11aa. Lower limb fracture Flashcards
Presentation fractured NOF
pain
shortened and externally rotated leg
patients with non-displaced or incomplete neck of femur fractures may be able to weight bear
what are the two areas of the NOF
intra-capsular (immediately proximal to trochanters)
extra-capsular
–> intra-trochanteric (between greater and lesser
–> subtrochanteric (from lesser to 5cm distal to this point)
blood supply to femoral head? consequences?
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.
management of extracapsular NOF
stable intertrochanteric fractures: dynamic hip screw
if reverse oblique, transverse or subtrochanteric fractures: intramedullary device
management of intracapsualr hip fracture
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
o/e posterior hip dislocation
The affected leg is shortened, adducted, and internally rotated.
most common type of hip dislocation
Posterior dislocation: Accounts for 90% of hip dislocations.
management hip dislocation
A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
Long-term management: Physiotherapy to strengthen the surrounding muscles.
what is avascualr necrosis
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.
causes of avascular necrosis
long-term steroid use
chemotherapy
alcohol excess
trauma
invetsigation of choice avasucalr necorsis
MRI
management avascualr necrosis
joint replacement may be needed
mechanism of injury patella fracture
direct trauma to the patella,
however less commonly can occur as a result of rapid eccentric contraction of the quadriceps muscle.
o/e patellar fracture
significantly swollen and bruised.
Often a visible and palpable patellar defect is present between the bone fragments.
invetsigation ?patellar fracture
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
management patellar fracture
undispalced:
hinged knee brace for 6 weeks and patients allowed to fully weight bear.
dispalced:
- surgical
what complications are common - tibilal fracture
open fracture
compartment syndrome
what ‘hold’ is used for tibial fractures
an above knee backslab (in slight flexion at the knee and neutral dorsiflexion at the ankle) should be applied to control rotation.
management tibial shaft fracture
Most tibial shaft fractures are managed surgically
Intramedullary (IM) nailing is the most commonly used method of fixing tibial shaft fractures
what are the ottowa knee rules
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)
ottowa ankle rules
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
weber classification of ankle fractures
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.
what ankle fractures require ORIF
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
most common type of ankle sprain
low ankle sprain - lateral collateral ligamanet (anterior talofibular ligament most common)
management ankle sprain
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.
most commonly fractured metatarsal
proximal 5th metatarsal
