© Springer-Verlag France 2015
Cyril Mauffrey and David J. Hak (eds.)Passport for the Orthopedic Boards and FRCS Examination10.1007/978-2-8178-0475-0_11Pelvis and Lower Extremity Trauma
(1)
Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, 80204, CO, USA
1 Pelvic Ring Injuries
Take-Home Message
Pelvic ring injuries are most commonly described using the Young-Burgess classification.
Hemodynamically unstable patients require emergent intervention with pelvic binder/sheet, volume resuscitation, possible external fixation and pelvic packing, possible angiographic embolization, skeletal traction in vertically unstable patterns, and possible C clamp.
Anterior pelvic ring injuries commonly treated with plate fixation. External fixation may be favorable in some patients, and injury patterns place the lateral femoral cutaneous nerve at risk.
Posterior pelvic ring injuries require anatomic reduction and stabilization with anterior plating, SI screws, or posterior tension band plating.
Placement of percutaneous sacroiliac screws requires meticulous fluoroscopic visualization with appropriate inlet, outlet, and lateral sacral views.
Vertical sacral fractures are at increased risk for loss of fixation/reduction.
Vertically unstable pelvic ring injuries should be treated with stabilization of the anterior and posterior pelvic ring; consider lumbopelvic fixation.
High incidence of thromboembolic disease and urogenital injuries.
Increased risk of mortality with blood transfusion requirement in the first 24 h, open fractures, associated bladder ruptures, and more severe/unstable fracture patterns.
General
Mechanism of injury: typically high-energy blunt trauma
High mortality rates
Closed fracture: 15–25 % mortality
Open fractures: up to 50 % mortality
Complete examination of the perineum, vagina, and rectum to rule out occult open injuries.
Open pelvis fractures may require a diverting colostomy.
High incidence of associated injuries
Chest, head, abdominal, long bone fractures, spine fractures, internal iliac vessels and branches, lumbosacral plexus (L5 and S1 most common), urogenital injuries.
Urogenital injuries: blood at the urethral meatus, high-riding prostate, significant displacement of the anterior pelvic ring.
Males (21 %) > females (8 %).
If retrograde urethrogram is negative and there is persistent hematuria, obtain a cystogram.
Fracture patterns with significant ilium/crescent components have increased risk of soft tissue degloving and bowel injury or entrapment.
Mortality usually results from sequelae of nonpelvic-associated injuries.
Hemorrhage is the leading cause of death
Internal pudendal artery injuries associated with the most significant intrapelvic hemorrhage
Must evaluate for nonpelvic sources of bleeding
Binders, sheeting, external fixation, pelvic clamp, and pelvic packing: decrease the volume of the pelvis and tamponade bleeding
Good for venous hemorrhage
Less effective for arterial hemorrhage
Angiography with embolization for ongoing arterial hemorrhage
Imaging
AP pelvis: assess each hemipelvis for asymmetry, rotation, and displacement and for possible associated fracture of the L5 transverse process, ischial spine, and ischial tuberosity.
Inlet view: 25–45° caudad angulation; S1 should overlie S2; assess anteroposterior displacement of the sacroiliac joint, sacroiliac joint widening, rotational deformity, and sacral ala impaction fracture.
Outlet view: 45–60° cephalad angulation; pubic symphysis shoulder overlies S2; assess vertical displacement of the sacroiliac joint and flexion/extension of the hemipelvis and disruption of sacral foramina.
CT scan: should be obtained routinely to further evaluate pelvic ring injuries
Better characterization of posterior ring injuries, involvement of sacral foramina, comminution, and rotation
Young and Burgess Classification
Anteroposterior compression injuries
High incidence of associated visceral injuries and retroperitoneal injuries
APC I: symphyseal diastasis <2.5 cm, posterior pelvic ring intact
APC II: symphyseal diastasis >2.5 cm, disruption of the sacrotuberous, sacrospinous, and anterior sacroiliac ligaments; posterior sacroiliac ligaments intact
APC III: symphyseal diastasis >2.5 cm, complete separation of the hemipelvis from the pelvic ring with disruption of the sacrotuberous, sacrospinous, and anterior and posterior sacroiliac ligaments
Lateral compression injuries
High incidence of closed head injury and intra-abdominal injury.
LC I: pubic ramus fracture with sacral compression fracture.
LC II: pubic ramus fracture with posterior iliac wing fracture-dislocation (crescent fracture).
LC III: pubic ramus fracture with ipsilateral lateral compression injury and contralateral APC injury (windswept pelvis); common mechanisms include rollover MVC and auto vs pedestrian.
Vertical shear injuries
Highest incidence of intrapelvic hemorrhage with resulting hemorrhagic shock (~65 %)
Posterior and superior directed force, common mechanism with fall from height
Combined mechanism injuries
Tile Classification
Stable (posterior arch intact)
A1: fracture not involving the pelvic ring (avulsion, iliac wing)
A2: minimally displaced, stable ring fracture
A3: transverse sacral fracture
Rotationally unstable, vertically stable
B1: anteroposterior compression injury (external rotation)
B2: lateral compression injury (internal rotation)
B2-1: anterior ring rotation with displacement through the ipsilateral rami
B2-2: anterior ring rotation with displacement through the contralateral rami
B3: bilateral
Rotationally and vertically unstable (complete disruption of the posterior arch)
C1: unilateral
C1-1: iliac fracture
C1-2: sacroiliac fracture-dislocation
C1-3: sacral fracture
C2: bilateral with one side B type and one side C type
C3: bilateral C type
Treatment
Emergent volume resuscitation and hemorrhage control
Massive transfusion protocol: PRBC-FFP-platelets in 1:1:1 ratio improves mortality.
Bleeding sources: intra-abdominal, intrathoracic, retroperitoneal, extremity, pelvic
Pelvic sources of hemorrhage
Venous plexus hemorrhage: 80–85 %
Bleeding cancellous bone
Arterial injury 15–20 %
Superior gluteal > internal pudendal > obturator > lateral sacral
Reduce pelvic volume and stabilize fracture.
Pelvic binder/sheet centered over greater trochanters, may internal rotate lower extremities and bind ankles together; prolonged pressure from binder or sheet can cause skin necrosis.
External fixation, skeletal traction (vertically unstable injuries), pelvic C clamp (rarely used) to decrease pelvic volume and tamponade bleeding and to stabilize fracture allowing clot to form over bleeding bone and venous plexus.
