HIGH-ENERGY TRAUMA OF THE LOWER EXTREMITY NORDIC FORUM 2016, AARHUS

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1 HIGH-ENERGY TRAUMA OF THE LOWER EXTREMITY NORDIC FORUM 2016, AARHUS Ken F. Linnau, MD, MS Emergency Radiology Harborview Medical Center University of Washington Seattle, WA

2 ACKNOWLEDGMENTS Nicole Kansier, MD, Department of Surgery, University of Washington, Seattle, WA, USA

3 SOMETIMES BIG CARS CRASH FAST CRASH!!

4 34 YOM MVC AT 65 KM/H (F250, BMI 54)

5 34 YOM MVC AT 65 KM/H (F250, BMI 54)

6 NONCONTIGUOUS FRACTURES OF THE FEMORAL SHAFT AND DISTAL FEMUR High energy trauma Often with torso injuries (ISS> 15) Uncommon association Shaft fractures + distal femur fracture: 3-4% Longitudinal loading of femur flexed at hip Dashboard injury Multifocal fractures are more difficult to treat: Diaphyseal femur fractures: medullary nailing. Distal articular surface needs to be preserved. Barei- DP, Journal of Trauma 2003 (55): 80

7 34 YOM MVC AT 65 KM/H (F250, BMI 54)

8 34 YOM MVC AT 65 KM/H (F250, BMI 54)

9 34 YOM MVC AT 65 KM/H (F250, BMI 54)

10 BASICERVICAL FEMORAL NECK FRACTURES High-energy femoral neck fractures usually vertical Consider Pauwels classification Ipsilateral femoral neck fractures occur in 2-8% of shaft fractures Often overlooked Shaft fracture is clinically obvious (deformity) Distracting torso injuries may be present Look on CT if you have abdomen-pelvis CT Femoral neck fracture repair most important Bartonicek-J, J Orthop Trauma 2001 (15): 358 Linnau KF, AJR 2002 (178): 428

11 34 YOM MVC AT 65 KM/H (F250, BMI 54)

12 34 YOM MVC AT 65 KM/H (F250, BMI 54)

13 42YOF MCC

14 42YOF MCC

15 SCHATZKER CLASSIFIACTION TIBIAL PLATEAU Schatzker J, McBroom R, Bruce D: The tibial plateau fracture: The Toronto experience Clin Orthop 1979;138:

16

17 42YOF MCC Schatzker type VI Bicondylar tib plateau fx

18 48 YOM MCC Bicondylar tibial plateau fractures: Schatzker 5 or 6 AO C-type fxs Posteromedial fx fragments Not in Schatzker Require different operative approach Barei-DP, et al. J Orthop Trauma 22 (2008): 176.

19 48 YOM MCC Vascular injury: Most commonly observed with tibial plateau fx Supracondylar femur fx Knee dislocations

20 48 YOM MCC

21 KNEE DISLOCATIONS Complete disruption of tibio-femoral joint ACL, PCL, posterolateral corner, MCL M : F == 4 : 1 High-energy dislocations are most common (50%) Poly trauma 14-45%. Sports related (30%) Spontaneous knee dislocation may occur with morbid obesity. Consider Schenk classification (1994) Focuses on pattern of ligament disruption High association of nerve and vascular injury Howells-NR, et al. Injury (42) 2011:

22 VASCULAR INJURY AFTER KNEE DISLOCATIONS Prevalence of vascular injury is 3.3% (267 of 8050) 13% need vascular repair Stratify risk for limb-threatening injury Physical exam Ankle Brachial Pressure Index (ABI) Signs of ischemia: vascular surgery emergency ABI < 0.9: CTA or conventional angiogram Natsuhara-KM, et al. Clin Orthop Relat Res (472) 2014: Howells-NR, et al. Injury (42) 2011:

23 ED MANAGEMENT VASCULAR INJURY Courtesy Nicole Kansier, MD, Department of Surgery, University of Washington

24 48 YOM MCC

25 LOWER EXTREMITY FASCIOTOMY ANTERIOR: Tibialis Anterior Extensor hallucus longus Extensor digitorum longus Peroneus tertius Anterior Tibial artery Deep Peroneal nerve LATERAL: Peroneus longus and brevis Superficial Peroneal nerve DEEP POSTERIOR: Tibialis Posterior Flexor hallucus longus Flexor digitorum longus Popliteus Posterior Tibial artery Peroneal artery Tibial nerve SUPERFICIAL POSTERIOR: Gastrocnemi us Soleus Plantaris Sural nerve

