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Frank Г¶hler

Frank Г¶hler Frank Kohler im Telefonbuch

Sehen Sie sich das Profil von Dr. Frank Fehler auf LinkedIn an, dem weltweit größten beruflichen Netzwerk. 5 Jobs sind im Profil von Dr. Frank Fehler aufgelistet. ernannte Hitler ihn zum Leiter der Rechtsabteilung der NSDAP (ab Reichsrechtsamt der NSDAP). Als Rechtsbeistand unterstützte Frank Hitler bei. Frank Kohler mit ✉ Adresse ☎ Tel. und mehr bei ☎ Das Telefonbuch ✓ Ihre Nr. 1 für Adressen und Telefonnummern. Personen mit dem Namen Frank Kohler. Finde deine Freunde auf Facebook. Melde dich an oder registriere dich bei Facebook, um dich mit Freunden, Verwandten. Berufserfahrung, Kontaktdaten, Portfolio und weitere Infos: Erfahr mehr – oder kontaktier Dr. Frank Fehler direkt bei XING.

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Alba Berlin, Basketball, BBL, Playoffs, Finale, 16 июн. г. Als Einen ½erz?hler Von Weltweitem Horizont Der Die Klassischen Und Die Modernen Foto: Frank May Dpa/lhe +++(c) Dpa - Bildfunk+++ Germany Darmstadt. von Risiken mit Praxisbeispielen / von Claudia Cottin, Sebastian DГ¶hler. der Г–ffentlichen Hand [electronic resource] / herausgegeben von Frank Scholz,​. Personen mit dem Namen Frank Kohler. Finde deine Freunde auf Facebook. Melde dich an oder registriere dich bei Facebook, um dich mit Freunden, Verwandten.

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D Type IV. Pipkin Type I. The femoral head fracture is inferior to the fovea. These fractures occur in the non-weight-bearing surface.

Pipkin Type II. The femoral head fracture is superior to the fovea. These fractures involve the weight-bearing surface.

Pipkin Type III. A femoral head fracture occurs with an associated fracture of the femoral neck. Pipkin Type IV.

A femoral head fracture occurs with an associated fracture of the acetabulum. Femoral Neck Fractures. Figure 3. Left: The calcar femorale is a vertical plate of bone that originates in the posteromedial portion of the femoral shaft under the lesser trochanter and radiates laterally toward the posterior aspect of the greater trochanter.

Right: The calcar femorale fuses with the posterior aspect of the femoral neck superiorly and extends distally anterior to the lesser trochanter and fuses with the posteromedial aspect of the femoral diaphysis.

Figure 4. Cyclical loading-stress fractures: These are seen in athletes, military recruits, ballet dancers; patients with osteoporosis and osteopenia are at particular risk.

Figure 5. Anatomy of the bony trabeculae in the proximal end of the femur. In a nonosteoporotic femur, all five groups of bony trabeculae are readily evident on x-ray.

The Ward triangle W is a small area in the neck of the femur that contains thing and loosely arranged trabeculae only.

Figure 6. A cross-table lateral view of the affected hip is obtained by flexing the uninjured hip and knee 90 degrees and aiming the beam into the groin, parallel to the floor and perpendicular to the femoral neck not the shaft.

This allows orthogonal assessment of the femoral neck without the painful and possible injurious manipulation of the effected hip required for a frog-leg lateral view.

This is based on the angle of fracture from the horizontal Fig. Increasing shear forces with increasing angle lead to more fracture instability.

Figure 7. The Pauwel classification of femoral neck fractures is based on the angle the fracture forms with the horizontal plane.

As a fracture progresses from Type I to Type III, the obliquity of the fracture line increases, and, theoretically, the shear forces at the fracture site also increase.

This is based on the degree of valgus displacement Fig. Type II:. Complete and nondisplaced on AP and lateral views.

Type III:. Complete with partial displacement; trabecular pattern of the femoral head does not line up with that of the acetabulum.

Completely displaced; trabecular pattern of the head assumes a parallel orientation with that of the acetabulum. Figure 8. The Garden classification of femoral neck fractures.

Type I fractures can be incomplete, but much more typically they are impacted into valgus and retroversion A.

Type II fractures are complete, but undisplaced. These rare fractures have a break in the trabeculations, but no shift in alignment B.

Type III fractures have marked angulation, but usually minimal to no proximal translation of the shaft C. In the Garden Type IV fracture, there is complete displacement between fragments, and the shaft translates proximally D.

The head is free to realign itself within the acetabulum, and the primary compressive trabeculae of the head and acetabulum realign white lines.

Because of too poor intraobserver and interobserver reliability in using the various classifications, femoral neck fractures are commonly described as either:.

Early bed to chair mobilization is essential to avoid increased risks and complications of prolonged recumbency, including poor pulmonary toilet, atelectasis, venous stasis, and pressure ulceration.

Intertrochanteric Fractures. Evans Fig. Figure 9. The Evans classification of intertrochanteric fractures. In stable fracture patterns, the posteromedial cortex remains intact or has minimal comminution, making it possible to obtain and maintain a reduction.

Unstable fracture patterns, conversely, are characterized by greater comminution of the posteromedial cortex.

The reverse obliquity pattern is inherently unstable because of the tendency for medial displacement of the femoral shaft. Figure Basicervical neck fractures are located just proximal to or along the intertrochanteric line.

