11aa. Lower limb fracture

Question 1

Presentation fractured NOF

Answer 1

pain
shortened and externally rotated leg

patients with non-displaced or incomplete neck of femur fractures may be able to weight bear

Question 2

what are the two areas of the NOF

Answer 2

intra-capsular (immediately proximal to trochanters)

extra-capsular
–> intra-trochanteric (between greater and lesser
–> subtrochanteric (from lesser to 5cm distal to this point)

Question 3

blood supply to femoral head? consequences?

Answer 3

retrograde

medial circumflex artery which lies directly on intra-capsular femoral neck

Consequently, displaced intra-capsular fractures disrupt the blood supply to the femoral head and, therefore, the femoral head will undergo avascular necrosis (even if the hip is fixed). Patients with a displaced intra-capsular fracture therefore require joint replacement (arthroplasty), rather than fixation.

Question 4

management of extracapsular NOF

Answer 4

stable intertrochanteric fractures: dynamic hip screw

if reverse oblique, transverse or subtrochanteric fractures: intramedullary device

Question 5

management of intracapsualr hip fracture

Answer 5

Undisplaced:
internal fixation, or hemiarthroplasty if unfit.

displaced
1. total hip replacement if:
- previously independent with no more than use of stick
- no cogn imp
- medically fit for anaesthesia
2. hemiarthroplasty

Question 6

o/e posterior hip dislocation

Answer 6

The affected leg is shortened, adducted, and internally rotated.

Question 7

most common type of hip dislocation

Answer 7

Posterior dislocation: Accounts for 90% of hip dislocations.

Question 8

management hip dislocation

Answer 8

A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
Long-term management: Physiotherapy to strengthen the surrounding muscles.

Question 9

what is avascualr necrosis

Answer 9

death of bone tissue secondary to loss of the blood supply. This leads to bone destruction and loss of joint function. It most commonly affects the epiphysis of long bones such as the femur.

Question 10

causes of avascular necrosis

Answer 10

long-term steroid use
chemotherapy
alcohol excess
trauma

Question 11

invetsigation of choice avasucalr necorsis

Answer 11

MRI

Question 12

management avascualr necrosis

Answer 12

joint replacement may be needed

Question 13

mechanism of injury patella fracture

Answer 13

direct trauma to the patella,

however less commonly can occur as a result of rapid eccentric contraction of the quadriceps muscle.

Question 14

o/e patellar fracture

Answer 14

significantly swollen and bruised.

Often a visible and palpable patellar defect is present between the bone fragments.

Question 15

invetsigation ?patellar fracture

Answer 15

The mainstay of investigation for suspected patella fracture is plain film radiographs (Fig. 2), obtaining three separate views (antero-posterior, lateral, and skyline*)

*Skyline view is often not possible in actual cases of patella fracture due to pain inhibiting

Question 16

management patellar fracture

Answer 16

undispalced:
hinged knee brace for 6 weeks and patients allowed to fully weight bear.

dispalced:
- surgical

Question 17

what complications are common - tibilal fracture

Answer 17

open fracture

compartment syndrome

Question 18

what ‘hold’ is used for tibial fractures

Answer 18

an above knee backslab (in slight flexion at the knee and neutral dorsiflexion at the ankle) should be applied to control rotation.

Question 19

management tibial shaft fracture

Answer 19

Most tibial shaft fractures are managed surgically

Intramedullary (IM) nailing is the most commonly used method of fixing tibial shaft fractures

Question 20

what are the ottowa knee rules

Answer 20

if no to everything, knee imaging not indicated

Age ≥55
Isolated tenderness of the patella (no other bony tenderness)
Tenderness at the fibular head
Unable to flex knee to 90°
Unable to bear weight both immediately and in ED (4 steps, limping is okay)

Question 21

ottowa ankle rules

Answer 21

These state that x-rays are only necessary if there is pain in the malleolar zone and:
1. Inability to weight bear for 4 steps
2. Tenderness over the distal tibia
3. Bone tenderness over the distal fibula
4. Tenderness over base of 5th metatarsal
5. Tenderness over navicular

Question 22

weber classification of ankle fractures

Answer 22

Related to the level of the fibular fracture.
Type A is below the syndesmosis
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
Type C is above the syndesmosis which may itself be damaged

The more proximal the injury, the higher the likelihood of ankle instability; consequently, Type C fractures almost always need surgical fixation.

Question 23

what ankle fractures require ORIF

Answer 23

Open reduction and internal fixation (ORIF) is often required in ankle fractures to achieve stable anatomical reduction of the talus within the ankle mortise. Ankle fractures that require an ORIF include:

Displaced bimalleolar or trimalleolar fractures
Weber C fractures
Weber B fractures with talar shift
Open fractures

Question 24

most common type of ankle sprain

Answer 24

low ankle sprain - lateral collateral ligamanet (anterior talofibular ligament most common)

Question 25

management ankle sprain

Answer 25

RICE
Occasionally a removable orthosis, cast and/or crutches may be required for short-term symptom relief.
If symptoms fail to settle or there is significant joint instability then an MRI and surgical intervention may be contemplated, but this is rare.

Question 26

most commonly fractured metatarsal

Answer 26

proximal 5th metatarsal