External fixator should be placed before pelvic packing (if performed) or laparotomy.
Angiographic embolization may be considered if there is ongoing arterial hemorrhage with the goal to selectively embolize bleeding sources, risk of gluteal necrosis, and impotence.
Nonoperative
Mobilization with weight bearing as tolerated indicated for mechanically stable pelvic ring injuries
LC I and APC I pelvis fractures, isolated pubic ramus fractures
May consider protected weight bearing for some anterior injuries with ipsilateral partial posterior ring injuries
Operative
Open reduction internal fixation
Indicated for symphyseal diastasis >2.5 cm, complete sacroiliac joint disruption, displaced sacral fractures, vertically unstable fractures, displacement or rotation of hemipelvis.
Anterior injuries: anterior plate fixation most common, external fixation with supra-acetabular pins or iliac wing pins (lateral femoral cutaneous nerve at risk, indicated with suprapubic catheter placement).
Posterior injuries: sacroiliac joint dislocations and fracture-dislocations require anatomic reduction.
Open reduction and anterior plating of the sacroiliac joint via lateral window, L4 and L5 nerve roots at greatest risk with retractor placement.
Sacroiliac screws: L5 nerve root at greatest risk; ensure screws are posterior to the iliac cortical density on the lateral sacral view and appropriately positioned on inlet and outlet pelvis views.
Posterior tension band plating: risk of prominent hardware and wound healing problems.
Vertically unstable injury patterns should be treated with anterior and posterior ring stabilization to decrease risk of loss of reduction; consider lumbopelvic fixation.
Complications
Poor outcomes associated with SI joint incongruity, increased injury severity and initial displacement, malunion with residual displacement >1 cm, nonunion, leg length discrepancy >2 cm.
Vertical sacral fractures have the highest risk of loss of fixation/reduction.
Neurologic injury
L5 nerve root at greatest risk as it courses over the sacral ala.
L4 and S1 nerve roots at lesser risk.
Additional sacral nerve root may be compromised at the time of injury, reduction of sacral fracture, or overcompression of transforaminal sacral fractures.
High risk of thromboembolic disease
Pharmacologic prophylaxis, mechanical prophylaxis, IVC filters in patients otherwise contraindicated for chemical anticoagulation
Urogenital injuries
Present in 10–20 % of pelvic ring injuries, more common in males.
Urethral tear, bladder rupture (increased risk of mortality).
May result in urethral stricture, impotence, incontinence, and increased risk of anterior pelvic ring infection.
Dyspareunia, possible need for cesarean section.
Chronic instability is a rare complication.
Assess with single-leg stance pelvis x-rays.
Increased risk of mortality associated with blood transfusion requirement in the first 24 h, open fractures, associated bladder ruptures, and more severe/unstable fracture patterns.
Bibliography
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Barei DP, Bellabarba C, Mills WJ, Routt ML Jr. Percutaneous management of unstable pelvic ring disruptions. Injury. 2001;32(Suppl 1):SA33–44.
2.
Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30(7):848–56.
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Croce MA, Magnotti LJ, Savage SA, Wood GW 2nd, Fabian TC. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg. 2007;204(5):935–9.
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Griffin DR, Starr AJ, Reinert CM. Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure? J Orthop Trauma. 2006;20:S30–6.
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Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-threatening pelvic fracture. J Am Acad Orthop Surg. 2009;17(7):447–57.
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Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV. Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. Int Orthop. 2011;35(9):1381–90.
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Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005;59(3):659–64.
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Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 735–8.
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Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma. 1996;10(3):171–7.
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Siegel J, Templeman DC, Tornetta P III. Single-leg-stance radiographs in the diagnosis of pelvic instability. J Bone Joint Surg Am. 2008;90(10):2119–25.
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Smith W, Williams A, Agudelo J, Shannon M, Morgan S, Stahel P, Moore E. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21(1):31–7.
12.
Starr AJ, Walter JC, Harris RW, Reinert CM, Jones AL. Percutaneous screw fixation of fractures of the iliac wing and fracture-dislocations of the sacro-iliac joint (OTA Types 61-B2.2 and 61-B3.3, or Young-Burgess “lateral compression type II” pelvic fractures). J Orthop Trauma. 2002;16(2):116–23.
13.
Tile M. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg. 1996;4(3):143–51.
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Tile M. Acute pelvic fractures: II. Principles of management. J Am Acad Orthop Surg. 1996;4(3):152–61.
2 Acetabular Fractures
Take-Home Message
Bimodal distribution with high-energy blunt trauma in the young and low-energy fall in the elderly.
Corona mortis is an anastomosis between the external iliac (or deep epigastric) vessels and the obturator vessels.
Corona mortis present in ~30 % of patients, risk life-threatening hemorrhage if injured.
Six cardinal lines on the AP pelvis: iliopectineal line, ilioischial line, anterior wall, posterior wall, sourcil, teardrop.
Iliac oblique profiles the anterior column and posterior wall.
Obturator oblique profiles the posterior column and anterior wall.
Fractures with roof arc angle >45° on AP; obturator and iliac oblique views do not involve the weight-bearing dome.
On axial CT scan, vertical fracture lines represent transverse or T-type fractures, while horizontal line represents column fractures.
Letournel classification divides acetabular fractures into five elementary and five associated types.
Associated both-column fractures: complete dissociation of the articular surface of the acetabulum from the axial skeleton; the spur sign on obturator oblique represents the undisplaced intact posterior ilium.
Nonoperative management of minimally displaced fractures, fractures outside the weight-bearing dome, and fractures with secondary congruence.
Surgical fixation indicated for displaced fractures, fractures with roof arc angle <45° on any view, incarcerated intra-articular fragments, irreducible fracture-dislocations, and unstable hips with associated wall fractures.
Posterior wall fractures: <20 % presumed to be stable, 20–40 % perform dynamic fluoroscopic EUA to determine stability, >40 % presumed to be unstable.
ORIF and acute total hip arthroplasty for patients >60 years with superomedial dome impact (gull sign), significant osteopenia and/or comminution, and associated femoral neck fractures
Posttraumatic arthrosis is the most common complication.
Heterotopic ossification is common; increased risk with extensile and posterior approaches.
High risk of thromboembolic disease; all patients should receive DVT prophylaxis and/or IVC filter.
Risk of iatrogenic sciatic nerve injury can be decreased by maintaining hip extension and knee flexion to reduce tension on the nerve.
