LE Fractures Flashcards
Pelvic Fractures
More prevalent in elderly
High impact injury (MVC) for younger people
May or may not be able to ambulate
May have pain radiating to groin
Can be confused for hip fx
In high impact injuries also check for bladder injury
Pelvis XRAY
MOI of Pelvic Fractures
MOI: Most common is fall
Pubic Rami Fracture Treatment
Non-displaced will usually do bed to chair with no weight bearing (NWB) on the affected side for anywhere from 2 to 6 weeks depending on the age
Always check for bladder injury by obtaining a urine to look for blood
Displacement of the fracture may require ORIF with plating as this can be an unstable fx
Pelvic Ring Fracture Treatment
Usually occurs from high energy injury
ATLS primary & secondary survey required
Diastasis > 2.5 cm requires ORIF
Iliac wing fracture treatment
Isolated fractures from the anterior non-weight bearing portion are relatively stable fractures & requires conservative treatment
Posterior fractures that involve the weight bearing surface are treated surgically with ORIF & require ATLS primary & secondary survey on initial presentation
Hip fracture MOI
usually fall in the elderly or high impact injury in younger
What occurs with a Hip Fracture
Limb is shortened & externally rotated
Pain in groin & anterior thigh
Unable to ambulate
Some with impacted fx may be able to ambulate for a short period of time
What would you order with a hip fracture?
Always include pelvis with hip XRAY to compare side to side
If plain film equivocal & high index of suspicion get an MRI 100% sensitivity
CT requires radiation & bone scan has 72 hour delay
Garden Classification System for femoral neck fractures?
Type 1 = impaction fracture with valgus displacement will usually occur in the sub capital area
Type 2 = non-displaced fracture
Type 3 = varus displacement of the femoral head
Type 4 = complete loss of continuity between fragments
Treatment of Garden Type 1 & Type 2 Fractures
Usually treated with cannulated screws
Up to 40% will develop AVN of the femoral head
If the patient is not a candidate for surgery the fx will heal with bed to chair & no weight bearing on the affected side for 6 weeks or more
Garden Type 3 fracture
Complete fx with varus displacement
Usually requires reduction
Garden Type 4 fracture
Complete loss of continuity between fragments
Usually requires a reduction
Garden Type 3 & Type 4 Fracture Treatment
> 70 y/o the literature recommends hemiarthroplasty as there is a high rate of non-union & AVN
< 50 y/o recommendation is reduction & internal fixation with cannulated screws
< 50 y/o if unstable compression screw & plate is recommended
Greater and Lesser Trochanter Fractures
Stable
Usually occur as avulsion fxs
Treated conservatively with rest & weight bearing as tolerated
Intertrochanteric fractures
Occurs between the greater trochanter where the gluteus medius & gluteus minimus attach & the lesser trochanter where the iliopsoas attaches
Classified as stable or unstable
Two part or three part is considered stable & treated with a compression screw & plate
Four part or greater is considered & treated with a sliding hip screw & intermedullary nail
Subtrochanteric Fractures
Occur below the greater & lesser trochanter
Always repaired surgically
Locking screw & IM nail is the standard
Hip Dislocations
High energy traumatic injury in the normal hip
Can occur after Total Hip Arthroplasty (THA) if restrictions of position are not maintained
MVC accounts for 2/3 of all traumatic hip dislocations
Posterior dislocation occurs in 80-90% of all dislocations secondary to MVC
Trauma patients should have ATLS primary & secondary survey
Present with severe pain that may radiate to the lower extremities, back, or pelvic area & an inability to move the leg on the affected side
THA patients may not have too much pain but are unable to move their hip & the lower leg appears internally rotated
All patients require a hip & pelvis x-ray
Treatment for a hip displacement
Trauma patients must be stabilized first before reduction
Trauma patients may have to go to the OR for either closed or open reduction
THA patients usually have closed reduction under conscious sedation
MOI of femur fractures
usually high impact injury
Femur Fractures
Can be pathologic May also occur around prosthesis or ORIF components Tender to palpation Unable to ambulate Many have deformities Needs good N/V check XRAY femur If proximal may need to include hip If distal may need to include knee
Femur Fracture treatment
external fixation
intramedullary nailing
plates and screws
External Fixation
metal pins or screws are placed into the bone above and below the fracture site. The pins and screws are attached to a bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position so they can heal.
