Lower Limb Fractures Flashcards
Mortality of NOF?
30%!!
Similar for ALL proximal femoral #s
Define INTRA and EXTRAcapsular hip fractures:
INTRA
- Head
- Neck
–> Subcapital
–> Cervical
At risk of avascular necrosis!
EXTRA
- Intertroch
- Subtroch
- Greater troch
- Lesser troch
Describe blood supply to hip, and its relevance in NOF:
Mostly circumflex arteries that come off the deep femoral
These go up under capsule and give retrograde supply to neck and head
–> INTRAcapsular fractures at risk of AVN
Small proximal supply to fem head (artery of ligament of head of femur, off obturator)- but very minimal.
Garden Classification:
For NOF
Predicts risk of AVN- ie. urgency.
I- Undisplaced, incomplete
II- Undisplaced, complete
–> ORIF
III- Displaced, hinge/tilt/rotate
IV- Displaced
–> Hemi/arthroplasty (*risk of AVN too high)
Shenton line
NOF
3 major complications of femoral shaft fracture:
- Haemorrhage (up to 1.5L)
- Compartment syndrome
- Deep femoral artery/ nerve
- Fat embolism
Describe how to reduce and splint this injury:
Should be done emergently in DEM.
- Titrated IV opioid
THEN - Fascia iliaca/ femoral nerve block
- Longitudinal traction in full extension
- Immobilise with:
–> Donway
–> Hare
–> (Thomas) - NV obs
How are femoral shaft fractures managed in toddlers?
Age < 5 = hip spica
How much skin traction should be applied to a femoral shaft fracture?
10% of body weight
How are distal femoral fractures classified:
Supracondylar
Intercondylar
Isolated condylar
What injury is this? What is its significance?
Metaphyseal corner fracture
AKA Bucket Handle #
Soft, poorly mineralised corners (long bones) crush off- usually from shaking
Most specific pattern for NAI
Management of this:
Bipartate patella- NOT FRACTURE
Patella fracture not well-corticated (see below)
–> Cast in full extension
ORIF if extensor mechanism lost, or >2mm displacement
Tibial plateau #
LOOK FOR:
- Contour
- Density change (thick or thin)
- Condylar line (<5mm overlap)
-?Segond
Usually associated with extensive soft tissue injury
–> cruciates, menisci
–> haemoarthrosis
–> compartment Sx
Schatzker classification
Almost all ORIF
What soft tissue injury is classically associated with this?
ACL rupture (75%)
Medial meniscus (70%)
This is a Segond #
Which important structure can be injured in fibular head/ proximal fibular #? How to test for it?
Peroneal nerve
MOTOR:
- Foot drop
SENSORY:
- Whole front and sides of leg and foot
What injury is this?
Maisonneuve
Fracture of:
- PROX fibula
+
- Wide mortise (usually ligamentous injury of tibfib syndesmosis)
Pronate + external rotation
Unstable
ORIF
Risk to peroneal nerve (foot drop)
Management of this #?
Always check for **?Maisonneuve*
Undisplaced prox fibula
–> NWB on crutches
–> No need for plaster unless displaced
Check peroneal nerve
- Foot drop/ dorsiflex
- Sensation to front/sides of leg and foot
Fibula is non-weightbearing. It is an ankle stabiliser.
Toddler #
Spiral or oblique and undisplaced
Mobile kids, up to 3yo
Twisting mechanism
MAY NOT BE VISIBLE on initial XRay
–> May see only a periosteal reaction
–> POCUS may help
Above-knee for 3 weeks
–> If suspected but not seen, can do same and reXR 10d
Not suspicious is isolation.
Tibial plafond
AKA pilon
Almost never in isolation (bimall here)
Unstable and intraarticular
ORIF
Ottawa Ankle Rules
Tenderness at any of:
- Posterior to malleoli (6cm)
- Base of 5th
- Navicular
AND
Inability to weight bear immediately AND in ED
Which ankle ligament is most commonly sprained?
