fixation or prosthetic replacement, rehabilitation efforts are focused toward early range of motion, muscle strengthening, and weight bearing. Early full weight bearing as tolerated is encouraged for patients with prosthetic replacements, cemented or not, and for patients with stable fixation of an intertrochanteric fracture to allow compression of the fracture fragments. Most authors now agree that the same applies for femoral neck fractures with stable internal fixation, although some still prefer partial weight bearing until radiologic evidence of bone healing is present to prevent hardware failure. When internal fixation does not provide stable fixation of the fracture fragments, supplemental protection may be added with a spica cast or brace; however, it is highly undesirable in elderly patients. Otherwise, restricted range of motion or weight bearing may be allowed according to the surgeon's specifications.
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- Fractures between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle.
- Closed intramedullary nailing is the standard of care for most of the fractures.
- Associated orthopedic injuries are common.
Diaphyseal Fractures (ICD-9:813.20)
Fracture of the shaft of the femur usually occurs as a result of severe trauma. Indirect force, especially torsional stress, is likely to cause spiral fractures that extend proximally or, more commonly, distally into the metaphyseal regions. Most are closed fractures; open fracture is often the result of compounding from within.
Extensive soft-tissue injury, bleeding, and shock are commonly present with diaphyseal fractures. The most significant features are severe pain in the thigh and deformity of the lower extremity. Hemorrhagic shock may be present, as multiple units of blood may be lost into the thigh, though only moderate swelling may be apparent. Careful radiographic examination in at least two planes is necessary to determine the exact site and configuration of the fracture pattern. The hip and knee should be examined and radiographs obtained to rule out associated injury. Concomitant ipsilateral femoral neck fractures may occur up to 9% of patients and must be suspected and evaluated as ipsilateral ligamentous and meniscal injury of the knee.
Injuries to the sciatic nerve and the superficial femoral artery and vein are uncommon but must be recognized promptly. Hemorrhagic shock and secondary anemia are the most important early complications. Later complications include those of prolonged recumbency, joint stiffness, malunion, nonunion, leg-length discrepancy, and infection.
Classically, the fracture is described according to its location, pattern, and comminution. Winquist has proposed a comminution classification that is now widely used.
- Type 1: Minimal or no comminution at the fracture site, stable after intramedullary nailing
- Type 2: Fracture with comminution leaving at least 50% of the circumference of the two major fragments intact
- Type 3: Fracture with comminution of 50–100% of the circumference of the major fragments; nonlocked intramedullary nails do not afford stable fixation
- Type 4: Fracture with completely comminuted segmental pattern with no intrinsic stability
Treatment depends on the age and medical status of the patient as well as the site and configuration of the fracture.
This remains a treatment option for some skeletally immature patients. Depending on the age of the pediatric patient and the amount of initial displacement at the fracture site, treatment may consist of immediate immobilization in a hip spica cast. In the adult, closed treatment of femoral shaft fractures is rarely indicated. Malalignment and joint stiffness are frequent. Other rare complications are pressure sores due to prolonged recumbency and DVT.
Reamed, locked, antegrade intramedullary nailing through the piriformis fossa is the gold standard for the treatment for most of the cases. Intramedullary fixation of femoral shaft fractures allows early mobilization of the patient (within 24–48 hours if the fracture fixation is stable), which is of particular benefit to the polytraumatized patient; more anatomic alignment; improved knee and hip function by decreasing the time spent in traction; and a marked decrease in the cost of hospitalization.
Although open nailing procedures have been described, intramedullary fixation is routinely performed closed. Utilization of the novel fluted reamer designs and use of sharp reamers help to avoid thermal necrosis and excessive fat embolization. Despite the theoretic damaging effect of reaming on the fracture healing, reaming allows use of a larger diameter and stronger implant, improves rotational control, and has been shown to reduce the rate of nonunion.
Closed nailing decreases the chance of infection by decreasing the amount of soft-tissue dissection necessary. In most cases, static interlocking should be used to provide rotational control and to prevent shortening of the bone at the fracture site. Dynamic interlocking screws are used at only one end of the nail, and this allows axial compression at the fracture site. Reamed interlocked nailing is recommended for most grade 1, 2, and 3a open fractures. Temporary bony stability may be achieved with external fixation devices when there is extensive soft-tissue loss associated, as in grade 3b and 3c open fractures.
Because of technical problems (eg, choice of a rod length) during the surgery, complications like malalignment or shortening may occur. Nonunions are rare, and one should always suspect deep infections if considered. Infections, leg-length discrepancy, and heterotrophic ossification are other complications after this procedure. The rod may be removed after healing is complete, usually at 12–16 months. Retrograde nailing may be beneficial in some multiply injured trauma patients and morbidly obese and pregnant patients.
Flexible intramedullary rods of the Ender type do not provide sufficient stability in the adult; however, they are routinely used in the pediatric population. Plates and screws require significant soft-tissue dissection and opening of the fracture hematoma and are usually reserved for special cases such as ipsilateral femoral neck and diaphyseal fractures. External fixation remains indicated in some open fractures. In polytrauma patients, initial external fixation may be indicated when early intramedullary nailing (first 24 hours after trauma) might be potentially hazardous due to hemodynamic instability or head or chest trauma. It has also recently gained acceptance as treatment for closed femoral shaft fractures in children to allow earlier mobilization and decreased hospital stays. The distal fragment pins should always be inserted with the knee in flexion to avoid quadriceps tenodesis that will prevent knee flexion. Superficial pin tract infection is common but rarely involves the bone.
Subtrochanteric Fractures (ICD-9:822.22)
- Between lesser trochanter and a point 5 cm distal to the lesser trochanter.
- Frequent site of pathologic fracture.
Subtrochanteric fractures occur below the level of the lesser trochanter and are usually the result of high-energy trauma in young to middle-aged adults. They are often comminuted, with distal or proximal extension toward the greater trochanter. The patient usually presents with a swollen painful proximal thigh with or without shortening or malrotation. If the lesser trochanter is intact, the proximal fragment will tend to displace in flexion, external rotation, and abduction because of the unopposed pull of the iliopsoas and abductor muscles.
Recent reports suggest there may be a correlation between bisphosphonate use and low-energy subtrochanteric fractures that radiographically present atypically as transverse or slightly oblique, with medial beaking and marked thickening of the lateral cortex. These fractures typically heal late and necessitate surgical intervention.
The Russell and Taylor classification (Figure 2–18) is a treatment-based classification system that incorporates involvement of the piriformis fossa. Type Ia Russell-Taylor fractures do not involve the piriformis fossa, with the lesser trochanter attached to the proximal fragment. These fractures may be treated with a first-generation intramedullary nail. Type Ib fractures do not involve the piriformis fossa; however, the lesser trochanter is detached from the proximal fragment. These fractures require a second-generation nail, with screw fixation into the head and neck. Type II fractures have fracture extension into the piriformis fossa and are best treated with a sliding hip screw or fixed angle plate.
Russell and Taylor classification of subtrochanteric femur fractures. (Reproduced, with permission, from Browner BD, Levine A, Jupiter J, et al, eds: Skeletal Trauma, 2nd ed. New York: WB Saunders; 1998.)
In the vast majority of cases, internal fixation (by closed or open methods) is now widely favored. Temporary skeletal traction will maintain femoral length until the definitive surgical procedure can be performed. A variety of devices are available.
Fixation can be obtained with first-generation intramedullary nails, “gamma nails,” intramedullary hip screws, or a variety of cephalomedullary nails or blades and long side plates based on the fracture pattern.
Postoperative activity depends on the adequacy of internal fixation. If fixation is solid, an agile cooperative patient can be out of bed within a few days after surgery and ambulating on crutches with toe-touch weight bearing on the affected side. The fracture is usually healed at 3–4 months, but delayed union and nonunion are not uncommon. Hardware failure is not uncommon. Repeat internal fixation with autogenous bone grafting is then the treatment of choice.
Black DM, Kelly MP, Genant HK, et al: Bisphosphonates and fractures of the subtrochanteric or diaphyseal femur. N Engl J Med
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Dora C, Leunig M, Beck M, et al: Entry point soft tissue damage in antegrade femoral nailing: a cadaver study. J Orthop Trauma
Giannoudis PV, MacDonald DA, Matthews SJ, et al: Nonunion of the femoral diaphysis. J Bone Joint Surg Br
Herscovici D, Ricci WM, McAndrews P, et al: Treatment of femoral shaft fracture using unreamed interlocked nails. J Orthop Trauma
Nowotarski PJ, Turen CH, Brumback RJ, et al: Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am
Ostrum RF, Agarwal A, Lakatos R, et al: Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma
Patton JT, Cook RE, Adams CI, et al: Late fracture of the hip after reamed intramedullary nailing of the femur. J Bone Joint Surg Br
Ricci WM, Bellabarba C, Lewis R, et al: Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma
Ricci WM, Bellabarba C, Evanoff B, et al: Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Orthop Trauma
Shepherd LE, Shean CJ, Gelalis ID, et al: Prospective randomized study of reamed versus undreamed femoral intramedullary nailing: an assessment of procedures. J Orthop Trauma
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Tornetta P 3rd, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol. J Bone Joint Surg Am
- Largest sesamoid bone in the body.
- Straight leg test is mandatory to assess extensor mechanism.
- Severe hemarthrosis is common.
Transverse Patellar Fracture (ICD-9:822.0)
Transverse fractures of the patella (Figure 2–19) are the result of an indirect force, usually with the knee in flexion. Fracture may be caused by sudden voluntary contraction of the quadriceps muscle or sudden forced flexion of the leg with the quadriceps contracted. The level of fracture is commonly in the middle. Associated tearing of the patellar retinacula depends on the force of the initiating injury. The activity of the quadriceps muscle causes upward displacement of the proximal fragment, the magnitude of which depends on the extent of the retinacular tear.
Transverse fracture of the patella. (Reprinted from Canale ST, ed: Campbells Operative Orthopaedics, 9th ed. Vol. 3. Copyright 1998, Mosby, with permission from Elsevier.)
Swelling of the anterior knee region is caused by hemarthrosis and hemorrhage into the soft tissues overlying the joint. If displacement is present, the defect in the patella can be palpated, and active extension of the knee is lost. A straight leg raise may be preserved if the retinaculum is intact.