External fixation is usually a temporary treatment for femur fractures
Intramedullary nailing
MC used
a specially designed metal rod is inserted into the marrow canal of the femur. The rod passes across the fracture to keep it in position.
An intramedullary nail can be inserted into the canal either at the hip or the knee through a small incision. It is screwed to the bone at both ends. This keeps the nail and the bone in proper position during healing.
plates and screws
bone fragments are first repositioned (reduced) into their normal alignment. They are held together with special screws and metal plates attached to the outer surface of the bone.
Plates and screws are often used when intramedullary nailing may not be possible, such as for fractures that extend into either the hip or knee joints
MOI of knee fractures
direct blow to anterior or lateral aspect, twisting, hyperextension
knee fractures
Present with pain & swelling
May be unable to bear full weight
Pain is worse with movement
Plain film XRAY is adequate to assess for fx
If soft tissue injury is suspected need MRI
If XRAY is equivocal & high index for suspicion for fx CT is indicated
In transverse fx’s of Patella Sunrise view may turn a non-surgical case into a surgical case
Tibial Plateau fractures
Intra-articular fx of proximal tibia 60-70% involve lateral tibial plateau 10-20% involve medial tibial plateau Common in the elderly High energy injury in young Present with acute hemarthrosis Unable to bear weight Joint line tenderness Decreased ROM Assess for popliteal artery & peroneal nerve injury
Treatment for tibial plateau fractures
Non-displaced fxs can be treated non-operatively with a knee immobilized & non-weight bearing for 6 weeks
Depressed or displaced fxs are usually surgically repaired using screws or plates & screws & may also need bone grafting
Surgically repaired fxs require non-weight bearing for 2 to 4 weeks & progress to light touch-down weight bearing & then weight bear as tolerated after 6 weeks
Patella fracture
Largest sesamoid bone in body
Integral part of extensor mechanism
1% of all fractures
Transverse fx is most common
Can occur at any age
MOI: direct or indirect trauma or dislocation
Present with pain, swelling, & ecchymosis
Weak or absent ability to extend depends on fracture pattern
Sunrise view is for alignment for vertical fx’s not to evaluate transverse fx’s of the patella
Patella Subluxation
The kneecap is designed to fit in the center of the trochlear groove (a groove on the femur), and slide evenly within the groove
In some people, the kneecap is pulled towards the outside of the knee & does not slide centrally within its groove
Patients who experience an unstable kneecap have a kneecap that does not slide centrally within its groove
Depending on the severity of the patellar subluxation, this improper tracking may not cause the patient any problems, or it may lead to patella dislocation
Etiology of patella subluxation
Dozens of factors implicated in the cause of patellar subluxation.
Factors that lead to instabiltiy of the kneecap:
A wider pelvis
A shallow groove for the kneecap
Abnormalaties in gait
Treatment for patella subluxation
First ensure that the patella is not dislocated
X-rays are taken to see if the kneecap is outside of its groove
Patients with a patellar dislocation, the kneecap may need a closed reduction
Physical Therapy
Bracing and Taping
Better Footware
Physical therapy for patella subluxation
Strengthen their VMO (part of the quadriceps muscle) to realign the pull on the kneecap.
More recent research has shown that this is probably not the critical factor in eliminating kneecap problems. Focusing instead on strengthening of the hip abductors and hip flexors (so-called pelvic stabilization exercises) offers better control of the kneecap
Better Footwear for patella subluxation
Footwear contributes to the gait cycle.
Motion control running shoes may help control your gait while running and decrease the pressure on the kneecap.
Surgery for patella subluxation
Some patients are not cured by simple treatments
Patients who have significant pain or recurrent dislocation.
Arthroscopy helps the surgeon assess the mechanics of the knee joint to see if there is an anatomic malalignment that could be corrected.
