Download - Lower limb fractures-Orthopedics
Lower limb fracturesTibia, Ankle, Foot.Given Sishekano
201404386MBChB IV
Feb 17,201714h00
Table of content
▪ Fractures of the tibia▪ Fractures of the ankle▪ Fractures of the foot
Tibial fractures
▪ 1. Anatomy▪ 2. Proximal tibia fractures▪ 3. Tibial shaft fractures.▪ 4. Distal tibia fractures
Anatomy
• Long & Tubular w/ a triangular cross section.
• Subcutaneous anteromedial border.
Fractures of the proximal tibia.
1. Fractures of tibial plateau▪ Usually caused by forcible Valgus or Varus strain.▪ Low energy fractures common in older females due to osteoporotic
bone changes.▪ High energy fractures are commonly the result of motor vehicle
accidents, falls or sports related injuries▪ Strong bending forces combined with an axial load e.g. bumper
fractures▪ A fall from a height in which the knee is forced into valgus or varus
position▪ Lateral tibial plateu is commonly affected but medial may also be
affected
Epidemiology & presentation
▪ 50% of presenting pts are over 50 y/o (females commonly)▪ Patients present with severe tenderness on side of
fracture and on opposing side if tendon damaged.▪ Swollen tendon with doughy feel due to haemarthrosis
Classification (Schatzker Classification)
Imaging
▪ X-rays are vital▪ CT scan not always done but help in evaluating extent of
fracture and planning management.▪ MRI scan if soft tissue damage is suspected▪ CT angiography if concerns of vascular compromise
Management
▪ Treatment is aimed at achieving a stable, aligned, mobile and painless joint and to minimize the risk of posttraumatic osteoarthritis.▪ Undisplaced & minimally displaced(Lc): conservative
management.▪ Marked displacement/ comminuted(Lc): ORIF▪ Medial condyle fractures: ORIF▪ Bicondylar fractures: internal fixation w/ Plates and
screws
Tibial Shaft Fractures
▪ Commonest long bone fractures.▪ Men>women▪ Often Open fractures w/ contaminated wound.
Mechanism of Injury
▪ 1.Direct: High energy: MVA, sporting injury-Transverse, comminuted, displaced fractures commonly occur.-Incidence of soft tissue trauma is high▪ Penetrating: gunshot-The injury pattern is variable.▪ Bending-Short oblique or transverse fractures occur,
with a possible butterfly fragment.-Crush injury.
▪ 2. Indirect▪ Torsional mechanisms-twisting with foot fixed, falls from low height.-minimal soft tissue damage.▪ Stress fractures-e.g in Ballet dancers.
Clinical Exam
▪ Neurovascular status▪ Assess soft tissue injury▪ Examine knee ligament(commonly damaged)▪ Examine for signs of compartment syndrome.
Imaging
▪ X-ray is usually sufficient-Two views-Two joints-Two occasions▪ Oblique X-ray to characterise pattern of injury if
necessary. ▪ Post reduction X-ray must be done.
Classification
▪ None Universal.▪ If open-Gustillo Anderson▪ If closed- Tscherne
Classification of closed fractures.
Management
▪ Low energy-Gastillo I, II: Conservatively▪ Undisplaced/minimally
displaced- full length cast from upper thigh to metatarsal neck, knee is slightly flexed and the ankle at a right angle▪ Displaced fracture
- reduction under general anaesthesia
▪ High energy-External fixation is the method of choice-intramedullary nailing is an alternative-- Open operations should be avoided unless there is already an open wound
Complications
▪ Vascular injuries▪ Compartment syndrome▪ Infection▪ Malunion▪ Delayed union and non
union▪ Joint stiffness
3. Distal Tibial fractures
▪ Injury occurs when a large axial force drives the talus upwards against the tibial plafond▪ Usually high Energy▪ Can be rotational with lower energy▪ Articular Surface is Involved▪ Can have severe comminution and severe soft tissue
injury
Clinical features
▪ Little swelling initially but this rapidly changes▪ Fracture blisters are common▪ Ankle may be deformed or dislocated
Classification(Rudi and Allgower)
▪ Type I – Fracture involving minimal displacement▪ Type II – Significant
displacement of the joint surface▪ Type III – Impaction and
comminution of the articular surface
Imaging
▪ X-ray(diagnostic)
Management
▪ Early management: SPAN, SCAN, PLAN.▪ Remember Life, Limb,
Fracture.▪ Manage soft tissue swelling.▪ Once skin has recovered, do
ORIF▪ Closed reduction w/ a cast.▪ External fixation if needed
2. Ankle fractures
▪ Anatomy of the ankle ▪ Tibia and fibula form a mortise which provides a constrained articulation for the talus.
