hip, pelvis, femur and knee lower extremity trauma 2012

HIP, PELVIS, FEMUR, AND KNEE Lower Extremity Trauma

AAOS/ASSH GENEERAL ORTHO REVIEW MATTHEW L. JIMENEZ

www.drjimenez.com

Mandatory Disclosure •  The 2012 14th Annual Chicago Trauma

Symposium received support from 40 industry partners

Mandatory Disclosure •  Foundation for Education and

Musculoskeletal Research (FEMR) several industry and philanthropic partners

OUTLINE •  Handouts are from OKUs

– Need to know for the test •  This lecture gives context to the written

material •  Trauma care is a visual art

WHAT IS HIGH ENERGY?

KE = ½MV²

PELVIC-ASSOCIATED INJURIES

•  HEMORRHAGE 75% •  UROGENITAL 12% •  LUMBOSACRAL PLEXUS 8%

HIGH ENERGY PELVIC FRACTURES •  MORTALITY RATE 15-25% •  OTHER ASSOCIATED

MUSCULOSKELETAL INJURIES 60-80%

PELVIC RADIOGRAPHY

ASSESSMENT (RADIOGRAPHS)

• AP PELVIS

INLET VIEW

OUTLET VIEW

PELVIC ANATOMY

PELVIS •  LINK

– Axial Skeleton – Lower Extremity Appendicular

Skeleton

PELVIS •  Several Structures

of Consequence Pass Through the Pelvis – Vascular – Neurologic – Genitourinary – Gastrointestinal

CAUSES OF DISABILITY

•  Persistent Pain – Malunion – Nonunion

•  Deformity – Pelvic Obliquity – Malrotation – Leg Length Discrepancy

INDICATIONS •  One Cannot Consider the Indications

for Treatment of Pelvic Fractures Without an Understanding of: – Pelvic Anatomy – Pelvic Biomechanics… Stability Concept

PELVIS

•  Bones Have No Inherent Stability

STABILITY

•  Stability Comes from the Ligaments

PELVIC DIAPHRAGM

•  Like a Trampoline

PELVIC DIAPHRAGM •  Coccygeal and

Levator Ani Muscles

•  Traversed by Three Major Structures – Urethra – Rectum – Vagina

DISRUPTED PELVIC DIAPHRAGM

PELVIC DIAPHRAGM Female: Recto-Vaginal Trauma

PELVIC DIAPHRAGM Male: Genitourinary Trauma

External Rotation-Abduction “Tractor-Pull”

URETHRAL INJURY

Prostate

Pelvic Floor

Bulbous Portion Urethra

URETHRAL INJURY

LUMBOSACRAL PLEXUS

• Anterior Rami of T12 through S4 • L4 through S1 Most Important Clinically

LUMBOSACRAL PLEXUS

S1 Shear

L5

S1

LUMBOSACRAL PLEXUS

BLOOD VESSELS •  Massive

Hemorrhage is the Major Complication of Pelvic Disruptions

PELVIC VEINS

•  Large Thin Walled Posterior Venous Plexus –  Most Drain Into the

Internal Iliac Vein •  Bleeding Often

Venous

PELVIC ARTERIES

•  The Internal Iliac Artery is the Vessel of Major Importance in Pelvic Trauma

PELVIC ARTERIES •  The Superior Gluteal

Artery is the Largest Branch of the Internal Iliac Artery

PELVIC STABILITY

FORCE VECTORS • Anteroposterior Compression •  Lateral Compression •  External Rotation Abduction • Vertical Shear

UNIVERSAL CLASSIFICATION

•  Type A: STABLE •  Type B: Partially Stable

– Rotationally Unstable •  Type C: Unstable

– Tri-planer Instability

STABILITY IS A CONTINUUM

Stable Unidirectional Instability

Multidirectional Instability

RATIONALE FOR SURGERY

• The goal is to Decrease the Incidence of: – Persistent Pain – Malunion – Nonunion

