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• In some cases, where the surgical risk is too big, or the patient refuses
surgery, the doctor conducts the patient to a pseudarthrosis: 14 days
of anti-rotatory cuff followed by walking
II. Fracture of the femoral neck
• II.6. Treatment
Osteosynthesis with 2 parallel
screws for Garden Type 2
fracture
II. Fracture of the femoral neck
• II.6. Treatment
• Partial hip
Total hip
arthroplasty
arthroplasty
II. Fracture of the femoral neck
• II.7. Complications
• Immediate due to prolonged decubitus:
• Local late complications: pseudarthrosis, avascular necrosis of the
femoral head. The greater the age of the patient, the greater the risk
of complications
II. Fracture of the femoral neck
• II.7. Complications
Comminuted sub
trochanteric fracture
operated with long
gamma nail
IV. Sub-Trochanteric fractures
IV.6. Complications and prognosis
Same as other hip fractures + the risk of an open fracture due to sharp
fracture fragment -> penetration of the skin
V. Fracture of the diaphysis of the femur
From 3 cm distal to the inferior edge of the lesser trochanter to ~ 10 cm
proximal of the femoral condyles.
V. Fracture of the diaphysis of the femur
V.1. Mechanism of occurrence
Direct or indirect
Fractures of the distal 1/3 of the diaphysis: direct impact mechanism
V. Fracture of the diaphysis of the femur
V.2. Classification
• Transverse
• Long or short oblique
• Comminuted
• Bi-focal fracture
V. Fracture of the diaphysis of the femur
V.3. Clinical examination
• Patient can be in shock due to the high impact trauma or to the blood
loss from the fracture (can be 1000 ml blood)
• Pain: constant, intense, accentuated by palpation, calmed by
immobilization
• Total functional impotence
• Thigh deformation
• Abnormal mobility, untransmisibility of motion
• Bone cracments
V. Fracture of the diaphysis of the femur
V.3. Radiological examination
Anterior—posterior view is usually enough
V. Fracture of the diaphysis of the femur
V.4. Treatment
Surgery = election treatment
Osteosynthesis with Kűntscher Rigid fixation nail, etc.
V. Fracture of the diaphysis of the femur
Fracture of the upper 1/3,
osteosynthesis with rigid nail and
dynamic screw
V. Fracture of the diaphysis of the femur
Fracture of the proximal 1/3
operated on with Centro
medullar nail
VI. Supracondylar femoral fracture
The distal fragment is pulled by the gastrocnemius muscles inserted on
it and Is rotated posteriorly while the proximal fragment pushes against
the subquadricipital cul-de-sac and penetrates the knee
VI. Supracondylar femoral fracture
VI.1. Clinical diagnosis
• Pain, accentuated by movement and palpation
• Abnormal mobility
• Bone cracments
• Palpable bone interruption
• Anterior-posterior diameter increase
• Late ecchymosis
• Possible hemartrosis
VI. Supracondylar femoral fracture
VI.2. Radiological diagnosis
Anterior posterior and lateral view enough to establish diagnosis
VI. Supracondylar femoral fracture
VI.3. Treatment
Orthopedic treatment possible only in cases of fracture without
fragment moving. Immobilization or continuous extension.
Surgical treatment: most used = osteosynthesis with DCS (Dynamic
Condylar Screw), plates and screws
VI. Supracondylar femoral fracture
DCS
VI. Supracondylar femoral fracture
VI.4. Complications
Vascular and nervous complications due to possible injury of the
popliteus region
VII. Fracture of the Patella
VII.1. Mechanism of occurrence
Direct fall with support on the knee, household accidents, auto, sports,
etc.
VII. Fracture of the Patella
VII.2. Clinical diagnosis
• Pain at fracture site
• Functional impotence -> impossible to actively extend the knee.
Flexion possible normally.
• Late ecchymosis that tends to spread distally + tumefaction
• “pencil sign” the two fragments are so distant that you can introduce
a pencil/finger between them
• !! No bone crepitation, because the bone fragments are not in
contact!!
VII. Fracture of the Patella
VII.3. Radiological exam
Anterior-posterior and lateral
views set the diagnosis
VII. Fracture of the Patella
VII.4. Treatment
In cases where the fragments do not move (incomplete fracture) ->
orthopedic treatment, femuro-tibial immobilization for 6 weeks
Surgical treatment:
• "figure-of-eight" configuration tension band. The figure-of-eight band
presses the two pieces together.
• Circle performed around the patella with wire, through the patellar
ligament and the tricipital tendon
VII. Fracture of the Patella
"figure-of-eight"
configuration
tension band
VII. Fracture of the Patella
–Pain.
–Hemartrosis.
–Abnormal mobility.
–Functional disability.
VII. Fracture of the Tibial Plateau
Rx:
Treatment:
–Orthopedic: rare case. Is leading to stiff knee.
Surgical:
–Most of the cases.
–Close reduction and screws: possible for Schatzker I, II, III, maybe IV, V
–ORIF with plate and screws (angular stability): for Schatzker IV, V, VI.