Nondisplaced fractures can be treated with a walking cylinder cast or brace for 6–8 weeks followed by knee rehabilitation. Open reduction is indicated if the fragments are displaced more than 3 mm or if articular step-off is more than 2 mm. The fragments must be accurately repositioned to prevent early posttraumatic arthritis of the patellofemoral joint. If the minor fragment is small (no more than 1 cm in length) or severely comminuted, it may be excised and the quadriceps or patellar tendon (depending on which pole of the patella is involved) sutured directly to the major fragment. Whenever possible, internal fixation of anatomically reduced fragments should be done, allowing early motion of the knee joint. This is best achieved by figure-of-8 tension banding over two longitudinal parallel K-wires or cannulated screws. Accurate reduction of the articular surface must be confirmed by lateral radiographs taken intraoperatively.
Comminuted Patellar Fracture (ICD-9:822.0)
Comminuted fractures of the patella are usually caused by a direct force. Severe injury may cause extensive destruction of the articular surface of both the patella and the opposing femur.
If comminution is not severe and displacement is insignificant, immobilization for 8 weeks in a cylinder extending from the groin to the supramalleolar region is sufficient.
Severe comminution can often be treated with ORIF with addition of a cerclage wire, but on rare occasions, excision of the patella with repair of the defect by imbrication of the quadriceps expansion is the only viable alternative. Excision of the patella can result in decreased strength, pain in the knee, and general restriction of activity. No matter what the treatment, high-energy injuries are frequently complicated by chondromalacia patella and patellofemoral arthritis.
Patellar Dislocation (ICD-9:836.3)
Acute traumatic dislocation of the patella should be differentiated from episodic recurrent dislocation, because the latter condition is likely to be associated with occult organic lesions. When dislocation of the patella occurs alone, it may be caused by a direct force or activity of the quadriceps, and the direction of dislocation of the patella is almost always lateral. Spontaneous reduction is apt to occur if the knee joint is extended. If so, the clinical findings may consist merely of hemarthrosis and localized tenderness over the medial patellar retinaculum. Gross instability of the patella, which can be demonstrated by physical examination, indicates that injury to the soft tissues of the medial aspect of the knee has been extensive. Balcarek et al found that 98.6% of the patients who had lateral patella dislocations also had medial patellofemoral ligament injuries, with a complete tear in 51.4% of cases and injuries most frequently localized at the femoral attachment site.
Reduction is maintained in a brace or cylinder cast with the knee in extension for 2–3 weeks. Isometric quadriceps exercises are encouraged. Physical therapy should be initiated to maximize the strength of the vastus medialis. Dynamic bracing may be helpful. Recurrent episodes require operative repair for effective treatment.
Tear of the Quadriceps Tendon (ICD-9:727.65)
Tear of the quadriceps tendon occurs most often in patients over the age of 40. Apparent tears that represent avulsions from the patella occur in patients with renal osteodystrophy or hyperparathyroidism. Preexisting attritional disease of the tendon is apt to be present, and the causative injury may be minor.
Swelling is caused by hemarthrosis and extravasation of blood into the soft tissues. The patient is unable to extend the knee completely. Radiographs may show a bony avulsion from the superior pole of the patella if a small flake of bone is avulsed from the superior pole of the patella.
Operative repair is recommended for complete tear. Postoperative immobilization should be encouraged in a walking cylinder cast or brace for 6 weeks, at which time knee mobilization is started.
Tear of the Patellar Tendon (ICD-9:727.66)
The same mechanism that causes tears of the quadriceps tendon, transverse fracture of the patella, or avulsion of the tibial tuberosity may also cause the patellar ligament to tear. The characteristic finding is proximal displacement of the patella. A bony avulsion may be present adjacent to the lower pole of the patella if the tear takes place in the proximal patellar tendon.
Operative treatment is necessary for a complete tear. The ligament is resutured to the patella, and any tear in the quadriceps mechanism is repaired. The extremity should be immobilized for 6–8 weeks in a cylinder cast extending from the groin to the supramalleolar region. Guarded exercises may then be started.
Balcarek P, Ammon J, Frosch S, et al: Magnetic resonance imaging characteristics of the medial patellofemoral ligament lesion in acute lateral patellar dislocations considering trochlear dysplasia, patella alta, and tibial tuberosity-trochlear groove distance. Arthroscopy
Jutson JJ, Zych GA: Treatment of comminuted intraarticular distal femur fractures with limited internal and external tensioned wire fixation. J Orthop Trauma
Meyer RW, Plaxton NA, Postak PD, et al: Mechanical comparison of a distal femoral side plate and a retrograde intramedullary nail. J Orthop Trauma
Stahelin T, Hardegger F, Ward JC: Supracondylar osteotomy of the femur with use of compression. J Bone Joint Surg
Woo SL, Vogrin TM, Abramowitch SD: Healing and repair of ligament injuries in the knee. J Am Acad Orthop Surg
Distal Femur Fractures (ICD-9:821.23)
- Account for 7% of all femur fractures.
- Important to distinguish between supracondylar and articular fractures.
- Increasingly seen as periprosthetic fractures.
These fractures involve the distal 10–15 cm of the femur and are usually seen as low-energy fractures in the elderly and high-energy fractures in young patients. The distal fragment is usually rotated into extension from traction by the gastrocnemius muscle. The distal end of the proximal fragment is apt to perforate the overlying quadriceps and may penetrate the suprapatellar pouch, causing hemarthrosis. The distal fragment may impinge on the popliteal neurovascular bundle, and an immediate thorough neurovascular examination is mandatory. Absence or marked decrease of pedal pulsations is an indication for immediate reduction. If this fails to restore adequate circulation, an arteriogram should be obtained immediately and the vascular lesion repaired as indicated. Injuries to the tibial or peroneal nerves are less frequent. Treatment should be aimed at restoring the mechanical axis, anatomic reduction of the articular surface, and early knee range of motion.
A temporary spanning external fixation can be used to stabilize the fracture in polytrauma patients. Two pins can be rapidly allocated in the femoral shaft and two additional pins in the tibial shaft. ORIF can be safely done in the first 2 weeks when the patient has been hemodynamically stabilized without increasing the risk of infection, provided that no infection at the pin sites has occurred. Complex trauma of the knee encompasses a distal supra- or intercondylar femoral fracture combined with a proximal tibial fracture (floating knee); a supra- or intercondylar femoral fracture with a second- or third-degree closed or open injury; or a complete knee dislocation and possible associated neurovascular injuries. Because of the complexity of injury and multidisciplinary team approach, this subset of patients is better treated in level 1 trauma centers.
Most extraarticular fractures are best treated with internal fixation: fixed-angle plates, locking plates using minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques, or retrograde intramedullary nailing. Skeletal traction treatment is reserved for patients for whom surgery is contraindicated.
As for any intraarticular fracture, maximal functional recovery of the knee joint requires anatomic reduction of the articular components and restitution of the mechanical axis. Closed reduction of displaced fragments is almost never successful. Displaced intraarticular fractures usually require ORIF with a variety of methods including dynamic compression screws, AO buttress plating, and less invasive stabilization system (LISS), with or without MIPPO.
According to the configuration of the articular fragments, displaced T- or Y-type fractures of the distal femoral epiphysis are best treated by open reduction. Even if the fracture heals in anatomic position, joint stiffness, pain, and posttraumatic arthritis are not uncommon outcomes.
Isolated fractures of the lateral or medial femoral condyles are rare and usually associated with ligament injury. They usually result from varus or valgus stress to the knee joint. Fractures of the posterior portion of one or the other condyle in the frontal plane can also be seen (Hoffa fracture).
ORIF is usually indicated and requires anteroposterior lag screws. Associated ligamentous ruptures are repaired as needed. If fixation is solid, postoperative immobilization is kept at a minimum, and the patient can start moving the knee joint early. Weight bearing is usually allowed at 3 months when clinical and radiologic evidence of bone healing is present.
Anatomy and Biomechanical Principles
The knee is a modified synovial hinge joint formed by three bones: the distal femur, the proximal tibia, and the patella. It is often divided into three compartments: medial, lateral, and patellofemoral.
The distal femoral diaphysis broadens into two curved condyles at the metaphyseal junction. Each condyle is convex and articulates distally with its corresponding tibial plateau. Their articular surfaces join anteriorly to articulate with the patella. Posteriorly, they remain separate to form the intercondylar notch. The lateral condyle is wider in the sagittal plane (preventing lateral patella displacement) and extends further proximally. The medial condyle is narrower but extends further distally. This difference in length of both condyles allows for the distance between both knees, when weight bearing, to be smaller than the distance between both hips. Both condylar surfaces form a horizontal plane parallel to the ground and create an anatomic angle (physiologic valgus position) of 5–7 degrees with the femoral shaft. Normally, the centers of the hip, knee, and ankle joints are all aligned to form a mechanical angle of 0 degrees. The supracondylar area of the femur is defined as the distal 9 cm. Fractures proximal to this are considered femoral shaft fractures and carry a different prognosis.
As for the distal femur, the proximal tibia widens proximally at the diaphyseal-metaphyseal junction to form the medial and lateral tibial plateaus (condyles). There is a 7- to 10-degree slope from anterior to posterior of the tibial plateaus. The tibial eminence, with its medial and lateral spines, separates both compartments and is the attachment for the cruciate ligaments and the menisci. Distal to the joint itself, the tibia has two prominences: the tibial tubercle anteriorly, where the patellar tendon attaches, and Gerdy's tubercle anterolaterally, where the iliotibial band inserts. Posterolaterally, the under surface of the tibial condyle articulates with the fibular head to form the proximal tibiofibular joint.
The patella is the biggest sesamoid bone in the body. It lies within the substance of the quadriceps tendon. The distal third of the under surface is nonarticular and provides attachment for the patellar tendon. The proximal two thirds articulates with the anterior surface of the femoral condyles and is divided into medial and lateral facets by a longitudinal ridge. The area of contact at the patellofemoral joint varies according to the degree of knee flexion. On each side of the patella are the medial and lateral retinacular expansions formed by fibers of the vastus medialis and vastus lateralis muscles. These expansions bypass the patella to insert directly on the tibia. When intact, they can allow active knee extension even in the presence of a fractured patella. The blood supply to the patella is derived from anastomosis of the genicular vessels from the distal pole proximally. Avascular necrosis of a proximal fracture fragment is not uncommon.