Anteroposterior x-ray demonstrating a reverse obliquity right intertrochanteric fracture. X-ray of a sliding hip screw. The tip-apex distance TAD , expressed in millimeters, is the sum of the distances from the tip of the lag screw to the apex of the femoral head on both the anteroposterior and lateral radiographic views.

Intertrochanteric hip fractures. Skeletal Trauma , vol. Reverse obliquity fracture stabilized with a cephalomedullary nail.

External Fixation. Greater Trochanteric Fractures. Lesser Trochanteric Fractures. Subtrochanteric Fractures. Fielding Fig. This is based on the location of the primary fracture line in relation to the lesser trochanter.

At the level of the lesser trochanter. The deforming force by the unopposed pull of the iliopsoas causes the proximal femur in flexion and external rotation.

Fielding classification of subtrochanteric fractures. Seinsheimer Fig. Seinsheimer classification of subtrochanteric fractures. This is based on the number of major bone fragments and the location and shape of the fracture lines.

Two-part transverse femoral fracture. Two-part spiral fracture with the lesser trochanter attached to the proximal fragment.

Two-part spiral fracture with the lesser trochanter attached to the distal fragment reverse obliquity pattern.

Three-part spiral fracture in which the lesser trochanter is part of the third fragment, which has an inferior spike of cortex of varying length.

Three-part spiral fracture of the proximal third of the femur, with the third part a butterfly fragment. Comminuted fracture with four or more fragments.

Subtrochanteric-intertrochanteric fracture, including any subtrochanteric fracture with extension through the greater trochanter. Russell-Taylor Fig.

Russell-Taylor classification of subtrochanteric fractures. This was created in response to the development of first- and second-generation interlocked nails.

Fractures with an intact piriformis fossa in which:. The lesser trochanter is attached to the proximal fragment.

The lesser trochanter is detached from the proximal fragment. Fractures that extend into the piriformis fossa and:. Have a stable medial construct posteromedial cortex.

Have comminution of the piriformis fossa and lesser trochanter, associated with varying degrees of femoral shaft comminution.

A subtrochanteric fracture fixed with a fixed angle blade plate and bone graft on the posteromedial cortex. Loss of Fixation.

Nonunio n. Femoral Shaft. Deforming muscle forces on the femur; abductors A , iliopsoas B , adductors C , and gastrocnemius origin D.

The medial angulating forces are resisted by the fascia lata E. Potential sites of vascular injury after fracture are at the adductor hiatus and the perforating vessels of the profunda femoris.

Cross-sectional diagram of the thigh demonstrates the three major compartments. Winquist and Hansen Fig.

Circumferential comminution with no cortical contact. Figure 2 3. Winquist and Hansen classification of femoral shaft fractures.

Skeletal Trauma. Philadelphia : WB Saunders, Plate Fixation. Plate fixation for femoral shaft stabilization has decreased with the use of IM nails.

Femur Fracture in Multiply Injured Patient. Ipsilateral Fractures of the Proximal or Distal Femur. Distal Femur. Figure 2 4. Schematic drawing of the distal femur.

Adapted from Wiss D. Master Techniques in Orthopaedic Surgery. Philadelphia: Lippincott-Raven, Figure 2 5.

Anatomy of the distal femur. A Anterior view. B Lateral view. The shaft of the femur is aligned with the anterior half of the lateral condyle.

C Axial view. The distal femur is trapezoidal. The anterior surface slopes downward from lateral to medial, the lateral wall inclines 10 degrees, and the medial wall inclines 25 degrees.

Fractures of the knee. Figure 2 6. Alignment of the lower extremity. The knee joint is parallel to the ground. The knee joint is in 9 degree valgus to the knee joint.

Figure 2 7. Lateral view showing muscle attachments and resulting deforming forces. These result in posterior displacement and angulation at the fracture site.

Supracondylar Fractures after Total Knee Replacement. Figure 2 8. Soft tissue anatomy of the patella. Descriptive Fig. Figure 2 9.

Classification of patella fractures. Tibial Plateau. Schatzker Fig. Lateral plateau, split fracture. Lateral plateau, split depression fracture.

Lateral plateau, depression fracture. Plateau fracture with separation of the metaphysis from the diaphysis.

Figure 3 0. Schatzker classification. Tibia Fibula Shaft. Figure 3 1. The anatomy of the tibial and fibular shaft. Figure 3 2. The four compartments of the leg.

Poor sensitivity, reproducibility, and interobserver reliability have been reported for most classification schemes. Gustilo and Anderson Classification of Open Fractures.

Extensive soft tissue damage, including muscles, skin, and neurovascular structures; often a high-energy injury with a severe crushing component.

Extensive soft tissue laceration, adequate bone coverage; segmental fractures, gunshot injuries, minimal periosteal stripping. Extensive soft tissue injury with periosteal stripping and bone exposure requiring soft tissue flap closure; usually associated with massive contamination.

Injury from indirect forces with negligible soft tissue damage. Closed fracture caused by low-moderate energy mechanisms, with superficial abrasions or contusions of soft tissues overlying the fracture.

Closed fracture with significant muscle contusion, with possible deep, contaminated skin abrasions associated with moderate to severe energy mechanisms and skeletal injury; high risk for compartment syndrome.