VIII. Fracture of the diaphysis of the tibia
VIII.1. Mechanism of occurrence
Indirect trauma -> most often
Direct trauma -> more often than other locations and cause open
fractures
VIII. Fracture of the diaphysis of the tibia
VIII.2. Clinical diagnosis
• Pain, deformation, edema
• Blisters due to high internal pressure
• Ecchymosis
• Interruption of bone continuity, abnormal bone motions
• Bone crepitation
• Untransmisibility of motion in case of both the tibia and the peroneus
fracture
VIII. Fracture of the diaphysis of the tibia
VIII.3. Radiological examination
Anterior posterior and lateral views set the diagnosis
VIII. Fracture of the diaphysis of the tibia
VIII.3. Classification
Regarding the localization:
• In the upper third of the diaphysis -> can interest the nutritive artery
of the tibia that leads to important hematoma -> compartment
syndrome -> possible amputation, delay in bone consolidation
• In the middle third of the diaphysis -> most rarely associated with
peroneus fractures
• Distal third of the diaphysis of the tibia -> most often associated with
peroneus fractures
VIII. Fracture of the diaphysis of the tibia
VIII.3. Classification
Regarding the fracture trajectory:
• Transverse fractures: peroneus intact and no signs of shortening
• Oblique short or long fractures ± peroneus fracture
• Spiroid fractures: almost always interest the peroneus in its upper
third
• Comminuted fractures: generally interest both bones, with associated
skin lesions
• Double fracture of the tibia: tibia bone fractured in two different
places. Do not confuse with both bones fracture!
VIII. Fracture of the diaphysis of the tibia
Oblique distal fracture in
the distal 1/3
VIII. Fracture of the diaphysis of the tibia
Spiroid fracture of the
tibia
VIII. Fracture of the diaphysis of the tibia
Comminuted, proximal
1/3 tibia fracture
VIII. Fracture of the diaphysis of the tibia
Double fracture of the
tibia
VIII. Fracture of the diaphysis of the tibia
Medium 1/3 fracture of
both bones with
intermediary fragment
VIII. Fracture of the diaphysis of the tibia
VIII.4. Treatment
Immobilization: Stable, without movement fractures
Surgical treatment: unstable fractures; reduction and osteosynthesis
Open fractures are fixed using an external fixation.
Sometimes, due to skin defects, the help of the Plastic Surgery
department is necessary
VIII. Fracture of the diaphysis of the tibia
VIII.5. Complications
• Open fractures
• Anterior or posterior compartment syndrome -> emergency
treatment
• Posttraumatic thrombophlebitis
• Fatty emboli difficult to prevent and treat
• Post thrombotic syndrome and chronic edema -> difficult to treat.
Physiotherapy
• Delay in consolidation
VIII. Fracture of the diaphysis of the tibia
VIII.5. Complications
• Open fractures
• Anterior or posterior compartment syndrome -> emergency
treatment
• Posttraumatic thrombophlebitis
• Fatty emboli difficult to prevent and treat
• Post thrombotic syndrome and chronic edema -> difficult to treat.
Physiotherapy
• Delay in consolidation
IX. Fracture of the ankle
The ankle articulation consists of three bones: tibia, peroneus and
astragal that allow for flexion-extension motion
IX. Fracture of the ankle
IX.1. Mechanism of occurrence
Indirect -> most often.
Inversion = adduction – internal rotation – supination
Eversion = abduction – external rotation - pronation
Direct -> associated with open fractures
IX. Fracture of the ankle
IX.2. Classification
Anatomical:
• Single malleolus fractures: internal or external
• Bi malleolus fractures: internal and external
• Low bi malleolus fractures
• Dupuytren type fracture: internal and external malleolus fracture 10 cm away
from the articular line
• High Dupuytren (or Maissoneuve) type fracture: internal malleolus fracture
associated with proximal third peroneus fracture
IX. Fracture of the ankle
IX.2. Classification
Anatomical:
• Complex: fractures that affect other anatomical elements
concomitantly
• Bi malleolus + posterior edge of the tibia (incorrectly called tri malleolus
fractures)
• Bi malleolus + anterior edge of the tibia
• Associated with the tibia pylon
IX. Fracture of the ankle
IX.2. Classification
Anatomical:
• Equivalent fractures: fractures of one malleolus + ligament rupture in
the area of the opposing malleolus. Most often external malleolus
fracture + rupture of the deltoid ligament
IX. Fracture of the ankle
IX.2. Classification
Weber-Denis classification: fracture of the external malleolus in
relation to anterior and posterior tibia-peroneal ligaments
• Subligamentary fracture
• Intraligamentary fracture: pseudodiasthasis of the tibia and peroneus
• Supraligamentary fracture: true diasthasis of the tibia and peroneus
IX. Fracture of the ankle
IX.2. Clinical diagnosis
• Pain, transverse and anterior-posterior increase in diameter deformation
• Deformation of the ankle axis: Valgus or Varus
• Ecchymosis that spreads to the toes
• Edema, Phlyctène
• Abnormal bone mobility
• Interruption of bone continuity: most often palpable at the internal
malleolus
• Crepitation absent at the internal malleolus because the fragments are not
in contact
IX. Fracture of the ankle
IX.3. Radiological diagnosis
Anterior-posterior and lateral view set the diagnosis
IX. Fracture of the ankle
IX.4. Treatment
Orthopedic treatment: first choice in cases without movement of the
fragments. Orthopedic reduction + immobilization.
