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2355852750185Neck of Femur Fracture00Neck of Femur Fracture15633706668770Intra-capsular00Intra-capsular601916510145395III-IV00III-IV5896610906716558966107802880II00II482790576809602597150768096025977846677025Subcapital (42%) vs transcervicalHigher risk of complications (poor blood supply, poor bone quality for OT); 1-2 have up to 20% avascular necrosis (due to disruption of trochanteric anastomosis and intracapsular haemarthrosis); 3-4 have worse prognosis than this; 15-35% risk of avascular necrosis overall00Subcapital (42%) vs transcervicalHigher risk of complications (poor blood supply, poor bone quality for OT); 1-2 have up to 20% avascular necrosis (due to disruption of trochanteric anastomosis and intracapsular haemarthrosis); 3-4 have worse prognosis than this; 15-35% risk of avascular necrosis overall15633705906770Assessment00Assessment25787355906770May be able to weight bear if impacted; tender ant-lat, axial compression and abduction; leg shortened and externally rotated if extracapsular (internally rotated in dislocation)MRI: 100% sensitivity Bone scan: 95% sensitivity USS: demonstrates effusion00May be able to weight bear if impacted; tender ant-lat, axial compression and abduction; leg shortened and externally rotated if extracapsular (internally rotated in dislocation)MRI: 100% sensitivity Bone scan: 95% sensitivity USS: demonstrates effusion15633704972685Epidemiology: female>male (until >60yrs, then male>female); 5% due to metastases from breast; 90% due to falls; 10% have ipsilateral femoral shaft fracture (30% of which are missed initially)X-ray: 95% sensitivity; asymmetry of Shenton’s line (along superior border of obturator foramen and medial aspect of femoral metaphysis); angle to neck of shaft normally 135°; interruption of trabecular pattern, cortical disruption; soft tissue swelling00Epidemiology: female>male (until >60yrs, then male>female); 5% due to metastases from breast; 90% due to falls; 10% have ipsilateral femoral shaft fracture (30% of which are missed initially)X-ray: 95% sensitivity; asymmetry of Shenton’s line (along superior border of obturator foramen and medial aspect of femoral metaphysis); angle to neck of shaft normally 135°; interruption of trabecular pattern, cortical disruption; soft tissue swelling377825027495500154813027501852393951157605Femoral Head Fracture 00Femoral Head Fracture 28352751158240Epidemiology: rare; usually due to dislocation (superior aspect if anterior dislocation, inferior aspect if posterior; occurs in 6-16% hip dislocations); avascular necrosis in 15-20%, arthritis in 40%, myositis ossificans in 2%Management: number of attempts at reduction in ED should be limited00Epidemiology: rare; usually due to dislocation (superior aspect if anterior dislocation, inferior aspect if posterior; occurs in 6-16% hip dislocations); avascular necrosis in 15-20%, arthritis in 40%, myositis ossificans in 2%Management: number of attempts at reduction in ED should be limited1548130115824000246380539750Femoral Fractures00Femoral Fractures 00 3105157637780Greater Trochanter Fracture 00Greater Trochanter Fracture 164973076384150031642057639050Epidemiology: often aged 7-17yrs with indirect trauma or direct blow to hip, or older patientsMOI: direct trauma (older), or avulsion from contraction of gluteus medius (younger)Assessment: more lateral tenderness, less on axial compression; can weight bearClassification: I no intertrochanteric # displaced <1cm II displaced >1cmManagement: I bed rest 3/7 crutches 4/52 NWBing II requires internal fixation00Epidemiology: often aged 7-17yrs with indirect trauma or direct blow to hip, or older patientsMOI: direct trauma (older), or avulsion from contraction of gluteus medius (younger)Assessment: more lateral tenderness, less on axial compression; can weight bearClassification: I no intertrochanteric # displaced <1cm II displaced >1cmManagement: I bed rest 3/7 crutches 4/52 NWBing II requires internal fixation310515539750Neck of Femur Fracture (cntd)00Neck of Femur Fracture (cntd)26650957135495Surgical in 15%; medical in 30%; 50-60% return to pre-morbid