The main plane of motion of the knee is flexion and extension, but physiologically, internal and external rotation, abduction and adduction (varus and valgus), and anterior and posterior translations also occur. The intrinsic bony configuration of the joint affords little stability. A complex soft-tissue network provides joint stability under physiologic loading. It includes passive stabilizers, such as medial and lateral collateral ligaments, medial and lateral menisci, anterior and posterior cruciate ligaments, and joint capsule, and active stabilizers, such as the extensor mechanism, the popliteus muscle, and the hamstrings with their capsular expansions. All these soft-tissue components work together in an extremely complex and finely tuned way to prevent excessive displacement of the joint surfaces throughout the full arc of motion under physiologic loading. When abnormal stresses that exceed the soft tissues' ability to resist them are transmitted across the joint, an infinite range of injuries can occur. These may be isolated or combined, partial or complete, and may or may not be associated with bony injuries. An accurate diagnosis, although sometimes difficult, is essential before the appropriate treatment can be decided upon.
- Associated injuries to bone, cartilage, and menisci are common.
- Knowledge of the mechanism of injury is of paramount importance, as certain injury patterns may be anticipated.
- Grade 1 and 2 medial collateral injuries can be treated conservatively.
An efficient clinical examination is sometimes difficult, because patients guard examinations due to pain in the acute phase and these are generally young muscular athletes with a large lower extremity, but clinical examination is essential and will usually provide key diagnostic information.
Plain radiographs are of limited benefit. They will show fractures, bony avulsions at ligament attachment sites, or capsular avulsions.
MRI is now by far the imaging tool of choice for ligamentous injuries of the knee, with an accuracy rate above 95%. Diagnostic arthroscopy is now reserved for cases when MRI is inconclusive or the surgeon is fairly sure that surgical treatment of a lesion will be necessary.
Medial (Tibial) Collateral Ligament Injury (ICD-9:844.1)
This ligament normally resists valgus angulation at the knee joint. It is the most commonly seen isolated ligament injury and generally seen in the young athletic population. A history of abduction injury, often with an external torsional component, is usually obtained. Examination reveals tenderness over the site of the lesion and often some knee effusion. When compared with the contralateral knee, valgus stressing with the knee flexed at 20–30 degrees will show exaggerated laxity at the joint line, signaling a complete tear. The subjective gapping on the medial joint line during valgus applied force at 30 degrees of knee flexion is used for grading these injuries (Table 2–6). Stress radiographs can, on rare occasions, be useful in confirming the diagnosis.
Table 2–6. Subjective Gapping of the Medial Joint Line during Valgus Applied Force at 30 Degrees of Knee Flexion. ||Download (.pdf)
Table 2–6. Subjective Gapping of the Medial Joint Line during Valgus Applied Force at 30 Degrees of Knee Flexion.
Grade 1 and 2 sprains (incomplete) are treated with protective weight bearing in a hinged brace or cast to prevent further injury while healing progresses. Grade 3 sprains (complete) are rarely isolated. Known associated injuries, such as medial meniscus damage, anterior cruciate ligament (ACL) tear, or lateral tibial plateau fractures, should be systematically ruled out. Most surgeons now favor conservative treatment of isolated grade 3 medial collateral ligament tears in a long leg hinged-knee brace for 4–6 weeks. Concomitant ACL injuries determine the success of treatment for these injuries.
Lateral (Fibular) Collateral Ligament Injury (ICD-9:844.0)
This ligament originates from the lateral femoral condyle and inserts on the fibular head. It is the primary static varus stabilizer of the knee joint. Isolated injuries are extremely rare. Most often, there is a combination of varying degrees of injury to the posterolateral corner (PLC), which includes the biceps tendon, posterolateral capsule, popliteus tendon, and iliotibial band. Associated ACL and posterior cruciate ligament injuries are more common than isolated injuries. Injury to the peroneal nerve can be seen. Pain and tenderness are present over the lateral aspect of the knee, usually with some intraarticular effusion. A through physical examination combined with plain x-ray and MRI is paramount for diagnosis. ACL and posterior cruciate ligament reconstructions often fail in the presence of an unrecognized fibular collateral or PLC injury. Varus stress radiographs are useful for detecting these injuries. In severe injuries, there is abnormal laxity on varus stressing at 0 and 30 degrees of flexion, compared with the other knee.
When there is an avulsion of the fibular head and this fragment is of sufficient size, internal fixation with a screw gives excellent results. Most injuries require operative treatment. Immediate repair or primary reconstruction in the acute setting gives better results than late reconstruction.
Anterior Cruciate Ligament Injury (ICD-9:844.2)
This ligament originates at the posteromedial aspect of the lateral femoral condyle and inserts near the medial tibial spine. Because it is composed of at least two distinct fiber bundles, part of it remains taut throughout the normal flexion-extension arc of motion. It prevents anterior translation (gliding) of the tibia under the femoral condyles. Isolated injuries are frequent, especially with hyperextension mechanism, as seen in skiers, volleyball players, or basketball players. Valgus, flexion, external rotation injury results in damage to the medial collateral ligament, medial meniscus, and ACL (the terrible triad). When the tear is complete, it most often occurs within the substance of its fibers. Rarely, bony avulsion at the femoral or tibial attachment will be seen on plain radiograms. Associated medial collateral ligament, medial meniscus, posteromedial capsule, and even posterior cruciate ligament injuries are more common.
The patient usually recalls the mechanism of injury and classically feels a popping or snapping sensation in the knee. A moderate effusion usually accumulates during the first few hours. The only clinical finding in acute ACL deficiency may be a positive Lachman test, which is the anterior drawer test performed with 20–30 degrees of knee flexion. The classic drawer test, done with the knee flexed at 90 degrees and the foot resting on the table, is not as reliable. The injured knee should always be compared with the uninjured contralateral knee. In chronic ACL deficiency, secondary restraints have stretched out and other clinical signs, such as the pivot shift and the active drawer sign, become more apparent.
Despite the fact that ACL reconstruction does not prevent osteoarthritis, ACL deficiency causes knee pain, functional impairment, and an increased risk of meniscus tear and early knee osteoarthritis. Although surgical reconstruction is indicated in most instances, functionally stable knees can be managed conservatively with rehabilitation therapy and bracing. Patients who remain unacceptably unstable after conservative treatment can still benefit from delayed reconstructive surgery. When bony avulsions from the femur or tibia are present, surgical repair is indicated, as bone-to-bone healing and good long-term results have been demonstrated. Primary repair of the ligament stumps without reconstruction is likely to fail. Arthroscopically assisted reconstruction with the middle third of the patellar tendon or harvest of an autogenous hamstrings graft gives excellent results. Recently, there has been a trend to perform anatomic double-bundle repairs and single-bundle reconstruction through an anteromedial portal.
Posterior Cruciate Ligament Injury (ICD-9:844.2)
The posterior cruciate ligament is a broad thick ligament that extends from the lateral aspect of the medial femoral condyle posteriorly and inserts extraarticularly over the back of the tibial plateau approximately 1 cm below the joint line. It resists posterior translation (gliding) of the tibia under the femoral condyle. It usually ruptures after a posteriorly directed force on the proximal tibia as is sometimes seen in dashboard injuries. Posterior cruciate ligament ruptures can also occur as the end stage of severe hyperextension injuries.
The posterior drawer test will be positive, as will the sag test, showing posterior sagging of the tibia with the knee flexed to 90 degrees compared with the opposite side. As for the ACL, the rupture may be at the bone–ligament junction or more often in the middle substance of the ligament.
Most isolated posterior cruciate ligament tears can be treated successfully with conservative treatment with rehabilitation (ie, reducing inflammation, strengthening extensor mechanism, regaining knee motion, and gradual return to sports within 3–6 weeks). If the posterior tibial translation compared with that of the contralateral knee is over 10 mm, there is associated PLC injury and surgical treatment is recommended.
Meniscal Injury (ICD-9:836.0, 1, 2)
The meniscus is a fibrocartilage that allows a more congruous fit between the convex femoral condyle and the flat tibial plateau. Both medial and lateral menisci are attached peripherally and have a central free border. They are wedge-shaped and thicker at the periphery. The medial meniscus is C-shaped, and the lateral meniscus is O-shaped, with both anterior and posterior horns almost touching medially. They are vascularized only at their peripheral third. Tears involving that vascularized portion have a better repair potential. The menisci spread the load more uniformly on the underlying cartilage, thus minimizing point contact and wear. They are secondary knee stabilizers but are more important in the ligament-deficient knee.
Tears can be secondary to trauma or attrition. The medial meniscus is more often involved. Symptoms include pain, swelling, a popping sensation, and occasionally locking and giving way. Examination usually reveals nonspecific medial or lateral joint-line pain, and occasionally grinding or snapping can be felt with tibial torsion and the knee flexed to 90 degrees (McMurray sign). Radiographs are of minimal value but may rule out other disorders; MRI has replaced contrast arthrography as the diagnostic tool of choice.
Initial conservative management with immobilization, bracing, protective weight bearing, and exercises can give good results. Arthroscopic evaluation and treatment are recommended for recurrent or persistent locking, recurrent effusion, or disabling pain. If the tear is large enough and in the vascularized portion, repair should be attempted. For other tears, the affected area should be removed, leaving as much as possible of the healthy meniscus. Routine total meniscectomy has been abandoned because of the high incidence of subsequent arthritis.
Chondral and Osteochondral Injuries (ICD-9:733.92)
The hyaline articular cartilage is avascular and has no intrinsic capability to repair superficial lacerations. Deep injuries involve the bone in the subchondral plate, and extrinsic repair occurs first with a fibrin clot replaced by granulation tissue, which is then transformed to fibrocartilage. Repetitive injury can cause abnormal motion with shearing stresses that can loosen chondral or osteochondral fragments. Compression injuries to the cartilage can lead to posttraumatic chondromalacia.
Chondral injuries usually give nonspecific symptoms that mimic meniscal injury. Plain radiographs will often reveal a loose body if the osteochondral fragment is big enough. Tunnel views and patellar tangential views can be helpful in visualizing fragments. Although it can miss the delaminating injuries, superficial flap tears, and surface fibrillations, MRI is the optimal diagnostic tool for articular lesions. However, arthroscopy remains the most accurate diagnostic procedure.
Debridement, fixation of the osteochondral fragment, bone marrow stimulation, which is excision of the free fragment, debridement of the donor site, microfracture or drilling of the underlying subchondral bone to promote fibrin clot formation, mosaicplasty, and autologous chondrocyte implantation with or without using a scaffold are the most common treatment options. Selection of the treatment depends on the age of the patient, size of the defect, skeletal maturity, and presence of adequate subchondral bone. After the surgery, gaining preoperative function usually takes months depending on the extent of the articular damage.
Knee Dislocation (ICD-9:836.5)
Traumatic dislocation of the knee is a rare injury that often results from high-energy trauma but may occur from low-energy injuries in the elderly. It is classified according to the direction of displacement of the tibia: anterior, posterior, lateral, medial, or rotatory. Complete dislocation can occur only after extensive tearing of the supporting ligaments and soft tissues. Injury to the neighboring neurovascular bundle is common and should be looked for systematically.
