lower limb fractures and dislocations

Question 1

most common proximal femoral fracture

Answer 1

typically intracapsujlar neck of femur fracture

Question 2

who is at risk of a NOF

Answer 2

can be caused by relatively minor trauma in elderly (osteoporosis)

Question 3

features of NOF 3

Answer 3

pain

shortened and externally rotated leg

may be able to walk with difficulty

Question 4

define intracapsula nof

Answer 4

occur just below femoral head to the insertion of the capsule of the hip joint

Question 5

types of intracapsular nof 3

Answer 5

subcapital (commonest)

transcervical

basicervical

Question 6

what is the risk with intracapsular nof

Answer 6

higher incidence of avasuclar necrosis

Question 7

manageemtn of intracapsular nof 4

Answer 7

minimal displacement- internal fixation in situ
-if major illness-> hemiarthoplasty

displaced fracture
-if <70yo and fit-> reduction and internal fixation
-if older and reduced mobility- hemiartho or THR

Question 8

what is the primary blood supply for the femoral head

Answer 8

retinacular arteries from the medial and lateral femoral circumflex arteries
-arises from profunda femoris artery

Question 9

what increases risk of avascular necrosis in a nof

Answer 9

if intracapsular nof and sufe (slipped upper femoral epiphysis)

risk of AVN <10% if undisplaced
- >80% if displaced

SURGERY SHOULD BE PERFORMED ON DAY OR DAY AFTER ADMISSION

Question 10

describe the gardner classification for intracapsular femoral neck fractures

Answer 10

Correlates with prognosis
-Key is to differentiate between undisplaced (I & II) & displaced (III & IV)

I = Stable fracture with inferior cortex intact
II = Complete undisplaced # through the neck
III = Complete neck # with partial displacement
IV = Fully displaced #

Question 11

where is an extracapsular nof defined

Answer 11

between insertion of hip joint capsule and 5cm below the lesser trochanter

*-blood supply is not interrupted so risk of ANV is rarer

Question 12

types of extracapsular nof 2

Answer 12

trochanteric

subtrochanteric

Question 13

management of extracapsular nof

Answer 13

dynamic hip screw

subtrochanteric hip fracture
-intramedullary hip screw

Question 14

overview of complications with femoral shaft fracture 4

Answer 14

requires considerable force so look for other injuries

500-1500ml of blood lost in a simple fracture

check distal pulses for possible femoraly artery damage

sciatic nerve injury may occur

Question 15

treatment of femoral shaft fracture 3

Answer 15

stabilise patient in ED and traction with a thomas splint

fluid resuscitate if needed

definitive treatment is with a locked intramedullary nail
-allows early mobilisation

Question 16

main cause of hip dislocation

Answer 16

mostly by direct trauma like RTA

-extremely painful

-may be associated with other fractures and life threatening injuries

Question 17

diagnosis of hip dislocation

Answer 17

prompt diagnosis and approparte managemnt important to reduce morbidity

early MRI diagnosis may prevent later equinus foot defmoritiy

Question 18

types of hip dislocation

Answer 18

posterior - most common 90%

anterior

Question 19

presenation of posterior hip dislocation 2

Answer 19

affected leg is shortened, adducted and internally rotated

femoral head can be felt in buttock

Question 20

presentation of anterior hip dislocation 2

Answer 20

usually abducted and externally rotated

NO leg shortening

Question 21

managemnt of hip dislocation 5

Answer 21

ABCDE approach

analgesia

reduction under GA within 4hrs to reduce risk of AVN

traction for three weeks promotes joint capsule healing

physio long term

Question 22

define distal femoral and proximal tibial fractures

Answer 22

divided into extra and intra articular fractures

Question 23

important point about distal femoral and proximal tibial fractures intracapsual

Answer 23

intracapsualar fractrues require fixation with an anatomically contoured locking plate

Question 24

overview of tibial plateau fracture

Answer 24

all intra-articular and difficult to treat

have a schaztzker classification system

non-operative treatment in the elderly

internal fixation to restore articular surface and minimise later OA

hinged cast braces locked in extension can reduce risk of chronic flexure contraction

Question 25

cause of patellar dislocation 1

Answer 25

most commonly a primary traumatic event -direct trauma

Question 26

movement that causes patellar dislocation

Answer 26

severe contraction of quadriceps with knee strechted in valgus and external rotation typically lateral dislocation -flexed knee with lateral deformity

Question 27

risk factors for patellar dislocation 3

Answer 27

genu valgum tibial torsion high riding patella

Question 28

imaging in patellar dislocation 1

Answer 28

skyline XR of patella are needed -can be clinically obvious

Question 29

treatment of patellar dislocation 4

Answer 29

reduction with firm medial pressure while extending the knee post reduction XR to check for patellar fracture period of immobilization in cast/ splint rehab w quad strengthening exercise