functionning; mortality 10% @ 1/12, 25% @ 1yr, 50% @ 3yrs; overall mortality 10-30%00Surgical in 15%; medical in 30%; 50-60% return to pre-morbid functionning; mortality 10% @ 1/12, 25% @ 1yr, 50% @ 3yrs; overall mortality 10-30%16497307135495Compli-cations00Compli-cations16497305863590Manage-ment00Manage-ment26650955863590Seek cause of fall; seek cancer; seek pelvic fracture, SDH; traction contraindicated in intracapsular as may compromise blood flow; no benefit from traction in any of these fracturesGarden I-II / all grades in younger patients / extracapsular = internal fixation with dynamic hip screwGarden III-IV = hemiarthroplastyConsider THJR in younger patient00Seek cause of fall; seek cancer; seek pelvic fracture, SDH; traction contraindicated in intracapsular as may compromise blood flow; no benefit from traction in any of these fracturesGarden I-II / all grades in younger patients / extracapsular = internal fixation with dynamic hip screwGarden III-IV = hemiarthroplastyConsider THJR in younger patient16497302496820Extra-capsularEvans Classification00Extra-capsularEvans Classification26422355469255IV00IV30581605469255Fracture spirals into femoral shaft00Fracture spirals into femoral shaft30581605129530Greater + lesser trochanter fracture + femoral neck separate00Greater + lesser trochanter fracture + femoral neck separate26422355129530III00III30581604766945Lesser trochanter fracture00Lesser trochanter fracture26422354766945II00II30581604438015Single fracture; minimal displacement00Single fracture; minimal displacement26422354438015I00I26562053152775026562052496820Intertrochanteric (43%), trochanteric, subtrochanteric (between trochanter and 5cm down); less risk of avascular necrosis; 4x more common; non-union rare; OT easier00Intertrochanteric (43%), trochanteric, subtrochanteric (between trochanter and 5cm down); less risk of avascular necrosis; 4x more common; non-union rare; OT easier1649730539750Intra-capsular Garden’sClassification00Intra-capsular Garden’sClassification30721301511935Fracture complete Displaced (femoral head abducted and int rotated)Inferior cortex broken00Fracture complete Displaced (femoral head abducted and int rotated)Inferior cortex broken26562051511935III00III30721302002790Fracture complete Fully displaced femoral head (in neutral position)Inferior cortex broken00Fracture complete Fully displaced femoral head (in neutral position)Inferior cortex broken26562052002790IV00IV26562051030605II00II30721301030605Fracture complete Non-displacedInferior cortex broken Unstable00Fracture complete Non-displacedInferior cortex broken Unstable2656205539750I00I3072130539750Trabeculae disrupted Non-displacedInferior cortex intact Stable00Trabeculae disrupted Non-displacedInferior cortex intact Stable3105156300470Femoral Shaft Fracture00Femoral Shaft Fracture16319508124825Assessment: leg shortened, externally rotated (like SUFE, extracapsular femoral neck fracture), slight abduction; may be rupture of profunda femorisWinquist classification: I minimal/no comminution II communition of <50% circumference of major # fragments III comminution of >50% circumference of major # fragments IV all cortical contact lost / circumferential comminution of segment of boneManagement: reduction and immobilisation ? pain and bleeding (use Thomas / Donway splint; splint OK but traction contraindicated if possible sciatic nerve injury); early internal fixation <8hrs in adults (II IM nail; III interlocking screws); may be treated in spica / traction if childComplications: can lose up to 2L blood; high risk of fat embolism if treatment delayed >24hrs; ARDS; malunion and nonunion rare00Assessment: leg shortened, externally rotated (like SUFE, extracapsular femoral neck fracture), slight abduction; may be rupture of profunda femorisWinquist classification: I minimal/no comminution II communition of <50% circumference of major # fragments III comminution of >50% circumference of major # fragments IV all cortical contact lost / circumferential comminution of segment of boneManagement: reduction and immobilisation ? pain and bleeding (use Thomas / Donway splint; splint OK but traction contraindicated