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lower limb fractures & DislocationsDr Guido Cabrera
LTraumatologa y OrtopediaCiruga Reconstructiva Extremidad
Superior.Servicio de Urgencia Clnica Las Condes
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TopicsAce tabular fractures.Pelvic Fractures.Hip
Dislocations.Proximal femoral fracture.Femoral Shaft
Fractures.Fracture tibial plateau.Tibial shaft Fractures.Ankle
fractures.
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Mechanism of fracturesLower limb fracture is a result of a high
energy trauma except in elderly people or diseased bonesTypes of
fracture are depend on position of limb during impaction and
magnitude of forces applied.
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ManagementThe proper way to treat a patient with high energy
trauma is to look at the patient as whole ,not to injured limb
alone!So the aim to treat such patient is to save life first, then
save limb ,finally to save function. A.B.C.D
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Pelvic FracturesPelvic fracture is a high energy trauma , as a
result of MVA, fall .Classifications. ( Tile) Type A. Stable A 1.
fractures of the pelvic not involving the Ring. A 2 . Stable ,
minimally displaced fracture of the Ring .
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Type B. Rotationally Unstable ,Vertically Stable. B1. Open
Book
B2 . Lateral Compression : Ipsilateral
B3. Lateral Compression :Contra lateral
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Type C. Rotationally and Vertically Unstable
C1 . Unilateral
C2 . Bilateral
C3 . Associated with Acetabular Fracture
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MANEGEMENTAggressive treatment .
Obtain X-Ray: AP pelvic, Inlet ,outlet ,Ct Scan.
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TreatmentAggressive treatment . By A.B.C.D.Obtain X-Ray: AP
pelvic, Inlet ,outlet Ct Scan.Think in systemic approach. Specific
treatment: type A . symptomatic treatment type B .ORIF with
plates& screws ,External Fix. Type C . ORIF with plates &
screws. Both AP.
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Emergency treatment
Protect primary blood clot by early pelvic splintage and
prevention of exessive movement
IV fluids, early blood transfusion, early fresh frozen plasma,
platelets, cryoprecipitate
Prevent hypothermia and acidosis
Stop other bleeding sites
Stabilize pelvis
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complications Hemorrhage life threateningBladder/bowel
injuriesNeurological damageObstetrical difficultiesPersistent
Sacro-iliac joint painPost traumatic arthritis of the hip with
acetabular fractures
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Acetabular fractureUsually it is a result of high- energy trauma
.The acetabulum is divided into four segmentsan anterior column and
wall (rim) and a posterior column and wall (rim). . Fractures of
the acetabulum are classified based on their involvement of these
structures .
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classification Letournel and Judet
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Investigation AP pelvis.Judat views ( Internal Oblique,Obturator
view)C T scan .
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TREATMENT
Indications for Nonoperative Treatment 1. Nondisplaced and
Minimally Displaced Fractures. 2. Fractures with Significant
Displacement but in Which the Region of the Joint Involved Is
Judged To Be Unimportant Prognostically
3.Secondary Congruence in Displaced Both-Column Fractures
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Medical Contraindications to SurgeryLocal Soft Tissue Problems,
Such as Infection, Wounds, and Soft Tissue Lesions from Blunt
Trauma.Elderly Patients with Osteoporotic Bone in Whom Open
Reduction May Not Be Feasible.skeletal traction for 4-6 weeks. And
then start physiotherapy in bed , PWP ,FWBAT.
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Operative TreatmentIndications for Operative Treatment. 1. An
acetabular fracture with 2 mm or more displacement in the dome of
the acetabulum. 2. any subluxation of the femoral head from a
displaced acetabular fracture noted on any of the three standard
roentgen graphic views
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More than 50% involvement of the articular surface of the
posterior wall or clinical instability with hip flexion to 90
degrees in posterior wall fractures .Incarcerated Fragments in the
Acetabulum after Closed Reduction of a Hip Dislocation.
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complicationsposttraumatic arthritis in 17%.a vascular necrosis
after posterior dislocation was 7.5%. Infections are reported to
occur in 1% to 5% Sciatic nerve palsies as a result of the initial
injury occur in approximately 10% to 15%.Heterotopic ossification
(HO) occurs after most extensile approaches
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HIP Dislocations
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Complicationpost traumatic arthritisFemoral head injury with
risk of AVN (100% if the dislocation last >12 H)Sciatic nerve
palsy 25% ( 10 % permanent)Femoral shaft /neck fracture knee
injury
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Treatmentneck of femur Nondisplaced fracture of neck of femur
can be treat with canulated screws. Displaced fracture
----------DHS in patient less than 60 years.> than 65 years look
for. . Level of activities. . Status of the acetabulum. then chose
THR vs hemi arthoplasty.
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Treatment Intertrochantaric fracture-------DHS .
DCP.Subtrochantaric fracture---------DHS.ABP.DCP.Combination of
both------- IM Nail with Canulated srews.