Knee dislocations require prompt reduction. This is most easily accomplished in the emergency room by applying axial traction on the leg. Rarely, reduction can only be obtained under general anesthesia. The role of angiography is controversial. If pulses and ankle-brachial pressure index are normal, the limb is closely observed. Studies have shown that the isolated presence of abnormal foot pulses is not sensitive enough to detect a surgical vascular injury. Furthermore, one study demonstrated no vascular injury in any of their traumatic knee dislocations with initial normal vascular examination. Angiograms can be useful in the limb with obvious vascular injury but should not delay treatment. Any vascular injury should be repaired as soon as possible. Ischemia of more than 4 hours implies a poor prognosis for salvage of a functional limb. Prophylactic fasciotomies should be performed at the time of vascular repair to prevent compartment syndrome caused by postrevascularization edema.
Most authors now agree that surgical repair of all ligaments is indicated in relatively young (<50 years) active patients. Early reconstructions yield better results. Open dislocations, irreducible dislocations, and popliteal artery damage necessitate immediate surgical treatment.
Intensive quadriceps and hamstring rehabilitation is necessary to minimize functional loss. The need for a brace for strenuous activities may be permanent.
Proximal Tibia Fractures (ICD-9:823.0)
Tibial Plateau Fractures (ICD-9:823.00)
- Tibia plateau represents a spectrum of intraarticular injuries with a wide variety of injury patterns.
- Regardless of the treatment choice, posttraumatic osteoarthritic changes are common.
Proximal tibia plateau fractures account for 1% of all fractures. Lateral tibial plateau fractures account for 60% of plateau fractures. Like other metaphyseal fractures, impaction injury creates a void of structural bone loss. These fractures commonly result from axial loading, combined with varus and valgus force. Associated meniscal and ligamentous injuries are common. Using MRI, Gardner et al showed that 91% of patients had evidence of lateral meniscus pathology, 44% had medial tears, 57% had ACL injuries, and 68% had pathology in the posterolateral corner. A thorough neurovascular evaluation should also be recorded as high-energy fractures and fracture-dislocations can be associated with a popliteal artery injury.
Many different classification systems have been proposed, none with universal acceptance. The most widely used system is the Schatzker classification: type I, split fracture of the lateral plateau; type II, split-depression of the lateral plateau; type III, depression of the lateral plateau; type IV, medial plateau fracture; type V, bicondylar fracture; and type VI, a fracture with metaphyseal-diaphyseal dissociation (Figure 2–20). Proper classification is based on quality radiographs, including oblique views if necessary. CT and three-dimensional CT have become an important adjuvant for preoperative planning and evaluating postoperative reductions. MRI is useful for the identification of associated soft-tissue injuries.
Schatzker classification of tibial plateau fractures: A, type I: lateral split; B, type II: lateral split depression; C, type III: lateral depression; D, type IV: medial plateau; E, type V: bicondylar; F, type VI: bicondylar with separation of metaphysis from diaphysis. (Reproduced, with permission, from Rockwood CA, Green DP, Bucholz RW, et al, eds: Fractures in Adults, 4th ed. Philadelphia: Lippincott; 1996.)
The goal of treatment is to restore the anatomic contours of the articular surface, facilitate soft-tissue healing, and prevent knee stiffness. Both closed and open treatment can achieve these goals. The choice will depend on multiple factors, including the patient's age and general medical condition, the degree of displacement and comminution of the fracture, associated local soft-tissue and bony injuries, local skin condition, residual knee stability, and fracture configuration.
Closed treatment with a functional brace is appropriate for minimally displaced fractures with stable ligaments. Varus and valgus laxity at full extension is a poor prognostic sign for closed treatment. Articular step-offs of 3 mm or less and condylar widening of 5 mm or less can be treated conservatively. Lateral or valgus tilt up to 5 degrees is well tolerated. Medial plateau fractures with any significant displacement should be surgically stabilized due to the propensity for further displacement. Bicondylar fractures with any medial displacement, valgus tilt of more than 5 degrees, or significant articular step-off should be surgically stabilized. Immediate range of motion is usually encouraged with protected weight bearing at 8–12 weeks. Noncomminuted fractures can undergo closed reduction with fluoroscopic imaging and percutaneous screw placement.
ORIF with plates and screws remains an effective operative treatment. Reduction should be as anatomically precise as possible, and fixation should be solid enough to allow early mobilization. More recently, minimally invasive plate osteosynthesis (MIPO) is being used in the treatment of these injuries. Bone defects should be grafted with autograft, allograft, or structural graft substitutes. Early range of motion is allowed according to the stability of the construct. Open surgery should only be undertaken when the soft tissues are minimally swollen; for unstable fractures, temporary external fixation with delayed definitive surgery has been shown to be safe and effective.
External monolateral or ring fixator can be used for provisional and definitive treatment depending on the clinical situation and experience of the surgical team. The proximal pin in the tibia must be no closer than 14 mm to the joint line to prevent septic arthritis. Hybrid and ring external fixators have been found to be useful for bicondylar injuries with severe soft-tissue trauma.
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Gardner MJ, Yacoubian S, Geller D, et al: The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma
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Kumar A, Whittle AP: Treatment of complex (Schatzker type VI) fractures of the tibial plateau with circular wire external fixation: a retrospective case review. J Orthop Trauma
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Early complications of tibia plateau fracture management include infection, DVT, compartment syndrome, loss of reduction, and hardware failure. Late complications include residual instability and posttraumatic degenerative joint disease that may require total knee replacement arthroplasty or arthrodesis.
Tibial Tuberosity Fracture (ICD-9:823-02)
Tibial tuberosity fractures can occur with a violent quadriceps muscle contraction causing avulsion of the tibial tuberosity. When the fracture is complete, the extensor mechanism is disrupted and active knee extension is impossible.
Although conservative treatment of a nondisplaced avulsion fracture with a cylinder cast in extension for 6–8 weeks will allow it to heal, rigid screw fixation permits earlier knee mobilization. Closed or open reduction with internal fixation is recommended for all fractures displaced by 5 mm or more.
Tibial Eminence (Spine) Fracture (ICD-9:823.80)
A tibial eminence fracture occurs as an isolated injury or as part of the comminution of tibial plateau fractures. The isolated type of injury occurs mostly in the pediatric population. Meniscal, capsular, or collateral ligament or osteochondral injuries are seen in up to 40% of patients.
Meyers has classified this lesion into three types. Nondisplaced type 1 can be treated nonsurgically with a cylinder cast with the knee in extension for 6 weeks. Type 2 is displaced in the anterior margin and can be treated nonsurgically if anatomic reduction is achieved with a cast. Type 3 fractures should be surgically fixed. Permanent or absorbable sutures, K-wire, or screws can be used for fixation. When associated with other fractures of the tibial plateau, the tibial eminence fragment usually keeps its attachment to the anterior cruciate ligament, and anatomic reduction with rigid fixation should be obtained.
Tibia and Fibula Injuries
- Tibia fracture is the most common long bone fracture.
- Due to the subcutaneous location of the anteromedial tibia, open fractures occur in high incidence.
- The treating physician must be aware of the clinical signs of compartment syndrome.
The tibial diaphysis is straight and triangular in cross-section. Its anteromedial border and anterior crest are palpable throughout the entire length of the bone and are useful landmarks for closed reduction techniques and cast molding with pressure relief, as are the palpable fibular head, distal third of the fibula, medial malleolus, and patellar tendon. The distal half of the leg has more tendons and less muscle than the proximal half, and thus soft-tissue coverage and blood supply of the distal tibia are more precarious than in the proximal portion. The fibula transmits approximately one sixth of the axial load from the knee to the foot and the tibia five sixths.
From a surgical standpoint, the leg is divided into four fascial compartments. A compartment is defined by the unyielding boundaries, such as bone and fascia, enclosing a group of muscles. The anterior compartment is limited medially by the tibia, posteriorly by the interosseous membrane, laterally by the fibula, and anteriorly by the crural fascia. The anterior compartment contains the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius muscles, responsible for ankle and toe extension, as well as the anterior tibial artery and the deep branch of the peroneal nerve. The lateral compartment contains the peroneus brevis and longus muscles responsible for ankle flexion and foot eversion and the superficial branch of the peroneal nerve. The superficial posterior compartment contains the gastrocnemius, soleus, plantaris, and popliteus muscles and the sural nerve. The deep posterior compartment is enclosed by the tibia, the interosseous membrane, and the deep transverse fascia and contains the tibialis posterior, flexor hallucis longus, flexor digitorum longus muscles, and posterior tibial and peroneal arteries and the tibial nerve.
Tib-Fib Fractures (ICD-9:823.22)
Fractures of the tibial or fibular diaphysis are the result of direct or indirect trauma, with some of these injuries being open fractures. A thorough assessment of the surrounding soft tissues is mandatory. One must remember that the size of the skin wound does not necessarily correlate with the amount of underlying soft-tissue damage. A 1-cm skin laceration can be associated with an extensive muscle and periosteal injury, making the fracture a Gustilo grade III instead of I, with a much poorer prognosis. Also, closed tibia fractures can be associated with significant soft-tissue injury. In 1982, Tscherne and Oestern classified the soft-tissue injury in ascending order of severity (grades 0–3):
- Grade 0: Soft-tissue damage is absent or negligible.
- Grade 1: There is a superficial abrasion or contusion caused by fragment pressure from within.
- Grade 2: A deep contaminated abrasion is present associated with localized skin or muscle contusion from direct trauma. Impending compartment syndrome is included in this category.
- Grade 3: The skin is extensively contused or crushed, and muscular damage may be severe. Subcutaneous avulsions, compartment syndrome, and rupture of a major blood vessel associated with a closed fracture are additional criteria.
When the fracture is displaced, the clinical diagnosis is usually evident. All compartments should be palpated, and a thorough distal neurovascular examination should be recorded.
Radiographs in the AP and lateral projections are taken of the entire leg, including the knee and ankle joints. Oblique views are sometimes necessary. Fractures of the distal end of the tibia (pilon or plafond fractures) can be better visualized with CT scanning.
Fibula Diaphysis Fractures (ICD-9:823.21)
Isolated fibula fractures can be associated with other injuries of the leg, such as fracture of the tibia or fracture-dislocation of the ankle joint. One should pay particular attention to the medial malleolus to rule out deltoid ligament rupture or medial malleolus fracture. Isolated fibula fracture can be the result of a direct blow; however, it can also coincide with syndesmosis disruption. If reduction of the mortise is congruent, radiographic follow-up is needed to ensure maintenance of reduction.
