I Fell and Cannot Get Up—Lower Extremity Trauma
Alexandra K. Schwartz, MD, FAAOS
Samir Mehta, MD, FAAOS
Giselle M. Hernandez, DMed, FAAOS
Theodore T. Guild, MD
John Y. Kwon, MD
Fernando E. Vilella, MD, FAAOS
Danielle C. Marshall, MD
Diane Ismat Ghanem, MD
Babar Shafiq, MD, MSPT, FAAOS, FAOA
Dr. Schwartz or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Synthes; serves as a paid consultant to or is an employee of OsteoCentric; and has stock or stock options held in OsteoCentric and Zimmer. Dr. Mehta or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Bioventus, DePuy, a Johnson & Johnson Company, and Smith & Nephew; serves as a paid consultant to or is an employee of Smith & Nephew and Synthes; has received research or institutional support from Becton-Dickinson and Synthes; and serves as a board member, owner, officer, or committee member of AO Foundation and Orthopaedic Trauma Association. Dr. Hernandez or an immediate family member serves as a board member, owner, officer, or committee member of Orthopaedic Trauma Association. Dr. Kwon or an immediate family member has received royalties from DJ Orthopaedics, Medline, Paragon 28, and Trimed and serves as a paid consultant to or is an employee of DJ Orthopaedics, Paragon 28, and Restor3D. Dr. Shafiq or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Smith & Nephew; serves as a paid consultant to or is an employee of Bone Foam and Synthes; has received research or institutional support from DePuy, a Johnson & Johnson Company and Synthes; and serves as a board member, owner, officer, or committee member of Orthopaedic Trauma Association. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Guild, Dr. Marshall, Dr. Vilella, and Dr. Ghanem.
PELVIC FRACTURES
Introduction
Lower extremity musculoskeletal trauma is increasing in incidence with a bimodal distribution—higher energy fractures in younger patients and lower energy fractures in older patients. These fractures are particularly important to manage and understand because they often require inpatient hospitalization until the fractures are stabilized, because mobilization (ie, discharge) is not possible.
Pelvic fractures range in severity from low to high energy and affects young to elderly patients. Young patients usually have high-energy injuries, such as those sustained from motor vehicle or motorcycle accidents, and elderly patients, or those with osteoporosis, may sustain a pelvic fracture from a fall from standing position. In young patients these injuries can be life-threatening and require a multidisciplinary approach to treatment. Even in elderly patients, there can be excessive bleeding from a pelvic fracture due to calcified vessels and/or the patient’s use of anticoagulants for other medical problems.
Epidemiology
Incidence: Pelvic fractures represent approximately 3% of skeletal injuries.1
Demographics affected: Pelvic fractures have a bimodal distribution.
Young patients typically sustain high-energy injuries, often with associated injuries, with unstable pelvic ring injuries.
Elderly patients usually sustain stable injuries from a low-energy mechanism.
Other pertinent information: Patients who sustain high-energy injuries, such as motor vehicle or motorcycle accidents, pedestrians versus auto, or falls from a height, require a multidisciplinary team approach.
This often includes general surgery, orthopaedic surgery, interventional radiology, urology, and critical care.
Pertinent Anatomy/Pathoanatomy
Soft tissue
Arteries are depicted in Figure 1.
Nerves are depicted in Figure 2.
Ligaments of the pelvis are depicted in Figure 3.
Bones
The bony pelvis is composed of the sacrum, and two innominate bones, each containing the ischium, pubis, and ilium.
 Figure 1 Schematic diagram showing four types of accessory pudendal arteries from a posterolateral view of the pelvis with angiographic views. (Reproduced with permission from Guimares M, ed: Uflacker’s Atlas of Vascular Anatomy, ed 3. Wolters Kluwer, 2020, Figure 19.22C.) |
Pertinent History/Physical Examination Findings Inspection
The patient requires a thorough inspection of skin and soft tissues.
Attention should be paid to any skin lacerations because they may represent an open fracture.
Any extensive ecchymoses or contusions should raise suspicion for a Morel-Lavallée lesion.
This is an internal degloving injury, which may be colonized with bacteria, even if it is a closed injury. Figure 4 depicts the classic appearance of a Morel-Lavallée lesion.
Figure 2 Photograph showing the course of the pudendal nerve, and internal pudendal artery and vein (small arrows) in the female lesser pelvis (posterior aspect). Large yellow arrow = indicated course of the sciatic nerve. (Reproduced with permission from Rohen JW, Yokochi C, Lutjen-Drecoll E, eds: Photographic Atlas of Anatomy, ed 9. Wolters Kluwer, 2021, Figure 7.107.)
Figure 3 Schematic drawing shows the ligaments of the pelvis and hip joint (posterior aspect). (Reproduced with permission from Rohen JW, Yokochi C, Lutjen-Drecoll E, eds: Photographic Atlas of Anatomy, ed 9. Wolters Kluwer, 2021, Figure 4.42.)
The perineum requires particular attention as any lacerations may also represent an open injury, with trauma to the urethra (blood at the meatus), vagina, or rectum.
A difference in leg length (vertically unstable pelvic fracture) or difference in rotation (anterior-posterior compression or lateral compression) may be noted.
 Figure 4 Photograph shows a Morel-Lavallée lesion (skin degloving injury). (Reproduced with permission from Egol KA, Koval KJ, Zuckerman J, eds: Handbook of Fractures, ed 6. Wolters Kluwer, 2019, Figure 26.7.) |
Palpation
The pelvis should be palpated to elicit tenderness.
The pelvis can also be manually stressed to elicit instability.
This should be done by one examiner because repeated examinations may dislodge organizing hematoma, which may adversely affect control of bleeding.
The pelvis can be stressed using manual compression both with external rotation and internal rotation.
According to retrospective data, instability with compression of the pelvis has limited sensitivity for detecting a pelvic fracture (8%) including unstable pelvic fractures (26%).2 However, when present, such instability is highly specific for both stable and unstable fractures (approximately 99% for each).
Rectal and Vaginal Examination
Must be performed to rule out an open fracture, as well as palpate for prominent bony fragments, gross blood, and a high-riding prostate
Neurologic Examination
This is critical for a patient with a pelvic fracture. A detailed sensory and motor examination must be performed. Figure 5 represents the nerve distributions to the lower extremity.
 Figure 5 Schematic drawing showing the dermatomes of the leg. (Reproduced with permission from Hickey JV, Strayer AL, eds: The Clinical Practice of Neurological and Neurological Nursing, ed 8. Wolters Kluwer, 2019, Figure 16.7.) |
Relevant Imaging
Pertinent radiographic findings
Radiographs: Images for a pelvic ring fracture include AP pelvis and inlet/outlet views.
The AP view is obtained with the patient supine. This image is usually obtained as part of Advanced Trauma Life Support (ATLS) protocol.
It should be repeated off the backboard, centered at the midpoint of the pubic symphysis. Figure 6 represents an AP radiograph of the pelvis.
Inlet and outlet views: Figure 7 demonstrates how these images are obtained.
The inlet view is obtained with the patient supine and the beam is angled 25° to 40° caudad.
This view shows anterior/posterior translation of the hemipelvis, as well as narrowing or widening of the pelvic ring.
The outlet view is obtained with the patient supine and the beam is angled 20° to 40° cephalad.
This view demonstrates vertical displacement of the hemipelvis.
