INDICATIONS FOR OPERATIVE TREATMENT OF LOWER LOMB FRACTURES.

INDICATIONS FOR OPERATIVE TREATMENT OF LOWER LOMB FRACTURES.

 

STAMATIS PARASCHOU CONSULTANT,M.D

 

FIRST DEPARTMENT OF ORTHPAEDICS-GENERAL HOSPITAL OF KILKIS

The development of new generation fixation materials has expended the indications of surgical treatment.Nevertheless we should follow strictly the indications considering the rate of complications which has been decreased last years.

1)Fractures of proximal femur.

A)Subcapital:Classification according to Garden in 4 types.Conservative treatment in patients with walking incapability and bad health condition.Sometimes in type I and II of all ages.Disadvantages longtime of  immobilization with possible general complications and high risk of displacement of the fracture and so operative treatment.The majority of authors support the surgical treatment of these fractures.In patients aged below 70 years we prefer open reduction and internal fixation with 3 canulated spongiosa partial threaded screws.The distance between the tip of  the screw and the articular surface is 5-10mm.The screws are 3mm far away from the medial and posterior cortex.When the patients are aged between 70-80 years the replacement of the femoral head is preferred with total arthroplasty or hemiarthroplasty.When we have active patients ,ipsilateral osteoarthritis,rheumatoid arthritis,femoral head necrosis,Paget, neoplasm or contralateral operated hip THA is preferred (Symeonidis 1996,Stromqvist 1983).THA is more expensive has high rate of dislocations but has better midterm and long term results and lower incidence of revisions(Healy 2004,Blomfeldt 2007).In ages above 80 years Unipolar,Thompson or Moore are preferred with cement(Shah 2002).

B)Peritrochanteric fractures.   

Most popular classification is that of  Muller(three groups A1,A2,A3 with 3 subcategories in each group).External fixation is indicated in patients with bad health condition,tumors,renal insufficiency and walking incapability before fracture.This method decreases the operation time,the blood loss and allows the patient to be mobilized and avoid general complications(Moroni 2005,Dabezies 1984).In active and good health conditions patients open reduction and internal fixation materials with DHS and gamma-nail to be the most popular.Comparative studies showed that these two methods are equivalent according to operation time,blood loss,functional results and complications rate with gamma-nail to have higher incidence of intraoperative fractures.Weight bearing is advised according to the weight of the patient the combination of the fracture and the degree of osteoporosis.Complications:femoral head necrosis,nonunion with or without material failure,cut out,intraoperative fracture.

2)Diaphyseal femoral fractures.

Classification of AO according to Muller A simple fracture,B with a third fragment,C comminuted fractures.Polytrauma patients with stable haemodynamic status external fixation or unreamed interlocking intramedullary nailing.If the haemodynamic status is unstable external fixation.Open fractures I,II,IIIa according to  Gustilo classification reamed interlocking intramedullary nailing IIIB and IIIC external fixation (Cole 1996,Brumback 1996).In fractures of type A dynamic nailing whereas in fractures of type B and C static nailing(Klemm 1986).Plate and screws are not used by the majority of surgeons.In dynamic nailing weight bearing after third day postoperatively in static nailing partial weight bearing for 6-8 weeks which is switched to full weight bearing after 8 weeks.Usual complications nonunions,malunion,material of fixation failure superficial or deep infection.

3)Fractures of distal femur.

Classification according to AO A-supracondylar,B-condylar,

C-supraintracondylar each group is divided to three subgroups.When the fracture is undisplaced conservative treatment is preferred.Disadvantages high risk of displacement nonunion,knee stiffness.If  the fracture is undisplaced and extraarticular type A functional brace locked in 20° and touch weight bearing for 6/52.Partial weight bearing and knee movements are allowed after 6/52,full weight bearing after 12/52 postoperatively.If it is undisplaced and intraarticular functional brace locked in 20° and touch weight bearing for 6/52.Between 6-12/52 full motion of the knee and touch weight bearing.Full weight bearing after 12/52.Many authors don’t accept operative treatment for these fractures.Open fractures:open reduction and mini internal fixation with K-wires or screws and external fixation.In supracondylar fractures partial weight bearing after 6/52p.op full weight bearing after 12/52 p.op removal of the device 16/52 p.op.In intrasupracondylar fractures removal of the external fixation at 6/52 and switching to locking plate or retrograde nailing with conventional or LISS technique.For closed fractures L-plate DCS or conventional plates have been abandoned.The most wide accepted methods are reamed intramedullary nailing and locking plates with LISS technique.They have equivalent results according to operation time blood los functional results and low incidence of complications(infection,nonunion)because they are atraumatic not disturbing the vascularity at the fracture site.