Tibia Diaphyseal Fractures (ICD-9:823.20)
Isolated fractures of the tibial diaphysis are usually the result of torsional stress. There is a tendency for the tibia to displace into varus angulation because of an intact fibula.
Fractures of both the tibia and fibula are more unstable, and displacement can recur after reduction. The fibular fracture usually heals independently of the reduction achieved. The same does not apply to the tibia. There is some controversy as to what is an acceptable reduction of a tibial shaft fracture in the adult. The following criteria are generally accepted: apposition of 50% or more of the diameter of the bone in both AP and lateral projections, no more than 5 degrees of varus or valgus angulation, 5 degrees of angulation in the anteroposterior plane, 10 degrees of rotation, and 1 cm of shortening. It is assumed that fracture healing in an unacceptable position (ie, malunion) will affect the mechanics of the knee or ankle joint and possibly lead to premature degenerative joint disease.
Acceptable reduction can be obtained in one of many ways, and this is another area of ongoing controversy: closed versus open treatment. The goal of any treatment is to allow the fracture to heal in an acceptable position with minimal negative effect on the surrounding tissues or joints. Closed reduction is obtained under general anesthesia if necessary, and the patient is immobilized in a long leg non–weight-bearing cast. If radiographs at 2 weeks show acceptable alignment, the patient can be transitioned to a Sarmiento type fracture brace with full weight bearing.
If acceptable and stable reduction cannot be obtained by closed means, common options for surgical treatment include early definitive fixation or delayed stabilization after provisional splinting or external fixation. A reamed intramedullary nail is the recommended treatment for most displaced closed and Gustilo type I–IIIA fractures. External fixation is used as temporary fixation until soft-tissue management permits definitive nailing. Intramedullary nails are placed percutaneously under fluoroscopic control without opening the fracture site. Dynamic or static interlocking can be achieved with transfixing screws on both ends of the nail, and this maintains length and provides rotational control.
ORIF with plates and screws is rarely performed for tibial shaft fracture. MIPPO may be used as if there is distal or proximal fracture extension prohibiting nailing. This technique avoids exposure of the fracture and decreases soft-tissue dissection, devascularization of the bone, risk of infection, and delayed union.
Fracture of the Distal End of the Tibia (ICD-9:823.80, 823.82)
- Protecting the soft-tissue envelope while restoring the articular surface and the alignment of the tibia are the primary goals of the treatment.
- Postoperative complications are common.
Also referred to as pilon or plafond fractures, these fractures involve the distal articular surface of the tibia at the tibiotalar joint. As for any intraarticular fracture, the goal of treatment is to restore an anatomic articular surface. This can be difficult and sometimes impossible. Closed reduction of displaced fractures is almost never successful, and external fixation spanning the injury, with or without ORIF of the fibula, can be initially performed. Once soft-tissue swelling subsides, ORIF can be safely undertaken. Bone graft can be added to metaphyseal defects to support the articular surface. When the fracture is so comminuted that internal fixation is impossible, an attempt at indirect reduction by ligamentotaxis should be done, with or without an ORIF of the fibular fracture to restore length, closed reduction, and external fixation of the tibia. This can usually restore normal contours and alignment of the distal leg and make an eventual tibiotalar fusion easier should disabling posttraumatic arthritis occur. Primary ankle fusion is an alternative for severely comminuted fractures.
Surgical incisions through hemorrhagic blisters should be avoided. Healing is likely to be slow, and weight bearing should be carefully started only when radiologic evidence of bone healing is present. Postoperative pain, stiffness, and swelling can be seen in almost 25% of patients. Failure of healing is higher than 5% after primary procedures.
Compartment Syndrome (ICD-9:958.62)
Compartment syndrome is a frequent concern in tibia fractures and is caused by increased pressure in any of the four closed osteofascial spaces, compromising circulation and perfusion of the tissues within the involved compartment. Nerves and muscle tissue are particularly susceptible. Compartment syndrome can occur in crush injuries without fractures and in open fractures. The hallmark of compartment syndrome is severe pain out of proportion to the injury. The pain is increased with passive stretch to the leg muscles.
Fasciotomies should be performed emergently and are performed through lateral and medial incisions in the skin and fascia of all four compartments. Compartment pressure measurements may be used preoperatively but are not mandatory if the diagnosis is clear. Debridement of all necrotic tissue is imperative. The wounds are left open, possibly with a wound VAC system, and then treated by delayed primary closure or split-thickness skin grafting within 5 days. Delaying treatment of any compartment syndrome by more than 6–8 hours can lead to irreversible nerve and muscle damage.
Complications are common after tibia and fibula fractures and include infection, malunion, nonunion, muscle contractions, and chronic pain.
Delayed Union or Nonunion
The tibia, particularly its distal third, is prone to delayed union or nonunion due to lower blood flow and muscle coverage. This occurs more frequently in high-energy, open, and segmental fractures. Pain and motion at the fracture are noted to be present more than 6 months after injury. Radiographs show the persistence of the fracture line with or without callus. Sclerosis and flaring of the bone ends characterize the hypertrophic nonunion, whereas osteopenia and thinning of the fragments are seen in atrophic nonunions. Early weight bearing is thought to stimulate bone healing. If nonunion develops, rigid fixation with or without bone grafting (atrophic nonunion) will be required to achieve healing. Electrical stimulation, ultrasound, and shock waves have limited efficacy but may achieve union in selected cases.
Malunion may lead to premature degenerative joint disease. Corrective osteotomies may be required. When associated with shortening, multiple-plane correction and lengthening can be obtained after corticotomy and external fixation with ring-type fixation devices, which allow progressive correction of the deformity.
Infection of the tibia following open fracture or surgical treatment remains the most severe complication, especially when associated with nonunion. Perioperative prophylactic antibiotic therapy and adequate debridement and irrigation of open fractures are not always successful in preventing this complication. Aggressive utilization of early muscle transfers to increase the local blood supply has significantly improved the overall results of treatment. However, amputation may be required and is a viable functional alternative.
Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy) (ICD-9:337.20)
Complex regional pain syndrome is a fortunately rare complication of unknown cause. It is characterized by pain out of proportion to the original injury. Swelling, pain, and vasomotor disturbances are the hallmarks of this syndrome. Gradual increase in weight bearing and early joint mobilization will minimize the occurrence of this complication. Chemical or surgical sympathetic blockade may be helpful for the more severe forms of this disease.
Posttraumatic arthritis is a frequent occurrence after pilon fractures or as a complication of tibial shaft malunion. Joint stiffness and ankylosis may occur after prolonged immobilization. Soft-tissue injuries, including those of nerve, vessels, or muscles, have been discussed in the compartment syndrome section. Sequelae may include dropfoot and claw toe deformities and may require further soft-tissue or bone procedures.
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A thorough physical examination should compare the injured extremity to the uninjured contralateral side (looking for ecchymosis, swelling, or deformity), palpating carefully all points of tenderness, stressing the different joints when indicated, and assessing the neurovascular status. Associated injuries and certain systemic disorders (particularly diabetes and peripheral vascular disease) should be identified. An appropriate radiographic evaluation is mandatory. AP and lateral views are standard. Oblique and special views are requested according to clinical suspicion. Although some fracture patterns are still best delineated by conventional tomography, CT scanning with three-dimensional rendering has recently proved to be valuable, especially for ankle and calcaneal fractures. Radionuclide imaging is helpful to identify occult injuries and stress fractures. MRI is gaining popularity and is particularly helpful in diagnosing soft-tissue damage to the tibialis posterior tendon or gastrocnemius muscle, osteochondral fractures, and avascular necrosis.
Anatomy and Biomechanical Principles
The foot is a complex, highly specialized structure that permits weight bearing in a smooth, energy-conserving pattern; thus, when planning treatment of an injured foot, delicate balance between soft tissues and bones should be addressed. High-energy injuries, such as crush injuries, generally have a poorer prognosis, even if the bones are anatomically reduced. Scarring of soft tissues, particularly specialized tissues like the heel fat pad or the plantar fascia, prevents normal function and is often painful.
Embryologically, the foot develops from proximal to distal into three functional segments: the tarsus, metatarsus, and phalanges. Anatomically, it is divided into the hindfoot (talus and calcaneus), the midfoot (navicular, cuboid, and three cuneiforms), and the forefoot (five metatarsals and 14 phalanges). Besides skin, vessels, and nerves, the soft tissues include extrinsic tendons, intrinsic musculotendinous units, a complex network of capsuloligamentous structures, and some uniquely specialized tissues such as fat pads.
The bones, ligaments, and muscles of the foot actively maintain the integrity of the three arches of the foot. The two longitudinal arches aid in weight bearing and absorbing the forces during motion. The transverse arch helps with the movements of the foot. The plantar aspect of the foot is divided into four layers, each containing different muscles and tendons, from superficial to deep.
These 28 bones, 57 articulations, and extrinsic and intrinsic soft tissues work harmoniously as a unit resembling functionally a ball and socket to allow walking, running, jumping, and accommodation of irregular surfaces with a minimal expense of energy.
Restoration of the complex relationship between bone and soft-tissue structures is often challenging, but is the goal of treatment of foot injuries.
Fractures Common to All Parts of the Foot
Also known as fatigue or march fractures, stress fractures are commonly seen in young active adults involved in vigorous and excessive exercise. These are fractures of bones due to repetitive loading rather than a single traumatic event. Fracture occurs when damage from cyclical loading of a bone overwhelms its physiologic repair capacity. A high longitudinal arch and excessive forefoot varus are intrinsic precipitating factors. Sites of fracture are most frequently the metatarsals and the calcaneus, but fatigue fractures can be found anywhere.
Incipient pain of varying intensity at rest is then accentuated by walking. Swelling and point tenderness are likely to be present. Depending on the stage of progress, radiographs may be normal or may show an incomplete or complete fracture line or only extracortical callus formation that can be mistaken for osteogenic sarcoma. Radionuclide imaging, CT, and MRI can be helpful for occult fractures. CT is also helpful to differentiate incomplete and complete fractures. Persistent unprotected weight bearing may cause arrest of bone healing and even displacement of the fracture fragment.
Treatment is by protection in a short leg cast, walking boot, or a heavy stiff-soled shoe. Weight bearing is restricted until pain has subsided and restoration of bone continuity is confirmed radiographically, usually within 3–4 weeks. Because of the high risk of displacement and nonunion, early surgical management is proposed for high-risk stress fractures in the elite athlete.