CT is the gold standard modality to assess pelvic ring injuries. CT better delineates fractures seen on plain radiographs. CT can also identify fractures not seen on plain
radiographs, such as sacral fractures. Figure 8 shows CT images of the pelvis.
Figure 6 Routine appropriate AP pelvis radiograph. An appropriate AP pelvis radiograph is confirmed by the tip of the coccyx being centered 1 to 3 cm above the pubic symphysis. (Reproduced with permission from Johnson DH, ed: Operative Arthroscopy, ed 4. Wolters Kluwer, 2012, Figure 45.13.)
Figure 7 Schematic illustration showing the outlet and inlet views of the pelvis. The outlet view (A) is directed in a plane parallel to the rim of the pelvis and perpendicular to the sacrum. The obturator foramina are well visualized. Vertical malalignment is best assessed with this view. The inlet view (B) is directed parallel to the anterior sacral cortex and demonstrates the pelvic rim. This view is best for assessing rotational malalignment. (Reproduced with permission from Callaghan JJ, Rosenberg AG, Rubash HE, Clohisy JC, Beaule PE, Della Valle CJ, eds: The Adult Hip, ed 3. Wolters Kluwer, 2015, Figure 23.6.)
MRI is usually not indicated except for suspected insufficiency fractures. An insufficiency fracture occurs from normal load on abnormal bone, usually osteoporotic bone. This diagnosis should be suspected in elderly patients without any trauma who complain of sacral pain or pelvic pain. Plain radiographs are often negative. If there is high suspicion for an insufficiency fracture, then MRI is indicated. Figure 9 depicts an insufficiency fracture seen on MRI.
 Figure 8 Vertical shear pelvic injury in a 45-year-old man. A, Axial CT image shows widening (arrow) of the right sacroiliac joint and a fracture through the left sacrum. B, Axial CT image shows a vertically oriented fracture (arrow) of the superior pubic ramus. C, Coronal CT image shows a vertically oriented fracture (arrow) of the superior pubic ramus. D, Coronal CT image shows widening and superior displacement of the right sacroiliac joint (arrow). (Reproduced with permission from Lee EY, Hunsaker A, Siewert B, eds: Computed Body Tomography with MRI Correlation, ed 5. Wolters Kluwer, 2019, Figure 10.68.) |
Nonsurgical Measures
Treatment depends on if the pelvic ring injury is stable or unstable.
Stable fractures are characterized by disruption in the pelvis in one location.
Modalities
The goal is to have elderly patients with stable pelvic fractures mobilize as early as possible. It is difficult for elderly patients to be non-weight bearing or partial weight bearing; therefore, if the fracture is stable, they are allowed to bear weight as tolerated.
Figure 9 Axial magnetic resonance image showing unilateral sacral insufficiency fracture of the left sacral ala (arrow). Most of the patients affected with pelvic insufficiency fractures are 60 years of age or older, with female predominance.
Young patients may also be treated nonsurgically, based on their fracture pattern. A study by Bruce et al3 predicts the risk of displacement based on fracture pattern (Table 1). It was concluded that patients with incomplete sacral and ipsilateral rami fractures can be treated nonsurgically and are unlikely to experience fracture displacement. However, consideration for
surgical stabilization should be given for complete sacral fractures, especially those with a significant anterior injury.
TABLE 1 Rate of Displacement Based on the Pelvic Ring Fracture Components
Fracture Pattern
Rate of Displacement
Number Displaced
Number of Fractures
Complete sacral fracture + bilateral rami
68%
13
19
Complete sacral fracture + single rami or no rami
30%
6
20
Incomplete sacral fracture + bilateral rami
8%
2
23
Incomplete sacral fracture + unilateral or no rami fracture
zero
0
55
Outcomes
One of the most recent studies assessing nonsurgical treatment of pelvic ring fractures with less than 1 cm of displacement concluded that acceptable functional outcomes can be expected after nonsurgical management of LC1 pelvic injuries with complete sacral fracture and less than 1 cm initial displacement.4
Surgical Intervention
Indications
Key findings on history
High-energy trauma in young patients raises the suspicion of an unstable pelvic ring fracture.
Key findings on examination
Any open fracture of the pelvis warrants immediate and thorough irrigation and débridement and fracture stabilization.
Grossly unstable pelvic ring fractures with manual stress are also unstable and are indicated for surgical treatment.
A gross leg length discrepancy or gross internal or external rotation of the lower extremity if not associated with a long bone fracture may represent an unstable pelvic ring fracture.
Key imaging findings
Diastasis of the pubic symphysis greater than 2.5 cm is classically associated with an unstable open-book pelvic fracture. However, the radiograph obtained at the hospital may not represent the true diastasis at the time of injury. Therefore, stress views may be indicated.
Other radiographic signs on plain imaging and/or CT include:
Sacroiliac displacement greater than 5 mm in any plane
A posterior fracture gap
Avulsion fracture of L4 or L5 transverse process
Avulsion fracture of the lateral border of the sacrum representing an avulsion of the sacrotuberous ligament
Avulsion fracture of the ischial spine representing an avulsion of the sacrospinous ligament
Gross malalignment of the pelvis such as a windswept pelvis or vertically unstable pelvis is also an indication for surgery.
Top three techniques
Indications for particular technique/fixation strategies
Posterior pelvic ring injuries: Most sacral fractures and sacroiliac joint injuries are managed with screw fixation.
There are different ways to achieve a reduction of the posterior pelvic ring injuries, including closed reduction versus open reduction.
Most of these injuries that require open reduction are managed in the prone position with a posterior approach.
If the injury can be reduced closed (or does not need a reduction maneuver), the screws can be placed with the patient in the supine or prone position.
Anterior pelvic ring injuries
Figure 10 A, Photograph showing entry point for sacroiliac (SI) screw on outer table of the ilium. Note proximity to the superior gluteal neurovascular bundle. SGA, superior gluteal artery. B, Photograph showing superficial landmarks for percutaneous SI screw placement. PSIS, posterior superior iliac spine; GT, greater trochanter. C, Lateral projection of pelvis showing the very narrow safe corridor in S1 as bordered by the iliac cortical density (L5 nerve root), the upper sacral nerve root tunnel, and the vestigial disk space at S1-S2. The iliosacral screw is in S2. D, Outlet projection showing path of iliosacral screw for SI joint dislocation. E, Inlet projection showing path of iliosacral screw for SI joint dislocation. F, Axial CT scan showing correct trajectory through safe corridor in S1 to perform lag technique in reducing the SI joint dislocation.
Figure 10 Cont’d G and H, Axial CT scan showing dysmorphic sacrum with compromised safe corridor. I, Lateral intraoperative fluoroscopic image demonstrating an S1 iliosacral screw below the two lilac cortical densities (red arrow). J, Intraoperative inlet projection demonstrating the correct trajectory for an iliosacral screw for a sacral fracture now perpendicular to the fracture plane, not the SI joint. K, Intraoperative outlet projection demonstrating the correct trajectory for an iliosacral screw for a sacral fracture now perpendicular to the fracture plane, not the sacroiliacl joint. L, Intraoperative fluoroscopic AP projection demonstrating the use of a transiliac plate and transsacral screw for fixation of a sacral fracture. (Reproduced with permission from Tornetta P III, ed: Operative Techniques in Orthopaedic Trauma Surgery, ed 3. Wolters Kluwer, 2021, Tech Figure 31.4.)
Symphyseal diastasis is managed with a Pfannenstiel approach and anterior plate fixation.