26 LOWER EXTREMITY FASCIOTOMY

27 42YOF MCC

28 Kim-PH, Leopold-SS. Clin Orthop Relat Res (2012) 470: 3270 GUSTILO-ANDERSON CLASSIFICATION OF OPEN WOUNDS Describes soft tissue injury only Developed for prediction of infection Type I II III A III B III C Wound < 1 cm Wound 1-10 cm Wound > 10 cm, high energy Adequate tissue for coverage Extensive periosteal strippuing Soft tissue transfer required Vascular injury requiring repair

29 20 YOM MCC

30 44 YOM MCC

31 LIMB-THREATENING INJURY: AMPUTATION OR SALVAGE? Profound physical, mental, social and financial implications of heroic limb salvage procedures. Lower Extremity Assessment Project (LEAP) Prospective cohort study: 8 centers, 7 year follow-up. No difference in self-reported incapacity yrs. No link of outcomes with technological sophistication of prosthesis Injury severity indices not useful No difference in return to 7 yrs. Cost similar at 2 yrs., life-time cost 3 times higher for amputees. Higgins-TF, Klatt- JB, Beals-TC. Orthop Clin N Am41 (2010) Bosse MJ, MacKenzie-EJ, et al. NEJM 347 (2002) 24:

32 LOWER EXTREMITY ASSESSMENT PROJECT (LEAP) Single greatest determining factor: Patient s degree of self-efficacy How well does patient believe they can handle change How can the patient maximize their future potential - Not within the control of surgeons Higgins-TF, Klatt- JB, Beals-TC. Orthop Clin N Am41 (2010)

33 44 YOM MCC

34 42YOF MCC 3 year follow up

35 17 YOM 12 M FALL

36 TIBIAL PLAFOND (PILON) FRACTURES Axial loading or rotational forces High-energy axial load injuries: worse prognosis Soft tissue envelope: crucial for reconstruction Wound blisters Compartment syndrome Circulatory supply (Doppler) CT scanning after provisional reduction Sagittal and coronal reformations Barei-DP, Nork-SE. Foot Ankle Clin N Am 13 (2008)

37 PILON FRACTURES Usually Open Reduction Internal Fixation Preliminary external fixation common Soft tissue envelope needs to stabilize Topliss Classification (2005) High-energy (axial load) fractures: sagittal, varus Lateral disruption or Functional diastasis Associated injuries of calcaneus, knee, hip and spine are common Barei-DP, Nork-SE. Foot Ankle Clin N Am 13 (2008)

38 17 YOM 12 M FALL

39 17 YOM 12 M FALL

40 72 YOM 8 FT FALL

41 Sanders classification of calcaneus fractures Daftary A et al. Radiographics 2005;25:

42 Coronal view Axial view

43 72 YOM 8 FT FALL talus calcaneus Coronal view

44

45

46 72 YOM 8 FT FALL Axial 8 mm MIP Axial view

47 Coronal Sagittal

48

49 ANKLE CT Place extremity in gantry as close as possible to anatomic position Scan at thin collimation (e.g. 0.6 mm) Review in 2 mm bone and soft tissue Correct sagittal images along 2 nd metatarsal Tilted coronal Tilted axial images Consider MIPS for calcaneus fxs

50 25 YOF CAR VS. BULLDOZER Lisfranc fracture-dislocation: Unique osseous and ligamentous anatomy Predisposition for MT I- II separation More disruption with high-energy Divergent Homolateral Radiographic clues Foster SC, Foster RR. Radiology Jul;120(1): Lisfranc's tarsometatarsal fracture-dislocation.

51 HIGH-ENERGY TRAUMA OF THE LOWER EXTREMITY -- summary When you find an injury, don t stop looking for more Up and down from obvious Look carefully for femoral neck fractures (CT pelvis!) Soft tissue envelope is important for outcomes Consider vascular evaluation Some extremities may not be saved (LEAP) Use CT with reformations for complex or equivocal findings

52 Thank you! Mahesh Thapa

Mohammad Ayati,M.D Department of Orthopaedics, Yazd University of Medical Science.

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