Multiple High-Energy Injuries
Violent forces applied to the foot may cause more extensive damage than initially appreciated. High-energy fractures are often open, and the basic principles of open fracture management should be applied.
The objectives of treatment are to preserve circulation and sensation (particularly of the plantar region), maintain a plantigrade position of the foot, prevent or control infection, preserve plantar skin and fat pads, preserve gross motion of the different joints (both actively and passively), achieve bone union, and, ultimately, preserve fine motion. Fasciotomies of the severely injured foot may be necessary to avoid compartment syndromes and their serious sequelae.
Early stabilization of multiple fractures and dislocations will simplify wound management. This can be accomplished through external fixation or internal fixation with K-wires, plates, or screws. Early soft-tissue coverage with local or free flaps is also beneficial.
Neuropathic Joint Injuries and Fractures
Fractures and other foot disorders often present in the patient with Charcot arthropathy. Neuropathic fractures are frequently seen with diabetes. Other rare causes are tabes dorsalis, syringomyelia, peripheral nerve injury, and leprosy.
The potential for bone healing is normal if no other comorbidities exist. It has been found, however, that healing of fractures is often delayed in this patient group. Protection, rest, and elevation can result in union without deformity. ORIF is sometimes necessary. Rarely, arthrodesis is indicated; however, the rate of nonunion is higher than for normal joints.
Ankle Fractures and Dislocations
- Among the most common injuries treated by orthopedic surgeons.
- Recognizing and treating syndesmotic injury are important for a successful outcome.
Anatomy and Biomechanical Principles
The ankle joint itself is limited to one plane of motion: plantarflexion and dorsiflexion in the sagittal plane. With incorporation of the motion of the subtalar joint (which allows for inversion and eversion in the coronal plane), the foot is able to move in a complex and varied arc in relationship to the leg.
The inner and distal articular surfaces of the distal tibia and fibula form the ankle mortise (a uniplanar hinge joint). The ankle mortise serves as the “roof” over the talus. The articular portions of the lateral and medial malleoli serve as constraining buttresses to allow for controlled plantarflexion and dorsiflexion in the ankle mortise. This geometric configuration resists rotation of the talus in the ankle mortise. Further constraint and stability are provided by ligaments and the soft tissue surrounding the ankle joint. The syndesmotic ligament is composed of four ligaments of which the posterior inferior tibiofibular ligament is the thickest and strongest and connects the tibia to the fibula at the level of the tibial plafond. The bony architecture of the mortise also provides some constraint to posterior subluxation of the talus. This is provided by the cup-shaped tibial plafond and the slightly increased width of the talar dome anteriorly as compared with posteriorly.
The distal tibia also serves to absorb the compressive loads and stress placed on the ankle. The internal trabecular pattern of the bone helps transmit, diffuse, and resorb the compressive forces. Cross-sectional studies have shown that reduced activity and old age lead to resorption of cancellous bone, thereby decreasing the compressive resistance of the distal tibia.
Fracture-dislocations of the ankle are frequently referred to as bimalleolar (fractures of the medial and lateral malleoli) or trimalleolar (fractures of the medial, lateral, and posterior malleoli). Fracture of the lateral malleolus with complete rupture of the deltoid ligament or fracture of the medial malleolus with complete disruption of the syndesmosis and a proximal fibular shaft fracture (Maisonneuve fracture) are also considered bimalleolar fractures on a functional basis.
The purpose of any classification scheme is to provide a means to better understand the extent of injury, describe an injury, and determine a treatment plan. Presently, the two most widely used classification schemes for describing ankle fractures are the Lauge-Hansen and Weber-Danis classifications.
In 1950, Lauge-Hansen described a classification system based on mechanism of injury that described over 95% of all ankle fractures (Figure 2–21 shows a comparison of the Weber-Danis and Lauge-Hansen schemes). By stressing freshly amputated limbs in combinations of supination, pronation, adduction, abduction, and external rotation, he was able to describe nearly all fracture patterns. Pronation and supination refer to the position of the patient's foot at the instance of injury, while adduction, abduction, and external rotation refer to the vector of the force that is applied. Thus, four mechanisms of injury were described for ankle fractures: (1) supination adduction, (2) supination-external rotation, (3) pronation abduction, and (4) pronation-external rotation. Lauge-Hansen later added a fifth type of injury, the pronation dorsiflexion injury, in order to include a mechanism for tibial plafond fractures. This fifth type is caused by a compression-type axial loading injury.
Comparison of Lauge-Hansen and Weber-Danis ankle classifications. (Reproduced, with permission, from Browner BD, Levine A, Jupiter J, et al, eds: Skeletal Trauma, 2nd ed. New York: WB Saunders; 1998.)
The Weber-Danis classification is much simpler and is based on anatomy rather than mechanism as it relates to the level at which the fibular fracture occurs.
- Type A: Fracture in which the fibula is avulsed distal to the joint line. The syndesmotic ligament is left intact, and the medial malleolus is either undamaged or is fractured in a shear-type pattern.
- Type B: Spiral fracture of the fibula beginning at or near the level of the joint line and extending in a proximal-posterior direction up the shaft of the fibula. Parts of the syndesmotic ligament complex can be torn, but the large interosseous ligament is usually left intact so that no widening of the distal tibiofibular articulation occurs. Complete syndesmotic disruptions, however, can result from this fracture pattern. The medial malleolus can either be left intact or sustain a transverse avulsion fracture. If the medial malleolus is left intact, there can be a tear of the deltoid ligament. Avulsion fracture of the posterior lip of the tibia (posterior malleolus) can also occur.
- Type C: Fracture of the fibula proximal to the syndesmotic ligament complex, with consequent disruption of the syndesmosis. Medial malleolar avulsion fracture or deltoid ligament rupture is also present. Posterior malleolar avulsion fracture can also occur.
The AO classification represents an alpha-numeric system based on the Weber-Danis classification.
Four criteria should be met for the optimal treatment of ankle fractures: (1) dislocations and fractures should be reduced as soon as possible; (2) all joint surfaces must be precisely restored; (3) the fracture must be held in a reduced position during the period of bony healing; and (4) joint motion should be initiated as early as possible. If these treatment goals are met, a good outcome can be expected, keeping in mind that disruption of the articular cartilage results in permanent damage.
Previous studies have demonstrated that the ankle has the thinnest articular cartilage but the highest ratio of joint congruence to articular cartilage thickness of any of the large joints. This suggests that loss in congruity of the ankle joint following fracture will be poorly tolerated and lead to posttraumatic arthritic changes. Thus, it is important to obtain anatomic reduction of the articular surfaces of the ankle after a fracture. A lateral talar shift of as little as 1 mm will decrease surface contact at the tibiotalar joint by 40%.
Initial treatment of ankle fractures should include immediate closed reduction and splinting, with the joint held in the most normal position possible to prevent neurovascular compromise of the foot. An ankle joint should never be left in a dislocated position. If the fracture is open, the patient should be given appropriate intravenous antibiotics and taken to the operating room on an urgent basis for irrigation and debridement of the wound, fracture site, and ankle joint. The fracture should also be appropriately stabilized at this time.
When performing ORIF of ankle fractures, several principles must be followed. It is important to gently handle the soft tissues about the ankle so as to minimize the risks of infection and wound-healing problems. In the treatment of bimalleolar and trimalleolar fractures, the lateral malleolus should usually be reduced and fixed first. This has two benefits: (1) it helps to correctly restore the original limb length, and (2) because of the strong ligamentous connections between the lateral malleolus and talus (anterior and posterior talofibular ligaments), initial fixation of the lateral malleolus will correctly position the talus in the mortise. When performing ORIF of the medial malleolus, it is important to remove any soft tissue or periosteum interposed in the fracture site. It is also preferable to fix the medial malleolus with either two cancellous-type lag screws or by tension banding principles to achieve interfragmentary compression.
The necessity for fixation of the posterior malleolar fragment is dependent on several factors. After the lateral and medial malleolar fractures have been internally fixed, ligamentotaxis often will anatomically reduce the posterior malleolar fragment. If this fragment represents less than 25% of the articular surface of the tibial plafond and there is less than 2 mm of displacement, internal fixation is not always required. If the fragment does not reduce on the intraoperative radiograph with ligamentotaxis, or if the fragment represents more than 25% of the articular surface, most authors agree that it should be internally fixed. Several methods have been described for this, using either direct fixation posteriorly via the posterolateral approach or by lag screw from anterior to posterior.
Following surgery, the limb is placed in a bulky sterile dressing with plaster splints from the ball of the foot to the proximal calf to allow for wound healing. The ankle is kept in neutral position to prevent equinus deformity. After the sutures are removed at 2 weeks, the surgeon must decide whether to begin early mobilization of the ankle joint. If the patient is reliable and stable fixation was achieved at the time of surgery, then early range of motion may be initiated, keeping the patient on crutches and not allowing weight bearing. If there is a question about patient reliability or stability of fixation, the limb can be placed in a short leg cast for added protection. Usually at 6 weeks, all immobilization is discontinued and weight bearing is slowly advanced. Physical therapy often helps promote ankle motion, strengthening, and regained ankle proprioception.
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Stark E, Tornetta P 3rd, Creevy WR: Syndesmotic instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma
Tornetta P: Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg
Wikerøy AK, Høiness PR, Andreassen GS, Hellund JC, Madsen JE: No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. J Orthop Trauma
Hindfoot Fractures and Dislocations
Talus Fractures (ICD-9:825.21)
- Second in frequency among all tarsal fractures after calcaneus fractures.
- Sixty percent of the talus is covered with articular cartilage.
Fractures of the talus commonly occur either through the body or the neck. Talar neck fractures represent almost 50% of all talus fractures. The blood supply enters the talar neck area and is tenuous. Fractures and dislocations may disrupt this vascularization, causing delayed healing or avascular necrosis. CT is essential for exact assessment and classification of the fracture and preoperative planning for every talus fracture.
Fractures of the Neck of the Talus
The most common mechanism of talar neck fracture is hyperdorsiflexion with an axial load causing impingement between the talar neck and tibia. The most widely used classification, which relies on the degree of initial dislocation and number of affected joints, has been described by Hawkins:
- Type 1: Nondisplaced vertical fracture
- Type 2: Displaced and dislocation or subluxation at the subtalar joint
- Type 3: Displaced and dislocation or subluxation at the subtalar and tibiotalar joints
- Type 4: Essentially type 3 injuries with talonavicular subluxation or dislocation (Figure 2–22)
Hawkins classification of talar neck fractures. (Reproduced, with permission, from Coughlin MJ, Mann RA, eds: Surgery of the Foot and Ankle, 7th ed. New York: WB Saunders; 1999.)
