1. Lower extremity xray rounds Heather Patterson PGY3 August 23, 2007

2. Objectives • Classification of fractures • Practice, practice, practice! • This will NOT be: • Clinical exam • Management

3. Hip • Classification: • Intracapsular • Femoral head • neck • Extracapsular • Intertrochanteric • Subtrochanteric • Greater/lesser trochanter

4. Hip • AVN: • Injuries to medal and lateral femoral circumflex arteries • After fracture the synovial fluid will lyse blood clots and prevent capillary formation needed for new bone formation/repair

5. Approach • Shenton’s Line • Obturator foramen to medial surface of the proximal femur

6. Approach • Normal and Reverse S • Medial and lateral margins of the fem head and neck

7. Approach • Trabecular groups • Follow the groups starting at the femoral head

8. Avulsion • Often in young athletes • Rapid accel/decel • Snap/pop • Locations: • ASIS: sartorius • AIIS: rectus femoris • Isch tuberosity: hamstring

9. Name this fracture

10. Femoral Neck Fractures • Classification: • Transcervical vs subcapital • Displaced vs nondisplaced

11. Femoral Neck Fractures • Displaced (80%) • Shortened, rotated • Vascular structures disrupted • Nondisplaced (20%) • Subtle fractures • Must use lines/trabec to see • May be impacted – increased subcapital density

12. Name this fracture

13. Intertrochanteric fractures • Fracture runs between greater and lesser trochanter • Excellent blood supply • Often will be in internal rotation • Int rotators attached to distal femur • Ext rotators attached to proximal fragment

14. Intertrochanteric fractures • Classification: • 2 part

15. Intertrochanteric fractures • Classification • 3 part:

16. Intertrochanteric fractures • Classification • 4 part:

17. Trochanter fractures • Isolated fractures are rare • From direct force with fall or avulsion from iliopsoas

18. Name this fracture

19. Subtrochanteric fractures • Location: • Btwn lesser trochanter and proximal 5cm of femoral shaft • Often comminuted • Hemodynamic instability is seen with this fracture type

20. Subtrochanteric fractures • Classification: • Short oblique • Short oblique + commin. • Long oblique • Long oblique + commin. • High transverse • Low transverse

21. Stress fractures • Need high index of suspicion • Symptoms: • A.M. stiffness, aching with first steps after rest, increasing pain with exercise • Pain in groin or medial thigh to knee • Antalgic gait, min pain with ROM except at extremes

22. Dislocations • High force • Classification: • Posterior • Anterior • Obturator • Inferior • Central

23. Fracture dislocations • Positioning: • Posterior: FDI • flexed aDducted internal rotation • shortened and greater troch/buttock unusually prominent • Anterior: FBE • flexed aBducted, externally rotated

24. Dislocations • Posterior: • Lesser trochanter superimposed on femoral shaft • Small femoral head

25. Dislocations • Anterior: • Lesser trochanter in profile • Large femoral head

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41. Name this fracture

42. Ottawa Knee rules • X-ray knees with knee injury and one or more of: • >55 years old • Tenderness to palpation of head of fibula • Isolated tenderness of patella • Inability to flex knee to 90 degrees • Inability to bear weight both immediately and inability to take four steps in ED

43. Ottawa Knee rules • Exclusion criteria: • Isolated skin injuries • Referred patients from another ED or clinic • Injury >7 days old • Patient returning for re-evaluation • Distracting injuries • Altered mental status • Age < 18 years old • Pregnant patients • Paraplegia

44. Distal femur fracture • Anatomy: • Vascular • close to femoral & popliteal vessels

45. Distal femur fracture • Anatomy: • Neuro • Tibial nerve • gastrocnemius, plantaris • Peroneal/Deep Peroneal nerves • Supplies anterior compartment (dorsiflexion) • Sensory to first dorsal interosseus cleft

46. Distal femur fracture

47. Distal femur fracture • Supracondylar • Extra-articular • No hemarthrosis • Intracondylar • Intra-articular • Condylar • Intra-articular

48. Name this fracture

49. Tibial Plateau Fractures • Anatomy • Vascular • High incidence of popliteal A damage • Neuro • Perineal N damage • Ligaments • 25% have associated ligamentous injury

50. Tibial Plateau Fractures • Plateau slopes 10 degrees from A  P • May not appear to be at same level • Lateral plateau slightly convex upward • Medial plateau slightly concave upwards