if possible sciatic nerve injury); early internal fixation <8hrs in adults (II IM nail; III interlocking screws); may be treated in spica / traction if childComplications: can lose up to 2L blood; high risk of fat embolism if treatment delayed >24hrs; ARDS; malunion and nonunion rare54311556300470Epidemiology: usually due to falls, MVA (ie. High force); consider NAI if infant / preschool; transverse most common; pathological are uncommon00Epidemiology: usually due to falls, MVA (ie. High force); consider NAI if infant / preschool; transverse most common; pathological are uncommon1631950630110516319504598035Epidemiology: early adolescence (older than Perthes); often overweight, male; may be associated with hypothyroidism, often bilateral; history of injury in <30%Examination: external rotation and shortening (like an extracapsular femoral fracture); especially internal rotation sore +/- flexion and abductionXR: AP: line though greater trochanter epiphysis should cut through femoral head epiphysis; always XR both hips to compare to other side for slip Lateral: Line on lateral should bisect head of NOF; mild <1/3, mod <1/2, severe >1/2Stable if: chronic, can walk, no effusion, evidence of remodellingUnstable if: acute, can’t walk, effusion present, no remodellingManagement: OT00Epidemiology: early adolescence (older than Perthes); often overweight, male; may be associated with hypothyroidism, often bilateral; history of injury in <30%Examination: external rotation and shortening (like an extracapsular femoral fracture); especially internal rotation sore +/- flexion and abductionXR: AP: line though greater trochanter epiphysis should cut through femoral head epiphysis; always XR both hips to compare to other side for slip Lateral: Line on lateral should bisect head of NOF; mild <1/3, mod <1/2, severe >1/2Stable if: chronic, can walk, no effusion, evidence of remodellingUnstable if: acute, can’t walk, effusion present, no remodellingManagement: OT3105152027555Slipped Upper Femoral Epiphysis00Slipped Upper Femoral Epiphysis53200304047490Salter Harris I00Salter Harris I453517025374600016230602000885310515436880Lesser Trochanter Fracture00Lesser Trochanter Fracture1623060436880003164205465455Epidemiology: children and young athletes (85%); due to iliopsoas avulsionAssessment: pain on flexion and internal rotation; Ludloff sign (can’t raise foot off ground when seated)Management: bed rest and slow mobilisation00Epidemiology: children and young athletes (85%); due to iliopsoas avulsionAssessment: pain on flexion and internal rotation; Ludloff sign (can’t raise foot off ground when seated)Management: bed rest and slow mobilisation3105153380105Femoral Condyle Fracture00Femoral Condyle Fracture42297353379470Intercondylar / condylar; possible popliteal artery injury and deep peroneal nerve (1st web space) Complications – DVT, fat embolus, delayed union, malunion, OA00Intercondylar / condylar; possible popliteal artery injury and deep peroneal nerve (1st web space) Complications – DVT, fat embolus, delayed union, malunion, OA310515465455Femoral Shaft Fracture00Femoral Shaft Fracture1622424338010500162242546545504838065464820Epidemiology: axial load to flexed knee; high energy needed if young; tend to rotate; may be grossly comminutedClassification (Muller AO): A extra-articular transverseB intra-articular unicondylar (lateral or medial or coronal) C intra-articular bicondylar shortening and anterior displacement of shaft, posterior angulation of rotationManagement: internal fixation; POP only if extra-articularComplication: vascular injury in 2-3%; knee ligament injury in 20%00Epidemiology: axial load to flexed knee; high energy needed if young; tend to rotate; may be grossly comminutedClassification (Muller AO): A extra-articular transverseB intra-articular unicondylar (lateral or medial or coronal) C intra-articular bicondylar shortening and anterior displacement of shaft, posterior angulation of rotationManagement: internal fixation; POP only if extra-articularComplication: vascular injury in 2-3%; knee ligament injury in 20% ................
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