This classification is of prognostic value for avascular necrosis of the body: 0–13% for type 1 fractures, 25–50% for type 2 fractures, 80–100% for type 3 fractures, and 100% for type 4 fractures.
Complications of talar neck fractures include infection, delayed union or nonunion, malunion, and osteoarthritis of the tibiotalar and subtalar joints.
Treatment of talar fractures is aimed at minimizing the occurrence of these complications. Type 1 fractures are best treated with a non–weight-bearing below-knee cast for 6–8 weeks until clinical and radiologic signs of healing are present. Closed reduction is first attempted for type 2 fractures, and if this is successful in attaining anatomic alignment, treatment is as for a type 1 fracture. In about 50% of cases, closed reduction is unsuccessful, and ORIF with K-wires, pins, or screws is indicated. Closed reduction of type 3 and 4 fractures is almost never successful; ORIF is the rule. The postoperative regimen is the same as above. Progressive weight bearing will be allowed after fracture union if there is no avascular necrosis of the body. Within 6–8 weeks, a subchondral lucency seen in the dome of the talus (“Hawkins sign”) is possible only if the talar body is vascularized. The absence of the Hawkins sign, however, does not predict the occurrence of avascular necrosis in histologic and MRI-based studies.
Fractures of the Body of the Talus
Talus body fractures occur mainly due to shear and axial compression forces, and they are intraarticular and involve the surfaces of both the tibiotalar and subtalar joints.
Fractures of the body of the talus are generally categorized as follows:
- Type 1: Osteochondral fracture
- Type 2: Coronal, sagittal, or horizontal fracture
- Type 3: Posterior process fracture
- Type 4: Lateral process fracture
- Type 5: Crush fracture of the body
Treatment of talar body fractures is based on restoring joint integrity of both the tibiotalar and subtalar joints. Minimally displaced fractures of the talar body are not likely to cause disability if immobilization is continued until union is restored. Associated fractures of the malleoli, talar neck, and calcaneus occur frequently. AP, mortise, lateral, and Broden (45 degrees internal oblique) views aid radiographic assessment of the injury and enable the quantification of articular surface involvement and displacement. CT is recommended in all talar body fractures to assess comminution and associated fractures.
Open anatomic reduction and internal fixation via a two-incision approach, lateral and medial, should be the choice of treatment. Fixation may also allow earlier motion. Medial malleolar osteotomy can be performed over the more comminuted side of the talar body side to allow direct access to the fracture fragments. If reduction is not anatomic, delayed healing of the fracture may follow, and posttraumatic arthritis is a likely sequela. If this occurs, arthrodesis of the ankle or subtalar joints may be necessary to relieve painful symptoms in the long term.
Osteochondral Fractures of the Talar Dome
Any chronic pain after ankle sprain should raise the suspicion of osteochondral lesions. A history of trauma may not always be present.
Initial radiograph evaluation often does not demonstrate these lesions. CT and MRI have been used successfully as imaging modalities, but they are not as sensitive and specific as arthroscopy.
Classic staging performed by Berndt and Harty is based on the appearance on the plain radiographs:
- Stage 1: Localized compression
- Stage 2: Incomplete separation of the fragment
- Stage 3: Completely detached but nondisplaced fragment
- Stage 4: Completely detached, displaced fracture
Others proposed classification systems are based on MRI, CT, and existence of a cystic component. A cyst around the lesion is accepted as a bad prognostic factor.
Symptomatic stage 1, 2, and 3 lesions are usually initially treated conservatively with immobilization and restricted weight bearing. Healing is monitored radiographically with AP and mortise views. Lesions that fail conservative treatment and all stage 4 lesions require surgical treatment. Reduction and pinning or fixation with screws and excision with or without drilling have been recommended. Arthroscopic management seems to give as good a result as arthrotomy, with fewer complications. Degenerative disease of the tibiotalar joint is a frequent long-term complication.
Subtalar Dislocation (ICD-9:837)
Subtalar dislocation, also called peritalar dislocation, is the simultaneous dislocation of the talocalcaneal and talonavicular joints. Inversion injuries result in medial dislocations (85%), whereas eversion injuries result in lateral dislocations (15%). Anterior and posterior dislocations are rare.
Prompt, gentle, closed reduction under sedation is usually successful. Immobilization in a non–weight-bearing short leg cast for 6 weeks is usually satisfactory. Soft-tissue interposition, particularly of the posterior tibial tendon, may prevent closed reduction. Open reduction, with or without internal fixation, is then indicated.
Total Dislocation of the Talus (Extrusion Injury)
This injury usually results from high-energy trauma, and most dislocations are open dislocations. Despite adequate prompt reduction and thorough wound debridement, the complication rate is extremely high, including persistent infection and avascular necrosis.
Calcaneus Fractures (ICD-9:825.0)
- The most common tarsal fracture.
- Approximately 75% involve an intraarticular component.
- Wound dehiscence and infection are the most common postoperative complications.
The most common mechanism of fracture is high-energy axial loading driving the talus downward. Ten percent of calcaneal fractures are associated with compression fractures of the thoracic or lumbar spine, and 5% are bilateral. Comminution and impaction are common features.
Pain is usually significant but may be masked by associated injuries. Swelling, deformity, and blistering of the skin occur frequently during the first 36 hours as a result of the severe damage to surrounding soft tissues. The heel pad in particular is a highly specialized fatty structure that acts as a hydraulic cushion. Major disruptions of the heel pad lead to persistent pain and deformity and can produce poor functional results despite adequate bony healing.
Initial radiographs include three views: anteroposterior, lateral, and axial projection (Harris view). Disruption of Böhler's angle and the angle of Gissane can be determined from initial radiographs (Figure 2–23). Oblique and Broden views are useful to demonstrate subtalar joint incongruity. CT scanning is the diagnostic tool of choice and will further delineate fracture patterns and occult injuries.
Böhler angle (A) and Gissane angle (B), indicating normal anatomic landmarks. (Reproduced, with permission, from Coughlin MJ, Mann RA, eds: Surgery of the Foot and Ankle, 7th ed. New York: WB Saunders; 1999.)
Various classification systems for calcaneus fractures have been advocated. In general, calcaneus fractures can be divided into intraarticular and extraarticular fractures. Intraarticular fractures are frequently (80%) associated with worse outcomes than extraarticular fractures. Sanders has developed a classification system for intraarticular fractures based on coronal CT images (Figure 2–24). This classification has been found to be useful in both treatment and prognosis. Type I fractures are nondisplaced articular fractures. Type II fractures are two-part fractures of the posterior facet and are divided into A, B, and C based on the location of the fracture line. Type III fractures are three-part fractures with a centrally depressed fragment, also divided into A, B, and C. Type IV fractures are four-part articular fractures with extensive comminution. The Essex-Lopresti classification describes the “joint depression–type” and the “tongue-type” fractures.
Sanders computed tomography classification of calcaneus fractures. Sust, sustentaculum. (Reproduced, with permission, from Coughlin MJ, Mann RA, eds: Surgery of the Foot and Ankle, 7th ed. New York: WB Saunders; 1999.)
These fractures (eg, Sanders type I) are successfully treated by nonoperative management with protected weight bearing for 6–8 weeks, until clinical and radiographic signs of healing are present.
This fracture pattern (Figure 2–25) splits the tuber in the axial plane and involves the subtalar joint. The pull of the achilles tendon displaces the dorsal fragment cranially.
Tongue-type fracture of the calcaneus showing involvement of the subtalar joint.
This fracture pattern (Figure 2–26) creates a separate fragment of the posterior facet with joint incongruity.
Joint depression-type fracture of the calcaneus. The posterior facet is a separate fragment.
Some fracture patterns create such comminution and impaction that they defy classification. They all have in common significant soft-tissue injury and subtalar joint incongruity.
Treatment of displaced intraarticular fractures remains controversial. As already stated, the final outcome can depend on soft-tissue as well as bony healing.
Prospective large-scale studies out of Canada have revealed excellent clinical outcomes by conservative treatment even for displaced intraarticular fractures. Heavy smoking, severe peripheral vascular disease, and poorly controlled diabetes are considered to be relative contraindications for surgery. The extent of varus displacement in the axial plane (Harris heel view) appears to guide operative management more than the extent of joint depression in the posterior facet.
Some surgeons advocate early closed manipulation of displaced intraarticular fractures to at least partially restore the external anatomic configuration of the heel region. Internal fixation with percutaneous pins may be performed. This is particularly successful for noncomminuted tongue-type fracture patterns. An axial pin is inserted in the tongue fragment, which is then disimpacted and reduced. The pin is then pushed further to stabilize the fracture (Essex-Lopresti technique). ORIF with pins, screws, or plates, with or without bone grafting, has gained acceptance. The aim of ORIF is to restore Böhler's angle and improve heel alignment out of varus through stable fixation. Immediate surgery is associated with a high incidence of wound healing complications. Therefore, a 10- to 14-day delay in surgical fixation is recommended to decrease the risk of wound breakdown and infection. The “wrinkle test” should be positive prior to surgery. More recently, concerns surrounding the complications of wound healing have encouraged the use of minimally invasive approaches. Few authors advocate primary subtalar arthrodesis for severely comminuted fractures.
Fractures of the sustentaculum represent rare injuries that are usually caused by a high-energy trauma. This fracture should be suspected in patients with a history of eversion injury and pain below the medial malleolus. The injury is mainly diagnosed by CT scan. Displaced sustentaculum fractures may require surgical fixation through a medial approach.
Fractures of the anterior process are usually caused by forced inversion of the foot and must be differentiated from midtarsal and ankle sprains. The firmly attached bifurcate ligament avulses a bony flake from the anterior process. Maximal tenderness and swelling occur midway between the tip of the lateral malleolus and the base of the fifth metatarsal. A lateral oblique radiograph will demonstrate the fracture line.
Fractures of the medial process give origin to the abductor hallucis and part of the flexor digitorum brevis muscle and can be avulsed in eversion-abduction injuries.
The most significant complications are postoperative wound breakdown and infection. Posttraumatic degenerative arthritis is a relatively common long-term complication requiring subtalar fusion or triple arthrodesis. The rate of wound complications after ORIF has been reported to be as high as 30–50%. Other complications include compartment syndrome, nerve entrapment syndromes (medial or lateral plantar branches and sural nerve, either from posttraumatic or postsurgical scarring), peroneal tendon injury, heel pad pain, exostosis, and malunion. Compartment syndrome is present in 10% of patients and should be excluded during the examination.