Quality of reduction is the most important determinant of outcome; increased risk of malreduction with delay to surgery.
General
Bimodal distribution
High-energy blunt trauma in young patients
Low-energy falls in elderly patients
Fracture pattern determined by position of the hip and force vector
Flexed hip with axial load most common (dashboard injury)
Associated injuries: hip dislocation, sciatic nerve injury, other lower extremity injuries (35 %), additional organ system injury (50 %)
Acetabulum supported by two columns of bone in an “inverted Y” and connected to the sacrum through the sciatic buttress
Posterior column: ischial tuberosity, greater and lesser sciatic notches, posterior wall and dome, and quadrilateral surface
Anterior column: lateral superior pubic ramus, iliopectineal eminence, anterior wall and dome, anterior ilium
Corona mortise: anastomosis of external iliac (or deep epigastric) vessels and the obturator vessels (arising from the internal iliac vessels)
Present in 30 % of patients
At risk with lateral dissection along the superior pubic ramus
Typically located ~3 cm from the symphysis pubis.
Variable anomalous branches may be present.
Risk of life-threatening hemorrhage if injured
Imaging Studies
AP pelvis: six cardinal lines
Iliopectineal line: radiographic representation of the anterior column
Ilioischial line: radiographic representation of the posterior column
Teardrop: radiographic representation of the medial acetabular wall
Sourcil
Anterior wall
Posterior wall
Shenton’s line: not a cardinal line, helps detect occult hip dislocation
Judet views (45° oblique views)
Obturator oblique: involved obturator foramen en face, anterior column, posterior wall
Iliac oblique: involved iliac wing en face, posterior column, anterior wall
Roof arc angles: angle from a vertical line to the geometric center of the acetabulum to the point where the fracture line intersects the acetabulum on AP, obturator and iliac oblique views
If roof arc angle is >45°, fracture does not involve the weight-bearing dome.
CT correlate: fracture line >10 mm from the apex of the dome does not involve the weight-bearing surface.
Cannot be applied to associated both-column fractures or posterior wall fractures (no intact portion of the acetabulum on which to base measurements).
CT scan: assess articular surface involvement, marginal impaction, posterior wall size, incarcerated intra-articular fragments, preoperative planning
Vertical fracture line on axial CT: transverse or T-type fracture.
Horizontal fracture line on axial CT: column fracture.
3D reconstruction with femoral head subtraction is a useful adjunct for some.
Letournel Classification
Elementary
Posterior wall: most common acetabular fracture, gull sign on obturator oblique
Posterior column: increased risk of injury to superior gluteal neurovascular bundle
Anterior wall: rare
Anterior column: more common with low-energy fractures in the elderly
Transverse: only elementary fracture pattern that involves both columns, anterior to posterior directed fracture line on axial CT
Associated
Posterior column posterior wall: only associated fracture pattern that does not involve both columns.
Anterior column posterior hemi-transverse: common in elderly patients.
Transverse posterior wall: most common associated fracture pattern.
T type: anterior to posterior fracture line on proximal axial CT scan with medial extension through the quadrilateral surface and the ischium distally.
Associated both columns: most commonly associated acetabular fracture pattern; no part of the articular surface of the acetabulum remains in contact with the axial skeleton (via the sacroiliac joint), spur sign on obturator oblique represents the undisplaced intact posterior ilium.
Treatment
Nonoperative management
Touchdown versus protected weight bearing for 8 weeks
Indications: nondisplaced and minimally displaced fracture (<1 mm step, <2 mm gap), roof arc angle >45°, posterior wall fragment <20 %, associated both columns with secondary congruence, severe comminution in the elderly with plan for total hip arthroplasty following fracture consolidation
Skeletal traction rarely indicated as definitive management
Operative
Open reduction internal fixation
Indications: displacement with >1 mm step or 2 mm gap with roof arc angle <45° on any view, instability on stress exam of the hip, marginal impaction, incarcerated intra-articular fragments, irreducible fracture-dislocations
Posterior wall fracture 20–40 %: dynamic fluoroscopic examination under anesthesia to assess hip stability
Posterior wall fracture >40 %: presumed to be unstable
Relative contraindications: morbid obesity, low-demand elderly and nonambulatory patients, known DVT with contraindication to IVC filter, delay to surgery >3 weeks.
Approach determined by fracture pattern, may be combined.
Risks specific to surgical approach for ORIF
Kocher-Langenbeck: sciatic nerve injury, avascular necrosis of the femoral head
Ilioinguinal: femoral nerve injury, LFCN injury, femoral vessel thrombosis, corona mortis laceration
Extensile (extended iliofemoral, triradiate): heterotopic ossification, gluteal necrosis
Outcomes correlate with quality of articular reduction, hip muscle strength, and restoration of gait.
ORIF and acute total hip arthroplasty
Relative indications: age >60 years with superomedial dome impaction (gull sign), significant osteopenia and/or comminution, associated displaced femoral neck fracture, significant preexisting hip arthrosis
Up to 80 % construct survival at 10 years
Worse outcomes in males, patients <50 or >80 years of age, and significant acetabular defects
Percutaneous fixation with column screws
Indications: minimally displaced column fractures, column fractures in elderly and low-demand patients to facilitate early mobilization and weight bearing
Imaging
Obturator oblique: best to assess joint penetration.
Iliac oblique: assess clearance of the sciatic notch and start point for supra-acetabular screws on the apex of the posterior inferior iliac spine (PIIS).
Inlet iliac oblique: assess position of screw in the pubic ramus.
Inlet obturator oblique: assess position of screw within tables of the ilium.
Obturator outlet: assess start point for supra-acetabular screws.
Complications
Posttraumatic arthrosis is the most common complication
Total hip arthroplasty, hip arthrodesis
Worse outcomes for total hip arthroplasty following acetabular fracture as compared to osteoarthritis
Heterotopic ossification
Greatest risk with extensile surgical approaches, lowest risk with ilioinguinal approach.
Extended approaches: 20–50 %
Kocher-Langenbeck: 8–25 %
Anterior approach: 2–10 %
Prophylaxis: indomethacin ×5 weeks post-op, low-dose external-beam radiation of 600 cGy within 48 h of surgery.
Excision of the devitalized gluteal muscle at time of surgery may help decrease incidence and severity.
In severe cases where heterotopic ossification interferes with hip function, may consider excision once mature.
