Lower limb fractures-Orthopedics

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Lower limb fractures Tibia, Ankle, Foot. Given Sishekano 201404386 MBChB IV

Lower limb fracturesTibia, Ankle, Foot.

Given Sishekano201404386MBChB IVFeb 17,201714h00

Table of contentFractures of the tibiaFractures of the ankleFractures of the foot

Tibial fractures1. Anatomy2. Proximal tibia fractures3. Tibial shaft fractures.4. Distal tibia fractures

Anatomy

Long & Tubular w/ a triangular cross section.Subcutaneous anteromedial border.

Fractures of the proximal tibia.1. Fractures of tibial plateauUsually caused by forcible Valgus or Varus strain.Low energy fractures common in older females due to osteoporotic bone changes. High energy fractures are commonly the result of motor vehicle accidents, falls or sports related injuriesStrong bending forces combined with an axial load e.g. bumper fracturesA fall from a height in which the knee is forced into valgus or varus positionLateral tibial plateu is commonly affected but medial may also be affected

Epidemiology & presentation50% of presenting pts are over 50 y/o (females commonly)Patients present with severe tenderness on side of fracture and on opposing side if tendon damaged.Swollen tendon with doughy feel due to haemarthrosis

Classification (Schatzker Classification)

ImagingX-rays are vitalCT scan not always done but help in evaluating extent of fracture and planning management.MRI scan if soft tissue damage is suspectedCT angiography if concerns of vascular compromise

ManagementTreatment is aimed at achieving a stable, aligned, mobile and painless joint and to minimize the risk of posttraumatic osteoarthritis.Undisplaced & minimally displaced(Lc): conservative management.Marked displacement/ comminuted(Lc): ORIFMedial condyle fractures: ORIFBicondylar fractures: internal fixation w/ Plates and screws

Tibial Shaft FracturesCommonest long bone fractures. Men>womenOften Open fractures w/ contaminated wound.

Mechanism of Injury1.Direct: High energy: MVA, sporting injury-Transverse, comminuted, displaced fractures commonly occur.-Incidence of soft tissue trauma is highPenetrating: gunshot-The injury pattern is variable.Bending-Short oblique or transverse fractures occur, with a possible butterfly fragment.-Crush injury.

2. IndirectTorsional mechanisms-twisting with foot fixed, falls from low height.-minimal soft tissue damage.Stress fractures-e.g in Ballet dancers.

Clinical ExamNeurovascular statusAssess soft tissue injuryExamine knee ligament(commonly damaged)Examine for signs of compartment syndrome.

ImagingX-ray is usually sufficient-Two views-Two joints-Two occasionsOblique X-ray to characterise pattern of injury if necessary. Post reduction X-ray must be done.

ClassificationNone Universal.If open-Gustillo AndersonIf closed- Tscherne Classification of closed fractures.

ManagementLow energy-Gastillo I, II: ConservativelyUndisplaced/minimally displaced- full length cast from upper thigh to metatarsal neck, knee is slightly flexed and the ankle at a right angleDisplaced fracture- reduction under general anaesthesia

High energy-External fixation is the method of choice-intramedullary nailing is an alternative-- Open operations should be avoided unless there is already an open wound

ComplicationsVascular injuriesCompartment syndromeInfectionMalunionDelayed union and non unionJoint stiffness

3. Distal Tibial fracturesInjury occurs when a large axial force drives the talus upwards against the tibial plafondUsually high Energy Can be rotational with lower energyArticular Surface is Involved Can have severe comminution and severe soft tissue injury

Clinical featuresLittle swelling initially but this rapidly changesFracture blisters are commonAnkle may be deformed or dislocated

Classification(Rudi and Allgower) Type I Fracture involving minimal displacementType II Significant displacement of the joint surfaceType III Impaction and comminution of the articular surface

ImagingX-ray(diagnostic)

ManagementEarly management: SPAN, SCAN, PLAN.Remember Life, Limb, Fracture.Manage soft tissue swelling.Once skin has recovered, do ORIFClosed reduction w/ a cast.External fixation if needed

2. Ankle fracturesAnatomy of the ankle Tibia and fibula form a mortise which provides a constrained articulation for the talus.Ankle stability is provided by 3 factors:Bony architecture, joint capsule and ligamentous structures:Syndesmotic ligamentsMedial collateral ligamentsLateral collateral ligaments

Stumbling and falling-Foot is usually anchored to the ground and the body lounges forward.Ankle twisting -Talus tilts or rotates forcibly in mortise causing a low energy fracture of one or both malleoli with associated injuries of the ligaments.

