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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
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
ACKNOWLEDGMENTS
Nicole Kansier, MD, Department of Surgery,
University of Washington, Seattle, WA, USA
SOMETIMES BIG CARS CRASH FAST
CRASH!!
34 YOM MVC AT 65 KM/H (F250, BMI 54)
34 YOM MVC AT 65 KM/H (F250, BMI 54)
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
34 YOM MVC AT 65 KM/H (F250, BMI 54)
34 YOM MVC AT 65 KM/H (F250, BMI 54)
34 YOM MVC AT 65 KM/H (F250, BMI 54)
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
34 YOM MVC AT 65 KM/H (F250, BMI 54)
34 YOM MVC AT 65 KM/H (F250, BMI 54)
42YOF MCC
42YOF MCC
SCHATZKER CLASSIFIACTION
TIBIAL PLATEAU
Schatzker J, McBroom R, Bruce D: The tibial plateau fracture: The Toronto experience 1968-
1975. Clin Orthop 1979;138:94-104.
42YOF MCC
Schatzker type VI
Bicondylar tib
plateau fx
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.
48 YOM MCC Vascular injury:
• Most commonly observed
with tibial plateau fx
• Supracondylar femur fx
• Knee dislocations
48 YOM MCC
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: 1198-1204.
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: 2615-20.
Howells-NR, et al. Injury (42) 2011: 1198-1204.
ED MANAGEMENT VASCULAR INJURY
www.escardio.org Courtesy Nicole Kansier, MD, Department of Surgery , University of Washington
48 YOM MCC
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
SUPERFICIAL
POSTERIOR:
Gastrocnemi
us
Soleus
Plantaris
Sural nerve
DEEP
POSTERIOR:
Tibialis Posterior
Flexor hallucus
longus
Flexor digitorum
longus
Popliteus
Posterior Tibial
artery
Peroneal artery
Tibial nerve http://www.hughston.com/hha/a_17_2_1.htm
LOWER EXTREMITY FASCIOTOMY
42YOF MCC
GUSTILO-ANDERSON CLASSIFICATION
OF OPEN WOUNDS
Type
I Wound < 1 cm
II Wound 1-10 cm
III A Wound > 10 cm, high energy
Adequate tissue for coverage
III B Extensive periosteal strippuing
Soft tissue transfer required
III C Vascular injury requiring repair
http://www.orthobullets.com/trauma/1003/gustilo-classification
Kim-PH, Leopold-SS. Clin Orthop Relat Res (2012) 470: 3270
• Describes soft tissue injury only
• Developed for prediction of infection
20 YOM MCC
44 YOM MCC
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 (SIP) @2 yrs.
– No link of outcomes with technological sophistication of
prosthesis
– Injury severity indices not useful
– No difference in return to work @ 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) 233-239.
Bosse MJ, MacKenzie-EJ, et al. NEJM 347 (2002) 24: 1924-31.
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) 233-239.
44 YOM MCC
42YOF MCC
3 year
follow
up
17 YOM 12 M FALL
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) 571-91.
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) 571-91.
http://www.foothyperbook.com/
17 YOM 12 M FALL
17 YOM 12 M FALL
72 YOM 8 FT FALL
Sanders classification of calcaneus fractures
Daftary A et al. Radiographics 2005;25:1215-1226
Coronal view Axial view
72 YOM 8 FT FALL
Coronal view
talus
calcaneus
Axial 8 mm MIP
Axial view
72 YOM 8 FT FALL
Sagittal Coronal
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 2nd metatarsal
• Tilted coronal
• Tilted axial images
• Consider MIPS for calcaneus fxs
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. 1976 Jul;120(1):79-83.
Lisfranc's tarsometatarsal fracture-dislocation.
• 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
HIGH-ENERGY TRAUMA OF THE
LOWER EXTREMITY -- summary