Avascular necrosis
Increased risk with posterior fractures and approaches, fracture-dislocations, and iatrogenic injury to the medial femoral circumflex artery
Thromboembolic disease
High risk of DVT and PE
Chemical prophylaxis recommended for all patients unless specific contraindications exist
Place IVC filter if not contraindicated.
Infection
Increased risk with associated Morel-Lavellée lesions (internal degloving)
Bleeding
Early surgery may have greater blood loss; however increased delay to surgery results in longer operative times (reduction more difficult to obtain) with resulting increased blood loss.
Significant, potentially life-threatening, bleeding possible with injury to corona mortis vessels.
Neurologic injury
Sciatic nerve injury
Increased risk of sciatic nerve injury (especially peroneal division) with associated posterior hip dislocation.
Maintain hip extension and knee flexion intraoperatively to reduce tension on the sciatic nerve.
Lateral femoral cutaneous nerve injury
Anterior approaches
Hardware malposition
Intra-articular hardware, violation of sciatic notch
Abductor muscle weakness
Posterior approach > anterior approach
Chondrolysis
Malreduction
Associated with increased delay to surgery
Nonunion
Very rare
Bibliography
1.
Engsberg JR, Steger-May K, Anglen JO, Borrelli J Jr. An analysis of gait changes and functional outcome in patients surgically treated for displaced acetabular fractures. J Orthop Trauma. 2009;23(5):346–53.
2.
Gardner MJ, Nork SE. Stabilization of unstable pelvic fractures with supraacetabular compression external fixation. J Orthop Trauma. 2007;21(4):269–73.
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Grimshaw CS, Moed BR. Outcomes of posterior wall fractures of the acetabulum treated nonoperatively after diagnostic screening with dynamic stress examination under anesthesia. J Bone Joint Surg Am. 2010;92(17):2792–800.
4.
Jimenez ML, Tile M, Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin North Am. 1997;28:435–46.
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Kazemi N, Archdeacon MT. Immediate full weightbearing after percutaneous fixation of anterior column acetabular fractures. J Ortho Trauma. 2012;26(2):73–9.
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Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;151:81–106.
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Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 738–43.
8.
Starr AJ, Reinert CM, Jones AL. Percutaneous fixation of the columns of the acetabulum: a new technique. J Ortho Trauma. 1998;12(1):51–8.
9.
Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001;9(1):18–28.
10.
Tornetta P 3rd. Non-operative management of acetabular fractures. The use of dynamic stress views. J Bone Joint Surg Br. 1999;81(1):67–70.
3 Sacral Fractures
Take-Home Message
Sacral fractures commonly comprise part of a pelvic ring injury.
~25 % associated neurologic injury with increased risk in transforaminal, medial/spinal canal, transverse, and U-type sacral fractures.
Lower sacral nerve roots control the anal sphincter, bulbocavernosus reflex, and perianal sensation.
Unilateral sacral nerve root function sufficient for bowel and bladder control.
Vertical sacral fractures at increased risk for loss of reduction/fixation with resulting nonunion, malunion, and poor functional outcomes
Sacral U fractures are unstable injuries that represent spinopelvic dissociation and require stabilization.
Stable injuries with incomplete sacral fractures can mobilize as tolerated.
Minimally displaced complete sacral fractures may be treated with protected weight bearing or surgical stabilization.
Unstable, displaced sacral fractures should undergo reduction and stabilization ± decompression with careful technique to avoid iatrogenic nerve injury.
General
Bimodal distribution, common in pelvic ring injuries
Young adults: high-energy trauma with MVC and fall from height most common
Elderly: low-energy falls, insufficiency fractures
Neurologic injury in 25 %
Lower sacral root function: anal sphincter, bulbocavernosus reflex, perianal sensation.
Neurologic deficit is the most important predictor of outcome.
Unilateral sacral nerve root function sufficient for bowel and bladder control.
Imaging
Radiographs demonstrate 30 % of sacral fractures.
AP pelvis: symmetry of foramina, associated L4 and L5 transverse process fractures.
Inlet view: sacral spinal canal, S1 body.
Outlet view: true AP of the sacrum; assess symmetry of the foramina.
Lateral view: kyphosis.
CT scan study of choice to further delineate fracture pattern and help guide treatment.
MRI is for cases with concern for neural compromise.
Denis Classification
Zone I: alar fracture (lateral to the foramina)
5 % neurologic injury, most commonly L5
Zone II: transforaminal
30 % neurologic injury, most commonly L5, S1, S2.
Vertical and shear-type fractures are highly unstable with increased risk of poor functional outcome.
Zone III: medial to the foramina into the spinal canal
60 % neurologic injury, most commonly the caudal nerve roots with bowel, bladder, and sexual dysfunction.
Unilateral sacral root preservation is sufficient for bowel/bladder control.
Transverse Fractures
High incidence of neurologic injury
Sacral U Fracture
High incidence of neurologic injury
Typically results from axial loading
Unstable injuries, often with kyphosis through the fracture, that represent spinopelvic dissociation and require surgical stabilization
Treatment Principles
Nonoperative: stable and minimally displaced fractures
Weight bearing as tolerated: incomplete sacral fractures where the intact sacrum remains in continuity with the ilium, neurologically intact
Anterior impaction sacral fractures with LC mechanism, isolated sacral ala fractures
Toe-touch weight bearing: consider in complete sacral fractures with minimal displacement.
Post-mobilization x-rays to assess for subsequent displacement.
Operative
Open reduction internal fixation ± decompression
Displaced fractures (>1 cm), displacement of fracture with trial of nonoperative management, foraminal compromise, unstable fracture patterns
Percutaneous sacroiliac screws, posterior tension band plating, transiliac sacral bars, lumbopelvic fixation
Open decompression considered for transforaminal fractures with neurologic injury and sacral U fractures with kyphosis and compromise of the spinal canal
Complications
Neurologic deficit is the most important predictor of outcome
Lower extremity deficits, bowel/bladder dysfunction, sexual dysfunction
Nerve compromise at the time of injury
Risk of iatrogenic nerve injury with implant malposition and overcompression of fractures involving the sacral foramina
Malunion/nonunion
Vertical sacral fractures at increased risk for loss of fixation/reduction with resulting malunion, nonunion, and poor functional outcomes
Thromboembolic disease
Chronic low back pain
Bibliography
1.
Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67–81.
2.
Mehta S, Auerbach JD, Born CT, Chin KR. Sacral fractures. J Am Acad Orthop Surg. 2006;14(12):656–65 (Review).
