16 - Lower Extremity Injuries

Question 1

Hip fracture

Answer 1

• ***27% mortality 1 year after a hip fracture
• ***This increases rate of mortality THREE TIMES
• Causes: fat embolism from break, pulmonary embolism, MI, stroke, narcotic pain killers, fall again, fuels “dementia fire”

Question 2

Anatomy

Answer 2

• LOTS of big vessels in the pelvis

- This means that a pelvic fracture can bleed out

Question 3

Pelvic fractures – two types

Answer 3

• Elderly patient/low energy (most common)

- Younger patient/high energy (most deadly)

Question 4

Stable fractures

Answer 4

• Single ramus
• Single non displaced fx through pelvic ring
• Chip off the pelvic rim
• Usually no long term complications

Question 5

Pubic ramus fractures

Answer 5

• Usually elderly with ground level fall

- Pain management – Observe or home with pain meds

Question 6

Unstable pelvic fractures

Answer 6

• Life threatening
• Nick a vessel
• Bone bleed
• Internal organ injury
• High energy trauma (likely other injuries)
• PE later on
• 60% long term complications (urinary, pain, sexual complications, nerve damage)

Question 7

Unstable pelvic fracture – MOI

Answer 7

• MVC
• Motorcycle
• Fall (horse)
• Pedestrian VS Car
• Crush injuries

Question 8

Emergency treatment

Answer 8

• Rock pelvis – only once, you will feel it!
• External fixation
• Stabilize vitals
• An unstable pelvic fracture NEEDS a surgeon, stabilize

Question 9

Unstable fracture on roadside

Answer 9

• Sheet/towel, anything used to stabilize

- You can save a life this way***

Question 10

Hip fracture

Answer 10

• 90% victims are people over 60
• 300,000/year
• Almost all get surgery
• 1/4 die of complications

Question 11

Hip fracture risk fractures

Answer 11

• Age
• Female
• Osteoporosis
• Medical conditions that increase fall risk

Question 12

Complication of hip fracture

Answer 12

• Pneumonia
• DVTs/PEs
• Bed sores
• Infection
• Nerve damage/bleed
• Delirium
• Death

Question 13

Types of hip fracture

Answer 13

• Subcapital neck fracture
• Transcervical neck fracture
• Intertrochanteric fracture
• Subtrochanteric fracture
• Fracture of great trochanter
• Fracture of the lesser trochanter

Question 14

Signs and symptoms of hip fracture KNOW THIS

Answer 14

• ***Pain
• ***Inability to ambulate
• ***Shortened/externally rotated leg
• ***Sometimes pain in knee (still need to get a hip x-ray to check)

Question 15

Physical sign of hip fracture

Answer 15

• The fractured hip is rotated way outward

- The normal hip is only slightly rotated outward

Question 16

Imaging for hip fracture

Answer 16

• X-ray usually enough – can get contra-lateral or pelvic X-ray to see other side
• May need CT

Question 17

Femur fracture

Answer 17

• Often significant force

- Can be significant blood loss

Question 18

When do you urgently reduce a fracture?

Answer 18

• No pulse
• No sensation
• Pain not controlled
• Tenting of skin

Question 19

Tibial plateau fracture

Answer 19

• Older person ground level fall
• OR young person with high energy or right mechanism (bumper to knee)
• If stable, no displaced – immobilize. Otherwise ORIF

Question 20

Patella fracture

Answer 20

• Not that difficult to break
• 1% of fractures – not that common
• 20-50 y/o
• If non-displaced/stable walking cast
• If displaced, ORIF

Question 21

Knee dislocation

Answer 21

• Can happen in Anterior or Posterior or Lateral or Medial
• Named for tibia location
• High incidence nerve injury
• 50% reduce prior to ER

Question 22

Maisonneuve fracture

Answer 22

• Spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane
• There is an associated fracture of the medial malleolus or rupture of the deep deltoid ligament

Question 23

Compartment syndrome

Answer 23

• Limb-threatening (rarely life threatening) condition where pressure of enclosed limb becomes so high causes ischemia, nerve damage and eventually tissue death

Question 24

Causes of compartment syndrome

Answer 24

• Crush injuries
• Envenomations
• Fractures
• Burns
• Soft tissue trauma

Question 25

***Signs and symptoms of compartment syndrome***

Answer 25

- Pain out of proportion - Numb/parenthesis - Pale/blue/cold - Decreased pulse - Tight compartment

Question 26

CASE STUDY 1

Answer 26

- 14-year-old kid fell on knee last night off of skateboard, felt pain but walked - Leg is swollen, cold, no palpable pulses - Diagnosed with compartment syndrome of the lower extremity - X-ray showed tibial fracture – these fractures typically bleed, cause compartment syndrome

Question 27

CASE STUDY 2

Answer 27

- Small rattlesnake was seen and bit her foot - Venemation: 25% are “dry” meaning that they were bit but no venom went in - First you get labs – PT, PTT, fibrinogen, EKG, CPK - If there is only a puncture wound and there are NO other symptoms, you can just watch them - Anti-venom: CroFab (no available everywhere, expensive takes a while to “swirl”) - Snake bites are another way to cause compartment syndrome

Question 28

CASE STUDY 3

Answer 28

- Rolled ATV at low speed, no other injuries – Unable to bear weight, crawled over 1 mile - First things first – check vitals, do overall physical to check for other injuries - PMHx: thrown from horse 6 yrs ago and was in a coma for 1 month due to subdural hematoma - Left calf much firmer than the right, so do not send this patient home - In some injuries, the bone will stop bleeding, but you can’t bet on this