LOWER LIMB
FRACTURE
JASON CHOW
HIP FRACTURES
FEMORAL HEAD BLOOD SUPPLY
• Extracapsular vessels have 2 regional anastomoses
• TROCHANTERIC anastomosis (Crock Ring)
• Centred on trochanteric fossa [think in terms of piriformis]
• Ascending branch of MFCA posteriorly
• Ascending branch of LFCA anteriorly
• Descending branch of superior gluteal artery
• Ascending branch of inferior gluteal artery
• CRUCIATE anastomosis
• Centred on lesser trochanter
• Transverse branches of MFCA + LFCA
• Ascending branch 1st perforator
• Descending branch of inferior gluteal artery
89 FEMALE FALL AT HOME
90 M
FEMORAL FRACTURES
• Bimodal
• Bilateral have 25%
mortality
• 5-10% have ipsilateral
femoral neck fracture
MANAGEMENT
• Analgesia
• NV obs
• Traction (skin or skeletal)
• Group and hold
• Definitive treatment is an IM nail
COMPLICATIONS
• FAT EMBOLISM SYNDROM
• VTE (THROMBOEMBOLISM)
• RESPIRATORY (ARDS)
• COMPARTMENT SYNDROME
• NON-UNION / DELAYED UNION / MALUNION
• HARDWARE FAILURE (USUALLY DUE TO NON-UNION)
• INFECTION
• HO
• NERVE INJURY (usually PUDENDAL NERVE from traction)
FAT EMBOLISM SYNDROME
• This is a condition characterised by a triad of features:
• Respiratory Distress
• Cutaneous Changes (Petechiae)
• Mental State Changes (Confusion)
• This occurs 24-72 hours after initial injury in patients with long bone fractures.
• Fatal in 15% of patients.
• Treatment is SUPPORTIVE THERAPY.
• Prevention is early STABILISATION (within 24 hours).
DISTAL FEMUR FRACTURE
• Bi modal distribution
• May be perprosthetic
• Usually needs CT scan if
suspected intra-articular
KNEE DISLOCATION
• Orthopaedic Emergency
• Vascular injury is limb threatening due to
tethering of popliteal artery
• Associated in 32-45% of all dislocation
• 25% associated with neurological (CPN) injury
• Multi ligament knee injury (>2 Ligaments)
ASSOCIATED INJURIES
• FRACTURES (60%)
• VASCULAR INJURY (50%)
• NEUROLOGICAL INJURY (25%)
• EXTENSOR MECHANISM INJURY
• MENSICAL INJURY
• CHONDRAL INJURY
MANAGEMENT
• Contact ortho and vascular
• Urgent closed reduction
• Assess vascular status post reduction
• Stabilise in POP or splnt or ex fix
• Immobilise in 20-30 degrees of flexion
• ABI
• CT Angio
ABI
• 100% sensitivity and specificity and PPV for significant arterial injury
when ABI <0.9
• technique = Doppler probe on either DP or TP with injured lower
limb SBP c/w ipsilateral non injured arm SBP
• Normal ABI should be >0.9
• ABI <0.9 is abnormal and indicates arterial injury.
• ABI <0.45 is critical ischaemia.
• Any abnormality requires urgent ANGIOGRAM.
EMERGENCY SURGERY
• Indicated in patients with:
• Vascular Injury
• Open Dislocations
• Irreducible Dislocations
• Compartment Syndrome
• EXTERNAL FIXATION is done first and then VASCULAR INJURY REPAIR/SAPHENOUS VEIN GRAFT
by VASCULAR SURGEON
• If a vascular repair / graft is required, FASCIOTOMIES of the leg are required.
• Open dislocation should be treated with reduction and wound debridement.
• Compartment syndrome requires urgent fasciotomies
TIBIAL PLATEAU FRACTURES
• 8% of fractures in the elderly
• Mechanism
• Axial force +/- varus and valgus force
• Associated Injuries
• 50% associated with meniscal tears
• 30% ligamentous injuries
• Peroneal nerve injuries from neuropraxia
• Arterial injuries not from trisection but intimal
stretching (present as thrombosis)
CLASSIFICATION
MANAGEMENT
• Analgesia
• Zimmer splint
• NV obs
• ABI if schatzker 4 or above
• If < 90 then CT angio
• May need external fixator
• Monitor for compartments syndrome
• High risk for compartments syndrome
• CT scan on tibial plateau fractures.
INDICATIONS FOR SURGERY
• OPEN FRACTURES
• MULTITRAUMA
• DISPLACED FRACTURES
• ARTICULAR GAP > 3-5MM
• CONDYLAR WIDENING > 5MM
• VARUS / VALGUS INSTABILITY
• ALL MEDIAL (TYPE 4)
• ALL BICONDYLAR (TYPE 5 & 6)
OPEN FRACTURES
GRADE 1
• WOUND < 1CM
• Clean Wound
• Low Energy Injury
• Mild Soft Tissue Injury
GRADE 2
• WOUND > 1CM & < 10CM
• Moderate Contamination
• Low or High Energy Injury
• Moderate Soft Tissue Injury (Without Extensive
Flaps)
GRADE 3
• WOUND > 10CM
• Highly Contaminated
• High Energy Injury
• Severe Soft Tissue Injury
• Includes All Segmental Fractures & GSW
• GRADE 3A: ADEQUATE SOFT TISSUE COVER
• GRADE 3B INADEQUATE SOFT TISSUE COVER (NEED
FLAP/GRAFT)
• GRADE 3C: ARTERIAL INJURY
PRINCIPLES OF OPEN FRACTURE MANAGEMENT
• Tetanus prophylaxis
• Antibiotics
• Grade 1 and 2 cephalosporin
• Grade 3 cephalosporin and aminoglycoside
• Wound debridement and irrigation
• +/- delayed primary closure.
