Common Lower Limb Fractures and Dislocations

Question 1

Extracapsular vs intracsapsular hip fractures

Answer 1

Question 2

Management of hip fractures

Answer 2

• Offer replacement arthroplasty (total hip replacement or hemiarthroplasty) to patients with a displaced intracapsular hip fracture.
• Offer total hip replacement rather than hemiarthroplasty to patients with a displaced intracapsular hip fracture who:
  
  • were able to walk independently out of doors with no more than the use of a stick and
  • are not cognitively impaired and
  • are medically fit for anaesthesia and the procedure.
• Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2).
• Use an intramedullary nail to treat patients with a subtrochanteric fracture.

Question 3

Post-operative management of hip fractures

Answer 3

• Offer patients physiotherapy assessment and, unless medically or surgically contrindicatred, mobilisation on the day after surgery
• Mobilise at least once a day and ensure regular physiotherapy review
• Remember management of metabolic bone disease!

Question 4

Complications of hip fractures

Answer 4

• Thromboembolic events (DVT, PE)
• Non-union
• AVN

Question 5

Clinical features of a high energy pelvic ring fracture

Answer 5

• Generally blunt trauma
• Pelvic pain/tenderness
• Clinical exam more useful in awake patients
• Haematuria
• Haematoma over ipsilateral flank, inguinal ligament, proximal thigh or perineum
• Neurovascular deficits in lower extremities
• Rectal bleeding
• Vaginal bleeding
• Instability on hip adduction and pain on hip motion suggests acetabular fracture

Question 6

Management of high energy pelvic fractures

Answer 6

• Classified using Tile Classification System and the Young and Burgess Classification System
• Address life-threatening conditions in emergency setting (i.e. external compression for haemorrhage)
• Consult orthopedics - can pack or use intrailiac balloon to control haemorrhage
• May require external fixation for unstable pelvic fracture
• Monitor for signs of ongoing blood loss, consider DVT prophylaxis, pain management and transfer to trauma centre

Question 7

Complications of hip and knee dislocation

Answer 7

• Hip
  
  • AVN caused by damage to blood supple
  • Disruption of the protective cartilage
  • Sciatic nerve damage
• Knee
  
  • Chronic stiffness
  • Instability
  • Postoperative nerve pain
  • Nerve injury (common peroneal and popliteal)
  • Vascular injury

Question 8

Management of femoral shaft fractures

Answer 8

• High energy injury
• Rule out life-threatening injuries
• ATLS guidelines should be followed
• Restore alignment and splint
• Surgical management depends on pattern but for femnoral shaft intramedullary nailing is treatment of choice although plate and screw and external fixation are also used

Question 9

Management of tibial shaft fractures

Answer 9

• Open fractures are surgical emergencies and should consult orthopedics immediately (debridement and irrigation)
• Casting in closed fractures with minimal displacement
• Bracing can also be used in minimally displaced fractures
• Surgical therapy when fractures are unstable
  
  • Plating
  • External fiation
  • Intramedullary nailing
  • Amputation

Question 10

High energy fracture patterns in the foot

Answer 10

• Lis Franc Injury
  
  • Lisfranc injury, also known as Lisfranc fracture, is an injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus.
  • Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. The severity of the injury can vary from simple to complex, involving many joints and bones in the midfoot.

Question 11

Management of ankle fractures

Answer 11

• Non-operative (non-displaced, stable)
  
  • Closed reduction and splinting
  • Boot/cast
• Operative (unstable/talar shift, closed reduction unsuccessful)
  
  • Lag screw fixation
  • Plates
  • Tension band fixation
  • Intramedullary screws
• Open fractures require emergency surgery
• Refer to vascular if vascular injury