Orthopaedic Surgery

Case Conference

BY EXT. ฐิ ติพร เผือกสุวรรณ

 Thai male 27 years old
 Chief complain: มีแผลฉีกขาด ขาซายผิ ้ ดรูป 2.5
ชวั่ โมง
 Present illness: 1.30 น. ขีร่ ถจักรยานยนต์ ล ้มเอง
ไม่มก ี ระแทกบริเวณศรี ษะ ไม่สลบ จำเหตุการณ์ได ้
้
ตลอด ขาซายกระแทกพื น
้ มีแผลฉีกขาด เลือดไหล
บริเวณต ้นขาซาย ้ ปวดบวมบริเวณต ้นขาซาย ้ ร่วมกับมี
ขาซายผิ้ ดรูป
 Past history:
no U/D
no drug/food allergy
NPO 1.30 ดืม
่ เหล ้า
Hx of Sx 1 yr ago; Ofx shaft of 2nd metacarpal bone
3.15 at ER
 BP 99/41 mmHg PR 105/min RR 24/min
 Lt leg: LW 20 cm, femur seen, active bleeding
 Mx) NSS loading NSS 500 ml

then NSS IV rate 150 ml/hr

 >> V/S 109/53 mmHg PR 114/min
 FAST -ve
 Dressing and splint
 Pressure pack with gauze
 Admit ortho
Physical examination
 V/S: 130/80 mmHg PR 110/min
RR 20/min Temp 36.8 C
 BW 60 kg, BH 175 cm, BMI 19.6 kg/m2
 GA: Thai man, good consciousness
 HEENT: not pale, no icteric sclera
 Respiratory system: trachea midline, Clear Lt=Rt
 Cardiovascular system: normal S1 S2, no murmur
 Abdomen: soft, not tender
 Ext: full and equal pulse both sides of upper and
lower extremities, capillary refill < 2 sec, warm
Affect part
 Lt leg: LW 20x5 cm expose f
emur, blood oozing,
no active bleeding,

tender around knee and LW,

varus deformity, shortening,
PT and DP pulse 2+ equal to
Rt side, able to flex and exte
nd Lt toes, limit ROM Lt knee
and ankle due to pain, intact
sensory by pinprick test
 Investigation
 Film Lt knee AP, Lat

>> Supra-intercondylar fracture Lt femur po

stero-lateral displacement, shortening 4 cm
 Film Pelvis AP: no fracture
 Problem list
 Open supra-intercondylar fracture of Lt femu
r AO/OTA classification type C1, open
fracture Gustilo and Andersons type IIIB
 Hypovolemic shock
Classification of open fractures
(Gustilo and Andersons)
 Acute management
of open fractures
 Provide primary survey & urgent resuscitation
 Immobilize the injured extremity and apply sterile dressing
to the wound
 Early intravenous antibiotics
 tetanus prophylaxis
 Perform urgent operative wound debridement and irrigation,
leave the wound open, and stabilize unstable skeletal injuries
 Perform repeated debridements
 Skeletal stabilization
 Promote fracture healing
 Prevent complication
 Debridement & irrigation
 Creation of a wound that can tolerate the residual
bacterial contamination and heal without infection
 Extension of the traumatized wound to allow identificati
on of the zone of injury
 Detection and removal of foreign material, especially
organic foreign material
 Detection and removal of nonviable tissues
 Reduction of bacterial contamination
 Role of 6 (treatment in 6 hrs.)
 0.9% NaCl is the best solution for irrigation
 Skeleton Stabilization
 Restore length & alignment
 Reduce articular surfaces
 Allow access to the traumatic wound
 Facilitate further reconstruction procedures
 Allow early use of the limb
 Facilitate fracture union and return to functio
n
 Complications
 Infection
 Nonunion or delay-union
 Malunion
 Loss of function
Antibiotics
 Infection

Open fracture wounds contamination – up to 7

0% Infection rates in literature
 Type I 0 - 2 %
 Type II 0 - 10%
 Type III 10 - 50%
 Fracture of the distal femur
 Supracondylar area: 5 cm above the flare of metaphysis
 Intercondylar area
 Fracture of the distal femur
 Associated injuries:
  - vascular Injury: 2-3% (popliteal artery)
  - knee ligament injuries: 20% (most common
ACL)
  - tibial plateau fractures are also common
- Nerve injury is rare because of protective
surrounding musculature
Anatomy of the distal femur
Alignment of the
lower extremity.
The knee joint is parallel
to the ground.
The anatomic access is in 9
degrees valgus to the knee joint.
Distal part: posterior angulation

Joint
Tibiofemoral joint (TF)
Patellofemoral joint (PF)
 Fracture of the distal femur
 Mechanisms of injuries; axial load to a flexed knee
› High energy trauma in young patients
› Low energy trauma in the elderly
 Symptoms and signs
› Pain around the knee
› Swelling around the knee
› Tenderness over the fracture site
 Radiographic evaluation:
› AP, lateral, and two 45-degree oblique radiographs of
the distal femur
› should include the entire femur
 A1 Simple (two-part)
A2 Metaphyseal wedge
A3 Metaphyseal complex (comminuted)
B Partial articular (unicondylar)
B1 Lateral condyle (fracture in the sagittal
plane)
B2 Medial condyle (fracture in the sagittal
plane)
B3 Frontal (fracture in the coronal plane)
C Complete articular (bicondylar)
C1 Articular simple and metaphyseal simple
(a T or Y fracture pattern)
C2 Articular simple and metaphyseal
multifragmentary
C3 Multifragmentary articular

