Lower Limb Fractures

Question 1

What is the most common fracture in the elderly population

Answer 1

Femoral neck fracture
- risk increases with age and osteoporosis
Can occur in the young population after a high energy trauma

Question 2

What are the anatomical classifications of a femoral neck fracture?

Answer 2

Intracapsular fracture
- occur within the joint capsule (proximal to intertrochanteric line)
Extracapsular fracture
- occurs distal to the joint capsule (involving or distal to the trochanteric line)

Question 3

Why does the site of a femoral fracture matter

Answer 3

Relationship to blood supply

• femoral head receives supple from the femoral neck
• an intracapsular fracture disrupts this blood supply and can cause avascular necrosis

Question 4

How are intracapsular fractures managed

Answer 4

Usually require surgical intervention to prevent AVN

• undisplaced = internal fixation (DHS)
• displaced = hemiarthroplasty
• total hip arthroplasty is they have symptomatic, pre-existing arthritis, or if the patient is very high functioning (elderly)
• children/young adults can have reduction and fixation

Question 5

How are extracapsular fractures managed

Answer 5

Only requires closed reduction and open fixation with DHS

Question 6

What are the complications of a femoral neck fracture

Answer 6

Mortality (20% at 90 days)
AVN of femoral head 
Dislocation of arthroplasty 
Loss of fixation 
Non-union 
Lower limb thromboembolic disease

Question 7

What are the risk factors for osteoporosis

Answer 7

Steroids 
Hyperthyroidism 
Alcohol
Thin
Testosterone (decrease)
Early menopause (female)
Renal/liver failure 
Erosive/inflammatory bone disease e.g. RA
Dietary 

Family history
Age

Question 8

What is a T-score

Answer 8

Bone mineral density compared to that of a healthy young adult
- T-score is the number of standard deviations the patients bone mineral density is from average

Question 9

T-score results meaning

Answer 9

T-score > 0 = BMD better than the reference range
T-score 0 to -1 = no evidence of osteoporosis
T-score -1 to -2.5 = osteopenia, increased risk of osteoporotic fracture
- requires lifestyle advice
T-score

Question 10

What is the management of femoral neck fracture, post-surgery

Answer 10

Bisphosphonates - reduce risk of recurrence, regardless of BMD
Calcium and vitamin D
Rehab
- fall-prevention assessment (med review, removing hazards in home, assessing muscle strength, balance and gait)
- home/osteoporosis/skilled nursing facilities
- early ambulation
Nutritional concerns need addressing
Periodic X-Ray to assess AVN risk (MRI if unsure)

Question 11

Two types of pelvic fractures

Answer 11

Low energy insufficiency

High energy fracture

Question 12

Describe a low energy insufficiency pelvic fracture

Answer 12

Age >60 years
Fall from standing height
Can be displaced, non-displaced and usually involves both the anterior and the posterior pelvis

Question 13

Describe a high energy pelvic fracture

Answer 13

Age <60 years
Caused by a RTA, fall from height or sports (e.g. horse riding)
- requires a lot of force

Question 14

Clinical features of a pelvic fracture

Answer 14

Inability to weight bear
Pelvic pain
Pelvic tenderness
Unstable pelvis on palpation
Haematuria 
Haematoma over ipsilateral flank, inguinal ligament, proximal thigh or perineum 
Lower limb neurovascular deficits 
- PR for tone and sensation 
Rectal bleeding
Instability and pain on hip adduction
- indicates acetabular fracture 
PR and vaginal exam to assess occult fracture

Question 15

Initial management of pelvic fracture

Answer 15

ABCDE
X-Ray
- anterior-posterior
- inlet
- occult
CT - for posterior pelvic structures

Question 16

Management of a stable (single ring) pelvic fracture

Answer 16

Bed rest
Analgesia
Early mobilisation

Question 17

Management of an unstable (multiple ring) pelvic fracture

Answer 17

Liable to massive haemorrhage
- due to tearing of posterior presacral venous plexus
ABCDE
Establish haemodynamic control
- fluid resuscitation
- X-match/O negative blood if needed
- pelvic binder for external hemorrhage control
Refer to orthopaedics
- external fixation followed by ORIF/screw fixation

Question 18

Why are hip dislocations a surgical emergency

Answer 18

Damage to local nerves and blood vessels occurs as the femoral head is forced from the socket
- typically requires an extreme amount of force
- damage to blood vessels: AVN
- damage to nerves: sciatic nerve damage
Posterior dislocation (90%) or anterior dislocation (10%)

Question 19

Why is a knee dislocation a surgical emergency

Answer 19

High rate of vascular injury - in both high and low impact cases

• assess limb perfusion (may require emergency vascular repair and fasciotomy)
• peroneal nerve injury

Question 20

Common causes of femoral fractures

Answer 20

High energy in young people

• RTA
• fall from height

Question 21

Why can a femoral fracture be an emergency

Answer 21

Association with major haemorrhage

• 1000-1500mls of blood can be lost into the femoral shaft (closed
• double that if open

Question 22

Emergency management - femoral fracture

Answer 22

ABCDE
Haemodynamic control - IV fluids, bloods (X-match)
Realign fracture and Thomas splint leg
- control pain and haemorrhage to allow X-Ray to be taken
External fixation - used in damage control scenarios and replaced at a later date
Full secondary survey

Question 23

Operative management - femoral fracture

Answer 23

Locked and reamed intramedullary nailing to provide rotational stability
Plate and screw- if ipsilateral NOF #
Traction splint if too sick for surgery

Question 24

Tibial fracture - complications

Answer 24

Compartment syndrome
- can occur in open and closed
- higher risk when lower leg damaged (vs thigh)
Mal/non-union
Knee pain
Malrotation
Nerve injury (during operative management)

Question 25

Tibial fracture - emergency management of open fracture

Answer 25

ABCDE
Fracture reduction 
Assess neurovascular status 
Normal management of open fracture 
- IV antibiotics, photo, remove gross contamination, tetanus vaccine, application of saline soaked gauze and immobilisation with splint

Question 26

Ankle fracture-dislocation - emergency management

Answer 26

Immediate closed reduction and backslab before X-Ray

• due to risk to blood vessels and nerves
• check neurovascular status before and after

Question 27

Ankle fracture-dislocation - management of a stable injury

Answer 27

Lateral malleolus with no talar displacement
- Weber A/B
Below-knee cast for 6 weeks
- post-cast X-Ray needed to check position
- allows weight-bearing

Question 28

Ankle fracture-dislocation - management of an unstable injury

Answer 28

Minimal displacement (2mm or less)
- acceptable in the elderly, treated as a stable fracture
Weber B/C fracture with medial tenderness or talar shift
- ORIF
- post-op cast (non-weight bearing for 6 weeks as fracture heals)

Question 29

Ankle fracture - most common type

Answer 29

Distal fibula fracture (and pilon)

Question 30

Metatarsal bone - fracture patterns

Answer 30

Avulsion fracture of 5th metatarsal
- twisting injuries (inversion)
- causes avulsion of the proximal tuberosity
Metatarsal shaft fractures
- diaphyseal, metaphyseal
- caused by crush injuries (car running over foot)
- less common

Question 31

Lisfranc injury

Answer 31

Disruption of articulation between the medial cuneiform and base of the second metatarsal

• high energy fracture pattern
• also causes incongruity between 2nd metatarsal and intermediate cuneiform (TMT joint)