femur and patella

Femoral neck fracture

Common in the elderly(female) : osteoporosis

Mechanism of injury:

1. Low-energy trauma (most common in elderly) : tripping ( rotation) , fall on the side

2. Pathologic fracture: spontaneously due to damages by : cancer, infection , bone disease.

3. High-energy trauma: young patient

symptoms of femoral neck fracture

the injured leg lies in external rotation and there is shortening of the leg

- hip pain,  swelling, tenderness

- inability to weight bearing

- walking difficulties  and pain (impacted fracture) - rare

Garden classification if hip fracture

type 1: incomplete impacted fracture , stable

type 2 : Complete fracture without displacement, stable

type 3 : Complete fracture with partial displacement, high risk of vascular necrosis

type 4: Completely displaced fracture: high risk of nonaligned healing

Pauwels classification

based on angle

type 1: < 30 : horizontal

type 2 : between 30-50 : oblique

type 3: >50 : vertical

treatments

Operation:

· Cannulated screw fixation → for non-displaced trans-cervical fx or displaced in young patient

· Dynamic hip screw (DHS) or intramedullary nail

· Hemi-arthroplasty → for less active patient, metabolic bone disease

· Total hip arthoplasty → for older active patients with preexisting hip osteoarthritis

after operation ( one day ) : xray and then in 3rd 6th 12th weeks

Early mobilization should be encouraged.

Weight bearing as tolerated (WBAT) is often preferred.

complications

1. Treating without prosthesis: The native femoral head is preserved and the fracture is fixed internally.

• Cannulated screws

• Dynamic hip screw (DHS)

Often preferred in:

• Younger patients

• Nondisplaced fractures

• Patients where preserving the femoral head is desirable

- faster operation

- minimal invasive technics

1. Non-union (Th: prothesis) : The fracture fails to heal.

2. Avascular necrosis of head of femur (Th: prothesis)

3. Implantation movements (sliding, fracture)

2. Treating with prosthesis

• Hemiarthroplasty

• Total hip arthroplasty (THA)

Commonly used in:

• Elderly patients

• Displaced femoral neck fractures

• High AVN/nonunion risk

• -longer operation time

• - wider incisions

• -

• -1. prosthesis dislocation

• -2. aseptic/septic(infection) loosening

3. both

Hematoma

Infection

blood loss

general risks : Deep vein thrombosis (DVT), pulmonary embolism, Pneumonia,Pressure ulcers.

Periprosthetic fracture : Fracture occurring around a prosthesis.

Peri-implant fracture : Fracture occurring around fixation hardware.

AO classification for intertrochanteric and subtrochanteric fractures

Within about 5 cm distal to the lesser trochanter.

In AO classification:

• 31 = proximal femur

Then fractures are divided into:

• A = trochanteric region

• B = femoral neck

• C = femoral head

A1 : Simple pertrochanteric fractures

A2 : Multi-fragmentary pertrochanteric fractures

A3: Reverse oblique / transverse intertrochanteric fractures

Evans classification

used for intertrochanteric (pertrochanteric) femur fractures.

1. Stable fractures:

• Simple two-part fractures

• Intact posteromedial support

2. Unstable fractures: Loss of medial/posteromedial support.

• Comminution

• Reverse oblique fractures

• Subtrochanteric extension

femoral shaft fracture

Diaphysis (shaft) of the femur

Longest bone in the body → usually takes a lot of force to break it.

Blood loss!

• Hemorrhagic shock

• Tachycardia

• Hypotension

Injury can be either closed or open.

In young → frequently due to high-energy collision (MVA, pedestrians, fall from height, GSW)

In older → a lower-force incident, such as a fall from standing.

symptoms :

Immediate, severe pain.

· Swelling

· Deformity

· Pts. is unable to put weight on the injured leg

· Blood loss due to muscle/vascular injury (1-2 L) → shock!

· Can be part of of polytrauma or multiple injury

Diagnosis

· Physical Exam.

· 2 directional X-rays → checking the hip and knee joint!

· CT

treatment of femoral shaft fracture

Most femoral shaft fractures require surgery\

32 = femoral diaphysis (shaft)

Then fractures are divided into:

• Type A = simple

• Type B = wedge

• Type C = complex

A1 — Spiral fracture line

A2 — Oblique > 30

A3 — Transverse, horizontal < 30

Type B — Wedge fractures

B1 — Spiral wedge

B2 — Bending wedge

B3 — Fragmented wedge

type C_complex fractures

C1 — Complex spiral

C2 — Segmental

C3 — Irregular/comminuted

methods :

1. Plate fixation in femoral fractures: First anatomically reduced/aligned then fix with plate or screws , laterally attached to femur 

Indications: When intramedullary (IM) nailing is not possible, Fractures extending into the hip or knee joint, Abnormally curved femur, Periprosthetic fractures, Nonunion, Treatment of deformity.

2. Intramedullary nailing of femoral shaft fractures : Most common operative method, Reamed or unreamed intramedullary nail, Locked proximally and distally with screws

Indications: Mid-shaft femoral fractures (diaphyseal middle third), Fractures near the transition zones: Proximal third (≈ 3/7 region), Distal third (≈ 5/7 region)

3. External fixation : Metal pins/screws (Schanz screws) are inserted into the bone, They are connected externally by rods/clamps.