Superior ramus fractures that are displaced and require fixation can be managed with either plate or screw fixation. Figure 10 represents various clinical and radiographic images of pelvic ring fixation.
Postoperative orders
Weight-bearing status: Most unstable pelvic ring fractures that require surgical fixation are non-weight bearing for 6 to 12 weeks postoperatively, depending on the severity of the injury and type of fixation, as well as bone quality.
Antibiotics: Usually standard 23-hour postoperative prophylactic antibiotics suffice.
Venous thromboembolism (VTE) prophylaxis: A recent study by Dwyer et al5 assessed risk of deep vein thrombosis (DVT) after pelvic fracture. Overall, 13,589 patients had a pelvic ring or acetabular fracture and surgical treatment. One hundred thirteen patients (0.83%) had a VTE within 90 days after hospital discharge: 0.51% had a DVT, 0.21% had a pulmonary embolism, and 0.12% had both. Twenty-eight percent of DVTs and 23% of pulmonary embolism occurred more than 35 days after discharge, being evenly distributed out to 90 days. Therefore, overall, DVT developed in fewer than 0.2% of patients and pulmonary embolism was diagnosed in fewer than 0.1% (<0.01% fatal) more than 35 days after the index hospitalization. The study authors concluded that a substantial proportion of VTE events occur more than 35 days after discharge; however, the overall risk is low, with fatal pulmonary embolism being extremely low (<0.01%). Given the diminished VTE risk after 35 days, the decision to further extend antithrombotic drug therapy may be guided by patient-specific factors, such as prolonged immobility.
Suggested pain regimen: A multimodal pain approach is best to minimize narcotics. This can include acetaminophen, gabapentin, and topical patches. Anti-inflammatory medications are often contraindicated because of chemoprophylaxis for DVT prevention.
Pearls and pitfalls
Potential complications
What to look for clinically. A careful and thorough neurologic examination is critical after pelvic fracture fixation. It is also important to monitor wound healing, in particular the open posterior approach.
Outcomes
Kokubo et al6 studied type B and C pelvic ring fractures (82 patients; mean age 54 years). Age, sex, associated injuries, fracture type, Injury Severity Score rating, and treatment methods were assessed, and Majeed score for functional outcome and radiographic studies at 1 year after injury (short-term) and at final follow-up (long-term), with mean follow-up of 98 months, were analyzed. It was concluded that fracture of lower extremity, nonsurgical therapy, and nerve damage showed significant relationship with unsatisfactory short-term functional outcome. Nerve damage and the pelvic ring displacement over 20 mm were significantly associated with unsatisfactory long-term functional outcome.
Top 10 Knowledge Drops for Your Rotation
Young patients with pelvic ring injury are at high risk of hemodynamic instability.
Elderly patients may sustain pelvic fracture from low-energy injury.
Despite low-energy falls, elderly patients also are at risk of bleeding because of calcified vessels and preinjury use of anticoagulants.
A Morel-Lavallée lesion is an internal degloving injury and warrants special attention.
Rectal and vaginal examinations are required for pelvic ring fractures to rule out open injury.
Appropriate plain radiographs include an AP pelvis as well as inlet and outlet views.
CT is the gold standard modality for a pelvic ring injury.
Nonsurgical treatment is indicated for stable fractures.
Surgical treatment is indicated for unstable fractures.
DVT prophylaxis is critical because of risk of DVT and pulmonary embolism.
HIP FRACTURES
Epidemiology
Incidence and demographics
According to Veronese and Maggi,7 hip fractures are an important and debilitating condition in older people, particularly in women. The epidemiologic data vary between countries, but it is globally estimated that hip fractures will affect approximately 18% of women and 6% of men. Although the age-standardized incidence is gradually decreasing in many countries, this is far outweighed by the aging of the population. Thus, the global number of hip fractures is expected to increase from 1.26 million in 1990 to 4.5 million by the year 2050. The direct costs associated with this condition are enormous because it requires a long period of hospitalization and subsequent rehabilitation. Furthermore, hip fractures are associated with the development of other negative consequences, such as disability, depression, and cardiovascular diseases, with additional costs for society.
Public health considerations
In The Lancet Public Health, Papadimitriou et al8 describe the public health effect of hip fractures on disability-adjusted life years (DALYs) using data from six large cohort studies from Europe and the United States. The results showed that DALYs for hip fracture were 27 per 1,000 individuals, representing an average loss of 2% to 7% of healthy life expectancy. Notably, the effect of hip fractures on DALYs was 2 to 29 times greater than years of life lost due to premature mortality, especially at younger ages (60 to 69 years) and in women. Fear of disability and loss of independence are highly prevalent in older adults. Efforts to address the crisis in the treatment of osteoporosis should emphasize the disability associated with hip fractures and the need to prevent the first hip fracture. Identification of individuals at high risk of hip fracture, such as those with a vertebral fracture, is needed. Fear of the disability associated with hip fracture might persuade women who are more likely to experience hip fracture to seek treatment. The population attributable fraction for major risk factors contributing to the
loss of life years free of disability was calculated. Smoking accounted for 7.5% (95% CI 5.2-9.7) of the total DALYs, followed by no vigorous activity (5.5%, 95% CI 2.1-8.5) and diabetes (2.8%, 95% CI 2.1-4.0).
Other pertinent information
The priority for elderly patients with hip fracture is efficient surgical treatment as soon as the patient is optimized for surgery with an implant and construct that allows for immediate weight bearing.
The priority for young patients with both femoral neck and intertrochanteric fractures is an anatomic reduction with appropriate fixation to avoid hardware failure and nonunion.
Femoral neck fractures in young patients are considered a surgical urgency.
These especially require critical attention to achieve an anatomic reduction and stable fixation; otherwise the fractures are at higher risk of malunion, nonunion, and osteonecrosis.
Pertinent Anatomy/Pathoanatomy
Soft tissue
Nerves/arteries (Figure 11)
The main blood supply to the femoral head is the posterior femoral circumflex artery. The sciatic nerve is posterior to the hip and the femoral nerve is anterior to the hip.
Bony/articular
The proximal femur is composed of the femoral head, femoral neck, greater and lesser trochanters, and the intertrochanteric region. The femoral neck is intracapsular, whereas the base of the neck (basicervical region) and intertrochanteric region are extra-articular. The femoral head is covered by cartilage and articulates with the acetabulum.
Pertinent History/Physical Examination Findings
For elderly patients, a thorough history must include key information.
It is very important to rule out syncopal fall leading to the fracture rather than a mechanical fall.
Figure 11 Illustration showing the hip flexor anatomy. The psoas arises from the lumbar spine transverse processes. At the level of the pubic ramus, as it exits the pelvis, it has an intramuscular tendon. Note the proximity of the femoral nerve and artery anteriorly. (Reproduced with permission from Wiesel SW, ed: Operative Techniques in Orthopaedic Surgery. Wolters Kluwer, 2010, vol 2, Section 4, Figure 40.1A.)
Any syncopal symptoms before the fall require an appropriate medical workup before surgery because the fall may be the result of and secondary to a significant comorbidity.
Determining the patient’s function before the fall is also important because it may require a change in the type of implant or arthroplasty used.
It is important to complete a thorough physical examination, including assessing for contractures of the hip and/or knees.