4)Patellar fractures.

If it is undiplaced and the patient has the ability to extend the knee the treatment is conservative with a brace locked for 4-6 weeks.After 4th week the patient is advised to start partial weight bearing.If the fracture is displaced with no knee extension surgical treatment with K-W and wire(tension band).If the fracture is comminuted we should think patellectomy.

5)Fractures of tibial condyles.

Classification according to Schatzker in 6 types.Type I fracture of  lateral condyle,type II fracture with impaction of articular surface of lateral tibial condyle,type III impaction in lateral condyle,type IV fracture of medial condyle,type V fracture of both condyles,type VI each of the above types combined with diaphyseal fracture.If it is undisplaced with no impaction or depression <5mm valgus or varus instability <10° with knee in extension we choose the conservative treatment. It includes functional brace locked in 20° with touch weight bearing for 6 weeks,full motion with touch weight bearing for the next 6 weeks.Partial weight bearing after 12 weeks p.op.If there is displacement or valgus,varus instability more than 10° or open fracture we proceed with operative treatment.For type I,II,III and IV open reduction and internal fixation with one or two conventional or locking plates with grafts.For types V,VI and open fractures two plates or minimal internal fixation with K-W or screws and circular external fixation with or without grafts.Arthroscopically assisted fixation has been described but it has the risk of compartment syndrome.

Concominant meniscal or cruciate ligaments tears or lesions of collateral ligaments can be found but it’s reconstruction will take place in a second stage.

6)Fractures of tibial diaphysis.

Classification according to AO(Muller A,B,C)like femoral diaphyseal fractures,When it is undisplaced conservative treatment with brace touch weight bearing for 6 weeks, partial weight bearing for the next 6 weeks, full weight bearing after third month.Disadvantages noncompliance of the patient possible nonunion or knee stiffness.Closed fractures type A dynamic nailing,type B and C static nailing with reaming.Polytrama patients if we have stable haemodynamic condition unreamed nailing or external fixation,unstable condition external fixation as a final treatment or switched to nailing after the stabilization of the patient’s condition (Scaler 2000).Open fractures I,II and IIIa according to Gustilo reamed intramedullary nailng,IIIb and IIIc external fixation(Singer 1996,Keating 1997,Finkemeier 2000).

7)Extraarticular fractures of the distal tibial metaphysis.

Usually surgical treatment.Options:conventional or locking plates, external fixation circular or intraarticular with mini internal fixation,reamed interlocking intramedullary nailing with always two distal screws(expert nails)(Tylianakis 2000,Megas 2003).

8)Intraarticular fracture of distal tibia(Pilon).

Classification according to Ruedi Algower in three types(undisplased, displaced,comminuted).Conservative treatment in undisplaced fracture.In all other cases surgical treatment.Always CT to confirm the size of the fracture.Therapeutic choices for open or closed fractures convetional or locking plates(Maffuli 2004)external fixation with K-W or screws (Aggarwal 2006).When we have open fractures type IIIc with bone loss primary arthrodesis with Illizarov(Feibel 2005).

9)Fractures of the malleoli.

Undisplaced brace for 12 weeks full weight bearing after 3 months. Displaced or open fractures or associated with talus dislocation or subluxation operative treatment.Lateral malleolus plate 1/3 with screws (K-W with wire in osteoporotic bone).Medial malleolus K-W or screws full weight bearing after 12 weeks.

10)Fractures of the talus.

Classification body fractures(osteochondral,transverse,sagital,oblique of the lateral process,comminuted)fractures of the neck(Hawkins I,II and III)and fractures of the talar head.Talar necrosis usual in Hawkins III fractures and comminuted fractures of the body CT is usefull for detailed imaging,Undisplaced brace for 2 months if they are extraarticular or for 3 months for intraarticular.Full weight bearing after 2 or 3 months respectively.Displaced fractures of the body,comminuted fractures of the body and Hawkins II and III surgical treatment with ORIF(K-W or screws canulated spongiosa and partial threaded).In difficult cases such as open fractures type III according to Gustilo,neglected Hawkins III and comminuted fractures of the body (high rate of necrosis)removal of the talar body and tibiocalcaneal arthrodesis is indicated in one or two stages (Shrivastava 2005).

11)Calcaneal fractures.