Indications: Open fractures, Pediatric fractures, Polytraumatized patients, Septic cases.

Complications: Pin site infection, Nonunion, Malunion.

4. physiotherapy : mobilization may be started on postoperative day 1., X-ray control within 24 hours,Static quadriceps exercises with passive range of motion of the knee should be encouraged. Stability of osteosynthesis

   The fixation is classified clinically as:

   • Stable fixation → allows earlier mobilization / loading

   • Partially stable → limited or partial weight bearing

   • Unstable fixation → restricted loading, protection required

Loading possibilities during physiotherapy:

Options:

• Non-weight bearing (NWB)

• Partial weight bearing (PWB)

• Weight bearing as tolerated (WBAT)

Supracondyler fractures (distal femur)

• Elderly (osteoporotic bone, low-energy falls)

• Young patients (high-energy trauma)

AO distal femur (33) classification.

Type A — Extra-articular fractures (33-A)

A1 — Simple: Simple metaphyseal fracture

A2 — Wedge: Metaphyseal wedge fragment

A3 — Complex: Multifragments

Type B — Partial articular fractures (33-B)

B1 — Lateral condyle (sagittal)

B2 — Medial condyle (sagittal)

B3 — Coronal

Type C — Complete articular fractures (33-C)

C1: simple

C2: Simple articular fracture, Metaphyseal multifragmentary

C3: Multifragments of articular surface, Highly complex injury

supracondylar fracture symptoms and diagnosis

Clinical features

· Pain with weight bearing

· Swelling and bruising

· Hemarthrosis : Blood accumulation in the knee joint

· Tenderness

· Deformity

diagnosis :

Physical examination: Check neurovascular status:

• distal pulses (dorsalis pedis, posterior tibial)

• capillary refill

• sensation and motor function

X-rays (2 views)

CT scan

Angiography (DSA): Used if there are signs of vascular injury.

Indications:

• absent or weak distal pulses

• expanding hematoma

• signs of ischemia

• high suspicion of arterial damage

Treatment of supracondylar (distal femur) fractures?

1. Non-operative treatment:

• Long leg splint (temporary)

• Long leg cast → hinged knee brace: non displaced fracture,

• Traction

2. Operative treatment (main treatment in most cases):

• Temporary external fixator: Open fractures, poly trauma .

• Retrograde intramedullary nailing: Inserted through the knee joint

• Plate fixation (standard method) : Most distal femur fractures

• Screw fixation

• Dynamic Condylar Screw (DCS)

Patellar fractures

The patella protects the knee and connects the muscles (m. quadricaps femoris) to the tibia

Extensor apparatus of the knee:

Muscle-quadriceps tendon – patella  and its retinaculum  - patellar tendon – tub. tibiae

Mechanism

-Most commonly caused by a direct blow → fall or MVA.

-Indirectly → thigh muscles can contract so violently that it pulls the patella apart. distraction

1. AO classification :

Type A — Extra-articular fractures

A1 — Avulsion: Tendon or ligament pull-off : quadriceps tendon,patellar tendon

A2 — Isolated body fracture: Fracture of patellar body, no joint

Type B — Partial articular fractures: Only part of the articular surface is involved.

B1 — Vertical lateral fracture

B2 — Vertical medial fracture

Type C — Complete articular fractures:

C1 — Transverse : most common

C2 — Transverse + second fragment

C3 — Complex

2. Patellar fractures — functional classification:

Undisplaced fracture: not separated , Extensor mechanism remains intact

Treatment (typical): conservative : immobilization

Displaced fracture (distraction fracture) : gap present, Rupture of extensor apparatus, Inability to actively extend knee

Treatment: Surgical fixation required: most commonly tension band wiring, sometimes partial patellectomy or ORIF depending on comminution.

clinical sign and diagnosis of patellar fracture

Clinical features

· Pain, Tenderness

· Swelling, Bruising

· Hemarthrosis

· Gap at the fracture site

· Inability to keep the elevated leg with extended knee position

Diagnosis

· Physical examination of the knee.

· 2 directional X-rays (front and side) views+/- axial patella wiew (looking for osteochondral injuries)

treatment of patellar fracture

1. Nonsurgical Treatment : Undisplaced fractures, Intact extensor mechanism

· If the pieces of broken bone are not displaced.

· Splint/cast/brace to keep the knee straight + crutches.

· Take 6-8 weeks, and perhaps longer – during this with brace extreme flexion is not allowed (<60 degrees).

2. Tension Band Wiring (TBW):

tensile (pulling) forces into compressive forces at the fracture site,

Indications

• Transverse patellar fractures

• Displaced fractures

• Intact or reconstructable articular surface

• Extensor mechanism disruption

Typically uses:

• Kirschner wires (K-wires)

• Stainless steel wire in a “figure-of-8” configuration

3. Knee function and rehabilitation after patellar fracture:Progressive mobilization, Muscle strengthening, Supervised physiotherapy. with a straight knee, using crutches or a walker, from postoperative day 1.

After the required period of splinting/immobilization:

• Knee stiffness (loss of range of motion)

• Quadriceps muscle weakness (atrophy)

• Reduced functional mobility