If a patient is found with a hip fracture after a prolonged or unknown period of time, a preoperative duplex may be obtained to rule out DVT. One study showed that the incidence of DVT in patients who did not present to the hospital until more than 48 hours after hip fracture was 55%, compared with 6% in those presenting sooner than 48 hours.9 In another study10 of 61 consecutive patients admitted for hip fracture, 62% of those who waited to undergo surgery at least 48 hours after hospital admission had preoperative venographic evidence of DVT.
Relevant Imaging
Pertinent radiographic findings
Radiographs: True AP and cross-table lateral radiographs are required for every hip fracture, as well as an AP pelvis and full-length femur radiographs.
If the fracture is displaced, a traction and internal rotation view can be helpful to further delineate the fracture pattern.
If the patient cannot tolerate traction and internal rotation, an obturator oblique view can be ordered instead.
Figure 12 shows a displaced femoral neck fracture.
CT may help elucidate the fracture pattern if plain radiographs are insufficient. They are not routinely required for hip fractures.
MRI should be obtained in any patient after fall or trauma with groin pain and concern for hip fracture.
A missed hip fracture can lead to disastrous outcomes.
Another unique indication for MRI is when an isolated greater trochanter fracture is identified on plain radiographs. A total of 110 patients were identified from 7 published studies. MRI documented isolated greater trochanter fractures diagnosed on initial radiographs in only 11 of 110 patients (10%). In 99 patients (90%), MRI revealed extension of the fracture into the intertrochanteric region. Surgical fixation was necessary for 61 patients, with a pooled percentage of 55%. No complications were observed after surgery.11
 Figure 12 AP radiograph of right hip shows a femoral neck fracture. (Reproduced with permission from Farrell TA, ed: Radiology 101: The Basics and Fundamentals of Imaging, ed 5. Wolters Kluwer, 2019, Figure 6.71.) |
Nonsurgical Measures
Modalities
Nonsurgical treatment is rarely indicated for hip fractures because of high complication and mortality rates. This is only indicated when the risk of surgery outweighs the risk of nonsurgical treatment.
Outcomes
Patients with hip fracture who were treated nonsurgically had a higher risk of mortality at both 1 (29.8%) and 2 years (45.6%) after fracture (P < 0.05). Their risk of mortality was four times higher at 1 year and three times higher at 2 years after fracture than the surgical group.12
There is also a risk of secondary displacement of nonsurgical femoral neck fractures. If a nondisplaced fracture displaces, the surgery to manage a displaced femoral neck fracture is more complex.
One study reviewed the records of 593 patients with femoral neck fractures from January 2000 to December 2009. Sixty-one patients (mean age 83.0 years [SD 9.9]) with nondisplaced femoral neck fractures initially received nonsurgical treatment. The occurrence and the time of secondary fracture displacement were documented, as well as demographics and radiologic parameters. Thirty-four fractures (55.7%) showed secondary displacement occurring within the first 12 weeks after initiation of nonsurgical treatment.13
Surgical Intervention
Indications
Key findings on history: Number of falls, history of fracture, gait devices, history of hip pain, use of bisphosphonates.
Key findings on examination: Shortened, externally rotated limb; check for soft tissue degloving and other orthopaedic injuries.
In general, unless there is a medical contraindication, surgery is indicated to reduce risk of postoperative morbidity/mortality.
Important clinical findings on physical examination that may influence surgery are significantly contaminated open wounds near surgical sites (uncommon) or vascular injury (uncommon).
It is important to note any preexisting contractures before surgery because this may influence surgical approach and/or implants.
Top three techniques
Applied anatomy/approaches
Anterior approach: Smith-Petersen approach as shown in Figure 13
Posterior approach: Kocher-Langenbeck approach as shown in Figure 14
Anterolateral approach: Watson-Jones approach
Lateral approach: Hardinge approach
Indications for femoral neck fractures
Femoral neck fractures: nondisplaced or valgus impacted
These fractures are fixed in situ with either cannulated screws, a sliding hip screw, or newer fixed-angle devices.
Femoral neck fractures: displaced or varus alignment
Figure 13 In this illustration, the Smith-Petersen (direct anterior) and the Watson-Jones (anterolateral) approaches to the hip take the same deep interval but pass on different sides of the tensor in their superficial dissections. The anterior approach is well suited for femoral head fractures, while the anterolateral approach is best for irreducible anterior dislocations. (Reproduced with permission from Bucholz RW, Heckman JD, eds: Rockwood and Green’s Fractures in Adults, ed 5. Lippincott Williams & Wilkins, 2001, Figure 37.29.)
Young patients (of note, there is no chronologic age criteria; this primarily depends on physiologic age and functional activity): These fractures require an anatomic reduction, which frequently requires an open approach,
usually via the Smith-Petersen approach. At times, an anatomic reduction can be achieved closed. However, the accuracy of the reduction is the most important factor in successful treatment of these fractures.
Figure 14 Illustration showing the Kocher-Langenbeck approach. A, The skin incision. B, The fascia lata and gluteus maximus have been split. The short external rotators are seen with the sciatic nerve lying on the dorsal surface of the quadratus femoris. The gluteus maximus tendon has been transected. C, The retroacetabular surface is exposed by transecting the tendons of the piriformis and obturator internus and reflecting them back toward the sciatic notches. (Reproduced with permission from Moed BR, Boudreau JA: Acetabulum fractures, in Tornetta P III, Ricci WM, Ostrum RF, McQueen MM, McKee MD, Court-Brown CM, eds: Rockwood and Green’s Fractures in Adults, ed 9. Wolters Kluwer, 2019, pp 2081-2179, Figure 50.46A-C.)
Elderly patients
Hemiarthroplasty: This surgery removes the fractured femoral head and replaces the native femoral head. This is indicated for low-demand patients, those with dementia, and systemically ill patients.
Fixation strategies
Nondisplaced, impacted valgus fractures, young and elderly patients: Cannulated screws in an inverted triangle configuration. The most inferior screw should begin at or proximal to the level of the lesser trochanter to minimize risk of iatrogenic fracture. The two superior screws are placed anterior and posterior to one another. The screws should be spread as far apart as possible, ideally within 3 mm of cortical bone when views on cross section of the femoral neck.14 Cannulated screw fixation of a femoral neck fracture is illustrated in Figure 15.
Displaced fractures, young patients: Cannulated screws placed in the same technique as above. More vertical fractures may benefit from a sliding hip screw with or without a derotation screw. There are newer fixed angle devices; however, long-term outcomes are still unknown.
Displaced femoral neck fractures, elderly patients: Hemiarthroplasty or total hip arthroplasty. Figure 16 illustrates a hemiarthroplasty of the hip.
Figure 17 demonstrates a total hip arthroplasty.
Indications for femoral neck fractures
Stable, standard obliquity fractures: If nondisplaced, may be treated on a flat top radiolucent table. If displaced, usually treated on a fracture table. These can be treated with either a sliding hip screw or short cephalomedullary nail.
Unstable fractures (lateral wall incompetent, significant posteromedial comminution, reverse obliquity, transtrochanteric, subtrochanteric extension) are best treated with a cephalomedullary nail. A short nail can be used for standard obliquity fractures with less than 3 cm distal extension from the lesser trochanter15 and those with an incompetent lateral wall. A long nail should be used for reverse obliquity, transtrochanteric, and fractures with greater than 3 cm subtrochanteric extension.
The classification of intertrochanteric fractures is shown in Figure 18.