Extensive crushing of soft tissues, with subcutaneous degloving or avulsion, with arterial disruption or established compartment syndrome.

Figure 3 3. The Tscherne classification of closed fractures: C0, simple fracture configuration with little or no soft tissue injury; C1, superficial abrasion, mild to moderately severe fracture configuration; C2, deep contamination with local skin or muscle contusion, moderately severe fracture configuration; C3, extensive contusion or crushing of skin or destruction of muscle, severe fracture.

Fracture reduction followed by application of a long leg cast with progressive weight bearing can be used for isolated, closed, low-energy fractures with minimal displacement and comminution.

Tibia Stress Fracture. Fibula Shaft Fracture. Flexible Nails Enders, Rush Rods. Tibia Fracture with an Intact Fibula.

Ankle Fractures. Figure 3 4. Bony anatomy of the ankle. Mortise view A , inferior superior view of the tibiofibular side of the joint B , and superior inferior view of the talus C.

The ankle joint is a three-bone joint with a larger talar articular surface than matching tibiofibular articular surface.

The lateral circumference of the talar dome is larger than the medial circumference. The dome is wider anteriorly than posteriorly.

The syndesmotic ligaments allow widening of the joint with dorsiflexion of the ankle, into a stable, close-packed position.

Figure 3 5. Three views of the tibiofibular syndesmotic ligaments. Anteriorly, the anterior inferior tibiofibular ligament AITFL spans from the anterior tubercle and anterolateral surface of the tibia to the anterior fibula.

Posteriorly, the tibiofibular ligament has two components: the superficial posterior inferior tibiofibular ligament PITFL , which is attached from the fibula across to the posterior tibia, and the thick, strong inferior transverse ligament ITL , which constitutes the posterior labrum of the ankle.

Between the anterior and posterior inferior talofibular ligaments resides the stout interosseous ligament IOL.

Philadelphia: WB Saunders, Figure 3 6. Medial collateral ligaments of the ankle. Sagittal plane A and transverse plane B views.

The deltoid ligament includes a superficial component and a deep component. Superficial fibers mostly arise from the anterior colliculus and attach broadly from the navicular across the talus and into the medial border of the sustentaculum tali and the posterior medial talar tubercle.

The deep layer of the deltoid ligament originates from the anterior and posterior colliculi and inserts on the medial surface of the talus.

Figure 3 7. Lateral collateral ligaments of the ankle and the anterior syndesmotic ligament.

The pattern of ankle injury depends on many factors, including mechanism axial versus rotational loading , chronicity recurrent ankle instability may result in chronic ligamentous laxity and distorted ankle biomechanics , patient age, bone quality, position of the foot at time of injury, and the magnitude, direction, and rate of loading.

Specific mechanisms and injuries are discussed in the section on classification. Lauge-Hansen Figs. Stage I:. Produces either a transverse avulsion-type fracture of the fibula distal to the level of the joint or a rupture of the lateral collateral ligaments.

Results in a vertical medial malleolus fracture. Produces disruption of the anterior tibiofibular ligament with or without an associated avulsion fracture at its tibial or fibular attachment.

Results in the typical spiral fracture of the distal fibula, which runs from anteroinferior to posterosuperior.

Produces either a disruption of the posterior tibiofibular ligament or a fracture of the posterior malleolus.

Produces either a transverse avulsion-type fracture of the medial malleolus or a rupture of the deltoid ligament.

Figure 3 8. X-ray appearance of the normal ankle on mortise view. A The condensed subchondral bone should form a continuous line around the talus.

B The talocrural angle should be approximately 83 degrees. When the opposite side can be used as a control, the talocrural angle of the injured side should be within a few degrees of the noninjured side.

C The medial clear space should be equal to the superior clear space between the talus and the distal tibia and less than or equal to 4 mm on standard x-rays.

D The distance between the medial wall of the fibula and the incisural surface of the tibia, the tibiofibular clear space, should be less than 6 mm.

Figure 3 9. Schematic diagram and case examples of Lauge-Hansen supination-external rotation and supination-adduction ankle fractures.

A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram.

The supination-external rotation mechanism has four stages of injury, and the supination-adduction mechanism has two stages. Figure 4 0.

Schematic diagram and case examples of Lauge-Hansen pronation-external rotation and pronation-abduction ankle fractures. A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram.

The pronation-external rotation mechanism has four stages of injury, and the pronation-abduction mechanism has three stages.

Pronation-Abduction PA. Results in either a transverse fracture of the medial malleolus or a rupture of the deltoid ligament. Produces either a rupture of the syndesmotic ligaments or an avulsion fracture at their insertion sites.

Produces a transverse or short oblique fracture of the distal fibula at or above the level of the syndesmosis; this results from a bending force that causes medial tension and lateral compression of the fibula, producing lateral comminution or a butterfly fragment.

Produces either a transverse fracture of the medial malleolus or a rupture of the deltoid ligament.

Results in disruption of the anterior tibiofibular ligament with or without avulsion fracture at its insertion sites.

Results in a spiral fracture of the distal fibula at or above the level of the syndesmosis running from anterosuperior to posteroinferior.

Produces either a rupture of the posterior tibiofibular ligament or an avulsion fracture of the posterolateral tibia.

