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Lower limb fracturesTibia, Ankle, Foot.Given Sishekano

201404386MBChB IV

Feb 17,201714h00

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Table of content

▪ Fractures of the tibia▪ Fractures of the ankle▪ Fractures of the foot

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Tibial fractures

▪ 1. Anatomy▪ 2. Proximal tibia fractures▪ 3. Tibial shaft fractures.▪ 4. Distal tibia fractures

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Anatomy

• Long & Tubular w/ a triangular cross section.

• Subcutaneous anteromedial border.

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Fractures of the proximal tibia.

1. Fractures of tibial plateau▪ Usually 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 injuries▪ Strong bending forces combined with an axial load e.g. bumper

fractures▪ A fall from a height in which the knee is forced into valgus or varus

position▪ Lateral tibial plateu is commonly affected but medial may also be

affected

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Epidemiology & presentation

▪ 50% 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

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Classification (Schatzker Classification)

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Imaging

▪ X-rays are vital▪ CT scan not always done but help in evaluating extent of

fracture and planning management.▪ MRI scan if soft tissue damage is suspected▪ CT angiography if concerns of vascular compromise

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Management

▪ Treatment 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): ORIF▪ Medial condyle fractures: ORIF▪ Bicondylar fractures: internal fixation w/ Plates and

screws

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Tibial Shaft Fractures

▪ Commonest long bone fractures.▪ Men>women▪ Often Open fractures w/ contaminated wound.

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Mechanism of Injury

▪ 1.Direct: High energy: MVA, sporting injury-Transverse, comminuted, displaced fractures commonly occur.-Incidence of soft tissue trauma is high▪ Penetrating: gunshot-The injury pattern is variable.▪ Bending-Short oblique or transverse fractures occur,

with a possible butterfly fragment.-Crush injury.

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

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Clinical Exam

▪ Neurovascular status▪ Assess soft tissue injury▪ Examine knee ligament(commonly damaged)▪ Examine for signs of compartment syndrome.

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Imaging

▪ X-ray is usually sufficient-Two views-Two joints-Two occasions▪ Oblique X-ray to characterise pattern of injury if

necessary. ▪ Post reduction X-ray must be done.

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Classification

▪ None Universal.▪ If open-Gustillo Anderson▪ If closed- Tscherne

Classification of closed fractures.

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Management

▪ Low energy-Gastillo I, II: Conservatively▪ Undisplaced/minimally

displaced- full length cast from upper thigh to metatarsal neck, knee is slightly flexed and the ankle at a right angle▪ Displaced 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

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Complications

▪ Vascular injuries▪ Compartment syndrome▪ Infection▪ Malunion▪ Delayed union and non

union▪ Joint stiffness

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3. Distal Tibial fractures

▪ Injury occurs when a large axial force drives the talus upwards against the tibial plafond▪ Usually high Energy▪ Can be rotational with lower energy▪ Articular Surface is Involved▪ Can have severe comminution and severe soft tissue

injury

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Clinical features

▪ Little swelling initially but this rapidly changes▪ Fracture blisters are common▪ Ankle may be deformed or dislocated

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Classification(Rudi and Allgower)

▪ Type I – Fracture involving minimal displacement▪ Type II – Significant

displacement of the joint surface▪ Type III – Impaction and

comminution of the articular surface

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Imaging

▪ X-ray(diagnostic)

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Management

▪ Early management: SPAN, SCAN, PLAN.▪ Remember Life, Limb,

Fracture.▪ Manage soft tissue swelling.▪ Once skin has recovered, do

ORIF▪ Closed reduction w/ a cast.▪ External fixation if needed

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2. Ankle fractures

▪ Anatomy 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 ligaments▪ Medial collateral ligaments▪ Lateral collateral ligaments

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▪ 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.

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▪ 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.

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Classification

1. Weber classification

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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.

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3. Fractures of the foot▪ Anatomy of the foot.

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Talus fracture

▪ Talus fracture is an injury of the hind foot

▪ Rare, 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 ankle

▪ Obvious deformity if fracture is displaced

▪ Skin overlaying the fracture or dislocation may be tented or split

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X-ray(Talus fracture)

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Hawkins Classification & management

▪ Type I : non displaced fracture▪ Type II : displaced fracture with

subluxation or dislocation of the subtalar joint and a normal ankle joint

▪ Type 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

Management▪ Undisplaced #: 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 screws

Complications-Malunion-AVN-Secondary Osteoarthritis

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Calcaneal fractures

▪ Common 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.

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Sanders Classification

▪ Type I: non-displaced fractures (displacement < 2 mm).

▪ 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.

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Presentation▪ Foot is painful, swollen and

bruised.▪ Wider, shortened, flatter heel

when viewed from behind + varus heel

▪ Tissues 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 views▪ Lateral, oblique and AP

views▪ Extra-articular #: fairly

obvious on xray▪ Intra-articular #: can be

identified on xray, if there is displacement of fragments lateral view may show reduced of Bohler’s angle

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Management

▪ Undisplaced 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 subsides▪ Pt 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

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Complications

▪ Early: swelling and blistering, Compartment Syndrome▪ Late: Malunion, Insufficiency of Achilles tendon (due to

loss of heel height), talocalcaneal stiffness and osteoarthritis

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Lisfranc fracture

▪ Lisfranc (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-dislocations▪ m.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 fractures and

dislocations of the joints.▪ It is often seen when someone stumbles over the top of a foot

plantar flexed.

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Mechanism of injury

Symptoms• Pain(worsened by

walking)• Bruising• Swelling

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X-rays▪ Full extent of injury hardly clear on plain x-ray; multiple

vies of CT may be needed.▪ Look out for fractures of navicular and cuneiform bones.

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Management

▪ Undisplaced sprain: cast immobilization for 4-6 weeks.▪ Subluxation and dislocation: Traction and manipulation

under anaesthesia achieves reduction.▪ Position is then held with K-wires or screws and cast

immobilization.▪ Non-weight bearing for 6-8 weeks.

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Metatarsal fractures

▪ Due to direct blow, severe twisting injury or repetitive stress▪ 5th metatarsal #s are usually

due to forced inversion of the foot (the pot hole injury) which then causes avulsion of the base of the 5th metatarsal tuberosity▪ Avulsion fracture occurs where a

tendon attaches to the bone▪ When an avulsion fracture

occurs, the tendon pulls off a tiny fragment of bone.

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Presentation

▪ Patient often complains of having sprained the ankle▪ Tenderness marked over area

of fracture.Management

▪ Fracture usually unites readily▪ Immobilisation in a below knee

plaster for 4 weeks is advised

X-rays

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Sesamoid fractures

▪ Fractures occur either due to a direct injury (i.e landing from a height on the ball of the foot), sudden traction or; ▪ chronic repetitive stress as seen in dancers and runners▪ Patient c/o pain over the sesamoids▪ O/E: Tender spot in the same area and pain may be

exacerbated by passively hyperextending the halluxRx:Conservative treatment▪ Use of local lignocaine injection for pain relief▪ In cases of marked discomfort, immobilise leg in cast 2-3

weeks

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References

1. Apley’s consice system of orthopaedics and fractures2. Toronto notes 20163. Orthopaedics and fractures lecture notes(4th ed.), wiley-Blackwell.