Figure 15 A, Sawbones lateral view of the proximal femur showing configuration for three parallel guidewires before placement of cannulated screws. The wire starting points form an inverted triangle. B, Intraoperative AP fluoroscopic view showing position and depth of the guidewires. The inferior wire runs right along the inferior cortex of the femoral neck—the calcar (arrow). C, Intraoperative lateral fluoroscopic view showing guidewire position. The posterior wire is directly adjacent to and supported by the posterior cortex of the neck (arrow). Care is necessary to ensure that the guidewire does not go outside of the neck and then reenter the femoral head. D and E, Intraoperative fluoroscopic views demonstrating cannulated screw insertion over guidewires. D, AP view showing use of washers in this metaphyseal location. E, Lateral view showing parallel insertion and appropriate depth. (Reproduced with permission from Wiesel SW, Albert T, eds: Operative Techniques in Orthopaedic Surgery, ed 3. Wolters Kluwer, 2021, Part 2, Tech Figure 6.1.)
Postoperative orders
Weight-bearing status: All postoperative hip fractures except displaced femoral neck fractures in young patients should be allowed to bear weight as tolerated. Displaced femoral neck fractures in young patients require 6 to 12 weeks of
non-weight bearing depending on fracture pattern and type. Patients who undergo arthroplasty via a posterior approach may require 6 weeks of posterior hip precautions, whereas those who undergo an anterior approach may require 6 weeks of anterior hip precautions.
Figure 16 Hemiarthroplasty of the hip joint. AP radiograph of the left hip of a 61-year-old woman, in whom advanced osteonecrosis of the femoral head was diagnosed, following hemiarthroplasty using a bipolar-type prosthesis. The cemented stem of the prosthesis is in neutral position within the femoral shaft. (Reproduced with permission from Greenspan A, Gershwin ME, eds: Imaging in Rheumatology: A Clinical Approach. Wolters Kluwer, 2017, Figure 4.2.)
Antibiotics: Typically, 23 hours of postoperative first-generation cephalosporin, except for those patients with an allergy.
VTE prophylaxis: This is controversial and ranges from compressive devices to aspirin to low-molecular-weight heparin, or other anticoagulants if the patient has other high-risk comorbidities.
Suggested pain regimen: A multimodal pain approach is best to minimize narcotics use. This is especially true in elderly patients to minimize the risk of delirium. This can include acetaminophen, gabapentin, and topical patches. Anti-inflammatory medications are often contraindicated because of chemoprophylaxis for DVT prevention.
Figure 17 Radiograph of hip after revision total hip arthroplasty. The cup has been revised because careful intraoperative testing revealed loosening, despite radiographs that suggested the cup was well fixed. (Reproduced with permission from Berry DJ, Trousdale RT, Dennis DA, Paprosky WG, eds: Revision Total Hip and Knee Arthroplasty. Wolters Kluwer, 2012, Figure 7.9B.)
Pearls and pitfalls
Potential complications
What to look for clinically: Postoperatively, the patient should be monitored for appropriate wound healing and to ensure there is no excessive oozing from the wound or into the thigh. The patient should be assessed for blood clots, as well as pressure sores.
What to look for radiographically: Follow-up radiographs approximately 6 weeks after surgery should ensure there is no hardware failure and fracture healing, or malposition of the arthroplasty.
Outcomes
A critical review of cohort studies of hip fracture patients reporting outcomes of mobility, participation in domestic and community activities, health or quality of life at 3 months postfracture or longer was conducted by Dyer et al.16 Thirty-eight studies from 42 publications were
included for review. Hip fracture survivors experienced significantly worse mobility, independence in function, health, quality of life, and higher rates of institutionalization than age-matched control patients. The bulk of recovery of walking ability and activities for daily living occurred within 6 months after fracture. Between 40% and 60% of study participants recovered their prefracture level of mobility and ability to perform instrumental activities of daily living, whereas 40% to 70% regained their level of independence for basic activities of daily living. For people independent in self-care prefracture, 20% to 60% required assistance for various tasks 1 and 2 years after fracture. Fewer people living in residential care recovered their level of function than those living in the community. In Western nations, 10% to 20% of hip fracture patients are institutionalized following fracture.
 Figure 18 Illustration shows the AO/OTA classification of intertrochanteric hip fractures. (Reproduced with permission from Gardner MJ, ed: Master Techniques in Orthopaedic Surgery: Fractures, ed 4. Wolters Kluwer, 2021, Figure 18.1.) |
Top 10 Knowledge Drops for Your Rotation
Femoral neck fractures are intracapsular.
Basicervical and intertrochanteric fractures are extracapsular.
Traction internal rotation view may help better characterize fracture pattern.
The goal in elderly patients is to operate as soon as medically stable and use fixation to allow immediate weight bearing.
The goal in young patients is anatomic reduction of the femoral neck with stable fixation.
MRI should be performed if there is high suspicion for hip fracture despite negative radiographs as well as for all isolated greater trochanter fractures.
Delayed presentation to the hospital after hip fracture is associated with a high rate of DVT.
Almost all hip fractures are managed surgically because of high morbidity and mortality associated with nonsurgical treatment.
Stable intertrochanteric fractures may be managed with a sliding hip screw device.
Unstable intertrochanteric fractures require management with a cephalomedullary nail.
TIBIAL PLATEAU FRACTURES
Tibial plateau fractures range in severity from low to high energy and affect both young and elderly patients. Young patients usually have high-energy injuries, such as those sustained from motor vehicle or motorcycle accidents. Elderly patients or those with osteoporosis sustain lower energy injuries, though complex patterns may be present. Goals of care include stabilization with restoration of alignment and early range of motion.
Epidemiology
Incidence: represent approximately 1% of skeletal injuries17
Demographics affected: have a bimodal distribution
Young patients typically sustain high-energy injuries, often with associated soft-tissue injuries.
Elderly patients usually sustain a crush injury with low-energy mechanism.
Other pertinent information: Patients who sustain high-energy injuries during motor vehicle or motorcycle accidents, pedestrians versus auto accidents, or falls from a height are at risk for compartment syndrome. The risk of soft-tissue injury to the structures around the knee can range from 10% to 45%.18
Pertinent Anatomy/Pathoanatomy
Soft-tissue anatomy, including arteries, ligaments, and nerves, is shown in Figure 19.
Bones
The tibial plateau is the upper third of the tibia and articulates with the femur and the patella. Its primary function is flexion and extension and, in conjunction with the soft-tissue structures of the knee, it also contributes to rotation and varus/valgus motion.
Pertinent History/Physical Examination Findings Inspection
The patient requires a thorough inspection of skin and soft tissues.
Attention should be paid to any skin lacerations because they may represent an open fracture.
Figure 19 Schematic drawing shows the relations of the right knee joint. (Reproduced with permission from Snell RS, ed: Clinical Anatomy, ed 7. Lippincott Williams & Wilkins, 2003, Figure 10.57.)
There can be a large effusion in the knee consistent with a hemarthrosis from bleeding from the intra-articular fractures.
Alignment of the limb should be assessed.
Palpation
A thorough examination of the structures around the knee is critical.
Stability of the knee will be difficult to assess because of motion through the fracture.
The compartments of the limb should be assessed with manual palpation, and if necessary, compartment pressure monitoring should be performed.
Neurologic Examination
This is critical for a patient with a tibial plateau fracture. A detailed sensory and motor examination must be performed with specific emphasis on the peroneal nerve.
Relevant Imaging
Pertinent radiographic findings
Radiographs: AP and lateral views of the knee and the tibia of the involved side (Figure 20).