One common malalignment is the result of too much lateral tension that pulls the kneecap out from its groove; this can place increased pressure on cartilage and lead to dislocation.
Lateral release procedure involves cutting the tight lateral ligaments & soft tissue to allow the patella to resume its normal position.
Patellar dislocation
Patellar (kneecap) dislocations occur with significant regularity, especially in younger athletes
Most of the dislocations occur laterally (outside)
Associated with significant pain and swelling.
First step is to reduce the patella into the trochlear groove
Often happens spontaneously as the individual extends the knee either while still on the field, in an emergency room or training room during the examination.
Occasionally relocation of the patella occurs spontaneously before examination
Non operative treatment for patellar dislocation
If no loose fragments immobilization of the knee for 7 to 10 days
Swelling is reduced and discomfort decreases
Slow mobilization of the knee and of the patellofemoral joint is then begun
Usually full recovery can be expected within a three to six week period
Significantly lengthened when the patellar dislocation is recurrent.
Once a patellar dislocation occurs, especially with hyperlaxity of the ligaments, which is common, recurrent dislocations can be expected
Can be significantly problematic for athletes during the season
Conservative management with rest, appropriate hip and thigh muscle strengthening, and use of a patellar buttress brace is appropriate
Operative treatment for patellar dislocation
Some situations of patellar dislocation can and/or should be treated surgically
Recurrent dislocations is most common reason
Reduces the chances for cartilage lesions on the undersurface of the patella, which often are non-reparable
Patellar stabilization procedures is performed
Can be either soft tissue or bone procedures, or a combination
First-time traumatic patellar dislocations can also be treated with these procedures
Incidence of recurrent dislocation can be as high as 40 percent
Surgically treating initial dislocations by lessening lateral tension and tightening medial restraint could reduce this recurrence rate to below 10 percent
Surgical procedures on the patella are usually done in the out-patient setting
Procedures limited to altering soft-tissue tension begin rehabilitation within a week and return to activity can be expected as early as six weeks
Procedures that require bone work (osteotomies) require a period of relative immobilization and need 10 to 12 weeks before a return to athletic activity is permitted
Tibia Fractures
MOI: most common is trauma
The most common fracture of the lower limb occurs at the tibial diaphysis
Pain with weight bearing
Fibula Fractures
MOI: rolled ankle particularly with significant weight bearing forces
May also occur due to an awkward landing from a jump (particularly on uneven surfaces), due to a fall or following a direct blow to the outer lower leg or ankle
Fibula fx may be able to bear full weight
Fibula is non-weight bearing bone
Fibula provides attachment surface for muscles
Pain with palpation, edema, & ecchymosis
Nonsurgical treatment may be recommended for patients who Tibia/Fibula Fracture Treatment
Poor surgical candidates due to their overall health problems
Are less active, so are better able to tolerate small degrees of angulation or differences in leg length
Have closed fractures with only two major bone fragments and little displacement (gap)
Initial treatment for Tib/Fib fracture treatment
Apply a long leg or stirrup splint to provide comfort and support with non-weight bearing on crutches or walker
Allows swelling to occur safely
May be placed in a long leg cast or continue with the splint & non-weight bearing if the patient is compliant
After 6 weeks in the cast, it can be replaced with a functional brace
Ankle sprains
MOI: extreme inversion injury & plantar flex
Anterior Talofibular Ligament (ATF) most commonly injured
65% isolated ATF injuries
Additional 20% involve Calcaneofibular Ligament as well
Individual Deltoid Ligament injuries are rare
Dorsiflexion & external rotation can cause damage to Syndesmosis ligament ie. High Ankle Sprain
Ankle XRAY is normal
Lateral Ankle Sprain Presentation
Edema, tenderness, & ecchymosis over lateral ligament structures
May have tenderness over lateral malleolus
May have Deltoid pain from compressive injury
Difficulty with ambulation
Syndesmotic Ankle Sprain Presentation
Tenderness over syndesmosis
Compression Test
External Rotation Test
Grade 1 ankle sprain
injuries involve a stretch of the ligament with microscopic tearing but not macroscopic tearing. Generally, little swelling is present, with little or no functional loss and no joint instability. The patient is able to fully or partially bear weight.
