lower limb fracture

Question 1

Transitional ankle fractures
1. triplanar fracture
2. tillaux fracture

Answer 1

Transitional fractures due to ossification in a set order:
central > anteromedial > posteromedial > lateral

Tillaux Fractures
- Salter-Harris III fracture of the anterolateral distal tibia epiphysis
- anterior inferior tibiofibular ligament
- older children
- >2mm = ORIF - cannulated screw

Triplanar fracture
- Overall salter harris IV
- AP salter harris III and lateral salter harris II
- epiphysis and metaphysis
- younger adolescents
- >2mm displacement = ORIF
- epiphyseal screw parallel to the physis
- metaphyseal screw

Question 2

management of proximal tibial epiphyseal fracture

Answer 2

risk:
- peroneal nerve injury
- popliteal artery tethered to posterior aspect of the tibia
- compartment syndrome - anterior tibial recurrent artery
- ligamentous injuries
- recurvatum - late

treatment options:
- non-op cast slight flexion
- Operative - CRRP vs ORIF

CRRP
- cannulated compression screws parallel to physis
- smooth pins if transphyseal

ORIF
- displaced >2mm
- periosteum blocking reduction
- midline anterior approach inferior pole of patella to tibial tubercle
- cannulated compression screws or smooth pins

Question 3

management of tibial tubercle fractures

Answer 3

Risks
- compartment syndrome - anterior tibial recurrent artery
- meniscal injury

features
- haemarthrosis/ swelling
- extensor lag

Managment
Non-op
cast 6 weeks
<2mm displacement

Operative
- midline incision and parapatellar approach
- remove periosteum
- reduce and fix with 4mm cannulated partially threaded cancellous screws
- assess joint surface and meniscus

Question 4

femoral shaft fracture management?
<6months

Answer 4

< 6 months
pavlik harness - dynamic splint
gallows traction - risk of AVN in heavier/ older child - limited to 12-18months
- 1lb and 1 week per year of life

6 months - 5 yrs
- traction - balanced traction - can be useful for NAI assessment
- spica - 1.5 legs - fracture to ankle other to knee - 90/90 hip/knee flexion - rotation is key

> 5yrs - skeletal maturity
<50kg - length stable - elastic nailing
more than50kg or length unstable
- submuscular plating
- ex-fix
- lateral entry point nail
- preserve lateral epiphyseal artery

Question 5

principles of elastic nailing

Answer 5

aim of fixation:
- reduce and stabilise fracture

principle of action
- bracing system of the 2 nails
- each nails bears against the bone at 3 points

each nail 40% isthmus
2 nails in femur to fill canal
bent - 3x diameter of bone canal
apex of bow at apex of fracture site
stay in for 1 yr
increase stability with an endcap to increase hold in bone
entry points - distal femur prox to physis - under II
retrograde