CT is the gold standard modality to assess tibial plateau fractures to aid in classification and development of a treatment plan. CT better delineates fractures seen on plain radiographs. CT can also identify fractures not seen on plain radiographs. Figure 21 is a CT scan of a tibial plateau fracture.
MRI can be considered for assessment of a tibial plateau fracture where a soft-tissue injury about the knee is suspected.
Figure 20 Schatzker type V fracture of the medial and lateral tibial plateau evident on an AP radiograph. (Reproduced with permission from Maniar H, Kubiak EN, Horwitz DS: Tibial plateau fractures, in Tornetta P III, Ricci WM, Ostrum RF, McQueen MM, McKee MD, Court-Brown CM, eds: Rockwood and Green’s Fractures in Adults, ed 9. Wolters Kluwer, 2019, pp 2623-2685, Figure 61.16.)
Figure 21 CT and three-dimensional (3D) CT of fracture of the tibial plateau. A 22-year-old man fell down from a tall ladder and injured his right knee. The conventional radiographs demonstrated fracture of the tibial plateau. A, Coronal reformatted CT scan shows extension of the lateral tibial plateau fracture into the tibial shaft. B, Posterior view of the 3D CT reconstruction shows the fracture line, but the interfragmental split is not well demonstrated. C, Anterior view of the 3D reconstruction shows the split better. D, Bird’s eye view of the 3D CT scan effectively demonstrates the details of the split and comminution of the tibial plateau. (Reproduced with permission from Greenspan A, Beltrain J, eds: Orthopaedic Imaging: A Practical Approach, ed 7. Wolters Kluwer, 2020, Figure 9.27.)
The classification of tibial plateau fractures based on CT and radiographic findings is critical to decision making regarding treatment.19 The Schatzker classification is commonly used to describe these fractures (Figure 22).
Type I: lateral plateau split fracture
Type II: lateral plateau split-depression fracture
Figure 22 Illustration shows the Schatzker classification of tibial plateau fractures. Type I: lateral plateau split fracture. Type II: lateral plateau split-depression fracture. Type III: lateral plateau depression fracture. Type IV: medial plateau fracture (split or depressed). Type V: bicondylar tibial plateau fracture. Type VI: metaphyseal-diaphyseal disassociation. (Reproduced with permission from Gardner MJ, ed: Master Techniques in Orthopaedic Surgery: Fractures, ed 4. Wolters Kluwer, 2020, Figure 26.1.)
Type III: lateral plateau depression fracture
Type IV: medial plateau fracture
Type V: bicondylar tibial plateau fracture
Type VI: metaphyseal-diaphyseal disassociation
Nonsurgical Measures
Nonsurgical management includes a period of non-weight bearing for 4 to 6 weeks followed by a graduated increase in weight bearing, a hinged knee brace to allow for protected range of motion, and interval radiographs to monitor healing and alignment.
There are several factors that affect the decision to treat a patient nonsurgically, including an articular step-off less than 3 mm, condylar widening less than 5 mm, no varus or valgus instability, or severe degenerative arthritis.
Outcomes
Nonsurgical management of tibial plateau fractures with no malalignment, stable ligaments, and no significant articular depression is acceptable as long as early range of motion can be performed.
Surgical Intervention
Indications
Key parameters
Articular step-off greater than 3 mm
Condylar widening greater than 5 mm
Varus or valgus instability
Medial tibial plateau fractures
Bicondylar tibial plateau fractures
Top three techniques
Acute management
Initial treatment in patients with high-energy fractures, fractures with instability, or fractures with soft-tissue compromise is a knee-spanning external fixator (Figure 23).
The external fixator allows for restoration of length, alignment, and rotation through ligamentotaxis.
Definitive management
Open reduction and internal fixation (ORIF) with the use of periarticular plates and screws.
For lateral tibial plateau fractures, a lateral-based buttress plate is applied through an anterolateral incision.
For medial tibial plateau fractures, a medial or posteromedial plate is applied through a medial exposure.
Figure 23 Intraoperative photographs of the lower extremity demonstrate a knee-spanning external fixation frame used to stabilize a bicondylar tibial plateau fracture with associated lower leg compartment syndrome in profile (A) and en face (B). (Reproduced from Tejwani N, Polonet D, Wolinsky PR: External fixation of tibial fractures. J Am Acad Orthop Surg 2015;23[2]:126-130.)
For bicondylar fractures, the medial and lateral sides are plated through dual incisions (Figure 24).
External fixation/ring fixation with minimally invasive restoration of the articular surface
Hybrid fixation uses principles of thin wire fixation in combination with traditional external fixation half-pins.
This technique is soft-tissue friendly and may be useful in patients with severe open fractures, poor soft-tissue envelope, or concern for infection.
Postoperative orders
Weight-bearing status: Most patients who require surgical fixation are non-weight bearing for 8 to 12 weeks postoperatively, depending on the severity of the injury and type of fixation as well as bone quality.
Antibiotics: Usually standard 23-hour postoperative prophylactic antibiotics suffice.
VTE prophylaxis: The risk of a DVT in a low-energy tibial plateau fracture with early range of motion is low and chemoprophylaxis with aspirin is often sufficient. For patients with high-energy injuries or multiple trauma or prolonged immobilization, consideration for higher order therapy such as low-molecular-weight heparin may be indicated.
Suggested pain management regimen: A multimodal approach is best to minimize narcotics use. This can include
acetaminophen, gabapentin, and topical patches. Anti-inflammatory medications are often contraindicated because of chemoprophylaxis for DVT prevention.
Figure 24 Images show a bicondylar tibial plateau fracture in a 66-year-old man who was injured after being struck by a car. AP (A) and lateral (B) radiographs showing a complex bicondylar fracture with tubercle involvement. C, Three-dimensional CT reconstruction showing comminution about the tibial tubercle, which can preclude the use of screw fixation alone. One-year follow-up AP (D) and lateral (E) radiographs showing tension band minifragment fixation of the comminuted tubercle after open reduction and internal fixation of the fracture. (Reproduced from Achor TS, Taylor RM: Tibial plateau and shaft fractures, in Grauer JN, ed: Orthopaedic Knowledge Update® 12. American Academy of Orthopaedic Surgeons, 2017, p 499, Figure 3.)
Pearls and pitfalls
Potential complications
What to look for clinically: It is important to monitor for compartment syndrome in the preoperative and perioperative period in the management of high-energy bicondylar tibial plateau fractures.20
What to look for radiographically: Intraoperative and postoperative radiographs should be monitored for loss of alignment, especially in osteoporotic fractures or bicondylar fractures in the absence of fixation of the medial side.
Outcomes
The strongest predictor of long-term outcomes after tibial plateau fractures is restoration of alignment with joint stability. Although articular reduction and congruity matter, stability and alignment have been shown to have a greater effect on the development of posttraumatic arthritis.21
Postoperative infection after ORIF is associated with high-energy injuries (bicondylar fractures), long surgical times, smoking, and pulmonary disease.
Patients with ligamentous instability, loss of meniscus, or change in mechanical axis of greater than 5° have worse results.
Top 10 Knowledge Drops for Your Rotation
CT is required for classification and surgical planning.
Temporizing external fixation is necessary for high-energy tibial plateau fractures.
Definitive fixation is most commonly performed through ORIF.
High-energy tibial plateau fractures must be monitored for compartment syndrome.