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Midfoot Fractures and Dislocations
Navicular Fractures (ICD-9:825.22)
Avulsion fractures of the tarsal navicular may occur as a result of severe midtarsal sprain and require neither reduction nor elaborate treatment. Avulsion fracture of the tuberosity near the insertion of the posterior tibialis tendon is uncommon and must be differentiated from a persistent ununited apophysis (accessory navicular) from the supernumerary sesamoid bone, or os tibiale externum. Dorsal lip avulsions also occur.
Body fractures occur either centrally in a horizontal plane or, more rarely, in a vertical plane. They are occasionally characterized by impaction. Noncomminuted fractures with displacement of the dorsal fragment can be reduced. Closed manipulation by strong traction on the forefoot and simultaneous digital pressure over the displaced fragment can restore normal position. If a tendency to redisplace is apparent, this can be counteracted by temporary fixation with a percutaneously inserted Kirschner wire. Non–weight-bearing immobilization in a cast or splint is required for a minimum of 6 weeks. Comminuted and impacted fractures cannot be anatomically reduced in a closed manner. Where fragments involve more than 25% of the bone, ORIF may be required to prevent dorsal subluxation of the navicular fragment. Bone graft may be used for depressed areas. Some authorities offer a pessimistic prognosis for comminuted or impacted fractures. It is their contention that even though partial reduction has been achieved, posttraumatic arthritis supervenes, and that arthrodesis of the talonavicular and naviculocuneiform joints will be ultimately necessary to relieve painful symptoms.
Stress Fractures (ICD-9:733.95)
The navicular is also a frequent site of fatigue fracture in runners. CT or radionuclide imaging is often necessary to make the diagnosis. Six weeks in a non–weight-bearing short leg cast is usually required for fracture healing.
Cuneiform and Cuboid Bone Fractures (ICD-9:825.23, 825.24)
Because of their relatively protected position in the midtarsus, isolated fractures of the cuboid and cuneiform bones are rarely encountered. Avulsion fractures occur as a component of severe midtarsal sprains. Extensive fractures usually occur in association with other injuries of the foot and often are caused by severe crushing. A “nutcracker” fracture is a compression fracture of the cuboid and, when associated with lateral column shortening, can be treated by lateral column lengthening, ORIF, and bone grafting.
Midtarsal Dislocations (ICD-9:838.12)
Midtarsal dislocation through the naviculocuneiform and calcaneocuboid joints, or more proximally through the talonavicular and calcaneocuboid joints (Chopart's joint), may occur as a result of a twisting injury to the forefoot. Fractures of varying extent of adjacent bones are frequently associated.
When acute treatment is administered, closed reduction by traction on the forefoot and manipulation is generally effective. If reduction is unstable and displacement tends to recur upon release of traction, stabilization for 4 weeks by percutaneously inserted Kirschner wires is recommended.
Forefoot Fractures and Dislocations
Metatarsal Fractures and Dislocations
Fracture of the metatarsals and dislocation of the tarsometatarsals are frequently caused by a direct crushing or indirect twisting injury to the forefoot. With severe trauma, circulation may be compromised from injury to the dorsalis pedis artery, which passes between the first and second metatarsals.
Metatarsal Shaft Fractures (ICD-9:825.25)
Undisplaced fractures of the metatarsal shafts cause only temporary disability, unless failure of bone healing occurs. Displacement is rarely significant when the first and fifth metatarsals are not involved because they act as internal splints. These fractures can be treated with a hard-soled shoe with partial weight bearing or, if pain is marked, a short leg walking cast.
For displaced fractures of the shaft, it is of paramount importance to correct angulation in the longitudinal axis of the shaft. Residual dorsal angulation causes prominence of the metatarsal head on the plantar surface. The concentrated local pressure may produce a painful skin callus. Residual plantar angulation of the first metatarsal will transfer weight to the heads of the second and third metatarsals. After reduction of angular deformity, a cast should be well molded to the plantar surface to minimize recurrence of deformity and support the transverse and longitudinal arches. If significant angulation or intraarticular displacement persists, open or closed reduction and internal fixation should be considered.
Metatarsal Neck and Head Fractures (ICD-9:825.25)
Fractures of the metatarsal “neck” are close to the head but remain extraarticular. Dorsal angulation is common and should be reduced to avoid reactive skin callus formation from pressure on the plantar skin. Intraarticular fractures of the metatarsal heads are rare. Even when they heal in a displaced position, some remodeling occurs and the functional outcome is surprisingly good. The indications for open reduction with or without internal fixation remain controversial.
Closed reduction of metatarsal fractures is best achieved by applying traction (Chinese finger traps) to the involved toes. Reduction is evaluated with intraoperative radiographs, and if judged unacceptable, ORIF with K-wires or plates and screws is indicated. Unstable reductions should also undergo percutaneous pinning under fluoroscopic imaging.
Tarsometatarsal (Lisfranc) Dislocations (ICD-9:838.25)
Lisfranc injuries have traditionally been associated with high-energy trauma such as motor vehicle collisions and industrial accidents, but recently there is an increased incidence of such energy resulting from low-energy trauma such as athletic activity. These injuries are often overlooked following an athletic injury or in a polytrauma patient, so a high index of suspicion is necessary for proper diagnosis.
The base of the second metatarsal is recessed proximally to the base of the other metatarsals in a cleft between the first and third cuneiforms, thus “locking” the joint. Whereas primary stabilization is provided by bony skeleton, the strong ligamentous attachments provide substantial stability to the Lisfranc joint. The ligament structures are divided into plantar, dorsal, and interosseous components, with plantar being the strongest. The medial border of the fourth metatarsal and the cuboid should align on the 30-degree oblique view, and on the lateral view, the superior border of the metatarsal base should be aligned with the superior border of the medial cuneiform. For subtle injuries, MRI, CT, or stress x-rays may be useful.
Three commonly occurring patterns of this injury are identified: total incongruity, partial incongruity, and divergent (Figure 2–27).
Classification of Lisfranc injuries. (Reproduced, with permission, from Coughlin MJ, Mann RA, eds: Surgery of the Foot and Ankle, 7th ed. New York: WB Saunders; 1999.)
With nondisplaced injuries, cast immobilization with limited weight bearing can be used. Generally a short-leg cast for 6 weeks is followed by 6 weeks in a walking cast until the pain and tenderness subside.
More than 2 mm of displacement between the first and second metatarsal bases compared with the contralateral foot is indication for operative treatment. Achieving anatomic reduction is the key to successful treatment, and if this cannot be achieved by closed means, open reduction is indicated. Reduction can be secured with screws, bioabsorbable screws, plates, or a suture endobutton, which has recently gained popularity.
Failure to diagnose the injury or malreduction may cause posttraumatic arthritis, which is the most common complication after Lisfranc injuries. Other common complications are complex regional pain syndrome, symptomatic hardware, and incomplete reduction or loss of reduction.
Fracture of the Base of the Fifth Metatarsal (ICD-9:825.25)
This is the most common of all metatarsal fractures. Three distinct patterns occur: (1) avulsion fracture of a variably sized portion of the tuberosity (styloid process) that may, on rare occasions, involve the joint between the cuboid and the fifth metatarsal; (2) acute Jones fracture involving the intermetatarsal joint (located at the metaphyseal-diaphyseal junction); and (3) transverse fracture of the proximal metatarsal diaphysis.
Avulsion fractures usually occur after adduction injury to the forefoot. The peroneus brevis muscle may pull and displace the fractured fragment proximally. A hard-soled shoe, cast brace, or elastic wrapping for 3 weeks is often successful for treatment, and bony healing rarely fails to occur. Symptomatic nonunions, displacement of more than 2 mm, and more than 30% involvement of the cubometatarsal joint should be treated surgically. Symptomatic small fragments can be excised.
Acute Jones fractures are best treated in a non–weight-bearing cast for 6–8 weeks. Some authors recommend acute ORIF of Jones fractures in the high-performance athlete. Proximal diaphyseal fractures, or “chronic Jones fractures,” are most probably secondary to fatigue failure. Again, conservative treatment in a non–weight-bearing short leg cast for 6 weeks will usually bring healing of the fracture. Nonunions do occur (due to the poor inherent blood supply) and are often symptomatic. If there is no evidence of bone healing at 12 weeks, internal fixation and bone grafting are recommended. Treatment of proximal metatarsal shaft fractures is similar to that for Jones fractures.
Fractures and Dislocations of the Phalanges of the Toes
Fractures of the phalanges of the toes are most commonly caused by a direct force such as a crush injury. Spiral or oblique fractures of the shaft of the proximal phalanges of the lesser toes may occur as a result of an indirect twisting injury. The injury should be assessed in terms of deformity, soft-tissue injury, and neurovascular status and also radiographically.
Comminuted fracture of the proximal phalanx of the great toe, alone or in combination with fracture of the distal phalanx, is a disabling injury. Because wide displacement of fragments is not likely, correction of angulation and support by a splint usually suffice. A weight-bearing removable cast boot may be useful for relief of symptoms arising from associated soft-tissue injury. Spiral or oblique fracture of the proximal or middle phalanges of the lesser toes can be treated adequately by binding the involved toe to the adjacent uninjured toe (buddy taping). Comminuted fractures of the distal phalanx are treated as soft-tissue injuries.
Dislocation of the metatarsophalangeal joints and dislocation of the proximal interphalangeal joints usually can be reduced by closed manipulation. These dislocations are rarely isolated and usually occur in combination with other injuries to the forefoot.
Fracture of the Sesamoids of the Great Toe (ICD-9:825.20)
Fractures of the sesamoid bones of the great toe are rare but may occur as a result of a crushing injury. These injuries must be differentiated from a bipartite sesamoid by comparing radiographs of the contralateral uninvolved foot.
Undisplaced fractures require no treatment other than a hard-soled shoe or metatarsal bar. Displaced fractures may require immobilization in a walking boot or cast, with the toe strapped in flexion. Persistent delay of bone healing may cause disabling pain arising from arthritis of the articulation between the sesamoid and the head of the first metatarsal. If conservative modalities have been exhausted, excision of the sesamoid may be necessary; however, this should be a last resort treatment.
Brin YS, Nyska M, Kish B: Lisfranc injury repair with the TightRope device: a short-term case series. Foot Ankle Int
Chuckpaiwong B, Queen RM, Easley ME, Nunley JA: Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res
DeOrio M, Erickson M, Usuelli FG, Easley M: Lisfranc injuries in sport. Foot Ankle Clin