Grade 2 ankle sprain
injuries stretch the ligament with partial tearing, moderate-to-severe swelling, ecchymosis, moderate functional loss, and mild-to-moderate joint instability. Patients usually have difficulty bearing weight.
Grade 3 ankle sprain
injuries involve complete rupture of the ligament, with immediate and severe swelling, ecchymosis, an inability to bear weight, and moderate-to-severe instability of the joint. Typically, patients cannot bear weight without experiencing severe pain
Ankle Sprain Treatment
Usually involves immobilization for 2 – 4 weeks
Tall BKO/removable cast boot is best
Some will require crutches but can be weight bearing as tolerated (WBAT)
RICE
RICE Treatment for Ankle Sprain
Rest Ice Elevation NSAID’s or Acetaminophen Physical therapy in those who continue to have pain & weakness
Ankle Fractures
Occurs when the deforming force is sufficient to overcome the strength of the bone Unimalleolar - Lateral Malleolus - Medial Malleolus - Posterior Malleolus Bimalleolar Trimalleolar Maisonneuve Pilon Presentation varies Tender to palpation over fx site STS Deformity Ability to weight bear varies widely
Unimalleolar Fracture Treatment
Treatment depends on severity of the injury, amount of displacement of the fracture, medical condition of a patient, and age
Simple non- or minimally displaced fractures require cast immobilization for 6-8 weeks
Displaced or open fractures require surgical intervention
Both require non-weight bearing for 4 – 6 weeks
May require PT to regain strength
Bimalleolar treatment
most cases of bimalleolar fracture, the lateral malleolus and the medial malleolus are broken and the ankle is not stable
A “bimalleolar equivalent” fracture means that in addition to one of the malleoli being fractured, the ligaments on the inside (medial) side of the ankle are injured. Usually, this means that the fibula is broken along with injury to the medial ligaments, making the ankle unstable
ORIF usually involves plate & screws for the fibula fx which many times reduces the fx to anatomic position & screws are not required in the medial malleolus
If medial malleolus reduction is not anatomic then 1 to 2 screws are placed to maintain the medial malleolus in anatomic position
Trimalleolar Treatment
All three malleoli of the ankle are broken
Unstable injuries
Often associated with a dislocation
Treatment includes reduction of dislocation (if necessary) & reduction of the fracture
Next step is to use a plate & screws to fix the fibula
Then a screw or pins is used to reduce & fix the medial &/or posterior malleoli fx
Maisonneuve fractures
involve a fracture of the proximal fibula in association with a fractured medial malleolus (or injured deltoid ligament) and diastasis of the distal tibiofibular syndesmosis
MOI: external rotation force to ankle w/ transmission of the force thru the interosseous membrane, which exits thru a proximal fibular fracture;
Patients present with proximal fibular pain in addition to medial ankle pain
Unstable ankle injury
Non operative treatment for Maisonneuve fractures
- exam under anesthesia is advised to evaluate degree of instability; - if stable, then long leg cast w/ frequent f/u w/ care that reduction is not lost after swelling has subsided; - in the following example, the fx was thought to be stable until the fx lost reduction w/ stress testing
Surgical treatment for Maisonneuve fractures
proximal fibular fx requires no fixation; - need to reaaproximate syndesmosis - may require 2 screws for two points of fixation;
Post Op: - short leg non wt bearing cast for 6 weeks
Tibial Plafond Fractures
tenderness along the distal tibia and may have severely decreased range of motion in the ankle
MOI: vertical loading drives talus into distal tibia
position of foot & rate of loading affects injury pattern
important to distinguish between low energy fx (from skiing) vs high energy fx (as from MVA);
plantar flexion: posterior articular damage;
dorsiflexion: anterior articular damage
Treatment is usually ORIF
Syndesmotic Injury
Syndesmosis joint is located between the tibia and fibula, and is held together by ligaments
Syndesmosis joint is located between the tibia and fibula, and is held together by ligaments
These sprains take longer to heal than the normal ankle sprain.