The Schatzker classification is one of the most common systems used to describe tibial plateau fractures.
Restoration of joint stability and alignment is the most critical factor affecting outcome.
Nonsurgical treatment is indicated for fractures with limited joint involvement, stability, and good alignment.
Immediate range of motion can be performed after stable fixation of tibial plateau fractures.
Patients with articular injuries should remain non-weight bearing for 8 to 12 weeks after fixation.
Soft-tissue injuries (meniscus tears, ligament tears) are common in conjunction with tibial plateau fractures.
TIBIAL SHAFT FRACTURES
Tibial shaft injuries are common long bone injuries that are frequently open. They can occur from both higher and lower injury mechanisms although trauma from vehicles is most common.
Epidemiology
Incidence and demographics
Most common long bone fractures; make up approximately 20% of all lower extremity fractures
Bimodal distribution, with younger patients often sustaining tibial fractures through high-energy mechanisms and older patients via falls
Other pertinent information
Compartment syndrome is a common complication, occurring in approximately 10% of fractures
Compartment syndrome can be diagnosed clinically by using the 5 P’s
Pain out of proportion to examination (during passive stretching)
Pallor (lack of color)
Paresthesias
Paresis
Pulselessness
Alternatively, compartment pressures can be quantified and calculated using a compartment pressure monitoring device. If the difference between the diastolic pressure and the intracompartmental pressure is less than 30 (delta P), a fasciotomy is indicated.
Open fractures of the tibia are the most common open long bone fractures, with an annual incidence of 3.4 per 100,000.
Pertinent Anatomy/Pathoanatomy
There are four compartments that make up the tibia. The compartments of the tibia contain arteries, nerves, and muscle. The anatomy of the compartments puts them at risk for compartment syndrome in the setting of trauma to the tibia. Understanding the anatomy of the compartments is critical in assessment of injuries to the tibia or an evolving compartment syndrome (Figure 25).
Pertinent History/Physical Examination Findings
Patients with tibial fractures will typically present immediately after an acute trauma. Determining the mechanism of injury can provide insight in terms of the energy of the injury and also the type of fracture that may be present.
Torsional or rotational injuries are typically low energy and result in spiral fractures of the distal tibia (Figure 26) and usually an associated fibular fracture.
High-energy injuries are associated with comminuted or segmental tibial shaft fractures. This mechanism can result in soft-tissue compromise or open fractures (Figure 26).
Patients will note severe leg pain and an inability to bear weight.
Physical examination
There may be an obvious deformity of the limb with respect to angulation or rotation.
The limb should be examined for open wounds, soft-tissue defects, and impending open wounds with threatened skin.
The classification system for closed injuries is presented in Table 2.
The classification for open fractures is presented in Table 3. Segmental fractures, barnyard injuries, or grossly contaminated open wounds with bone loss are classified as type III despite the size of the wound.
Manual compression can be performed to assess for compartment syndrome, but this method is not reliable. If compartment syndrome is suspected, formal measurement of compartment pressures should be performed.22
A thorough neurovascular examination should be performed including the deep peroneal nerve, superficial peroneal nerve, sural nerve, tibial nerve, and the saphenous nerve, in addition to dorsalis pedis and posterior tibial pulses.
 Figure 25 Compartments of leg at midcalf level in transverse anatomic section. A, Illustration shows that the anterior (dorsiflexor or extensor) compartment contains four muscles (the fibularis tertius lies inferior to the level of this section). The lateral (fibular) compartment contains two evertor muscles. The posterior (plantarflexor or flexor) compartment, containing seven muscles, is subdivided by an intracompartmental transverse intermuscular septum into a superficial group of three (two of which are commonly tendinous/aponeurotic at this level) and a deep group of four. The popliteus (part of the deep group) lies superior to the level of this section. B, Illustration shows the overview of compartments of leg. C, Magnetic resonance image of the leg. Abbreviations are defined in the labels for panels A and B. (Panels A and B reproduced with permission from Dalley AF, Agur AMR, eds: Moore’s Clinically Oriented Anatomy, ed 9. Wolters Kluwer, 2022, Figure 5.56. Panel C reproduced with permission from The Visible Human Project. National Library of Medicine; Visible Man 2551.) |
 Figure 26 A, AP and B, lateral radiographs of the tibia revealing a distal third tibia fracture spiraling into the articular surface of tibia from a torsional injury during skiing. C, AP radiograph of an open IIIB tibial shaft fracture resulting from a high-energy crush injury. D, Photograph showing type IIIB open wound in a tibial shaft fracture. The wound will require flap coverage. (Courtesy of Samir Mehta, MD, FAAOS, Penn Medicine, Philadelphia, Pennsylvania.) |
Relevant Imaging
Full-length AP and lateral radiographs of the tibia should be obtained along with views of the ipsilateral ankle and knee.
TABLE 2 Tscherne Classification of Closed Fracture Soft-Tissue Injury | ||||||||
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TABLE 3 Gustilo-Anderson Classification of Open Tibial Fractures | ||||||||||||
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Nonsurgical Measures
Acute management of tibia fracture includes a thorough assessment of the involved limb and also examination for associated injuries.
A reduction of the tibia should be performed to restore length, alignment, and rotation.
A posterior splint that can be supplemented with a “U” splint along with a knee immobilizer should be applied.
Compartments should be assessed frequently.
Neurovascular assessment should be performed postreduction.
Open fractures
Require immediate antibiotics24
Cephalosporin given for all open fractures
Figure 27 A, AP radiograph of a typical tibia and fibula fracture sustained in a characteristic indirect torsional injury to the leg. The patient’s fracture resulted from the foot and ankle being fixed while the upper body twisted about the tibia, resulting in the classic spiral oblique fracture from the distal medial cortex up to the superior lateral cortex of the tibia. B, CT scan from a 48-year-old man who was involved in a skiing accident. He has a spiral metadiaphyseal tibial fracture with contiguous displaced anterolateral plafond fracture. The surgical tactic included an anterolateral exposure of the distal tibial articular surface with adjunctive percutaneous medial plating to stabilize the metadiaphyseal injury. (Panel A reproduced with permission from Bucholz RW, Heckman JD, eds: Rockwood & Green’s Fractures in Adults, ed 5. Lippincott Williams & Wilkins, 2001, Figure 5.56B. Panel B reproduced with permission from Wiss D: Master Techniques in Orthopaedic Surgery: Fractures, ed 3. Wolters Kluwer, 2012, Figure 31-9C.)
Aminoglycoside added in type III injuries
Penicillin added in farm injuries
Tetanus vaccination status should be confirmed and prophylaxis administered when necessary.
Large debris should be removed from the open wound.
The open wound should be irrigated with saline in the emergency department or trauma bay.
The open wound should be covered with a moist dressing or betadine dressing before splint application.
Closed reduction and cast immobilization can be considered for closed low-energy injuries with alignment that meets and can be maintained using the following criteria:
Less than 10° of rotational malalignment
Less than 1 cm of shortening
Greater than 50% cortical apposition
Less than 10° of AP angulation
Less than 5° of varus/valgus angulation
The patient is placed in a long leg cast initially, which is converted to a functional (patellar tendon bearing) brace at approximately 4 to 6 weeks. However, close follow-up with repeat radiographs to ensure no displacement is necessary, with monitoring of soft tissue, especially in at-risk groups such as patients with diabetes.