ATFL
With INversion
Describe the ankle examination:
WHOLE fibula
–> *Maisonneuve: fibula # with medial ankle instability (either deltoid inj/ med mall#)
Ottawa Areas
- On/ behind malleoli
- Base of 5th
- Navicular
Anterior Drawer
- ATFL
Talar tilt
Squeeze Test
- Talofibular syndesmosis
**
Which neurovascular structures are at risk in an ankle fracture?
MEDIAL
- Posterior tibial artery
- Posterior tibial nerve
- Great saphenous vein
LATERAL
- Small saphenous vein
- Saphenous nerve
- Sural nerve
Danis-Weber classification (and Mx of each type)
Distal fibular # (lat mall)
Relative to syndesmosis
Weber A- below
- Stable
- Tx like sprain. CAM boot
Weber B- through
- Get weight bearing/ mortise views
- If mortise/ tibiofib instability (stress/ weight bearing mortise views) or significant medial ligamentous laxity - treat as unstable with slab.
Weber C- above
- Unstable
- Syndesmosis always disrupted
- Usually bimalleolar
- Plaster
Talar (neck) #
High-force injury
–> *look for ankle/ subtalar joint disruption
- Head (rare)
- Neck (50%)
- Body (lateral avulsion in sport)
- Dome
Risk of avascular necrosis
–> Hawkins classification
If displaced, all need urgent reduction
CAM is okay for avulsions
Navicular #
Most common midfoot #
At risk of AVN
Plaster or ORIF
Lisfranc Injury: (#/sublux/disloc)
- Planted rotation
- OFTEN MISSED- 20-40%!!
- Potentially disabling
‘Lisfranc joint’ complex:
Lisfranc ligament joins base of 2nd with medial cuneiform
OE/
Can’t weight bear on toes
Ecchymosis to sole
Piano key
Metatarsal squeeze
Weightbearing XR
- Fleck Sign (subtle)
- Widening
<2mm widening, no #-
can be conservative with NWB. Slow and painful.
Almost all for OT.
How are Lisfranc injuries classified?
Relative to Lisfranc joint:
- 1st displaces medial
- All 5 displace med or lat
- Divergent/ splaying
Management of phalynx #:
Reduce under digital block
Buddy strap
Stiff shoe for 3 weeks
If great toe, # clinic.
Calcaneal #
Vertical compression/ landing
Not good:
Associated injuries +, including vertebral (10%)
Mostly intraarticular
Risk of compartment syndrome
Chronic pain/ disability common
XR:
May need calcaneal views
–> Flattened Bohler’s angle <20 deg
Mx:
These suck. Slab and talk to ortho.
Often admit and watch for compartment Sx +/- operative planning
What does this XR show?
A normal calcaneal growth plate!
Appears 5yo
Fused by 15yo
What is a normal Bohler’s angle?
20 - 40 deg
<20 deg = calcaneal #
Management of metatarsal head/ neck/ shaft fractures.
Most = CAM boot
Great toe = plaster
Reduce if >3mm, 10 deg angulation
Base of 5th #s
Zone 1: tuberosity, pseudojones #
–> INVERSION
–> Avulsion, minor
–> Stiff shoe
Growth plate in same area can look similar!
Zone 2: Jones #
–> ADDUCTION
–> Watershed area, prone to non-union (10 -30%)
–> Involves 4th/5th articulation
–> Plaster and full NWB for 6 weeks minimum
Zone 3: Stress #
–> Associated with deformity and neuropathy
–> Same as Jones
Management of phalangeal #:
Most = Buddy strap
Great toe = CAM 3 weeks
Schatzker Classification:
Tibial plateau
1- Have just split up. Feeling alone and on the outside
2- Feeling really depressed from the split
3- Now just pure depression
4- You’re coming out other side too now
5- Starting to see both sides of the break up
6- Complete mess after running into them again
Tilleaux #
Salter-Harris III of distal tibia
—> anterolateral (medial fuses first)
Children + adolescents