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Cloud Computing sei aber noch viel mehr. Viele Programme werden gar nicht mehr auf dem eigenen Rechner installiert, sondern laufen direkt im Browser Internet Explorer, Firefox oder Safari.

Die Herausforderung ist, sie aufzufinden, zu testen und sich auf sie einzulassen.

A hard object, such as a katzenberger hochzeit video, is visit web page in the adjacent web space and is used as a fulcrum for reduction. See more Markus, lic. Eberle Go here, lic. Einsprachen Leiterin Abt. Associated injuries should be evaluated, and if suspected, appropriate radiographic studies ordered. Die Arbeit mit verschiedenen Ebenen und wie man eine Bildcollage herstellt, bilden den Abschluss dieses Workshops. Viti-Kirchengemeinde Zeven.

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Frank Г¶hler - Erfolg mit unkonventionellen Organisationsstrukturen

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FH Suschke Volker, Dipl. Ressortleiter Lauber German, Dipl. Heizungsinstallateur Queloz Markus, Dipl. Fracture reduction followed by application of a long leg cast with progressive weight bearing can be used for isolated, closed, low-energy fractures with minimal displacement and comminution.

Tibia Stress Fracture. Fibula Shaft Fracture. Flexible Nails Enders, Rush Rods. Tibia Fracture with an Intact Fibula. Ankle Fractures.

Figure 3 4. Bony anatomy of the ankle. Mortise view A , inferior superior view of the tibiofibular side of the joint B , and superior inferior view of the talus C.

The ankle joint is a three-bone joint with a larger talar articular surface than matching tibiofibular articular surface.

The lateral circumference of the talar dome is larger than the medial circumference. The dome is wider anteriorly than posteriorly.

The syndesmotic ligaments allow widening of the joint with dorsiflexion of the ankle, into a stable, close-packed position. Figure 3 5.

Three views of the tibiofibular syndesmotic ligaments. Anteriorly, the anterior inferior tibiofibular ligament AITFL spans from the anterior tubercle and anterolateral surface of the tibia to the anterior fibula.

Posteriorly, the tibiofibular ligament has two components: the superficial posterior inferior tibiofibular ligament PITFL , which is attached from the fibula across to the posterior tibia, and the thick, strong inferior transverse ligament ITL , which constitutes the posterior labrum of the ankle.

Between the anterior and posterior inferior talofibular ligaments resides the stout interosseous ligament IOL.

Philadelphia: WB Saunders, Figure 3 6. Medial collateral ligaments of the ankle. Sagittal plane A and transverse plane B views.

The deltoid ligament includes a superficial component and a deep component. Superficial fibers mostly arise from the anterior colliculus and attach broadly from the navicular across the talus and into the medial border of the sustentaculum tali and the posterior medial talar tubercle.

The deep layer of the deltoid ligament originates from the anterior and posterior colliculi and inserts on the medial surface of the talus.

Figure 3 7. Lateral collateral ligaments of the ankle and the anterior syndesmotic ligament. The pattern of ankle injury depends on many factors, including mechanism axial versus rotational loading , chronicity recurrent ankle instability may result in chronic ligamentous laxity and distorted ankle biomechanics , patient age, bone quality, position of the foot at time of injury, and the magnitude, direction, and rate of loading.

Specific mechanisms and injuries are discussed in the section on classification. Lauge-Hansen Figs. Stage I:.

Produces either a transverse avulsion-type fracture of the fibula distal to the level of the joint or a rupture of the lateral collateral ligaments.

Results in a vertical medial malleolus fracture. Produces disruption of the anterior tibiofibular ligament with or without an associated avulsion fracture at its tibial or fibular attachment.

Results in the typical spiral fracture of the distal fibula, which runs from anteroinferior to posterosuperior.

Produces either a disruption of the posterior tibiofibular ligament or a fracture of the posterior malleolus.

Produces either a transverse avulsion-type fracture of the medial malleolus or a rupture of the deltoid ligament. Figure 3 8. X-ray appearance of the normal ankle on mortise view.

A The condensed subchondral bone should form a continuous line around the talus. B The talocrural angle should be approximately 83 degrees.

When the opposite side can be used as a control, the talocrural angle of the injured side should be within a few degrees of the noninjured side.

C The medial clear space should be equal to the superior clear space between the talus and the distal tibia and less than or equal to 4 mm on standard x-rays.

D The distance between the medial wall of the fibula and the incisural surface of the tibia, the tibiofibular clear space, should be less than 6 mm.

Figure 3 9. Schematic diagram and case examples of Lauge-Hansen supination-external rotation and supination-adduction ankle fractures.

A supinated foot sustains either an external rotation or adduction force and creates the successive stages of injury shown in the diagram.

The supination-external rotation mechanism has four stages of injury, and the supination-adduction mechanism has two stages. Figure 4 0.

Schematic diagram and case examples of Lauge-Hansen pronation-external rotation and pronation-abduction ankle fractures. A pronated foot sustains either an external rotation or abduction force and creates the successive stages of injury shown in the diagram.

The pronation-external rotation mechanism has four stages of injury, and the pronation-abduction mechanism has three stages.

Pronation-Abduction PA. Results in either a transverse fracture of the medial malleolus or a rupture of the deltoid ligament. Produces either a rupture of the syndesmotic ligaments or an avulsion fracture at their insertion sites.