Classification according to Sanders in 4 types.Extraarticular conservative treatment-Essex-Lopresti.Intraarticular-Operative management. Complications(Sudeck,talocalcaneal arthritis)ORIF,External fixation with circular frame Illizarov(closed reduction ligamentotaxis).

12)Fractures of the tarsal bones.

Displaced ORIF with K-W or screws.

13)Fractures of the metatarsals.

They are classified to fractures of the head(extraarticular,intraarticular)the diaphyseal fractures and fractures of the base.Undisplaced conservative treatment.Displaced operative management with screws or mini plates and screws or K-W.Partial weight bearing after 8th week p.op.Nonunion of the fracture at the base of the fifth metatarsal due to of the peroneal tendons.

14)Fractures of the phalanges.

Undisplaced conservatively.Displaced surgical management with K-W or mini plate or screws.Partial weight bearing after 4-6 weeks postoperatively.

Recent Announcements

Monday, 20 Feb 2017

5th Congress of ECOSEP & 2nd UAE FA Football Medicine Update 25th-27th November 2017 Dubai

read more

Monday, 05 Sep 2016

5th ANNUAL PODIATRIC SPORTS MEDICINE CONFERENCE In association with EUROPEAN COLLEGE OF SPORTS & EXERCISE PHYSICIANS INSPIRING CLINICAL EXCELLENCE – THINKING BEYOND BIOMECHANICS

read more

Recent Articles

Platelet Rich Plasma (PRP)

An innovative treatment, for  Musculoskeletal Pathologies , PRP uses your own blood for healing muscle, tendon and ligament injuries. 

A common form of healing is scarring which affects function . Most of the Current therapies  treating sports Injuries  do not change the intrinsically poor healing properties. Given this situation, biologically based strategies involving the stimulation of cell activities through the delivery of Growth Factors have attracted considerable interest. 

Platelet Rich Plasma is derived by placing a small amount of your blood in a filtration system which separates red blood cells from platelets. The high concentration of platelets (containing a high level of Growth Factor) is then injected into the injured tissue which initiates the body’s natural healing response.

read more

Extra Shockwave Therapy & Treatment

At European SportsCare, Extracorporeal Shockwave Therapy (ECSWT) is available for the treatment of musculoskeletal softtissue pathology such as Tendon, Ligament, Muscle and bone. Shockwave Therapy is a non-invasive treatment provided by fully trained Consultants providing this treatment for more than 15 years. It is available as an out-patient treatment in one of our comfortable consultation rooms at 68 Harley Street.

read more

Acute Lateral Ankle Sprains In Track & Field Athletes: A Proposal Of An Expanded Classification

We present a longitudinal observational study on classification of acute lateral ankle ligament injuries in track & field athletes, based on objective criteria. These very common and sometimes troublesome sports injuries are treated functionally but there is a lack in international literature in predicting the time needed for full recovery.

read more

Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes

Objective: To compare long term outcome of highly active patients with anterior cruciate ligament ruptures treated operatively versus non-operatively.

Design: We reviewed high level athletes with an anterior cruciate ligament rupture on either MRI or arthroscopic evaluation more than 10 years previously, who were treated conservatively. They were pair-matched with patients who had had an anterior cruciate ligament reconstruction with bone-patella-tendon-bone, with respect to age, gender and Tegner activity score before injury.Participants: In total 50 patients were pair-matched.

Results: We found no statistical difference between the patients treated conservatively or operatively with respect to osteoarthritis or meniscal lesions of the knee, as well as activity level, objective and subjective functional outcome. The patients who were treated operatively had a significantly better stability of the knee at examination.

Conclusion: We conclude that the instability repair using

a bone-patella-tendon-bone anterior cruciate ligament reconstruction is a good knee stabilising operation. Both treatment options however show similar patient outcome at 10 year follow up.

read more

ACL injuries. Diagnosis, treatment and rehabilitation

The ability to recognize the ACL deficient knee is lacking, even among orthopaedic surgeons. The history of an acute ACL tear is remarkably constant, because the injury is often non contact, and patients usually report a twist on the flexed knee, turning to the same side as the injured knee, although hyperextension or direct injury is the cause in some sports. Patients often remember a loud pop, but, because there are no nociceptors in the ACL, pain is not an immediate feature in the isolated lesion. Players may attempt to continue to play, but they usually stop because the knee feels insecure. Pain ensues in association with a hemarthrosis: 70% of acute hemarthroses of the knee are associated with a tear of the ACL. The diagnosis must be confirmed before treatment is offered.

read more