FRACTURES OF

1

• FRACTURES OF
• THE HIP AND ANKLE
• James M. Steinberg, D.O.
• Garden City Hospital

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HIP FRACTURES

• More than 250,000 hip fractures in the U.S. each
  year, expected to double by year 2050
• Falls are the most common cause of fracture in
  the elderly
• High energy trauma is the most common cause in
  young adults
• Femoral head has a very fragile blood supply

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Femoral Head Fractures

• Usually a result of hip dislocations, 10 of
  posterior hip dislocations
• Most are shear or cleavage type fractures
• Radiographic evaluation must include an AP and
  Judet views of the pelvis
• Blood supply to the femoral head
• -medial femoral circumflex artery (majority)
• -lateral femoral circumflex
• -artery of the ligamentum teres

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Pipkin Classification

• Type I
• -Hip dislocation with fracture of the
  femoral head caudad to the fovea capitis
  femoris
• Type II
• - Hip Dislocation with fracture of the
  femoral head cephalad to the fovea capitis
  femoris

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Pipkin Classification

• Type III
• -Type I or II injury associated with
  fracture of the femoral neck
• Type IV
• -Type I or II injury associated with
  fracture of the acetabular rim

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Treatment of Femoral Head Fractures

• Pipkin Type I
• -If lt 1mm step-off closed treatment, four
  weeks of traction and four weeks of toe-touch
  weight bearing
• -If gt 1mm step-off, ORIF with small
  cancellous screws or herbert screws
• -In young patients immediate ORIF
  recommended to allow for early mobilization
  and prevention of AVN

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Treatment of Femoral Head Fractures

• Pipkin Type II
• -For nonoperative care an anatomic reduction
  must be achieved
• -ORIF is the treatment of choice utilizing
  screw fixation

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Treatment of Femoral Head Fractures

• Pipkin Type III
• -ORIF of the femoral head followed by screw
  fixation of the femoral neck
• -In young patients, emergent ORIF
• -Prognosis for this fracture is poor and
  depends on the degree of displacement of the
  femoral fracture

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Treatment of Femoral Head Fractures

• Pipkin Type IV
• -Fracture must be treated in tandem with its
  associated acetabular fracture
• -Surgical approach dictated by acetabular
  fracture
• -Femoral head should be fixed internally even
  if nondisplaced

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Complications of Femoral Head Fractures

• AVN
• Degenerative arthritis
• Sciatic nerve palsy
• Heterotopic ossification
• Wound infection
• Chronic instability

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Femoral Neck Fractures

• Low energy trauma (older patients)
• -Fall onto the greater trochanter or forced
  external rotation of the lower extremity
• High energy trauma (younger patients) -MVA or
  fall from significant height
• Cyclical loading/stress fractures (athletes)

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Evaluation of Femoral Neck Fractures

• Physical exam
• -Weight bearing status
• -Shortening and external rotation
• -Pain with provocative movements
• Imaging
• -AP in internal rotation and cross-table
  lateral
• -MRI if x-rays are negative with a high index
  of suspicion (first 48 hours)
• -Bone scan 48 hours after injury

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Classification of Femoral Neck Fractures

• Anatomic
• -Subcapital
• -Transcervical
• -Basicervical
• Pauwel
• -Based on angle of fracture from horizontal
• -Type I 30 degrees Type II 50 degrees
  Type III 70 degrees

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Garden Classification of Femoral Neck Fractures

• Based on degree of valgus displacement
• -Type I incomplete/impacted
• -Type II complete nondisplaced
• -Type III complete with partial
  displacement (trabecular pattern does not line
  up)
• -Type IV completely displaced (trabecular
  pattern in a parallel orientation)

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Treatment of Femoral Neck Fractures

• Fatigue/stress fractures
• -Tension in situ screw fixation
• -Compression crutch ambulation
• Impacted/nondisplaced fractures
• -In situ fixation with three cancellous
  screws except in pathologic fractures, severe
  OA/RA and Pagets disease (prosthetic
  replacement)

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Treatment of Femoral Neck Fractures

• Displaced fractures ORIF and capsulotomy
• -25 incidence of AVN within 12 hours
• -30 within 12-24 hours
• -40 within 24-48 hours
• -In young patients, treat as a surgical
  emergency

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Operative Techniques of Femoral Neck Fractures

• Multiple screw fixation
• -Favored technique
• -Threads should cross the fracture site to
  allow for compression
• -Three parallel screws yield the best
  fixation
• Sliding screw devices
• -Not recommended
• -If used, second pin should be inserted
  superiority to control rotation

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Hemiarthroplasty of Femoral Neck Fractures