Syndesmotic injury sometimes includes both a ligament sprain and one or more fractures
These are unstable injuries and they do very poorly without surgical treatment
Talus Fractures
Most injuries to the talus result from motor vehicle accidents, although falls from heights also can injure the talus
Often associated with injuries to the lower back
Increasing number of talar fractures result from snowboarding, which uses a soft boot that is not rigid enough to prevent ankle injuries
Talus is unique in that no tendons attach to it & it is held in place by ligamentous and bony structures
The talus articulates superiorly with the tibia, medially and laterally with the medial and lateral malleoli (respectively), inferiorly with the calcaneus, and anteriorly with the navicular.
What can fractures of the talus lead to?
Fractures of the talus can lead to avascular necrosis (AVN), arthritis, and, when unrecognized, chronic pain and nonunion
Non surgical treatment for fractures
Non-surgical treatment is recommended for fractures in which the pieces of bones remain close together and the joint surfaces are well aligned
Patients who smoke or have diabetes or poor circulation may be treated without surgery due to the very high risk of developing complications if surgery is performed
Most patients will require an ORIF
Post-op non-weight bearing for 8 – 12 weeks with crutches or a walker
Stable fracture
This type of fracture is nondisplaced. The broken ends of the bones meet up correctly and are aligned. In a stable fracture, the bones usually stay in place during healing.
Displaced fracture
When a bone breaks and is displaced, the broken ends are separated and do not line up. This type of fracture often requires surgery to put the pieces back together.
Open Fractures
Broken bones that break through the skin are called open, or compound. These types of injuries often involve much more damage to the surrounding muscles, tendons, and ligaments. Open fractures have a higher risk for complications and take a longer time to heal.
Closed Fracture
With this injury, the broken bones do not break the skin. Although the skin is not broken, internal soft tissues can still be badly damaged.
Comminuted fracture
This type of break is very unstable. The bone shatters into three or more pieces.
Calcaneal Fractures
Most often occur during high-energy collisions — such as a fall from height or a motor vehicle crash
Because of this, calcaneus fractures are often severe and may result in long-term problems
The severity of a fracture usually depends on the amount of force that caused the break.
Surgical and non surgical for calcaneal fracture
Nonsurgical Treatment
If non- displaced immobilization with a Jones Dressing, Cast shoe, & non-weight bearing with crutches or walker for 6 – 8 weeks or longer depending on healing progress
Surgical Treatment
If displaced surgery is usually indicated
Foot Fractures
MOI: twisting or crush most common
Present with pain, edema, difficulty ambulating
XRAY foot if tender over metatarsals & cuneiforms
XRAY toes if tender over phalanges
Jones Fracture
- transverse fx distal to the metatarsal-
cuboid joint- usually occurs in the absence of inversion
Avulsion Fracture of 5th metatarsal
- sudden inversion of plantar flexed foot
- usually extra articular
- symptoms can mimic ankle sprain
5th Metatarsal Avulsion Fracture Treatment
Immobilization with a short BKO/removable cast boot for 6 weeks
WBAT
Follow up x-ray in 3 weeks
Significant displacement may require ORIF with a screw placed to stabilize the fragment
Jones Fracture Treatment
Jones Dressing with a fracture shoe & WBAT
Short BKO/removable cast boot with WBAT
Mostly a stable fracture & rarely requires surgery except if it becomes a non-union
Lisfranc Fracture
Fracture dislocation of the tarsometatarsal joint
MOI: crush injury or rotational force on a plantar flexed forefoot
XRAY of foot usually sufficient, but may require CT
Non surgical treatment for Lisfranc Fracture
If there are no fractures or dislocations in the joint and the ligaments are not completely torn, nonsurgical treatment may be all that is necessary for healing
Nonsurgical treatment plan includes wearing a non-weightbearing cast for 6 weeks
Strict non-weight bearing for 6 weeks
Progresses to weightbearing in a removable cast boot or an orthotic.