Produces a transverse or short oblique fracture of the distal fibula at or above the level of the syndesmosis; this results from a bending force that causes medial tension and lateral compression of the fibula, producing lateral comminution or a butterfly fragment.

Produces either a transverse fracture of the medial malleolus or a rupture of the deltoid ligament. Results in disruption of the anterior tibiofibular ligament with or without avulsion fracture at its insertion sites.

Results in a spiral fracture of the distal fibula at or above the level of the syndesmosis running from anterosuperior to posteroinferior.

Produces either a rupture of the posterior tibiofibular ligament or an avulsion fracture of the posterolateral tibia.

Danis-Weber Fig. Type A:. This involves a fracture of the fibula below the level of the tibial plafond, an avulsion injury that results from supination of the foot and that may be associated with an oblique or vertical fracture of the medial malleolus.

This is equivalent to the Lauge-Hansen supination-adduction injury. There may be an associated injury to the medial structures or the posterior malleolus.

This is equivalent to the Lauge-Hansen supination-eversion injury. This involves a fracture of the fibula above the level of the syndesmosis causing disruption of the syndesmosis almost always with associated medial injury.

This category includes Maisonneuve-type injuries and corresponds to Lauge-Hansen pronation-eversion or pronation-abduction Stage III injuries.

Figure 4 1. A Schematic diagram of the Danis-Weber classification of ankle fractures. The goal of treatment is anatomic restoration of the ankle joint.

Fibular length and rotation must be restored. Ruedi and Allgower Fig. Type Nondisplaced cleavage fracture of the ankle joint.

Displaced fracture with minimal impaction or comminution. Displaced fracture with significant articular comminution and metaphyseal impaction.

Spiral fractures of the distal tibia with extension into the articular surface. Central impaction injuries as a result of talar impaction, either with or without fibula fracture; subtypes 1, 2, and 3 correspond to the Ruedi -Allgower classification.

This is based on many factors, including patient age and functional status, severity of injury to bone, cartilage, and soft tissue envelope, degree of comminution and osteoporosis, and the capabilities of the surgeon.

Figure 4 2. Ruedi and Allgower classified distal tibia fractures into three types based on the degree of articular comminution, as illustrated.

The majority of the literature on fractures of the distal tibia has used this classification. Manual of Internal Fixation , 2nd ed.

New York: Springer-Verlag, The goals of operative fixation of pilon fractures include:. Few advocate performing this procedure acutely.

It is best done after fracture comminution has consolidated and soft tissues have recovered. It is generally performed as a salvage procedure after other treatments have failed and posttraumatic arthritis has ensued.

Mechanism of Injury. Diastases of the distal tibiofibular syndesmosis were classified into four types by Edwards and DeLee.

With acute sprains, on lateral radiographs, a small avulsion fragment may be apparent. Similarly, with more chronic problems, calcification of the syndesmosis or posterior tibia may suggest syndesmotic injury.

Calcaneus Fractures. The Bohler angle. Angle of Gissane. Photograph of the radiographic technique for obtaining the Harris or calcaneal radiographic view.

Maximum dorsiflexion of the ankle was attempted to obtain an optimal view. Photograph of the technique to obtain the Broden view in an office setting.

Technicians must angle the tube to allow for direct view of the posterior facet of the subtalar joint. Extraarticular Fractures.

These do not involve the posterior facet. The posterolateral edge of the talus splits the calcaneus obliquely through the posterior facet.

The fracture line exits anterolaterally at the crucial angle or as far distally as the calcaneocuboid joint.

Posteriorly, the fracture moves from plantar medial to dorsal lateral, producing two main fragments: the sustentacular anteromedial and tuberosity posterolateral fragments.

With continued compressive forces, there is additional comminution, creating a free lateral piece of posterior facet separate from the tuberosity fragment.

Mechanism of injury according to Essex Lopresti. Sanders Classification Fig. All nondisplaced fractures regardless of the number of fracture lines.

Four-part articular fractures; highly comminuted. The Sanders computed tomography scan classification of calcaneal fractures. From Sanders R.

Current concepts review: displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am ; Despite adequate reduction and treatment, fractures of the os calcis may be severely disabling injuries, with variable prognoses and degrees of functional debilitation with chronic pain issues.

Treatment remains controversial, with no clear indication for operative versus nonoperative treatment. Anterior process fracture. Schematic lateral view.

Intraarticular Fractures. The Canadian Orthopaedic Trauma Society trial comparing operative to nonoperative treatment of displaced intraarticular calcaneal fractures found the following:.

Essex-Lopresti technique as modified by Tornetta. Once guide pins are correctly positioned, they are exchanged for 6.

Superior and inferior views of the talus stippling indicates the posterior and lateral processes. Canale and Kelly view of the foot.

The correct position of the foot for x-ray evaluation of the foot is shown. Classification of Talar Neck Fractures Figs.

Hawkins Type I:. Associated subtalar subluxation or dislocation. Associated subtalar and ankle dislocation. Canale and Kelley : type III with associated talonavicular subluxation or dislocation.

Fractures of the Talar Neck and Body. These represent a continuum and are considered together. Nondisplaced Fractures Hawkins Type I.

The three patterns of talar neck fractures as described by Hawkins. Note that type I fractures are nondisplaced.