▪ Ankle stability is provided by 3 factors:
▪ Bony architecture, joint capsule and ligamentous
▪ structures:▪ Syndesmotic ligaments▪ Medial collateral ligaments▪ Lateral collateral ligaments
▪ Stumbling and falling-Foot is usually anchored to the ground and the body lounges forward.▪ Ankle twisting -Talus tilts or rotates forcibly in mortise causing a low energy fracture of one or both malleoli with associated injuries of the ligaments.
▪ Simple description: ▪ Joint can be injured on one side
only (single malleolus) or on both sides (bi-malleolar fracture)
▪ Rotational injuries: ▪ 1/both sides may be injured.▪ Posterior lip of the lower end of
the tibia (posterior malleolus) may be fractured.
▪ Degree of instability depends on how much of ankle complex is damaged.
Classification
1. Weber classification
2. LAUGE-HANSEN CLASSIFICATION: Uses two terms: First: describes position of the foot at time of injury, second: the motion of the talus relative to the tibiaTypes:1. supination – adduction2. supination – external rotation3. pronation – abduction4. pronation – eversion5. pronation – dorsiflexionDescription is used because most ankle injuries are caused by the weight of the falling person applying force on the ankle with the foot in a fixed position.Classification proposes that mechanism of injury can be deduced from the X-ray appearances and that reduction involves applying the reverse movement.
3. Fractures of the foot▪ Anatomy of the foot.
Talus fracture
▪ Talus fracture is an injury of the hind foot
▪ Rare, occur due to considerable violence with axial loading or hyper dorsiflexion.
▪ Injuries include fracture of the head, neck, body, or bony processes of talus.
▪ Patients present with painful and swollen foot and ankle
▪ Obvious deformity if fracture is displaced
▪ Skin overlaying the fracture or dislocation may be tented or split
X-ray(Talus fracture)
Hawkins Classification & management
▪ Type I : non displaced fracture▪ Type II : displaced fracture with
subluxation or dislocation of the subtalar joint and a normal ankle joint
▪ Type III : displaced fracture with body of talus dislocated from both subtalar and ankle joint.
▪ Type IV: in addition to features describes in type III there is dislocation or subluxation of the head of the talus at the talonavicular joint
Management▪ Undisplaced #: Backslab until
swelling has subsided followed by non-weight bearing below knee CPOP (6-8 weeks)
▪ Displaced #: closed reduction attempted first, if it fails, ORIF is performed where the reduced # is stabilised with 1 or 2 lag screws
Complications-Malunion-AVN-Secondary Osteoarthritis
Calcaneal fractures
▪ Common mechanism axial loading ▪ Calcaneum driven up against talus and
is split or crushed.▪ 10% of calcaneus #s associated with
compression injuries of spine, pelvis or hip.
▪ Two types:▪ Extra-articular #: involve calcaneal
processes or posterior part of bone. Easy to manage and have good prognosis.
▪ Intra-articular #: cleave bone obliquely and run into superior articular surface. Articular facet is split apart and there may be severe comminution.
Sanders Classification
▪ Type I: non-displaced fractures (displacement < 2 mm).
▪ Type II: consist of single intraarticular fracture dividing the calcaneus into 2 pieces.
