NECK OF FEMUR (INTRA-CAPSULAR)

Fracture neck of femur is still the unresolved fracture as evident by the number of procedures available and practiced, thus none is universally applicable and the surgeon has to select one which would be ideal in a given situation. The treatment varies with the age of the patient, the level of the fracture and the displacement of the fragments. Also the duration of the fracture is a major deciding factor. If union of the fracture Is not likely to be achieved then alternative method should be adopted which will suit the patient, keeping in mind his age, lifestyle, profession and economic status. Majority of our patients are not covered by health insurances, hence all the expenditure has to be borne by the patient himself. It is therefore desirable on the part of the treating orthopaedic surgeon to choose a method which these patients can afford.

Fracture neck femur is commonly seen in old people, but in our country quite a good number of patients are young adults. It is infrequent in children. Fracture neck femur whether intra-capsular or extra-capsular can be diagnosed and differentiated by clinical examination and confirmed by the roentgenograms. Any underlying pathologic condition like metastasis or osteoporosis if present can also be identified on roentgenograms.

Principles of management:

BELOW AGE 50

·                 Child:-fixation with

·       MOORES PIN

·       HAGES PIN

·       KNOWELS PIN

·                 Adults

·       Cannuated Iag screw

·       Subtroca nferic abduction osfeotomy

·       DHS

ABOVE AGE 50

1.                THR

2.                BIPOLAR hemiarthropasy

Fracture more than 3 weeks duration

BELOW 50- Osteosynthesis along with mcrnurray osteotomy ABOVE 50-THR

If patient is poor afford ing wise:- girdle stone or bachelor procedure can be done

TROCHANTERIC FRACTURES (EXTRA-CAPSULAR FRACTURE NECK FEMUR)

lntertrochanteric hip fractures account for approximately half of the hip fractures in the elderly; out of this more than 50% fractures are unstable. Unstable patterns occur more commonly with increased age and with low bone mineral density. The fracture commonly occurs through a bone affected by osteoporosis. The presence of osteoporosis in intertrochanteric fractures is important because fixation of the proximal fragment depends entirely on the quality of cancellous bone present, Unstable intertrochanteric fractures are those in which comminution of posteromedial buttress exceeds as implelesser trochanteric fragment or those with subtrochanteric extension. The results of fixation in unstable fractures are less reliable and have a high rate of failure (8%-25%).

Investigations- X-rays of the pelvis including both hips and knee joint and of other areas if required, General Investigations and specific if required according to the status of the health of the patient.

Examination- Pt should be carefully examined for distal vascular and neurological deficit, if any. If there is any pt should be referred to higher centre immediately.

Management- These pts need surgical treatment for early mobilization as they are generally elderly people. If the pt is kept in bed and immobalized he s bound to develop bed-sore and other complications. In case pt is unfit for surgery then pt should be put on skeletal traction in 30 deg of abduction for inter trochanteric fractures til radiological signs of union are visible on x- rays

FRACTURE SHAFT OF FEMUR

Fractures of the shaft of the femur are the result of high-energy trauma and therefore can be both life-threatening injuries and causes of severe permanent disability. Isolated injuries can occur with repetitive stress and may occur in the presence metabolic bone diseases, metastatic disease, or primary bone tumors.

The femur is very vascular and even a fracture can result in significant occult blood loss into the thigh. Up to 40% affected with isolated fracture shaft femur may require blood transfusion, as such injuries scan result in loss of up to 3 units of blood This factor is significant, especially in elderly patients who have less cardiac reserve.

Most femoral diaphyseal fractures are treated surgically with intramedullary nails or extra-medullary plate fixation. The goal of treatment is reliable anatomic stabilization, allowing mobilization as soon as possible. Surgical stabilization is also important for early extremity function, allowing both hip and knee motion and strengthening. Injuries and fractures of the femoral shaft may have significant short-and long-term effects on the hip and knee joints if alignment is not restored

Investigations- X-rays of the part including hip and knee and of other areas if required, x-ray of pelvis with both hips is must. General Investigations and specific if required, according to the status of the health of the patient.

Examination- Patient should be carefully examined for distal vascular and neurological deficit, if any. If there's any patient should be referred to higher Centre immediately.

Management- As these patients have profuse infernal bleeding, special attention to hemodynamic status should be given. Intravenous fluids such as Ringer, Dextrans (plasma expander) and blood transfusion should be used. Patient should be catherized to have a check on renal output. Leg traction should be applied to immobalize and align the fracture. Thomas splint should be used to transport the patient.

