Lower Leg Fractures

Question 1

distal femoral fracture

Answer 1

usually osteoperotic bone with fall onto flexed knee

can be extra articular (supracondylar) or intra articular (intercondylar)

usually fixed with a plate and screws as fracture position is difficult to maintain in cast

Question 2

proximal tibial fracture

Answer 2

intra-articular

associated neurovascular injury and compartment syndrome

often due to valgus stress - lateral tibial plateau fracture

if they are high energy there is often substantial soft tissue damage

CT to determine fracture personality

ORIF (plates and screws)

disappointing surgery results - post-traumatic OA, and subsequent TKR

Question 3

how is fracture with substantial soft tissue damage managed

Answer 3

external fixator spanning the joint for inital stability while swelling resolves

then definitive ORIF

Question 4

tibial shaft fracture

Answer 4

Tibial shaft fractures usually occur with indirect force and either bending (transverse fracture) or rotational energy (spiral fracture), compressive force from deceleration (oblique fracture), a combination of these forces or from high energy injuries (comminuted fracture).

open fractures not uncommon due to tibial shaft being subcutaenous

Question 5

what is the most common cause of compartment syndrome after trauma

Answer 5

tibial shaft fracture

Question 6

non operative treatment of tibial shaft fractures

Answer 6

up to 50% displacement and 5 angulation can be tolerated with conservative management. any internal rotation is poorly tolerated

frequent cast changes and x rays

Question 7

what happens to the position of the tibia if the fibula is not fractured after tibial shaft fractures

Answer 7

fibula not fractured - tibia drifts into varus

fibula fractured - tibia drifts into valgus

Question 8

operative treatment of tibial shaft fractures

Answer 8

tibia is one of the slowest healing bones (16 weeks). several healing techniques - no single best.

internal fixation using IM nails - control fracture position and remove need for cast

Question 9

what is not tolerated by the tibia

Answer 9

internal rotation

Question 10

extra articular distal tibial fracture in acceptable position

Answer 10

treat conservatively

Question 11

intra articular distal tibial fracture

Answer 11

Pilon fracture

usually high energy - check for other injuries

surgical emergency - ORIF

if there is significant soft tissue damage, externally fixate until soft tissue swelling settles

Question 12

what investigation is best for Pilon fractures

Answer 12

CT

Question 13

what does the Ottawa criteria describe

Answer 13

used to identify suspected ankle fracture and give guidance on use of x rays

basically if there is bony tenderness x ray or inability to bear weight - x ray

Question 14

isolated distal fibular fracture treatment

Answer 14

stable - treat conservatively

walking cast/splint for around 6 weeks

Question 15

distal tibial fracture/rupture of deltoid ligament

Answer 15

unstable

ORIF

Question 16

what does talar shift/tilt imply

Answer 16

that deltoid ligament must be ruptured

risk of post traumatic OA

• anatomic reduction and rigid fixation reqired to minimise talar shift

Question 17

bimalleolar fractures

Answer 17

• Pott’s
• unstable and can cause talar shift
• ORIF

Question 18

midfoot fracture

Answer 18

Lisfranc fracture

fracture at base of 2nd metatarsal is associated with dislocation at base of it with/out dislocation of other metatarsals

typically a swollen, bruised foot which is unable to be weight born on

easily missed on x ray - if clinical suspicion get X ray

ORIF recommended

Question 19

metatarsal fracture

Answer 19

5th commonly

• due to inversion with avulsion at insertion of fibularis brevis. heal well: cast, bandage or stout boot

1st uncommon, but important so fixture is recommended

2nd - common for stress fracture

• may not appear on x ray until callus formed, bone scan can aid diagnosis. Apply cast

Question 20

toe fractures

Answer 20

usually do nothing - stout boot?

intra articular at base of proximal halanx of hallux may benefit from reduction and fixation

open - debride

dislocated - strap to neighbour

Question 22

what movement are tibial shaft fractures assoicated with

Answer 22

twisting

Question 23

what movement are distal tibial fractures associated with

Answer 23

sudden deceleration after fall from height

Question 24

fall onto flexed knee

Answer 24

distal femoral fracture

Question 25

calcaneal fractures

Answer 25

• fall from height onto heel
• can cause compartment syndrome
• manage with ORIF