3.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 738.
4.
Robles LA. Transverse sacral fractures. Spine J. 2009;9(1):60–9. Epub 2007 Nov 5. Review.
4 Hip Dislocations
Take-Home Message
High-energy trauma; position of the hip at the time of injury determines the direction of the dislocation and risk of associated injuries.
Hip dislocations require emergent closed reduction within 6 h to decrease the risk of avascular necrosis.
If closed reduction is not possible, proceed to the operating room in urgent fashion for open reduction.
Obtain a postreduction CT scan to assess for associated fracture and incarcerated fragments.
Commonly associated injuries include acetabular fractures, femoral head fractures, labral tears, sciatic nerve injury, and ipsilateral knee injuries.
General
Typically occur in young adults following high-energy trauma.
Axial loading; position of the hip determines the direction of the dislocation.
90 % of hip dislocations are posterior.
High incidence of associated injuries
Acetabular fractures (posterior wall fracture, marginal impaction), femoral head fractures, chondral injury, labral tears (30 %), sciatic nerve injury, ipsilateral knee injuries (25 %)
Imaging
AP pelvis: dislocated femoral head appears smaller than the contralateral side (posterior dislocation); discontinuity of Shenton’s line; carefully assess femoral neck for possible fracture.
Lateral hip: confirm direction of dislocation.
Postreduction AP pelvis and lateral hip to confirm reduction; consider Judet views to further evaluate for possible associated acetabular fracture.
Postreduction CT scan mandatory: assess for loose bodies, incarcerated fragments, femoral head fracture, and acetabular fracture.
MRI may be useful in follow-up to further evaluate concern for subsequent avascular necrosis or labral injury.
Classification
Simple: hip dislocation with no associated fracture
Complex: hip dislocation with associated acetabular or proximal femur fracture
Anatomic classification
Posterior dislocation (90 %)
Hip flexed, adducted, and internally rotated
“Dashboard injury”
Associated injuries: posterior wall fracture, anterior femoral head fracture, ipsilateral knee injury
Increased hip flexion and internal rotation at the time of injury decreases the risk of associated fracture.
Anterior dislocation
Hip extended, abducted, and externally rotated
Associated injuries: impaction fracture, chondral injury
Obturator dislocation
Treatment
Nonoperative
Emergent closed reduction within 6 h; evaluate hip stability postreduction
Closed reduction contraindicated with ipsilateral femoral neck fractures
Weight bearing as tolerated vs protected weight bearing for 4–6 weeks: stable hip without associated injuries.
Consider traction and/or abduction pillow for unstable hips or associated injuries requiring further intervention.
Operative
Open reduction ± removal of incarcerated fragments
Irreducible hip dislocation, incarcerated fragments, incongruent reduction
Open reduction internal fixation
Associated acetabular, femoral head, and femoral neck fractures.
Femoral neck fracture should be stabilized prior to reduction.
Hip arthroscopy
May be used to remove incarcerated fragments
Complications
Avascular necrosis: 10–20 %
Increased risk with delay to reduction
Posttraumatic arthritis
Sciatic nerve injury: 10–20 %
Peroneal division most common
Increased risk with delay to reduction
Rare recurrent dislocation
Bibliography
1.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 743–4.
2.
Schmidt GL, Sciulli R, Altman GT. Knee injury in patients experiencing a high-energy traumatic ipsilateral hip dislocation. J Bone Joint Surg Am. 2005;87:1200–4.
3.
Tornetta P 3rd, Mostafavi HR. Hip dislocation: current treatment regimens. J Am Acad Orthop Surg. 1997;5(1):27–36.
5 Femoral Head Fractures
Take-Home Message
Typically associated with hip dislocations with position of the hip at the time of dislocation, determining the location and size of the femoral head fracture.
Treatment goals are to restore congruity of the weight-bearing portion of the femoral head, restore hip stability, remove incarcerated fragments, and address associated femoral head and acetabular fractures appropriately.
Smith-Peterson approach favored when possible for not increasing the risk of AVN and providing good access to most femoral head fractures.
Risk of AVN greatest in Pipkin III fractures as related to the degree of displacement of the associated femoral neck fracture.
Increased risk of AVN with delay to reduction of associated hip dislocation.
May consider arthroplasty in older patients and significantly comminuted fractures not amenable to primary reconstruction.
General
Femoral head fractures are rare injuries that typically occur in combination with hip dislocations,
High-energy mechanism: MVC, fall from height.
The position of the hip at the time of dislocation determines the location and size of the femoral head fracture.
Posterior hip dislocations: 5–15 % associated femoral head fracture
Anterior hip dislocations: associated with impaction fractures of the femoral head
Associated injuries: femoral neck fracture, acetabular fracture, sciatic nerve injury, femoral head avascular necrosis, ipsilateral knee injury (dashboard)
Primary blood supply to the femoral head in adults: medial femoral circumflex artery
Imaging
AP pelvis and lateral hip: assess for symmetry, femoral head fracture, and hip dislocation; obtain pre- and postreduction.
Judet views: assess for associated acetabular fracture.
Postreduction CT scan: assess for concentric reduction, incarcerated fragments, associated femoral neck, and acetabular fractures.
Pipkin Classification
Type I: infrafoveal fracture, below the weight-bearing surface of the femoral head
Type II: suprafoveal fracture, involves the weight-bearing surface of the femoral head
Type III: type I or II plus femoral neck fracture
Type IV: type I, II, or III plus acetabular fracture
Treatment
Nonoperative
Emergent closed reduction of hip fractures within 6 h (see Sect. 4 above)
Touchdown weight bearing for 4–6 weeks, hip dislocation precautions
Pipkin I fractures, nondisplaced Pipkin II fractures
Follow closely with serial radiographs to assess for subsequent displacement of initially nondisplaced Pipkin II fractures.
Operative
Open reduction internal fixation
Displaced Pipkin II fractures ± associated acetabular or femoral neck fractures (Pipkin III, Pipkin IV), irreducible fracture-dislocation, incarcerated fragments.
Smith-Peterson approach preferred, no associated increased risk of AVN, facilitates reduction and fixation as femoral head fractures are often anteromedial.
Worse outcomes for fractures addressed via a Kocher-Langenbeck approach.
Treat associated acetabular fractures according to the type of acetabular fracture.
Arthroplasty
Consider in femoral head fractures in older patients, particularly with significant displacement, comminution, and osteoporosis.
