Lower Limb Fractures Flashcards by Melanie Thomas

Mortality of NOF?

30%!!

Similar for ALL proximal femoral #s

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Define INTRA and EXTRAcapsular hip fractures:

INTRA
- Head
- Neck
–> Subcapital
–> Cervical
At risk of avascular necrosis!

EXTRA
- Intertroch
- Subtroch
- Greater troch
- Lesser troch

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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.

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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)

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Shenton line

NOF

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3 major complications of femoral shaft fracture:

Haemorrhage (up to 1.5L)
Compartment syndrome
Deep femoral artery/ nerve
Fat embolism

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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

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How are femoral shaft fractures managed in toddlers?

Age < 5 = hip spica

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How much skin traction should be applied to a femoral shaft fracture?

10% of body weight

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How are distal femoral fractures classified:

Supracondylar
Intercondylar
Isolated condylar

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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

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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

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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

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What soft tissue injury is classically associated with this?

ACL rupture (75%)
Medial meniscus (70%)

This is a Segond #

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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

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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