SURGICAL INDICATIONS

EMERGENT STABILIZATION •  PELVIC SLING

– STANDARD SHEET •  INTERNAL ROTATION LOWER

EXTREMITIES •  SANDBAGS


Uniplanar Instability

• Rotationally Unstable Pelvic Fracture – Pubic Symphysis

Widening of Greater than 2.5 cm

Rotationally Unstable, but Vertically Stable


Multi-planar Instability

•  Unstable Posterior Pelvic Ring –  SI Joint Dislocation –  SI Joint Fracture-

Dislocation –  Unstable Sacral

Fractures –  Unstable Posterior Iliac

Wing Fractures


Multi-planar Instability •  Unstable Posterior

Pelvic Ring –  SI Joint Dislocation –  SI Joint Fracture-



Wing Fractures


Multi-planar Instability

•  Unstable Posterior Pelvic Ring –  SI Joint Dislocation –  SI Joint Fracture-



Wing Fractures

ACETABULAR FRACTURES

Acetabular Fractures Disrupt the Contact Area Between the Acetabulum and

Femoral Head

Displacement of the Articular Surface leads to rapid Destruction of the Hip

Articular Fracture Principles

•  Anatomic Reduction of Articular Surface

•  Congruent, Stable joint with restored contact area

ANATOMY

•  ANTERIOR COLUMN •  POSTERIOR COLUMN

ANATOMY •  ANTERIOR COLUMN

– ANT BORDER ILIAC WING

– ANTERIOR WALL – SUPERIOR PUBIC

RAMUS – ENTIRE PELVIC

BRIM

ANATOMY

•  POSTERIOR COLUMN – GREATER SCIATIC NOTCH – LESSER SCIATIC NOTCH –  ISCHIAL TUBEROSITY – POSTERIOR WALL

RADIOLOGY • AP PELVIS • AP & LAT HIP • OBTURATOR OBLIQUE •  ILIAC OBLIQUE

CLASSIFICATION

•  1964 JUDET – ANATOMIC CLASSIFICATION

•  LETOURNEL - SLIGHT MODIFICATION

Surgical Indications •  Displaced

Fractures (>2-3 mm)

•  Roof Arc Measurements <45°

•  > 20-40% of posterior wall width

Treatment Protocol •  Radiographs Allow Proper Fracture

Classification •  Fracture Location and Displacement

Determine Need for Surgery •  Fracture Pattern Determines Approach

SURGICAL APPROACHES

•  KOCHER-LANGENBECK – Posterior

•  ILIOINGUINAL – Anterior

•  EXTENDED ILIOFEMORAL

KOCHER-LANGENBECK

•  POSTERIOR WALL •  POSTERIOR COLUMN •  TRANSVERSE •  “SOME” T-TYPE

ILIOINGUINAL • ANTERIOR WALL • ANTERIOR COLUMN •  TRANSVERSE •  “SOME” T-TYPE • MOST - BOTH COLUMN

EXTENDED ILIOFEMORAL

•  TRANSVERSE AND T-TYPE –  TRANSTECTAL –  SEVERE COMMINUTION –  LATE PRESENTATION

•  BOTH-COLUMN –  LATE PRESENTATION –  SEVERE COMMINUTION

HIP FRACTURES AND DISLOCATIONS

RELEVANT ANATOMY

•  Blood supply to the femoral head is derived primarily from the medial femoral circumflex artery, which forms an extracapsular ring with the lateral femoral circumflex artery

RELEVANT ANATOMY

•  Ascending arteries follow the posterior femoral neck and perforate the femoral head at the junction of the inferior articular surface.

HIP DISLOCATION •  Associated with vascular injury •  Can result in AVN

– Subsequent post-traumatic hip arthrosis

POSTERIOR HIP DISLOCATION

•  Account for nearly 90% of all hip dislocations


•  Treatment – Emergent closed reduction – Open reduction through a Kocher-Langenbeck

approach if closed reduction is unsuccessful


•  Sciatic nerve is an at risk structure –  Initial injury – Surgical reduction – Occur in 8-19% of patients

COMPLICATIONS OF HIP DISLOCATIONS

•  Avascular necrosis of femoral head in 10% of hip dislocations – Risk of AVN increases with associated

acetabular fracture – Early reduction of hip dislocations is

associated with a lower rate of AVN •  Post-traumatic hip arthritis in 15% of hip

dislocations.