Surgical treatment:
• In cases of orthopedic treatment failure
• Big fragment movement
• Soft tissue interposition
• Unstable fractures
IX. Fracture of the ankle
IX.4. Treatment
• Surgical treatment must be extremely precise
• In cases where the surgeon has to choose, an imperfect orthopedic
treatment is preferred to an imperfect surgical treatment
IX. Fracture of the ankle
Ankle arthrosis
secondary a “tri
malleolus” fracture
X. Fractures of the astragalus
Complex, hard bone with no muscular insertion -> bad vascularization.
-> fractures are rare, and with bad consolidation
X. Fractures of the astragalus
X.1. Mechanism of occurance
Indirect -> most often
Direct -> rare: gunshot
X. Fractures of the astragalus
X.2. Classification
Anatomo-clinical:
• Fracture of the neck of the astragalus
• Fracture of the body of the astragalus
• Fracture of the posterior aphophysis of the astragalus
X. Fractures of the astragalus
X.2. Classification
Classification of the fractures of the neck of the astragalus:
• Type 1: Fractures with no or minimal movement. Necrosis still
possible
• Type 2: Fractures with big movement, subluxation of the astragalus
body, they compromise 2/3 of vascularization. Necrosis highly likely.
• Type 3: Fractures with full luxation of the astragalus body. They
compromise the entire circulation. Necrosis certain.
X. Fractures of the astragalus
X.3. Clinical diagnosis:
• Pain and functional impotence
• Ankle deformation; enlarged transverse diameter
• Varus equine position in cases of Type 2 astragalus neck fractures
• Hurtful, globe-like tumefaction of the tibia pylon, anterior of the
Achilles tendon, which is the luxated astragalus body in Type 3 neck
fractures of the astragalus
X. Fractures of the astragalus
X.4. Radiological diagnosis
Anterior-posterior and lateral view set the diagnosis
X. Fractures of the astragalus
X.5. Treatment
Orthopedic treatment: in cases of fracture without movement,
immobilization for 8-9 weeks
Surgical treatment: laborious and very precise, it must not hurt the
vascularization even more. In Type 2 and Type 3 fractures.
-> surgical reduction + osteosynthesis by broche or screws followed by
immobilization
X. Fractures of the astragalus
X.6. Prognosis -> generally reserved
Type 1 fractures tend to consolidate well
Type 2 and Type 3 fractures often lead to pseudarthrosis and avascular
necrosis of the astragalus body, with important functional deficit.
XI. Fracture of the calcaneus
Spongious, complex shape, good vascularization bone.
XI.1. Mechanism of occurrence
Indirect mechanism: fall on the foot or explosion under the foot/
ripping caused by the sudden contraction of the sural triceps muscle
XI. Fracture of the calcaneus
XI.2. Classification: simplified Burghele
• With thalamic interest:
• Without fragment movement
• With horizontal immersion
• With vertical immersion
• With mixed immersion
• Comminuted fractures
XI. Fracture of the calcaneus
XI.2. Classification: simplified Burghele
• Extra thalamic fractures
• Fractures of the great tuberosity: horizontal, parrot beak
• Fracture of the great apophysis
• Fracture of the sustentaculum tali
• Complex fractures: associated fractures present
XI. Fracture of the calcaneus
XI.2. Classification: Böhler (reference point = Böhler angle = the straight
line that unites the superior pole of the thalamus and the beak of the
great apophysis angled with the tangent of the superior edge of the
great tuberosity)
XI. Fracture of the calcaneus
XI.2. Classification: Böhler
Böhler type 1: angle over 20 degrees
Böhler type 2: angle ~ 0 degrees
Böhler type 3: angle under 0 degrees
XI. Fracture of the calcaneus
XI.3. Clinical diagnosis
• Constant pain
• Late ecchymosis at plantar level
• Local deformation
• Functional impotence
XI. Fracture of the calcaneus
XI.4. Radiological diagnosis
Lateral and axial view of the calcaneus set the diagnosis and establish
the Böhler classification
XI. Fracture of the calcaneus
XI.5. Treatment
Orthopedic treatment in cases without fragment movement.
Immobilization followed by no load bearing on the affected member
Surgical treatment:
Microsurgery by two broches in Böhler type 2 fractures
Surgery with rising of the articular surface and filling the gap with bone
material + osteosynthesis with plates and screws in Böhler type 3
fractures
XI. Fracture of the calcaneus
XI.6. Prognosis
There fractures always consolidate.
Often they cause vicious callous, algic osteoporosis, under-astragalin
arthrosis
Thank You!!