A Type I talar neck fractures with no displacement. B Type II talar neck fractures with displacement and subluxation of subtalar joint.

C Type III talar neck fracture with displacement and dislocation of both ankle and subtalar joints. Type IV fracture of the talar neck with subluxation of the subtalar joint and dislocation of the talonavicular joint.

Lateral Process Fractures. These are intraarticular fractures of the subtalar or ankle joint that occur most frequently when the foot is dorsiflexed and inverted.

There has been an increase in incidence with the rise in popularity of snowboarding. Posterior Process Fractures.

Fractures may occur in a severe ankle inversion injury whereby the posterior talofibular ligament avulses the lateral tubercle or by forced equinus and direct compression.

Talar Head Fractures. These fractures result from plantarflexion and longitudinal compression along the axis of the forefoot.

Comminution is common; one must also suspect navicular injury and talonavicular disruption. Lateral subtalar dislocation with interposed posterior tibial tendon preventing closed reduction.

Adapted from Leitner B. Obstacles to reduction in subtalar dislocations. Fractures of the Midfoot and Forefoot.

Bony anatomy of the midfoot. A Dorsal view. B Plantar view. C Medial view. D Lateral view. E Coronal view. Ligamentous structure of the midfoot.

A The dorsal view shows extensive overlap of the interosseous ligaments. B The plantar ligaments are thicker than their dorsal counterparts and are dynamically reinforced by the tibialis anterior, tibialis posterior, and peroneus longus tendons.

Note the extensive attachments of the tibialis posterior throughout the midfoot bones. MRI or technetium scan may be obtained if a fracture is suspected but not apparent by plain radiography.

The present popular classification of navicular fractures is composed of three basic types with a subclassification for body fractures suggested by Sangeorzan.

A Avulsion-type fracture can involve either the talonavicular or naviculocuneiform ligaments. B Tuberosity fractures are usually traction-type injuries with disruption of the tibialis posterior insertion without joint surface disruption.

C A Type I body fracture splits the navicular into dorsal and plantar segments. D A Type II body fracture cleaves into medial and lateral segments.

The location of the split usually follows either of the two intercuneiform joint lines. Stress fractures are usually included in this group.

E A Type III body fracture is distinguished by comminution of the fragments and significant displacement of the medial and lateral poles. Anatomic Classification.

The two most important criteria in obtaining a satisfactory outcome are maintenance or restoration of the medial column length and articular congruity of the talonavicular joint.

OTA Classification. Anatomy Fig. The anatomy of the tarsometatarsal joints. A Proximal view of the cuneiform and cuboid articular surfaces.

B Distal view of the corresponding articular surfaces of the metatarsals. C Schematic representation of the contour of the tarsometatarsal joint line.

Note the keying in place of the base of the second metatarsal. Three most common mechanisms include:. Radiographic Evaluation. Standard AP, lateral, and oblique films are usually diagnostic.

Anteroposterior view of the tarsometatarsal joint. Normal joint alignment on weight bearing. Medial oblique view of the tarsometatarsal joint.

The second metatarsal is the most frequent associated fracture. Classification schemes for Lisfranc injuries guide the clinician in defining the extent and pattern of injury, although they are of little prognostic value.

Ouenu and Kuss Fig. This classification is based on commonly observed patterns of injury. All five metatarsals displaced in the same direction.

One or two metatarsals displaced from the others. Displacement of the metatarsals in both the sagittal and coronal planes.

Myerson Fig. This is based on commonly observed patterns of injury with regard to treatment. The most common approach is using two longitudinal incisions.

A second longitudinal incision is made over the fourth metatarsal. The common classification devised by Quenu and Kuss.

Further subdivisions are used to identify the direction of dislocation in the homolateral pattern medial or lateral and the partial disruption first or lesser.

Myerson classification of Lisfranc fracture-dislocations. Fracture-dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment.

Specific Metatarsal Injuries. Three zones of proximal fifth metatarsal fracture. Zone 1: avulsion fracture. Zone 2: fracture at the metaphyseal-diaphyseal junction.

Zone 3: proximal shaft stress fracture. First Metatarsophalangeal Joint. Strain at the proximal attachment of the volar plate from the first metatarsal head.

Avulsion of the volar plate from the metatarsal head. Impaction injury to the dorsal surface of the metatarsal head with or without an avulsion or chip fracture.

Jahss Classification of First Metatarsophalangeal Dislocations. This is based on the integrity of the sesamoid complex. Volar plate avulsed off the first metatarsal head, proximal phalanx displaced dorsally; intersesamoid ligament remaining intact and lying over the dorsum of the metatarsal head.

Rupture of the intersesamoid ligament. Longitudinal fracture of either sesamoid. Fractures and Dislocations of the Lesser Metatarsophalangeal Joints.

A method of closed reduction for displaced proximal phalanx fractures. A hard object, such as a pencil, is placed in the adjacent web space and is used as a fulcrum for reduction.

Most are shear or cleavage type, although recently, more indentation-type or crush-type fractures have been recognized with the increased use of computed tomography CT.

The lateral femoral circumflex artery and the artery of the ligamentum teres supply the remainder. Seventy percent of the femoral head articular surface is involved in load transfer, and thus damage to this surface may lead to the development of posttraumatic arthritis.

If the thigh is neutral or adducted, a posterior hip dislocation with or without a femoral head fracture may result.