Femur should be fixed surgically with Nailing or Plating depending upon fracture site and pattern.

FRACTURE OF TIBIA/FIBULA

Introduction

·       Lower leg fractures include fractures of the tibia and fibula. Of these two bones, the tibia is the main weight bearing bone: Fractures of the tibia generally are associated with fibula fracture, because the force is transmitted along the interosseous membrane to the fibula.

·       The skin and subcutaneous tissue are very thin over the anterior and medial tibia and as a result of this; a significant number of fractures to the lower leg are open. Even in closed fractures, the thin, soft tissue can become compromised. In contrast, the fibula is well covered by soft tissue.

·       Fractures of the tibia can involve the tibial plateau, tubercle, shaft, and plafond.

Incidence - Fractures of the tibia are the most common long bone fractures. The most common fracture of the lower limb occurs at the tibial diaphysis. Isolated mid-shaft or proximal fibula fractures are uncommon.

Clinical presentation Unnatural mobility crepitation

absence of transmitted movement

Investigations - Perform radiographs of the knee, tibia/fibula, and ankle as indicated and of other areas if required, General Investigations and specific if required according to the status of the health of the patient. In patients with tibial plateau fractures and tibial plafond fractures, computed tomography can help further reevaluate the extent of the fracture. In tibial plateau fractures, radiographs may under estimate the degree of articular depression when compared with computed tomography. This is important because articular depression of greaterthon 3 m may be considered for surgery.

Examination- Pt should be carefully examined for distal vascular and neurological deficit, if any. If there's any pt should be referred to higher center immediately.

Management- Most of tibial diaphyseal fractures can be managed conservatively with plaster of paris cast. But with the advent of image intensifier nailing can be done and patient made mobile next day if the fracture is stable. Trans articular fractures and compound fractures need specialized care and should be ref to higher centre after splinting.

MENISCAL INJURIES

 Meniscal tears are among the most common knee injuries. Athletes, particularly those who play contact sports, are at risk for meniscal fears. However, anyone at any age can get a meniscal tear. When people talk about torn cartilage in the knee, they are usually referring to a torn meniscus.

Three bones meet to form your knee joint: your thigh bone (femur), shin bone (tibia), and knee cap (patella).

Two wedge-shaped pieces of cartilage act as "shock absorbers" between your thigh bone and shin bone. These are called meniscus. They are tough and rubbery to help cushion the joint and keep it stable.

Menisci tear in different ways. Common tears include longitudinal, parrot- beak, flap, bucket handle, and mixed/complex.

Sports-related meniscal fears often occur along with other knee injuries, such as anterior cruciate ligament tears.

Causes- Sudden meniscal tears often happen during sports with rotational injury. Players may squat and twist the knee, causing a tear.

Older people are more likely to have degenerative meniscal tears. Cartilage weakens and wears over time. Aged, worn tissue is more prone to tears. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.

Symptoms- You might feel a "pop" when you tear a meniscus. Most people can still walk on their injured knee. Many athletes keep playing with a tear. Over 2 to 3 days, your knee will gradually become more stiff and swollen.

The most common symptoms of meniscal tear are:

·       Pain

·       Stiffness and swelling

·       Catching or locking of your knee

·       The sensation of your knee "giving way"

·       You are not able to move your knee through its full range of motion

Without treatment, a piece of meniscus may become loose and drift into the joint. This can cause your knee to slip, pop, or lock.

Examination - McMurray's Test-There are many tests to localize the lesion. Like anterior drawer test, posterior drawer test, Lachman test etc.

Nonsurgical Treatment

If your tear is small and on the outer edge of the meniscus, it may not require surgical repair. As long as your symptoms do not persist and your knee is stable, nonsurgical treatment may be all you need.

RICE - The RICE protocol is effective for most sports-related injuries. RICE stands for Rest, Ice, Compression, and Elevation.

•           Rest - Take a break from the activity that caused the injury. Use crutches to avoid puffing weight on your leg.

•           Ice - Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.

•           Compression - To prevent additional swelling and blood loss, wear an elastic compression bandage.

•           Elevation - To reduce swelling, recline when you rest, and put your leg up higher than your heart.

•           NSAIDs - Drugs like aspirin and ibuprofen reduce pain and swelling.

Surgical Treatment - If your symptoms persist with nonsurgical treatment, patient should be referred to higher center for arthroscopic or open surgery.