Lower limb injuries Flashcards
Sign of femoral neck fracture?
Shortened, flexed and externally rotated limb
Shenton’s line interrupttion
Surgical emergency in the young:
Displaced intracapsular fractures of the femoral neck
What are the three types of intracapsular fractures of the femoral neck?
Subcapital
Transcervical
Basicervical
Which blood vessels are associated with the femoral neck?
Lateral and medial circumflex arteries from the femoral give branches to the neck
These include the lateral epiphyseal arteries and the posterior superior retinacular arteries
Three major types of femur neck fracture:
Intracapsular
Intertrochanteric
Subtrochanteric
Garden classification of fractured neck of femur:
I = vagus impacted II = non-displaced III = complete: partially displaced IV = complete: fully displaced (III+IV are unstable)
What is trochanteric pain syndrome?
Inflammation/trauma in muscles, tendons, fascia or bursar
Women > Men; 40-60 y/o
What is trochanteric pain syndrome concurrent with?
Low back pain
OA of the knee
RA
Fibromyalgia
What is osteitis pubis?
Inflammation of the pubic symphysis and surrounding structures from repetitive trauma + opposing shearing forces in the symphysis
What is piriformis syndrome?
Neuropathy due to entrapment of the sciatic nerve
What causes entrapment of the sciatic nerve?
Trauma to buttocks
Scarring and fibrosis around nerve due to piriformis strain
Branches of nerve passing through a bifid piriformis
Sign of piriformis syndrome?
Wallet sign
Paraesthesia when sitting on wallet
What is athletic pubalgia?
Damage to soft tissue in groin area
aka sports hernia
What is femoacteabular impingement?
Abnormal contact between ant fem head and acet rim
Cam = non-spherical fem head causes abnormal forces in hip flexion
Pincer = over-coverage of the femoral head by the acetabulum
Management of fractured shaft of femur:
Assess neurovasculature
Blood loss of 0.75-1L = start IV fluids and send blood for G and S
IV analgesia and donway splint + ortho referral
What does the Drawer test test?
The stability of the anterior cruciate ligament
Must relax hamstrings at 80 degree angulation
What are Ottawa’s knee rules that warrant knee X-ray?
Age > 55 Isolated tenderness of the patella Tenderness at head of fibula Inability to flex 90 degrees Inability to bear weight immediately/ED (4 steps)
Which X-rays are ordered for a knee?
AP + Lateral views
Skyline view for patellar problems
Tunnel view for intercondylar area (e.g. loose bodies)
Sunrise view for vertical patellar fracture
Management of fractured patella?
Elderly = bandage with ortho opinion Young = POP cylinder/cricket splint + patient may walk Displaced/comminuted = internal fixation/excision, admit
Management of dislocated patella:
Reducible under N2O mostly X-ray to exclude osteochondral fracture Aspirate if large effusion 1st = POP cylinder/crickent splint and may walk Recurrent = compression bandage
When is an apprehension test carried out?
If a dislocated patella is self re-located
What is a Segond fracture?
Avulsion fracture of the lateral aspect of the proximal tibia below the articular surface
What causes a Segond fracture?
Internal rotation and stress tensing the lateral capsular ligament
Associated injuries with the Segond fracture:
Tear of the anterior cruciate ligament (75-100%)
Injuries of medial and lateral menisci (66-70%)
Avulsion fracture of fibular head/Gerdy tubercle
What is an avulsion fracture?
Small chunk of bone attached to a tendon/ligament gets pulled away from the main bone
What is the protocol with identifying a second fracture with a Segond fracture?
MRI to assess ACL, menisci and other structures
Fractured tibial condyle may require…
Internal fixation
What should you order with an intercondylar tibial fracture?
Tunnel view X-ray
What should you do in the case of a fracture to the tibial shaft +/- fibula?
Check the neurovascular status and the compartments
If tibial fracture is due to direct blow what should you do?
Admit for 24 hours observation to make sure compartment syndrome does not occur
When should you admit a tibial fracture?
If direct blow
If open or displaced
Management of pre-tibial lacerations?
Avoid suturing unless very distracted wound edges
Management of fractured fibula shaft from direct blow?
Crepe bandage
Exclude compartment syndrome
Exclude common peroneal nerve injury if at neck
Where is compartment syndrome more common?
Gluteal and peroneal compartments
Signs of compartment syndrome:
Pain out of proportion - active and passive
Paraesthesia, pallor, paralysis, pulseless (pulse presence does not exclude compartment syndrome)
Diagnosis of compartment syndrome:
Pressure >20mmHg is abnormal and >40mmHg is diagnostic
Treatment of compartment syndrome:
Fasciotomies
Complications of compartment syndrome:
Myoglobinuria causing renal failure and requiring IV fluids
Necrosis - requiring debridement and possibly amputation
Which fractures are most likely to cause compartment syndrome?
Supracondylar fractures
Tibial shaft fractures
80-85% of inverted ankle sprains are due to what?
The anterior talofibular ligament
others include calcaneofibular ligament
What are the Ottawa ankle rules for ordering a lateral view X-ray?
Pain in malleolar zone + either:
Bone tenderness at posterior tip of lateral malleolus
OR inability to bare weight immediately/ED
What are the Ottawa ankle rules for ordering a medial view X-ray?
Pain in mid-foot zone + either:
Bone tenderness at base of 5th metatarsal
OR bone tenderness at the navicular
OR inability to bare weight immediately/ED
What signs in the context of ankle fractures are considered abnormal?
Tibiofibular overlap <10mm (syndesmotic injury)
Tibiofibular clear space >5mm (syndesmotic injury)
Talor tilt >2mm
What is a type A Weber fracture?
Tip of lateral malleolus fracture closest to ankle
What is a type B Weber fracture?
Fracture of lateral malleolus further up, may be medial damage
What is a type C Weber fracture?
Fracture of fibula higher up still with potential medial involvement
Management of Weber A:
POP + walking if only tip
BKBS and non weight-bearing for 3 weeks if undisplayed oblique fracture
Displaced/gap between bone ends then referral
Management of Weber B:
If stable then POP with walking
If undisplayed fracture of lateral malleolus + medial malleolus/swelling over deltoid ligament with no talar shift then refer
If displaced/lateral talar shift then internal fixation
Management of Weber C:
Non-displaced = non-weight bearing BKBS for 3 weeks
Displaced/lateral talar shift = admission
Management of ankle fracture if circulation in jeopardy?
Reduce immediately under Entonox + chocolate before X-ray
What is Simmond’s test?
A test for tendoachilles tear
Normally supine squeeze of calf muscle will cause plantar flexion
This reflex will not be present in tear
What should you consider with achilles tendon tear?
RA SLE Renal failure Hyperparathyroidism Hyperlipoproteinuria Gout
Management of achilles tendon tear?
Operative
Indications of calcaneus fracture?
Fall from height
Associated spinal and pelvic injuries
Bohler’s angle >20 degrees
Risk with calcaneus fracture?
Compartment syndrome
Which is the most common metatarsal fracture and what is the management?
5th metatarsal
Treatment is symptomatic - BKPOP for 3-4 weeks for pain
Double tubigrip for swelling
Differential between Jones’ and pseudojones’ fracture:
Jones’ fracture occurs at the metaphyseal-diaphyseal junction and involves the 4th-5th metatarsal articulation
Pseudojones’ fracture involves the proximal tubercle
Jones is caused by a sudden change in direction whereas Pseudojones is caused by landing on the ankle awkwardly
Important management step in femoral fractures?
Fluid repletion