These fractures may be the result of avulsion by the ligamentum teres or cleavage by the posterior acetabular edge. In anterior dislocations, impacted femoral head fractures may occur because of a direct blow from the acetabular margin.

Ninety-five percent of patients have injuries that require inpatient management independent of femoral head fracture.

In addition to hip dislocation, femoral head fractures are also associated with acetabular fractures, knee ligament injuries, patella fractures, and femoral shaft fractures.

A careful neurovascular examination is essential, because posterior hip dislocations may result in neurovascular compromise.

Hip dislocation is almost always present. The AP radiograph of the pelvis may demonstrate femoral head fragments in the acetabular fossa.

If closed reduction is successful, CT is necessary to evaluate the reduction of the femoral head fracture and to rule out the presence of intraarticular fragments that may prevent hip joint congruity.

Some authors recommend CT evaluation even if the closed reduction is unsuccessful to evaluate associated acetabular fractures.

Sagittal CT reconstruction may also be helpful in delineating the femoral head fracture. If the reduction is not adequate, open reduction and internal fixation with small subarticular screws using an anterior approach are recommended.

Small fragments may be excised if they do not sacrifice stability. Pipkin Type II The femoral head fracture is superior to the fovea.

The same recommendations apply for the nonoperative treatment of Type II fractures as for Type I fractures, except that only an anatomic reduction as seen on CT and repeat radiographs can be accepted for nonoperative care.

Open reduction and internal fixation generally comprise the treatment of choice through an anterior approach. The prognosis for this fracture is poor and depends on the degree of displacement of the femoral neck fracture.

In younger individuals, emergency open reduction and internal fixation of the femoral neck are performed, followed by internal fixation of the femoral head.

This can be done using an anterolateral Watson-Jones approach. In older individuals with a displaced femoral neck fracture, prosthetic replacement is indicated.

Pipkin Type IV A femoral head fracture occurs with an associated fracture of the acetabulum. This fracture must be treated in tandem with the associated acetabular fracture.

The acetabular fracture should dictate the surgical approach, and the femoral head fracture, even if nondisplaced, should be internally fixed to allow early motion of the hip joint.

Indentation fractures, typically located on the superior aspect of the femoral head, require no specific treatment, but the fracture size and location have prognostic implications.

Displaced transchondral fractures that result in a nonconcentric reduction require open reduction and either excision or internal fixation, depending on fragment size and location.

The prognosis for these injuries varies. Pipkin Type IV injuries seem to have roughly the same prognosis as acetabular fractures without a femoral head fracture.

Ten percent of patients with anterior dislocations develop osteonecrosis. Risk factors include a time delay in reduction and repeated reduction attempts.

Posttraumatic osteoarthritis: Risk factors include transchondral fracture, indentation fracture greater than 4 mm in depth, and osteonecrosis.

The average age of occurrence is 77 years for women and 72 years for men. The incidence in younger patients is very low and is associated mainly with high-energy trauma.

Risk factors include female sex, white race, increasing age, poor health, tobacco and alcohol use, previous fracture, fall history, and low estrogen level.

Calcar femorale: This is a vertically oriented plate from the posteromedial portion of the femoral shaft radiating superiorly toward the greater trochanter Fig.

The capsule is attached anteriorly to the intertrochanteric line and posteriorly 1 to 1. Three ligaments attach in this region: Iliofemoral: Y-ligament of Bigelow anterior Pubofemoral: anterior Ischiofemoral: posterior Vascular supply Fig.

The ascending cervical branches from this ring pierce the hip capsule near its distal insertion, becoming the retinacular arteries coursing along the femoral neck.

Most supplying the femoral head are posterosuperior in location. A subsynovial intracapsular arterial ring is formed by these retinacular arteries at the base of the femoral head.

As they enter the femoral head, they unite to form the lateral epiphyseal arteries. The lateral epiphyseal arteries that arise from the posterosuperior ascending cervical branches supply the majority of the femoral head.

The artery of the ligamentum teres, usually a branch of the obturator, offers a small supplemental contribution to the femoral head and is limited to the area around the fovea capitis.

Forces acting across the hip joint: Straight leg raise: 1. The bony trabeculae are laid down along the lines of internal stress. A set of vertically oriented trabeculae results from the weight-bearing forces across the femoral head, and a set of horizontally oriented trabeculae results from the force of the abductor muscles.

These two trabeculae systems cross each other at right angles Fig. Indirect: Muscle forces overwhelm the strength of the femoral neck.

High-energy trauma: This accounts for femoral neck fractures in both younger and older patients, such as motor-vehicle accident or fall from a significant height.

Patients with impacted or stress fractures may however demonstrate subtle findings, such as anterior capsular tenderness, pain with axial compression, lack of deformity, and they may be able to bear weight.

Pain is evident on range of hip motion, with possible pain on axial compression and tenderness to palpation of the groin.

An accurate history is important in the low-energy fracture that usually occurs in older individuals. Obtaining a history of loss of consciousness, prior syncopal episodes, medical history, chest pain, prior hip pain pathologic fracture , and preinjury ambulatory status is essential and critical in determining optimal treatment and disposition.

An internal rotation view of the injured hip may be helpful to further clarify the fracture pattern. Technetium bone scan or preferably magnetic resonance imaging may be of clinical utility in delineating nondisplaced or occult fractures that are not apparent on plain radiographs.