Complications
Avascular necrosis in up to 25 %
Highest incidence of AVN in Pipkin III injuries
Rate of AVN increases with increasing displacement of the femoral neck fracture.
Increased risk with delay to reduction of dislocated hip
Sciatic nerve injury in 10–25 %
Related to associated hip dislocation
Involvement of peroneal division most common
Posttraumatic arthritis in 10–75 %
Cartilage damage at the time of injury
Joint incongruity/imperfect reduction
Heterotopic ossification in 5–65 %
May consider adjunctive therapy (radiation, indomethacin) at time of surgery in patients at increased risk (head injury)
Bibliography
1.
Droll KP, Broekhuyse H, O’Brien P. Fracture of the femoral head. J Am Acad Orthop Surg. 2007;15(12):716–27 (Review).
2.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 744–6.
6 Femoral Neck Fractures
Take-Home Message
High-energy femoral neck fractures are more likely to be vertical and associated with femoral shaft fractures.
Depending on fracture characteristics, patient age, functional status, and comorbidities, femoral neck fractures may be treated with cannulated screws, sliding hip screw, hip hemiarthroplasty, and total hip arthroplasty.
Increased risk of avascular necrosis with increased initial displacement, nonanatomic reduction, and increasing patient age.
Increased risk of nonunion with displaced fractures, vertically oriented fractures, varus malreduction, and cannulated screw fixation.
Quality of reduction is more important than time to reduction.
Cannulated screws should begin above the lesser trochanter to decrease the risk of peri-implant subtrochanteric fracture.
Hemiarthroplasty has a lower risk of dislocation compared to total hip arthroplasty.
Active elderly patients have improved functional outcomes with total hip arthroplasty.
Mortality at 1 year in elderly patients is 15–35 %.
Pre-injury cognitive function and mobility are the more important determinants of postoperative functional outcome.
General
Bimodal distribution
Young: high-energy injuries
More likely to have a vertically oriented fracture and associated femoral shaft fracture
Elderly: low-energy injuries
Increasing incidence with the aging population.
More common in women and Caucasians.
Elderly patients should proceed to the OR as soon as medically ready to allow early mobilization.
Associated injuries
5–10 % of femoral shaft fractures have an associated femoral neck fracture.
~30 % of femoral neck fractures associated with femoral shaft fractures are missed upon initial presentation.
Healing potential
Intracapsular fractures bathed in synovial fluid with no periosteum.
Displaced femoral neck fractures will disrupt the blood supply.
Primary blood supply: lateral epiphyseal artery arising from the medial femoral circumflex artery.
Impact of intracapsular hematoma is debated.
Imaging
AP pelvis, AP and cross-table lateral of the hip, full-length femur films
Obtain AP films with the legs in internal rotation to adjust for femoral neck anteversion.
Assess orientation of trabecular lines and displacement.
Consider contralateral hip films for arthroplasty templating.
Traction views may be helpful in some cases.
CT scan is helpful to further assess displacement and comminution in some cases.
MRI is the study of choice to evaluate for occult fracture.
Classification
Garden classification
Type I: incomplete, valgus impacted
Type II: complete, nondisplaced
Type III: complete, 50 % displaced
Type IV: complete, >50 % displaced
Pauwels classification
Increasing vertical orientation increases shear forces across the fracture, which increases the risk of nonunion and fixation failure.
Type I: <30° verticality
Type II: 30–50° verticality
Type III: >50° verticality
Stress fractures
Tension side (superior neck): high risk for fracture completion; treat with surgical stabilization.
Compression side (inferior neck): lower risk for fracture completion, may treat with protected weight bearing.
Treatment
Nonoperative
Observation
May consider in valgus impacted fractures in older patients, nonambulators, and patients at excessively high surgical risk
Leadbetter maneuver for closed reduction of femoral neck fractures
Hip flexion to 90°, adduction, traction.
Then internally rotate to 45° while maintaining traction.
Then bring the leg into slight abduction and full extension while maintaining traction and internal rotation.
Typically proceed with surgical fixation and formal open reduction if fracture is not adequately reduced.
Operative
Open reduction internal fixation
Indications: young (<50) and physiologically young patients with nondisplaced and displaced fractures, older patients with nondisplaced fractures
Considered a surgical emergency in young patients.
Quality of reduction is the most important factor impacting outcome.
Posterior translation or angulation of the femoral head leads to increased reoperation rates.
Cannulated screws
Start point at or above the level of the lesser trochanter to avoid generating a stress riser that propagates into a subtrochanteric femur fracture.
Minimize cortical passes when placing guide wires to minimize additional lateral stress risers.
3-screw inverted triangle along calcar; consider 4 screws for posterior comminution.
Sliding hip screw ± derotational screw
Sliding permits dynamic compression of the fracture with axial loading and can facilitate fracture healing.
Sliding/compression may result in shortening of the femoral neck and may make implants prominent and/or affect joint biomechanics.
Hip hemiarthroplasty
Advocated for displaced fractures in older debilitated patients, demented patients (unable to comply with hip precautions), patients with neuromuscular disorders.
Outcomes for cemented technique superior to uncemented.
Posterior approach has increased risk of dislocation, while approach has increased risk of abductor weakness.
Total hip arthroplasty
Advocated for displaced fractures in older active patients, patients with preexisting hip arthropathy
Higher risk of dislocation
Complications
Avascular necrosis in 10–40 %
Increased risk with increased initial displacement, nonanatomic reduction, and increasing patient age.
Quality of reduction is more important than time to reduction.
Importance of decompressing intracapsular hematoma is controversial.
Treatment
Young symptomatic patients: core decompression (controversial), free vascularized fibula graft, total hip arthroplasty, hip arthrodesis
Elderly symptomatic patients: prosthetic replacement
Nonunion in 10–30 %
Increased risk with displaced fractures, varus malreduction, and cannulated screw fixation.
Tend to be more symptomatic than AVN and will require intervention.
Consider MRI to evaluate for concurrent AVN.
Treatment
Young patients: valgus intertrochanteric osteotomy (converts shear forces into compression forces across the fracture), free vascularized fibula graft, total hip arthroplasty, hip arthrodesis
Elderly patients: prosthetic replacement
Dislocation
Higher risk of dislocation for THA vs hemiarthroplasty
~10 % incidence for THA performed for femoral neck fracture
Mortality
1-year mortality 15–35 %.