• Allows for immediate weight bearing
• Indications comminuted fractures, pathologic
  fractures, nonambulatory status, and neurological
  conditions
• Contraindications young active patients, active
  sepsis, and acetabular disease
• Bipolar reduces acetabular erosion (young
  patients)
• Unipolar less active patients

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Total Hip Arthroplasty of Femoral Neck Fractures

• Indications
• -Contralateral hip disease
• -Ipsilateral acetabular metastatic disease
• -Preexisting degenerative disease

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Complications of Femoral Neck Fractures

• Nonunion
• Osteonecrosis
• -10 of nondisplaced fractures
• -27 of displaced fractures
• Fixation failure
• Infection
• Thromboemboli

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Intertrochanteric Hip Fractures

• Fracture between the greater and lesser
  trochanters
• Extracapsular fracture
• Musculature produces shortening, external
  rotation and varus position at the fracture site
• -Abductors displace the greater troch.
• -Iliopsoas displaces the lesser troch.
• -Hip flexors, extensors, and adductors pull
  the shaft proximally

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Evaluation of Intertrochanteric Hip Fractures

• Typically fractures result from a fall, direct
  blow to the greater troch.
• Imaging
• -AP and cross-table lateral
• -Bone scan or MRI may be useful in
  nondisplaced or occult fractures

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Classification of Intertrochanteric Hip Fractures

• Kyle
• -Type I nondisplaced, stable
• -Type II displaced into varus with a small
  lesser troch. fragment
• -Type III displaced into varus, posteromedial
  comminution and greater troch. fracture
• -Type IV Type III with subtrochanteric
  extension
• Other classifications Boyd and Griffin, Evans,
  and Zuckerman

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Treatment of Intertrochanteric Hip Fractures

• Nonoperative only for patients who are an
  extreme risk for surgery
• Sliding hip screw (130 degrees-150 degrees)
• -Screw placement should be within 1cm of
  subchondral bone
• -Screw should be located slightly
  posterioinferior or centrally in the femoral
  head

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Treatment of Intertrochanteric Hip Fractures

• Prosthetic replacement
• -For patients with failed ORIF
• -Calcar replacement hemiarthroplasty or
  bipolar endoprosthesis
• Cephalomedullary nails for reverse obliquity
  fracture pattern
• Greater troch. displacement should be fixed with
  tension banding
• Large posteriomedial fragments should be fixed
  with a lag screw or cerclage wires

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Complications of Intertrochanteric Hip Fractures

• Fixation failure
• Malunion
• Nonunion
• Infection
• Acetabular penetration
• Pressure sores

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Subtrochanteric Hip Fractures

• Fracture between the lesser troch. and a point 5
  cm distal to the lesser troch.
• Closed reduction difficult because straight
  femoral traction does not neutralize deforming
  muscle forces
• -Proximal Fragment Abduction (gluteus),
  External Rotation (short rotators), Flexion
  (psoas)
• -Distal Fragment Varus (adductors)

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Subtrochanteric Hip Fractures

• Frequent site for pathological fractures, 17-35
  of all subtroch. fractures
• Mechanism of injury
• -High energy trauma in younger patients with
  normal bone
• -Minor fall in older patients with weakened
  bone

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Seinsheimer Classification

• Type I nondisplaced fracture or any fracture
  with lt2mm of displacement of the
  fracture fragments
• Type II -A two-part transverse femoral
  fracture
• -B two-part spiral fracture with the
  lesser troch. attached to the proximal
  fragment
• -C two-part spiral fracture with the
  lesser troch. attached to the distal fragment

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Seinsheimer Classification

• Type III -A three part spiral fracture in
  which the lesser troch. is part of the 3rd
  fragment
• -B three part spiral fracture of the
  proximal third of the femur, with the 3rd part
  a butterfly fragment

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Seinsheimer Classification

• Type IV Comminuted fracture with four or more
  fragments
• Type V Subtroch-intertroch fracture, any
  subtroch. fracture with extension into the
  greater troch.
• Other Classifications
• -Fielding based on location of primary
  fracture line in relation to lesser troch.
• -AO based on comminution of fracture

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Nonoperative Treatment of Subtrochanteric Hip
Fractures

• Reserved for poor operative candidates
• Skeletal traction in the 90/90 position followed
  by spica casting or cast bracing
• Associated with increased morbidity and mortality

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Operative Treatment of Subtrochanteric Hip
Fractures

• Choice of fixation dependent on the involvement
  of the trochanters
• -Intact greater and lesser trochs.
  conventional locked IM nail
• -Intact greater troch., fractured lesser
  troch. recon nail (2nd gen. IM device)
• -Fractured greater and lesser trochs. 95
  degree blade plate or dynamic compression
  screw

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Complications of Subtrochanteric Hip Fractures

• Malunion
• Nonunion
• Loss of fixation
• Technical difficulty of fixation device