Simple description: Joint can be injured on one side only (single malleolus) or on both sides (bi-malleolar fracture)Rotational injuries: 1/both sides may be injured.Posterior lip of the lower end of the tibia (posterior malleolus) may be fractured.Degree of instability depends on how much of ankle complex is damaged.

Classification1. Weber classification

2. LAUGE-HANSEN CLASSIFICATION: Uses two terms: First: describes position of the foot at time of injury, second: the motion of the talus relative to the tibiaTypes:1. supination adduction2. supination external rotation3. pronation abduction4. pronation eversion5. pronation dorsiflexionDescription is used because most ankle injuries are caused by the weight of the falling person applying force on the ankle with the foot in a fixed position.Classification proposes that mechanism of injury can be deduced from the X-ray appearances and that reduction involves applying the reverse movement.

3. Fractures of the footAnatomy of the foot.

Talus fractureTalus fracture is an injury of the hind footRare, occur due to considerable violence with axial loading or hyper dorsiflexion.Injuries include fracture of the head, neck, body, or bony processes of talus.Patients present with painful and swollen foot and ankleObvious deformity if fracture is displacedSkin overlaying the fracture or dislocation may be tented or split

X-ray(Talus fracture)

Hawkins Classification & managementType I: non displaced fractureType II: displaced fracture with subluxation or dislocation of the subtalar joint and a normal ankle jointType III: displaced fracture with body of talus dislocated from both subtalar and ankle joint.Type IV: in addition to features describes in type III there is dislocation or subluxation of the head of the talus at the talonavicular joint

ManagementUndisplaced #: Backslab until swelling has subsided followed by non-weight bearing below knee CPOP (6-8 weeks)Displaced #: closed reduction attempted first, if it fails, ORIF is performed where the reduced # is stabilised with 1 or 2 lag screwsComplications-Malunion-AVN-Secondary Osteoarthritis

Calcaneal fracturesCommon mechanism axial loading Calcaneum driven up against talus and is split or crushed.10% of calcaneus #s associated with compression injuries of spine, pelvis or hip.Two types:Extra-articular #: involve calcaneal processes or posterior part of bone. Easy to manage and have good prognosis.Intra-articular #: cleave bone obliquely and run into superior articular surface. Articular facet is split apart and there may be severe comminution.

Sanders ClassificationType I: non-displaced fractures (displacement < 2mm).Type II: consist of single intraarticular fracture dividing the calcaneus into 2 pieces.Type IIA: occurs on lateral aspect of calcaneus.Type IIB: occurs on central aspect of calcaneus.Type IIC: occurs on medial aspect of calcaneus.Type III: consist of two intraarticular fractures that divide the calcaneus into 3 pieces.Type IIIAB: two fracture lines are present, one lateral and one central.Type IIIAC: two fracture lines are present, one lateral and one medial.Type IIIBC: two fracture lines are present, one central and one medial.Type IV fractures consist of fractures with more than three intrarticular fractures.

PresentationFoot is painful, swollen and bruised. Wider, shortened, flatter heel when viewed from behind + varus heelTissues are thick and tender and normal concavity below the lateral malleolus is lacking. Subtalar joint cannot be moved but ankle movement is possible. Always check for signs of Compartment syndrome

X-ray viewsLateral, oblique and AP viewsExtra-articular #: fairly obvious on xrayIntra-articular #: can be identified on xray, if there is displacement of fragments lateral view may show reduced of Bohlers angle

ManagementUndisplaced fractures: Closed non-surgical treatment (backslab, CPOP), use crutches for 4-6 weeks.Displaced avulsion #: ORIF, Immobilise foot in slight equinus to relieve tension on tendo Achillis. Non-weight bearing for 4-6 weeks.Displaced intra-articular #: ORIF with plates and screws.Bone grafts may be used to fill defects.Encourage exercise when pain subsidesPt allowed to use crutches 2-3 weeks after (non-weight bearing) -> Partial weight bearing only when fracture has healed -> full weight bearing only 4 weeks after that

ComplicationsEarly: swelling and blistering, Compartment SyndromeLate: Malunion, Insufficiency of Achilles tendon (due to loss of heel height), talocalcaneal stiffness and osteoarthritis

Lisfranc fractureLisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn.Varies from minor sprains to severe fracture-dislocationsm.o.i: simple twist and fall. This is a low-energy injury, commonly seen in football and soccer players. More severe injuries occur from direct trauma, such as a fall from a height.These high-energy injuries can result in multiple fractur