Pre-injury cognitive function and mobility are the most important determinants of postoperative functional outcome and survival.
Increased mortality in patients to undergo surgical fixation/replacement >48 h after injury.
Bibliography
1.
Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck fracture in young adults. J Trauma. 1986;26(10):932–7.
2.
Gurusamy K, Parker MJ, Rowlands TK. The complications of displaced intracapsular fractures of the hip: the effect of screw positioning and angulation on fracture healing. J Bone Joint Surg Br. 2005;87(5):632–4.
3.
Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004;86:1711–6.
4.
Holt EM, Evans RA, Hindley CJ, Metcalfe JW. 1000 femoral neck fractures: the effect of pre-injury mobility and surgical experience on outcome. Injury. 1994;25(2):91–5.
5.
Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006;88(2):249–60.
6.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 746–7.
7.
Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg. 1998;6:106–13.
7 Intertrochanteric Hip Fractures
Take-Home Message
Fragility fractures in the elderly typically resulting from low-energy falls, sequelae of high-energy trauma in the young.
MRI is the study of choice to evaluate for occult fracture.
Stability related to size and location of lesser trochanteric fragment and integrity of the lateral femoral cortex.
Sliding hip screw indicated for fixation of most intertrochanteric fractures; expectations include reverse obliquity fracture, subtrochanteric fractures, and fractures with disruption of the lateral femoral cortex.
Cephalomedullary nails indicated for fixation of most intertrochanteric fractures; long nails should be used for reverse obliquity and subtrochanteric fractures.
Lowest risk of implant failure/cutout with tip-apex distance <25 mm.
Sliding hip screws more likely to have excessive collapse and medialization which can alter hip mechanics.
Cephalomedullary nails associated with increased risk of peri-implant fracture, although less common with modern designs.
Mortality rates of 15–35 % at 1 year.
Delay to surgery >48 h associated with increased risk of mortality at 1 year.
ASA classification predicts mortality.
General
Extracapsular hip fractures between the greater and lesser trochanters
Bimodal distribution
Elderly: low-energy falls, osteoporosis
More common in women
Increased risk with osteoporosis, history of prior hip fracture, and history of falls
Patients typically older than those sustaining femoral neck fractures
Young: high-energy trauma
Imaging
AP pelvis, AP hip, cross-table lateral of the hip, full-length femur films.
Traction views may be helpful to further delineate fracture pattern in some cases.
Isolated fracture of the lesser trochanter should be considered pathologic until proven otherwise.
MRI is the study of choice to evaluate for occult fracture.
Classification
Stability (once reduced)
Stable: resist medial compressive loads
Unstable: risk of varus collapse, medial shaft translation
Number of parts
Two-part fracture: typically stable, low risk of collapse.
Three-part fracture: intermediate stability determined by size and location of lesser trochanter fragment; large posteromedial fragments are less stable.
Four-part fracture: comminuted, unstable fractures at increased risk for shortening, varus collapse, and nonunion.
Treatment
Nonoperative
Touchdown weight bearing for 6–8 weeks, early mobilization
Nonambulatory patients, excessively high perioperative mortality risk, patients who desire comfort measures only.
High rates of pneumonia, thromboembolic disease, urinary tract infections, and decubitus ulcers.
Surgical fixation may be considered in nonambulatory patients for pain control and/or palliation.
Operative
Internal fixation is indicated for nearly all intertrochanteric fractures.
Goal of operative management is to restore neck-shaft alignment and translation.
Medial displacement osteotomy has no proven benefit.
Sliding hip screw
Dynamic interfragmentary compression with axial loading
Goal for center-center screw position, tip-apex distance <25 mm associated with lowest screw failure rate
Consider mild valgus overreduction for unstable fracture patterns.
Risk of extension deformity when fixing left hip fractures from torque forces on screw insertion.
Contraindicated in reverse obliquity fractures, subtrochanteric fractures, and fractures without an intact lateral femoral cortex.
Cephalomedullary nail
Resists excessive fracture collapse and medicalization as the IM nail reconstitutes the lateral buttress
Short nails indicated for standard obliquity fractures
Long nails indicated for standard obliquity fractures, reverse obliquity fractures, and subtrochanteric fractures
Goal for center-center position with tip-apex distance <25 mm for single lag screw or helical blade
Increased risk of peri-implant fracture and screw cutout compared to sliding hip screws
95 blade plate/proximal femoral locking plate
Indicated for reverse obliquity fractures, severely comminuted fractures, and nonunion repair.
Proximal femoral locking plates have an increased risk of nonunion when used for primary fracture repair.
Arthroplasty
May consider in severely comminuted fractures, preexisting hip arthropathy, salvage of failed surgical fixation
Typically requires a calcar replacing prosthesis
Attempt fixation of the greater trochanter to the shaft
Complications
Excessive collapse with limb shortening and medicalization
Reduces abductor moment arm, alters hip mechanics, and may result in functional deficits
More collapse with sliding hip screws compared to cephalomedullary nails and with greater displacement of the lesser trochanter
Implant failure and cutout
Most common complication, typically within 3 months of surgical fixation
Young: revision ORIF, corrective osteotomy
Elderly: arthroplasty
Peri-implant fracture
More common with cephalomedullary nail fixation compared to sliding hip screws.
Implant design changes have decreased the risk of peri-implant fractures
Tapered end of the nail, smaller distal interlock screws, reduced trochanteric bend
Anterior perforation of the distal femoral cortex with cephalomedullary nail
Radius of curvature mismatch between the femur and the implant
Nonunion in <2 %
Treat with revision ORIF ± bone grafting, arthroplasty ±.
Calcar replacing prosthesis or proximal femoral replacement
Malunion
Varus and rotational deformity
May consider corrective osteotomy if very symptomatic
Mortality
1-year mortality rate 20–30 %.
Surgery within 48 h provided medically ready improves 1-year mortality outcomes.
ASA classification predicts mortality.
Bibliography
1.
Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010;92(4):792–8.
2.
Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77(7):1058–64.
3.
Bolhofner BR, Russo PR, Carmen B. Results of intertrochanteric femur fractures treated with a 135-degree sliding screw with a two-hole side plate. J Orthop Trauma. 1999;13:5–8.
4.
Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable peritrochanteric hip fractures. Clin Orthop Relat Res. 2004;425:82–6.
5.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 747–8.
6.
Mohan R, Karthikeyan R, Sonanis SV. Dynamic hip screw: does side make a difference? Effects of clockwise torque on right and left DHS. Injury. 2000;31(9):697–9.