OTA/AO Classification of fractures of distal femur

 Fracture of the distal femur
 Treatment
 Goal: restore joint surface and alignment
› Nonoperative
 Nondisplaced
 Traction 4-6 wk
 Cast brace with NWB and early ROM
› Operative
 Significant displaced
 Implant
 Condylar blade plate
 Condylar sliding nail-plate
 Screws
 Intramedullary nail
 Indications for
Nonoperative Treatment
 Patient Factors
- Medical contraindications to operative treatment
- Nonambulatory patients (e.g., paraplegia, quadriplegia)
 Fracture Factors
- Undisplaced fracture
- Impacted stable fracture
- Unreconstructable fracture
- Severe osteopenia
 Surgeon Factors
Lack of experience in operative treatment
Unavailability of appropriate instrumentation or facilities
 Traction pin

The placement of a traction pin anteriorly in the distal femur, as it lies

anterior to the center of rotation, will result in correction of the
deformity by negating the muscle forces producing the deformity
 Treatment Options for
Specific Fracture Types
Fracture
Potential Reduction Techniques Potential Fixation Devices
Type

Open direct, open indirect,

A1
or closed
95-degree blade plate,
condylar screw, locking plate,
A2
antegrade intramedullary (IM) nail, retrograde IM
Open indirect or closed nail
A3

B1 Interfragmentary lag screws

with or without buttress screw
B2 or buttress plate
Open direct

B3 Interfragmentary lag screws

 Treatment Options for
Specific Fracture Types
Fracture Intra-articular Extra-articular Intra-articular
Extra-articular Component
Type Component Component Component

C1 95-degree blade plate, condylar

screw,
locking plate,
antegrade
or retrograde IM nail
C2 Open direct Open indirect Interfragmentary lag
or closed screws

95-degree blade plate, condylar

screw,
C3 locking plate,
retrograde nail
95-Degree Blade Plate
Dynamic Condylar Screw (DCS)
Condylar Buttress Plate
Locking Condylar Plate
Antrograde intramedullary nail
Retrograde intramedullary nail
 Complication
 Early
- Vascular Complications
- Infection; Ofx 20%, Cfx 1%
- Failure of Reduction
- Early Failure of Fixation
 Complication
 Late
- Late Infection; osteomyelitis, chronic septic
arthritis, infected nonunion
- Nonunion
- Malunion
- Painful Internal Fixation
- Knee Stiffness
- Posttraumatic Osteoarthrosis
 Postoperative Management
 continuous passive motion device in the immediate
postoperative period if the skin and soft tissues will tole
rate.
 Physical therapy consists of active range-of-motion
exercises and partial weight bearing with crutches 2 to
3 days after stable fixation.
 A cast brace may be used if fixation is tenuous.
 Weight bearing may be advanced with radiographic
evidence of healing (6 to 12 weeks).
Management
in this patient
One day order Continuation order
2/10/53 3.30 AM 2/10/53 3.30 AM

- Admit Ortho - Record V/S

- NPO
- 5%DNSS/2 100 ml IV rate 150 ml/hr Med
- Lab: CBC with platelet, BUN, Cr,
E’lyte, DTX (194), anti-HIV, CXR - Cefazolin 1 gm IV q 6 hr
- TT 1 course
- G/M PRC 4 U, FFP 1000 ml
 CBC: WBC 21500 /uL, Hb 11.6, Hct 35.7%, P
lt 228000 PMN 90% Lymph 5% Mono 5%
 Chem: BUN 12 Cr 1 Na 137 K 3.46 Cl 103 CO
2 21.1 Anion gap 16.4
 Anti-HIV non reactive
 Irrigate with NSS 10 L
 Debridement and foreign body removal
 ORIF with K-wire x 3 + plate and screw
 (2/10/53)
One day order Continuation order
2/10/53 10.30 AM 2/10/53 10.30 AM
Post-op order for irrigation &
debridement + ORIF with plate and - Record V/S, I/O, RD as ml
screw 2/10/53 - Regular diet
- Dressing OD
- Routine post-op care
- keep BP >/= 100/60 Med
- 5% DNSS/2 IV rate 120 ml/hr
- Hct at ward keep > 30% (28%) >> - Cefazolin 1 gm IV q 6 hr
PRC 1 U Hct หลัง PRC หมด 4 hr - Gentamycin 240 mg IV OD
- Record urine output - Paracetamol (500 mg)
keep >/= 30 ml/hr 2 tabs @ prn for pain q 4 hr
- Morphine 3 mg - CaCO3 1x2 @ pc
IV prn for pain q 3 hr
- Plasil 1 Amp
IV prn for N/V q 6 hr
- Film post-op Lt knee AP, Lat include
femur
- ตื่นดีกินได้
 Progress note
 Post-op
 Fever 38-39.2
 Wound: good approximate, minimal bleeding
no pus D/C, warm, slightly tense
 Drain day1 640 day2 40 day3 20 >> off drai
n
Thank you ^^
 Reference
 Canale & Beaty: Campbell's Operative Ortho
paedics, 11th ed.
 Bucholz, Robert W.; Heckman, James D.; Co
urt-Brown, Charles M. : Rockwood & Green's
Fractures in Adults, 6th Edition
 Koval, Kenneth J.; Zuckerman, Joseph D. : H
andbook of Fractures, 3rd Edition
 http://www.wheelessonline.com/ortho/supra
condylar_femoral_fractures