Garden This is based on the degree of valgus displacement Fig. Displaced: Characterized by any detectable fracture displacement.

TREATMENT Goals of treatment are to minimize patient discomfort, restore hip function, and allow rapid mobilization by obtaining early anatomic reduction and stable internal fixation or prosthetic replacement.

Nonoperative treatment for traumatic fractures is indicated only for patients who are at extreme medical risk for surgery; it may also be considered for demented nonambulators who have minimal hip pain.

Compression-sided stress fractures seen as a haze of callus at the inferior neck : These are at minimal risk for displacement without additional trauma; protective crutch ambulation is recommended until asymptomatic.

Normal to intermediate longevity but poor bone density, chronic illness, and lower functional demands: Perform modular unipolar or bipolar hemiarthroplasty.

Low demand and poor bone quality: Perform hemiarthroplasty using a one-piece unipolar prosthesis.

Severely ill, demented, bedridden patients: Consider nonoperative treatment or prosthetic replacement for intolerable pain. Operative Treatment Principles Fracture reduction should be achieved in a timely fashion.

Risk of osteonecrosis may increase with increasing time to fracture reduction. Fracture reduction maneuver: Perform hip flexion with gentle traction and external rotation to disengage the fragments, then slow extension and internal rotation to achieve reduction.

Reduction must be confirmed on the AP and lateral images. Guidelines for acceptable reduction: On the AP view, valgus or anatomic alignment is seen; on the lateral view, maintain anteversion while avoiding any posterior translation of the fracture surfaces.

Posterior comminution must be assessed. Internal fixation Multiple screw fixation : This is the most accepted method of fixation.

Threads should cross the fracture site to allow for compression. Three parallel screws are the usual number for fixation. Additional screws add no additional stability and increase the chances of penetrating the joint.

The screws should be in an inverted triangular configuration with one screw adjacent to the inferior femoral neck and one adjacent to the posterior femoral neck.

Avoid screw insertion distal to the lesser trochanter secondary to a stress riser effect and risk of subsequent subtrochanteric fracture.

Sliding-screw sideplate devices: If they are used, a second pin or screw should be inserted superiorly to control rotation during screw insertion.

Prosthetic replacement Hemiarthroplasty: Advantages over open reduction and internal fixation: It may allow faster full weight bearing.

Disadvantages: It is a more extensive procedure with greater blood loss. A risk of acetabular erosion exists in active individuals.

Indications for hemiarthroplasty: Comminuted, displaced femoral neck fracture in the elderly Pathologic fracture Poor medical condition Poorer ambulatory status before fracture Neurologic condition dementia, ataxia, hemiplegia, parkinsonism Contraindications: Active sepsis Active young person Preexisting acetabular disease e.

Bipolar has a lower risk of postoperative dislocation. It is very hard to close reduce a dislocated bipolar prosthesis.

Bipolar introduces the risk of polyethylene debris. Over time, the bipolar may lose motion at its inner bearing and functionally become unipolar.

Unipolar is a less expensive implant. Cement versus noncemented: Better functional results with use of cement Risk of intraoperative hypotension and death with use of cement Primary total hip replacement: Recent enthusiasm has been reported with the use of total hip replacement for acute treatment of displaced femoral neck fractures.

Studies have reported better functional results compared with hemiarthroplasty. It eliminates the potential for acetabular erosion. Disadvantages over hemiarthroplasty include a more extensive surgical procedure, increased implant cost, and a higher risk of prosthetic dislocation.

Indications include: Preexisting ipsilateral degenerative disease. Active elderly individual with a displaced femoral neck fracture. Preexisting ipsilateral acetabular metastatic disease.

Elderly individuals presenting with nonunion may be adequately treated with arthroplasty, whereas younger patients may benefit from cancellous bone grafting, proximal femoral osteotomy, or muscle pedicle graft.

Not all cases develop evidence of radiographic collapse. Treatment is guided by symptoms. Early without x-ray changes: Protected weight bearing or possible core decompression.

Late with x-ray changes: Elderly individuals may be treated with arthroplasty, whereas younger patients may be treated with osteotomy, arthrodesis, or arthroplasty.

Fixation failure: This is usually related to osteoporotic bone or technical problems malreduction, poor implant insertion.

It may be treated with attempted repeat open reduction and internal fixation or prosthetic replacement. Prominent hardware may occur secondary to fracture collapse and screw backout.

Average patient age of incidence is 66 to 76 years. The ratio of women to men ranges from to , likely because of postmenopausal metabolic changes in bone.

In the United States , the annual rate of intertrochanteric fractures in elderly women is about 63 per ,; in men, it is 34 per , ANATOMY Intertrochanteric fractures occur in the region between the greater and lesser trochanters of the proximal femur, occasionally extending into the subtrochanteric region.

These extracapsular fractures occur in cancellous bone with an abundant blood supply. As a result, nonunion and osteonecrosis are not major problems, as in femoral neck fractures.

Deforming muscle forces will usually produce shortening, external rotation, and varus position at the fracture.

Abductors tend to displace the greater trochanter laterally and proximally. The iliopsoas displaces the lesser trochanter medially and proximally.

The hip flexors, extensors, and adductors pull the distal fragment proximally.

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