Question 30

define stable and unstable ankle fractures

Answer 30

stable- only involve one side of the ankle -Wever A/B unstable-he ankle joint itself is displaced or can be displaced when it is subject to normal forces

Question 31

management of stable or minimally displaced ankle fracture

Answer 31

stable or minimally displaced fractures may be treated non-operatively in a cast

Question 32

management of unstable or displaced fractures

Answer 32

require surgery -compression plate

Question 33

how does the weber classification for ankle fracture work

Answer 33

defines ankle fractures by the level of fibula fracture relative to the tibiofibular syndesmosis

Question 34

define weber type A

Answer 34

below the syndesmosis

Question 35

define weber type B

Answer 35

fractures start at level of the syndemosis

Question 36

define weber type C

Answer 36

above the syndesmosis

Question 37

when is an ankle XR only required in a suspected fracture 4

Answer 37

any pain in the malleolar zone & any of the following: -bony tenderness at lateral malleolar zone -bone tenderness at medial malleloar zone -inability to weight-bear (immediately after injury & in ED)

Question 38

define a maisonneuve fracture 3

Answer 38

proximal spiral fibula fracture with syndesmosiss rupture -medial malleous fracture or deltoid ligament rupture always examine proximal fibula with 'ankle sprains' treatment is surgical as fractures are unstable and require fixation to restore ankle mortise

Question 39

define a lisfranc fracture dislocation at 1st tarsometatarsal joint

Answer 39

commonly missed fracture in multitrauma patients can occur by stepping awkwardly off kerb can cause compartment syndrome of medial foot -later arthritis and perisitnet pain On foot XR look for widening of the gap between medial cuneiform & base of 2nd metatarsal -MRI gives better view -Treat with precise anatomic reduction with screw fixation across 2nd metatarsal joint -Lisfranc joint

Question 40

define fracture neck of talus

Answer 40

can occur after forced dorsiflexion serious injury because interripton of vessels may lead to AVN of talus body displaced fractures require ORIF

Question 41

define calcaneus fracture

Answer 41

often bilateral known as lovers fracture (cheater jumping out the window) frequently poor outcome ALWAYS look for assoc spinal fracture signs included sweling, bruising and inability to weight bear

Question 42

define 2nd metatarsal fracture

Answer 42

look for lisfranc dislocations usually heals well with non-operative cast and weightbearing as pain allows

Question 43

define 5th metatarsal fracture

Answer 43

proximal avulsion fracture typically associated with ankle inversion -treat conservatively jones fracture -transverse fracture near the base -requires surgical intervention due to risk of non-union

Question 44

complications of hip fractures

Answer 44

fracture fixation can fail if poorly done -ensure screws and plates secured and proper position hemiarthoplasy may dislocate if ptx falls or if capsule gives way mobile patient to avoid -DVT -chest infection -pressure sores

Question 45

post-op hip fracture managemnt 5

Answer 45

require assistance to mobilise physiotherapies OT care of elderly medicine team home care -ptx may not be able to return home

Question 46

define a DEXA scan

Answer 46

measurement taken at lumbar spin and hip gives a t-score assessed against health adult age 30

Question 47

how is a DEXA can result interpretted

Answer 47

higher T-score indicates lower bone density -can calculate fracture risk T score of -1.0 means bone mass of one standard deviation below that of young reference population Z score is adjusted for age, gender and ehtnic factors REMEMBER: > -1= normal -1 to -2.5 = osteopenia <-2.5= osteoporosis

Question 48

what is the pelvis made of up

Answer 48

sacrum posteriorly ilium ischium pubis

Question 49

differentiate between low and high energy pelvic fractures

Answer 49

high energy -usually from RTA/ fall from height -V dangerous high mortaillty rate -high risk of bleeding and risk of damage to pelvic structures low energy elderly -often osteoporotic -low energy -stable -low blood loss

Question 50

managemnt of low energy pelvic fractures

Answer 50

non-operative mobilisation with analgesia normally heal spoppntaneously

Question 51

management of high energy pelvic fractures

Answer 51

stabilse to rpevent blood loss -use pelvic binder until definitive stabilisation -fractures can be fixed definitively with plates/bolts

Question 52

three types of pelvic fracture 3

Answer 52

AP compression lateral compression vertical shear

Question 53

what is important to note with high energy pelvic fractures

Answer 53

always nood for 2nd site of injury pelvic ring usually breaks in 2 places