Outcomes
Although angulation and rotation can be maintained in a cast, shortening can be difficult to control. There is an increased risk of varus if the fibula is intact (not broken). The nonunion rate is between 1% and 3% for closed treatment of tibia fractures.
Surgical Intervention
Indications
Surgery is indicated for tibial fractures where nonsurgical management cannot maintain necessary alignment and stability.
Immediate weight bearing is possible with surgical stabilization, particularly intramedullary nailing.
Open fractures require surgical management.
Top three techniques
Débridement and stabilization of open fractures25
Open tibia fractures require emergent incision, débridement, and irrigation in the operating room.
The traumatic wound is extended to allow for débridement of the bone edges sharply followed by copious irrigation with saline (typically, 3 to 9 L).26
Soft-tissue coverage in type IIB open tibial fractures
Proximal third—gastrocnemius rotation flap
Middle third—soleus rotation flap
Distal third—free flap
External fixation is indicated for type IIB and IIIC injuries where the soft-tissue envelope is compromised or there is significant bone loss.
Polytrauma patients may benefit from damage control orthopaedics with application of an external fixator for tibial shaft fractures.
Intramedullary nailing
Intramedullary nailing of tibial shaft fractures is the standard treatment regimen used for most patients.
Insertion of an intramedullary nail for tibial fractures can be performed in a minimally invasive manner using either a suprapatellar or infrapatellar technique (Figure 28).
The intramedullary nail is usually placed with reaming to allow for placement of a larger device and also to initiate a healing cascade (Figure 29).
ORIF
The use of plates and screws for fixation of tibial shaft fractures is usually limited to those fractures that are proximal or distal in the tibial shaft.
Modern intramedullary nails allow for treatment of extra-articular proximal and distal third tibial fractures.
Figure 28 Intraoperative photograph showing the suprapatellar approach to the intramedullary nail of the tibia.
Figure 29 Displaced closed fractures of the tibia shaft, when shortened more than 1 cm or considered to be unstable, are best managed with interlocking nails. A and B, Preoperative radiographs of a shortened, unstable segmental fracture of the tibia shaft. C and D, The interlocking nail in place. The screws placed through the holes in the nail proximal and distal to the fracture provide length and rotational stability for the fracture. Nearly all fractures of the femoral shaft in skeletally mature individuals are treated with similar interlocking nails, allowing mobilization of the patient and early range of motion of adjacent joints. (Reproduced with permission from Swiontkowski MF, ed: Manual of Orthopaedics, ed 7. Wolters Kluwer, 2012, Figure 26-3.)
ORIF may be necessary in patients who have preexisting hardware present precluding insertion of a nail (eg, those with total knee arthroplasty)
Postoperative orders
Weight-bearing status: With intramedullary fixation and no involvement of the proximal or distal articular surface of the tibia, immediate weight bearing can be initiated. In situations where there may be proximal or distal extension of the fracture, weight bearing may be limited for 2 to 6 weeks.
Antibiotics: Typically, 23 hours of postoperative first-generation cephalosporin, except for those with an allergy. In open fractures, the antibiotic regimen may be more aggressive and extended to 48 hours depending on the soft-tissue contamination.
Compartment checks: Tibial compartments should be assessed at least every 2 hours in the acute postoperative period to monitor for the development of an acute compartment syndrome.
VTE prophylaxis: This is controversial and ranges from compressive devices to aspirin to low-molecular-weight heparin, or other anticoagulants if the patient has other high-risk comorbidities or has experienced polytrauma. There is concern about aggressive anticoagulation immediately after a tibial fracture because of the risk of increased bleeding leading to a compartment syndrome.
Suggested pain regimen: A multimodal pain approach is best to minimize narcotics use. This can include acetaminophen, gabapentin, and topical patches. Anti-inflammatory medications are often contraindicated because of chemoprophylaxis for DVT prevention.
Pearls and pitfalls
Potential complications
What to look for clinically: The primary complication that is devastating is compartment syndrome and must be a consideration for all tibial fractures, including open fractures, whether they are managed surgically or nonsurgically. Close monitoring and appropriate vigilance is necessary to prevent a catastrophic complication. If compartment syndrome is identified, a two-incision fasciotomy to release all four compartments is indicated (Figure 30).
What to look for radiographically: Tibial fractures should reveal radiographic union by approximately 6 months. If the patient has persistent pain or other clinical symptoms and radiographs at 6 months show incomplete healing, additional treatment should be considered.
Outcomes
Intramedullary nailing allows for shorter immobilization time, earlier weight bearing, and accelerated healing compared with casting. However, union rates are approximately
80%.27 Alignment is improved with suprapatellar nailing compared with infrapatellar nailing.28 Reaming also has been shown to be beneficial.29
Figure 30 Photograph shows the lateral fasciotomy incision releasing the anterior and lateral compartments in a patient with a tibial shaft fracture and compartment syndrome.
Outcomes of ORIF compared with intramedullary nailing have shown increased radiation exposure, similar rates of union, and increased risk of wound complications and hardware issues as a result of the poor soft-tissue envelope around the tibia.
Complications associated with tibia fractures include:
Nonunion in approximately 10% of patients
Risk factors are open fractures, lack of cortical contact of greater than 50%, and fracture gap in a transverse fracture pattern.
Malunion is common in proximal third tibia fractures with approximately 50% showing some loss of reduction, typically valgus and procurvatum (Figure 31).
Open tibial fractures with associated soft-tissue injury can result in infection or amputation (Table 4).
Anterior knee pain occurs in approximately 30% of patients after intramedullary nailing, more commonly with the infrapatellar approach.
 Figure 31 A and B, AP views, before and after placement of an ideally placed blocking screw in the concavity of the deformity, shifting the nail medially, avoiding valgus deformity. C and D, Lateral views, before and after placement of an ideally placed blocking screw in the concavity of the deformity, shifting the nail anteriorly, avoiding procurvatum deformity. (Reproduced from Avilucea FR, Yoon RS, Stinner DJ, Langford JR, Mir HR: Lower extremity fractures: Tips and tricks for nails and plates. Instr Course Lect 2020;69:433-448.) |
TABLE 4 Complication Rates Associated With Gustilo-Anderson Type of Open Fracture | ||||||||||||||||||
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Top 10 Knowledge Drops for Your Rotation
Tibial fractures are at risk for compartment syndrome.
If a patient has an open tibial fracture with violation of the fascia, compartment syndrome can still occur.
There are four compartments of the tibia, each with its own nerve.
The most common treatment option for a tibial shaft fracture is intramedullary nailing.
If there is no joint involvement, weight bearing can be initiated immediately after stabilization.
Open fractures can be classified using the Gustilo-Anderson classification system.
Open fractures should be managed with antibiotics immediately as the primary means of infection prevention.
Urgent surgical débridement is indicated for open contaminated tibial fractures.
CT of the distal tibia should be performed in spiral distal third tibial fractures to determine whether there is articular involvement.
Close monitoring and sequential examination are critical in high-energy tibial fractures to identify compartment syndrome.
PILON FRACTURES
The terms pilon and plafond are often used interchangeably, both referring to the weight-bearing portion of the distal tibial articular surface. A pilon fracture is a fracture of the weight-bearing articular portion of the distal tibia. Ankle fractures usually involve the nonweight-bearing portions of the ankle joint, including the medial, lateral, and posterior malleoli. Ankle fractures are typically associated with low-energy twisting mechanisms, whereas pilon fractures are associated with high-energy axial forces.
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