Follow up x-rays are taken to make sure your foot is healing
If there is any evidence that the bones in the injured joint have moved, then surgery will be needed to put the bones back in place
Surgical Treatment for Lisfranc Fracture
Surgery is recommended for all injuries with a fracture in the joints of the midfoot or with abnormal positioning (subluxation) of the joints
Goal of surgical treatment is to realign the joints and return the broken (fractured) bone fragments to a normal position
Internal Fixation for surgical treatment for Lisfranc fracture
the bones are positioned correctly (reduced) and held in place with plates or screws. Because the plates or screws will be placed across joints that normally have some motion, some or all of this hardware may be removed at a later date. This can vary from 3 to 5 months after surgery, and is at the surgeon’s discretion.
Fusion for Lisfranc Fracture
If the injury is severe and has damage that cannot be repaired, fusion may be recommended as the initial surgical procedure
A fusion is essentially a “welding” process to fuse together the damaged bones so that they heal into a single, solid piece.
Lisfranc injuries that may require fusion include joints that cannot be repaired with screws or plates or when the ligaments are severely ruptured.
The hardware will not need to be removed because the joints are fused and will not move after they heal.
Rehab for Lisfranc Fracture
After either surgery (reduction or fusion), a period of nonweightbearing for 6 to 8 weeks is recommended in a cast or cast boot
Weightbearing is started while the patient is in the boot if the x-rays look appropriate after 6 to 8 weeks
The amount of weight a patient can put on their foot, as well as the distance the patient is allowed to walk, is at the surgeon’s discretion
Impact activities, such as running and jumping, should be avoided until the hardware has been removed.
Metatarsal Fracture
First metatarsal is larger and more important for foot function than the other metatarsals,
Misalignment of a first metatarsal fracture is less well tolerated than misalignment of a lesser metatarsal
Adjacent metatarsals act as splints for a fractured metatarsal
Therefore, metatarsal fractures are usually not displaced unless there are multiple fractures or the fracture is near the metatarsal head
When displacement does occur, the metatarsal head usually displaces in a plantar direction as a result of traction from the flexor tendons and intrinsic muscles of the foot
MOI for metatarsal fractures
MOI: most shaft fractures are caused by direct blows or twisting forces
Patients typically present with pain, swelling, ecchymosis, and difficulty walking
Swelling is often severe, especially if the patient has not elevated the foot
There is usually point tenderness over the fracture site
Applying an axial load to the head of a fractured metatarsal usually produces pain at the fracture site
This maneuver should not be painful in patients with soft tissue injury alone
non displaced metatarsal fracture
metatarsal shaft fractures may be treated with a soft, padded elastic dressing or immobilized in a posterior splint for 6 weeks
Crutches and weight bearing allowed as tolerated (WBAT)
RICE
Follow up x-rays in 2 – 3 weeks to make sure alignment is maintained & early signs of healing have occurred
Stress Fracture
Abrupt increase in activity or chronic overload may cause a stress fracture of the metatarsal shaft
Initially, pain occurs only with activity
Point tenderness is often present over the fracture, and axial loading of the metatarsal head may produce pain at the fracture site
If the injury is not allowed to heal, worsening pain, swelling, and even frank fracture may occur
Stress Fracture treatment
Stress fractures of the metatarsal shaft usually heal well with immobilization, in part because of excellent blood supply
They typically respond well to cessation of the causative activity for four to eight weeks
If walking causes pain, several weeks of using crutches and partial weight bearing may be helpful
A non–weight-bearing, short leg cast can be used for one to three weeks in patients with severe pain
After four to eight weeks of treatment, pain typically resolves
Activities can then be gradually resumed
Recurrence is possible if activities are resumed prematurely or too rapidly
Custom orthotic may benefit certain foot structures, such as a rigid or long second metatarsal, but clinical trial evidence for injury prevention is lacking
Toe fractures MOI
MOI: direct blow, twisting or crush injury
Toe fracture
Tenderness to palpation at the fracture site
Lacerations are common with crush type injuries
Subungual hematoma can occur
Treatment usually involves buddy taping for non-displaced fractures
Closed reduction after digital block may be needed for displaced fxs
Some displaced unstable fxs may need to be pinned
Lacerations need to be repaired & abx initiated
Open fx’s should go to the OR for debridement, irrigation & fx reduction
Subungual hematomas require trephination