▪ Type IIA: occurs on lateral aspect of calcaneus.▪ Type IIB: occurs on central aspect of calcaneus.▪ Type IIC: occurs on medial aspect of calcaneus.▪ Type III: consist of two intraarticular fractures that
divide the calcaneus into 3 pieces.▪ Type IIIAB: two fracture lines are present, one
lateral and one central.▪ Type IIIAC: two fracture lines are present, one
lateral and one medial.▪ Type IIIBC: two fracture lines are present, one
central and one medial.▪ Type IV fractures consist of fractures with more
than three intrarticular fractures.
Presentation▪ Foot is painful, swollen and
bruised.▪ Wider, shortened, flatter heel
when viewed from behind + varus heel
▪ Tissues are thick and tender and normal concavity below the lateral malleolus is lacking.
▪ Subtalar joint cannot be moved but ankle movement is possible.
▪ Always check for signs of Compartment syndrome
X-ray views▪ Lateral, oblique and AP
views▪ Extra-articular #: fairly
obvious on xray▪ Intra-articular #: can be
identified on xray, if there is displacement of fragments lateral view may show reduced of Bohler’s angle
Management
▪ Undisplaced fractures: Closed non-surgical treatment (backslab, CPOP), use crutches for 4-6 weeks.▪ Displaced avulsion #: ORIF, Immobilise foot in slight equinus
to relieve tension on tendo Achillis. Non-weight bearing for 4-6 weeks.▪ Displaced intra-articular #: ORIF with plates and screws.▪ Bone grafts may be used to fill defects.▪ Encourage exercise when pain subsides▪ Pt allowed to use crutches 2-3 weeks after (non-weight
bearing) -> Partial weight bearing only when fracture has healed -> full weight bearing only 4 weeks after that
Complications
▪ Early: swelling and blistering, Compartment Syndrome▪ Late: Malunion, Insufficiency of Achilles tendon (due to
loss of heel height), talocalcaneal stiffness and osteoarthritis
Lisfranc fracture
▪ Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn.
▪ Varies from minor sprains to severe fracture-dislocations▪ m.o.i: simple twist and fall. ▪ This is a low-energy injury, commonly seen in football and soccer
players. ▪ More severe injuries occur from direct trauma, such as a fall from a
height.▪ These high-energy injuries can result in multiple fractures and
dislocations of the joints.▪ It is often seen when someone stumbles over the top of a foot
plantar flexed.
Mechanism of injury
Symptoms• Pain(worsened by
walking)• Bruising• Swelling
X-rays▪ Full extent of injury hardly clear on plain x-ray; multiple
vies of CT may be needed.▪ Look out for fractures of navicular and cuneiform bones.
Management
▪ Undisplaced sprain: cast immobilization for 4-6 weeks.▪ Subluxation and dislocation: Traction and manipulation
under anaesthesia achieves reduction.▪ Position is then held with K-wires or screws and cast
immobilization.▪ Non-weight bearing for 6-8 weeks.
Metatarsal fractures
▪ Due to direct blow, severe twisting injury or repetitive stress▪ 5th metatarsal #s are usually
due to forced inversion of the foot (the pot hole injury) which then causes avulsion of the base of the 5th metatarsal tuberosity▪ Avulsion fracture occurs where a
tendon attaches to the bone▪ When an avulsion fracture
occurs, the tendon pulls off a tiny fragment of bone.
Presentation
▪ Patient often complains of having sprained the ankle▪ Tenderness marked over area
of fracture.Management
▪ Fracture usually unites readily▪ Immobilisation in a below knee
plaster for 4 weeks is advised
X-rays
Sesamoid fractures
▪ Fractures occur either due to a direct injury (i.e landing from a height on the ball of the foot), sudden traction or; ▪ chronic repetitive stress as seen in dancers and runners▪ Patient c/o pain over the sesamoids▪ O/E: Tender spot in the same area and pain may be
exacerbated by passively hyperextending the halluxRx:Conservative treatment▪ Use of local lignocaine injection for pain relief▪ In cases of marked discomfort, immobilise leg in cast 2-3
weeks
References
1. Apley’s consice system of orthopaedics and fractures2. Toronto notes 20163. Orthopaedics and fractures lecture notes(4th ed.), wiley-Blackwell.