7.
Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am. 2002;84-A(3):372–81.
8.
Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77(10):1551–6.
8 Subtrochanteric Femur Fractures
Take-Home Message
Proximal fragment pulled into abduction, flexion, and external rotation by the gluteus medius and minimus, iliopsoas, and short external rotators, respectively.
Bisphosphonate-associated fractures may have preceding thigh pain and are characterized by beaking of the lateral femoral cortex, transverse fracture patterns, and a medial spike. Consider screening and even prophylactic fixation of the contralateral side in bisphosphonate-associated fractures.
Varus and procurvatum (flexion) is the most pattern of malreduction.
Piriformis entry nails better resist varus deformity compared to lateral entry nails.
Increased risk of nonunion in bisphosphonate-associated fractures and varus malreduction.
Nonunions often treated with conversion to fixed-angle plate with compression.
General
Proximal femur fractures from the lesser trochanter to 5 cm distally
Proximal fragment deforming forces: gluteus medius and minimus → abduction, iliopsoas → flexion, short external rotators → external rotation
Distal fragment deforming forces: adductors → adduction and shortening
Bimodal distribution
Young: high-energy trauma
Elderly: low-energy falls
May be associated with prolonged bisphosphonate use
“Fosamax fractures,” beaking of lateral femoral cortex, transverse fracture pattern, medial spike, history of preceding thigh pain
Screen for involvement of the contralateral side and consider prophylactic fixation if there is concern for bisphosphonate-associated fractures
Imaging
AP pelvis, AP/lateral hip, AP/lateral femur films
Dedicated films of the contralateral side warranted if bisphosphonate-associated fracture is suspected
Russell-Taylor Classification
Type IA: fracture below the lesser trochanter
Type IB: fracture involves the lesser trochanter, greater trochanter intact
Type IIA: greater trochanter involved, lesser trochanter intact
Type IIB: greater and lesser trochanters involved
Treatment
Nonoperative
Observation, comfort care
Nonambulatory patients who have exceedingly high risk of perioperative mortality
Operative
Surgical fixation indicated in nearly all patients
Intramedullary nail
Load-sharing implant, stronger construct for unstable fractures.
Intramedullary fixation has a lower reoperation rate at 1 year than fixed-angle plate fixation.
Stand proximal locking for fractures with intact lesser trochanter.
Reconstruction interlocking for fracture with involvement of the lesser trochanter.
Piriformis entry nails better resist varus malreduction; contraindicated in fractures involving the piriformis fossa.
Lateral nailing: easier reduction of flexion deformity, facilitates obtaining start point – particularly for piriformis entry nails.
Supine nailing: may be indicated in spine-injured and polytrauma patients, easier to assess correction of external rotation deformity.
Fixed-angle device with side plate
Weaker construct, increased risk of varus collapse.
Blade plate may function as a tension band construct, converting tensile forces on the lateral cortex to compressive forces on the medial cortex.
May consider in fractures with significant proximal comminution, preexisting femoral shaft deformity, or nonunion.
Complications
High rates of implant failure
Nonunion
Increased risk in bisphosphonate-associated fractures and varus malreduction
Often treated with conversion to fixed-angle plate with compression
Malunion: varus and procurvatum (flexion)
Bibliography
1.
Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma. 2001;15(4):254–63.
2.
Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res. 1989;238:122–30.
3.
Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007;15(11):663–71 (Review).
4.
Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 748–9.
5.
Ricci WM, Bellabarba C, Lewis R. Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma. 2001;15(2):90–5.
6.
Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgically treated femur fractures associated with long-term bisphosphonate use. J Trauma. 2011;71(1):186–90.
9 Femoral Shaft Fractures
Take-Home Message
Reamed intramedullary nails are the treatment of choice for nearly all femoral shaft fractures.
Anterior start point in piriformis entry nails increases hoop stresses and risk of iatrogenic fracture. Piriformis entry nail contraindicated in skeletally immature patients (increased risk of osteonecrosis) and in fractures that involves the piriformis fossa.
Maintain a high index of suspicion for associated femoral neck fracture – present in up to 10 % of femoral shaft fractures, often nondisplaced, vertical, and basicervical.
Prioritize fixation of associated femoral neck fractures, when present. Fixation of combined femoral neck and shaft fractures with separate devices recommended as fixation with a single device increases the risk of malreduction of at least one of the fractures.
Polytrauma patients, particular those with significant head and chest injuries, may benefit from damage control strategies with initial external fixation and safe conversion to intramedullary nail up to 3 weeks later.
Comminuted femur fractures are at increased risk for malrotation and leg length discrepancy – compare to the contralateral limb.
Nonunions may be treated with exchange reamed nailing or conversion to plate fixation ± bone grafting.
General
Mechanism
High-energy injuries in young patients are most common.
High incidence of associated injuries.
Ipsilateral femoral neck fracture in 5–10 % of femoral shaft fractures, increased incidence in comminuted midshaft fractures; up to 30 % of these are missed on presentation.
Prioritize treatment of neck fractures.
Often nondisplaced, vertical, and basicervical.
Decreased risk of malunion of concurrent ipsilateral femoral neck and shaft fractures when separate devices are used for fixation.
Favored constructs include cannulated screw or sliding hip screw fixation of the femoral neck fracture with retrograde nail of plate fixation of the femoral shaft fracture.
Bilateral femur fractures have increased risk of complications.
Critical to avoid hypotension in patients with closed head injuries to prevent second hit. May benefit from delay to definitive fixation.
Low-energy injuries in the elderly
Fall from standing
Early stabilization associated with: decreased pulmonary and thromboembolic complications, improved rehabilitation, decreased hospital costs
Imaging
AP and lateral femur
AP and lateral hip: assess for associated femoral neck fractures AP and lateral knee.
CT scan: frequently obtained in the work-up of polytrauma patients; assess carefully for occult femoral neck fracture.
Winquist-Hansen Classification
Based on degree of comminution and cortical continuity
Type 0: no comminution
Type I: comminution <25 %
Type II: comminution 25–50 %, >50 % cortical contact
Type III: comminution >50 %, <50 % cortical contact
Type IV: segmental fracture with no contact between proximal and distal fragments
Treatment
Nonoperative
Splint or cast immobilization
Rarely indicated; consider in nonambulatory patients and patients with excessively high risk of perioperative mortalityRelated posts:
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