FEMORAL HEAD FRACTURES

•  Pipkin Classification- Four types –  Type I- inferior to the

fovea –  Type II- superior to the

fovea –  Type III- associated

femoral neck fracture –  Type IV- associated

acetabular fracture

FEMORAL HEAD FRACTURES

•  Treatment based on: – Fragment size – Fragment location – Fragment displacement – Hip stability

FEMORAL HEAD FRACTURES- treatment

•  Type I (infra-foveal) –  Nondisplaced-

nonsurgical –  Small displaced

fragments- surgical excision

–  Large displaced fragments- reduction and surgical fixation


•  Type II (supra-foveal) –  Requires accurate

anatomic reduction and stable internal fixation


•  Type III (associated femoral neck frx) –  Young patient

•  Anatomic reduction and stable internal fixation of both the femoral neck and femoral head

–  Older patient •  Hemiarthroplasty

Pipkin Type IV Fracture

FEMORAL NECK FRACTURES

FEMORAL NECK FRACTURES- Classification

•  Pauwel’s Classification - based on fracture verticality –  Type I- Less than 30

degress –  Type II- 30-50

degrees –  Type III- Greater

than 50 degrees

FEMORAL NECK FRACTURES- Classification

•  Garden Classification – Type I and II –

nondisplaced – Type III and IV -

displaced

FEMORAL NECK FRACTURES- Nondisplaced

•  Nondisplaced femoral neck fractures – Treatment is the same regardless of the patient

age


•  Nondisplaced femoral neck fractures – Internal Fixation – Three parallel

screws


•  Ideal screw configuration – Inverted triangle – Screws positioned along the

endosteal surface

The Concept of “Cortical Support”

Case Study: 64 year old

woman with impacted

femoral neck fx

Implant Position

Rx: Fixation in situ

Cortical Support

Ten days

Post-op

Cortical Support

Cortical Support

FEMORAL NECK FRACTURES- Displaced

•  Young Patients (<65 years old) – Efforts are focused on preservation of the

femoral head and avoiding arthroplasty at a young age

– ORIF


•  Young patients – Timing is urgent – Lower rates of AVN with early treatment – Anatomic reduction and stable fixation – Slight valgus acceptable – Avoid varus reductions

ORIF: most important variable is quality of reduction


•  Young patients – High shear angle

fractures (Pauwel’s III)

•  Supplement fixation with a fixed angle device

•  Additional Oblique screw

PROBLEM CHILD!!


•  Older patients –  In North America, prosthetic replacement is

favored


•  Why endoprosthesis in older patients? – Need for rapid mobilization – ORIF failure rate of 40%

•  Osteoporotic bone •  Comminution


•  Older patients- type of prosthetic replacement? –  Unipolar

hemiarthroplasty –  Bipolar

hemiarthroplasty –  Cemented vs.

uncemented Unipolar Bipolar


•  Older patients- type of prosthetic replacement? – NO difference in morbidity, mortality, or

functional outcome


•  Older patients- Total Hip Arthroplasty – Classic indication

•  Displaced fracture with ipsilateral hip arthritis

– Recently indication expanded •  Displaced fracture and an active elderly patient

with no hip arthritis

INTERTROCHANTERIC HIP FRACTURES- Classification

INTERTROCHANTERIC HIP FRACTURES- Treatment

•  Intertrochanteric hip fractures are treated the same, regardless of age


•  Anatomic reduction and stable internal fixation

•  Choice of implant based on – Fracture pattern – Associated stability of the fracture


•  Sliding hip screw –  Useful for most (avoid

in reverse oblique) –  Simple and predictable


•  Sliding hip screw – Do not use with reverse oblique fracture

patterns

Reverse Obliquity Intertochanteric Fixation

Mode of failure

l Medialization of the distal fragment

l Cutout

l Non-union

56% FAILURE RATE Haidukewych et al JBJS 2001


•  Reverse oblique fracture pattern –  95 degree plate fixation

•  95 degree dynamic condylar screw •  95 degree condylar blade plate

– Cephalomedullary device

Reverse Obliquity Intertochanteric Fracture

Options for Treatment


•  Outcomes – No difference

between a two-hole and four-hole sliding hip screw


•  Cepholomedullary device – No clear advantage over conventional sliding

hip screw for most fractures – Exceptions

•  Reverse oblique fractures •  Intertrochanteric fractures with subtrochanteric

extension – More studies necessary

Cephalomedullary Nails

Principles of IM Nailing: – Mechanics:

• Stable fixation allows mobility

– Biology • Dissection away from

fracture environment

Femoral Shaft Fractures

Reamed Antegrade Nailing Winquist JBJB 1984 520 99.1% Brumback JBJS 1988 100 98% Brumback JBJS 1989 89 Open 100% Nowotarski JBJS 1994 39 GSW 95% Bergman J Trauma 1993 65 GSW 100%

98-99% union rate!


•  Static locked antegrade nails •  98% ultimate healing

The “Gold Standard”


Ante vs. Retro Femoral Nailing

3 comparative studies •  Ricci et al., JOT, 2001 •  Tornetta and Tiburzi, JBJS-Br., 2000 •  Ostrum et al., JOT, 2000

Ricci Tornetta Ostrum


A R

Final Healing %

99 100 100

97 100 98

No difference in healing rates



A R

Knee Pain

9% 14% 10%

36% 13% 11%

Maybe a difference in knee pain



A R

Hip/ Thigh Pain

10% n/a 26%

4% n/a 4%

More hip pain after antegrade

or

or All 3 options appear “reasonable”

Femoral Nailing: Summary

We all “know” basic nailing

•  Good starting point •  Quality reduction •  Ream •  Large nail •  Lock

DISTAL FEMUR FRACTURES

GENERAL PRINCIPLES

•  Anatomic reduction of the articular surface •  Restoration of

– Length – Rotation – Alignment

•  Stable fixation- Soft tissue friendly •  Early mobilization

THE ARTICULAR SEGMENT

• Anatomic reduction • Absolute Stability

– Compression • Do not compromise

ARTICULAR CARTILAGE

•  No Blood Supply •  No Nerve Supply •  No Lymphatic

Supply •  Nutrition From

Synovial Fluid (Diffusion)

Meta-diaphyseal Segment

•  Bridge •  Relative stability •  Avoid dissection in the zone of injury •  Restoration of overall


PREVIOUS PLATING OPTIONS

• Condylar Buttress • Angled Blade Plate • Dynamic Condylar Screw

Condylar Buttress Plate

Blade Plate

Comminuted fracture with short metaphyseal segment

95 degree DCS

Screw Cut-out

IS THERE ANOTHER SOLUTION?

•  Locking Plate fixation with multiple fixed angle screws in the metaphyseal segment – Locking Condylar Plate – Liss Plate

Conventional Plate First Screw Failure

Conventional Plate Sequential Screw Failure

Conventional Plate Plate/Bone Dissociation

Locking Plate

Locked Screws are Fixed Angle Constructs

Threaded Head

Locking Plate

Must Fail Simultaneously

Locking Plate

Locking Plate

Catastrophic Failure Less Likely

MIPPO • Minimally invasive percutaneous

plate osteosynthesis •  “Submuscular plating”

C. Kretek

MIPPO: What is it? • A Concept • A Technique •  Involves reduction •  Involves stabilization • Not implant driven

Conventional Plating

MIPPO- Limited incisions and submuscular plate application

OR Logistics •  Supine on a radiolucent table •  Limb prepped free •  Knee support •  Femoral distractor or large external fixator

Lateral tensor-splitting surgical approach

Beware of soft tissue stripping in the zone of injury

Lateral Peripatellar Approach

REDUCTION •  Articular segment reduced under direct

vision –  3.5 cortical screws – Compression when possible

•  Indirect reduction of meta-diaphyseal segment – Avoid soft-tissue stripping

Osteoporotic, short metaphyeal segment, intra-articular extension

-Note sub-articular 3.5 cortical screws -Joint reduced under direct vision

SUMMARY •  Anatomic reduction and absolutely stable

fixation of articular surface •  Restore


•  Stable Fixation – Biologically friendly

THANK YOU

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hip, pelvis, femur and knee lower extremity trauma 2012

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