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Ankle Fractures

• The most common type of fracture treated by
  orthopedic surgeons
• Only slight variation from normal is compatible
  with good joint function
• Imaging AP, lateral, and mortise views

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Ankle Anatomy

• Complex hinge joint with articulations with the
  fibula, tibia, and talus
• Ligaments
• -Deltoid ligament superficial and deep
• -ATFL
• -PTFL
• -Calcaneofibular
• -Syndesmosis anterior and posterior inferior
  tibiofibular ligaments, inferior transverse
  ligament, and interosseous ligament

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Lauge-Hansen Supination-Adduction

• 10-20 of malleolar fractures
• Stage I transverse/avulsion fracture of the
  distal fibula or a rupture of the lateral
  collateral ligaments
• Stage II vertical fracture of the medial
  malleolus

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Lauge-Hansen Supination-External Rotation

• Most common malleolar fracture
• Stage I disruption of the ATFL with or without
  an avulsion fracture at its attachment
• Stage II spiral fracture of the distal fibula
• Stage III disruption of the PTFL or a fracture
  of the posterior malleolus
• Stage IV transverse/avulsion fracture of the
  medial malleolus or a rupture of the deltoid
  ligament

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Lauge-Hansen Pronation-Abduction

• Stage I transverse fracture of the medial
  malleolus of rupture of the deltoid ligament
• Stage II rupture of the syndesmotic ligaments
  or an avulsion fracture at their insertions
• Stage III transverse or short oblique fracture
  of the distal fibula at or above the level of the
  syndesmosis

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Lauge-Hansen Pronation-External Rotation

• Stage I transverse fracture of the medial
  malleolus or rupture of the deltoid ligament
• Stage II disruption of the ATFL with or without
  avulsion fracture at its insertion sites
• Stage III spiral fracture of the distal fibula
  at or above the level of the syndesmosis
• Stage IV rupture of the PTFL or avulsion
  fracture of the posteriolateral tibia

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Weber Classification

• Based on the level of the fibular fracture
• Type A fracture below the level of the
  syndesmosis
• Type B oblique or spiral fracture at the level
  of the syndesmosis
• Type C fracture above the level of the
  syndesmosis

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Fracture Variants

• Maisonneuve fx ankle injury with a fracture of
  the proximal third of the fibula, PER
• Curbstone fx avulsion fracture of the posterior
  tibia
• LeForte-Wagstaffe fx anterior fibular tubercle
  avulsion by ATFL, SER
• Tillaux-Chaput fx avulsion of anterior tibia by
  ATFL

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Treatment of Ankle Fractures

• Reduce dislocated ankles prior to x-rays
• Cover open fractures with sterile, saline soap
  dressing, antibiotics, tetanus, etc.
• Nonoperative(closed reduction) reserved for
  stable fracture patterns with an intact
  syndesmosis
• Operative treatment required when closed
  reduction requires forced abnormal positioning of
  the foot, unstable fractures, open fractures, and
  widening of the mortise (1-2mm)

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Operative Treatment of Ankle Fractures

• Key to reduction is restoration of fibular
  length lag screw and 1/3 tubular plate
• Medial malleolus can be held with 2 cancellous
  screws perpendicular to the fracture line
• Posterior malleolus should be fixed if there is
  gt2mm of displacement or involvement of gt25 of
  the articular surface
• Syndesmotic screw for fibula fractures above the
  syndesmosis, placed 1.5-2cm above the joint line
  from the fibula to the tibia

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Complications of Ankle Fractures

• Nonunion
• Malunion
• Infection
• Posttraumatic arthritis
• Compartment Syndrome
• Reflex sympathetic dystrophy
• Tibiofibular synostosis

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Pilon Fractures

• Mechanism of injury
• -Axial compression force through the talus
• -Shear rotation combined with a varus or
  valgus stress
• Etiology mva, fall from height, direct crush
  injury, and sporting injuries (ski boot)
• Imaging AP, lateral, and oblique x-rays CT
  scan for articular surface

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Ruedi and Allgower Classification

• Based on the severity of comminution and
  displacement of the articular surface
• Type I nondisplaced with splitting fracture
  lines
• Type II articular surface displaced split
  fracture types
• Type III significant comminution and
  displacement of articular surface
• Other classifications AO, Mast, and Ovadia and
  Beale

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Treatment of Pilon Fractures

• ORIF of the fibula with 1/3 tubular plate
• Reconstruction of tibial joint surface with
  K-wires
• Bone graft metaphyseal deficits
• Plate tibia (medial malleolus), cloverleaf plate
• Fractures with metaphyseal comminution and
  severe soft-tissue injury consider external
  fixation

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Complications of Pilon Fractures

• Skin slough
• Infection
• Nonunion
• Malunion
• Posttraumatic arthritis
• Joint stiffness