• Fracture stabilisation
• Coverage
TIBIAL SHAFT FRACTURE
• Common in young patients
• Usually high energy
• Association
• Compartments syndrome
• Open fracture
• Extension into plateau or plafond
TIBIAL PLAFOND FRACTURE
• High energy injuries and treatment dictated
by soft tissue status.
• Young and middle aged adults.
• Axial compression
MANAGEMENT
• Initial management is for soft tissue
• External fixator for 10-14/7
• Span/scan/plan
• Definitive treatment
• ORIF and bone graft
COMPARTMENTS SYNDROME
• Circulation of tissues within a closed osteo-fascial space are compromised by increased
pressure within that space
• Prerequisite is volume restricting envelope
• fascia & skin
• POP
• dressings
COMPARTMENTS SYNDROME
• Aetiology
• 1. Increased contents
• Bleeding / edema
• fracture
• osteotomies
• crush injuries
• post - ischaemic swelling
• 2. Decreased size
• Tight casts & dressings
• Tight closure of fascial defects
• Fracture reduction
COMPARTMENTS SYNDROME
• Increased local tissue pressure increases pressure within intracompartmental veins
• local AV gradient is reduced
• causes decreased local perfusion secondary to Starling Forces
• Metabolic tissues demands not met
• loss of tissue function & viability
• distal pulses remain as ICP < SBP
• digit capillary refill remains as venous return extracompartmenta
COMPARTMENTS SYNDROME
• P’s
• Pain (most important)
• Paraesthesia (often early)
• Palpation (swollen and tense)
• Passive stretch
• Paresis (proximal nerve injury or guarding)
• Pulseless (late sign)
COMPARTMENTS SYNDROME
• Clinical Diagnosis
• Tense compartment and pain +++
• Pressure measurement
• Patient is unresponsive
• Uncoperative
• Underlying peripheral nerve defect.
COMPARTMENTS SYNDROME
• Management
• Prevention
• Remove tight dressings
• Split plasters
• Early fasciotomy < 8 hours
• Complications
• Ischemic muscles fibrosis and contractions
• Deformity and stiffness
• Nerve damage and variable numbness
ANKLE FRACTURE
• Danis-Weber Classification
• Type A – at the level of the plafond or distal to it,
transverse fracture, syndesmotic ligaments intact
• Type B – at the level of the distal tibiofibular joint,
it starts at the plafond and travels proximally,
variable disruoption of the syndemsosis
• Type C – proximal to the distal tibiofibular,
complete disruption of the syndesmosis (all 3
ligaments)
•
MECHANISM
MANAGEMENT
• Webber A – Non operative
• Weight bearing films for isolated
webber B
• Look for talar shift
• Webber C – Opoerative
• Medial Mal fracture – operate.
MANAGEMENT CONTINUED
• Webber A – WBAT in cam boot review 2/52 with an xray
• Webber B – nil talar shift WBAT in cam boot. Xray at 2/52 and boot 6/52 total
• Webber C – Operate will need syndesmotic screw
MAISONNEUVE FRACTURE
CALCANEAL FRACTURE
• Mechanism is fall on heel with axial load
• Can be intra-articular (compression) or
extra-articular (avulsion)
• Associated
• 10% lumbar spine
• 10 %Contralateral clac
ANGLES
MANAGEMENT
• CT all calc fractures
• UNDISPLACED fractures are treated NON-OPERATIVELY.
• These patients are immobilised in POP for 6-12 WEEKS NWB.
• DISPLACED fractures required SURGERY with ORIF.
• (The exceptions are elderly and multiple comorbidities patients)
5TH METATARSAL FRACTURE
• Zone 1 – tuberosity avulsion fractures
• Fracture or the lateral aspect of the tuberosity, extending
proximally into the MT joint
• Zone 2 (jones)– # at the metaphyseal-diaphyseal junction
• Begins in the lateral distal part of the tuberosity and extends
obliquely into the base of the 4th and 5th MT articulation
• always an acute injury
• Injury described by Jones
• Zone 3 (Mrach) – stress fracture of the proximal 1.5cm of the
shaft
• Distal to the fourth and fifth metatarsal base articulation
• Not acute with prodromal symptoms or
• Radiological signs of repetitive stress injury
MANAGEMENT
• Type 1 – WBAT in cam boot for 4-6/52
• Type 2/3 – Backslab then full fiberglass for 6 weeks
• Surgical fixation
• Displaced
• Symptomatic nonunion
• Athlete
• Articular
