management options

Tsukayama Classification

Definition

Fracture distal to articular surface & proximal to intertrochanteric region

Epidemiology

On average 4 years younger than intertrochanteric fracture

One year mortality as high as 36%

Only 1/3 will return to pre-fracture living environment

Indications

Patient > 70

Gjertsen et al JBJS Am 2010

- 4335 patients > 70 with displaced subcapital fractures

- minimum 1 year follow up

- 1 year mortality same in each group / 25%

- 22% reoperation in ORIF v 3% in hemiarthroplasty

- more pain / higher dissatisfaction / lower quality life in ORIF group

Options

Hemiarthroplasty

- unipolar monoblock

- unipolar modular

Operative v Nonoperative Literature

1.  Buckley etal JBJS Am 2002

Prospective multi-centred RCT

- 309 displaced intra-articular fractures

- operative v non operative management

- 2 year follow up

Findings

- used patient orientated functional outcomes

- overall VAS and SF36 not significantly different between 2 groups

Improved Operative Outcome if

- not workers compensation

- women

- < 29

Incidence

Knee > Hip

- superficial position

- limited cover of well vascularised muscle 

- watershed area of skin blood supply anterior to the skin incision 

- much increased in fully constrained prosthesis 

Ideal < 1%

Risk Factors

Increased with

- revision

- prior infection

- RA / Psoriatic arthropathy

- DM

NHx

European Orthopaedic Paediatric Study JPO 1999

- 452 patients

- juvenile and adult

Findings

- stable lesion with cartilage intact and no dissection had good prognosis

- if signs dissection, surgical management better than non surgical

- sclerosis on x-ray poor prognostic sign

- lesions > 2cm poor prognosis

- 20% OCD in juveniles abnormal x-ray findings at 3 years (not benign process)

Non-operative Management

Natural history

Return to Sport

Shelbourne et al. Am J Sports Med 1999

- 133 patients with isolated PCL injuries followed for mean of 5 years

- 1/2 returned to sport at same level of play

- 1/3 returned to sport at lower level of play

https://pubmed.ncbi.nlm.nih.gov/10352760/

Agolley et al. Bone Joint J 2017

Definition

Epidemiology

Athletic / high impact exercises

Aetiology

First described in ballet dancers (Burrows 1956)

- tension side of bone / lateral side

- progression to complete fracture has been well documented in athletes

Signs

Point tenderness

- lateral aspect of tibia

Over time develop bony lump

AVN  

Largely related to degree of displacement

Incidence

Hawkins Type I

- 0% to 13% 

Hawkins Type II 

- 20% to 50% 

- usually only patchy and not a problem (rarely collapses)