Lower limb

• Pelvic fractures


  • < 5% of skeletal injuries
  • 10% visceral injuries
  • Low vs high energy
• Immediate hemorrhage control


  1. MAST

  2. C-Clamp

  3. EX. FIX.

  4. Pelvic packing

  5. Embolization
• Classifications of low energy pelvic fractures

  • Avulsion
  • Direct
  • Stress
• Young-Burgess classification


  • Antero-posterior
  • Lateral compression
  • Vertical shear
• Non-operative treatment


  • Weight bearing as tolerated
  • LC1
  • APC1
  • Isolated pubic rami fracture
  • Parturition induced diastasis
• Complications of pelvic fractures

  • Infection
  • Thromboembolisim
  • Malunion
  • Non union
  • Death
• Primary survey is life saving in pelvic fractures
• Don't send for radiographs or CT scan until stabilization of patient hemodynamically
• Pelvic radiograph is mandatory in all conscious poly trauma patients
• Pan-CT scan is mandatory for all unconscious high energy trauma patients
• Acetabular fractures


  Need high index of suspicion to pick it up
• Non-operative treatment of acetabular fractures

  • Reduction of hip dislocation
  • Non displaced acetabular fracture (less than 2mm)
  • Toe touch or weight bearing as tolerated
• CT scan mandatory before and after reduction of hip dislocation
• In recent years opinion has moved in favor of operative treatment (ORIF) for displaced acetabular fractures
• Complications of acetabular fractures

  • DVT
  • Sciatic nerve injury
  • Heterotopic bone formation (myositis ossificans)
  • Avascular necrosis of the femoral head
  • Secondary osteoarthritis
• You should train your eyes on normal radiographs to know abnormal ones
• Usually treat patient not radiographs
• Neurovascular examination
• Don't miss the back examination
• Femoral Shaft Fracture


  • Well padded with muscles (advantage in protecting the bone from all but the most powerful forces)
  • Fractures are often severely displaced by muscle pull, making reduction so difficult
• Femoral Shaft Fracture


  • Essentially a fracture of young adults and usually results from a high energy injury
  • Diaphyseal fracture in elderly patients should be considered pathological unless proved otherwise
  • In children under 4 years of age, the possibility of physical abuse must be kept in mind

  
• 1. ray of Femoral Shaft Fracture


  • Most fractures have some degree of communication, reflecting the amount of force involved
  • Displacement may be in any direction
  • Sometimes there are two fracture lines separated by an unbroken length of bone (segmental fracture)
  • The pelvis and knee must always be x-rayed to avoid missing a fracture in them

  
• Treatment of Femoral Shaft Fracture

  1. General: assessment of blood loss and resuscitation of patient

  2. Traction and bracing: main indications are fractures in children, contra-indications to anesthesia, lack of suitable skill or facilities for internal fixation

  3. Open reduction and plating: fixation with plates and screws, main indications are combination of femoral neck and shaft fractures, shaft fracture with associated vascular injury

  4. Intra-medullary nailing: method of choice for most femoral shaft fractures, controls rotation and ensures stability even for sub-trochantric and distal third fractures

  5. External fixation: indication is the treatment of severe open injuries, management of patients with multiple injuries when there is need to reduce operating time, dealing with severe bone loss by bone transport, treating femoral fractures in adolescents

  
• Treatment of Open Femoral Fractures

  1. Antibiotics, wound cleansing and debridement

  2. With little skin loss or small clean wound, the fracture can be treated as closed

  3. With massive skin loss, large wound, contaminated wound, tissue destruction, the internal fixation should be avoided and the wound left open and do external fixation

  
• Treatment of Femoral Fracture in Children

  1. Infants: 1-2 weeks in balanced traction followed by spica for another 3-4 weeks

  2. Children up to 10 years: 2-4 weeks of traction and 6 weeks in spica

  3. Teenagers: may require longer duration of traction and spica, if satisfactory reduction can't be obtained or healed, internal fixation with plate and screws is justified especially in those with multiple injuries
• Complications of Femoral Shaft Fractures


  • General: severe blood loss, shock, fat embolism, and acute respiratory distress
  • Vascular injuries: the vascular lesion takes priority and the vessels must be repaired or grafted without delay
  • Thrombo-embolism: due to prolonged traction in bed, movement and exercise are important to prevent it
  • Infection: in open injuries and following internal fixation, prophylactic antibiotics and careful attention to principles of surgery
  • Delayed union and non union
  • Malunion: fractures treated by traction and bracing often develop some deformity, no more than 15 degrees angulation
  • Joint stiffness: the knee joint is affected and may be injured at the same time of insult, or it's stiffness is due to soft tissue adhesion during treatment

  
• Supracondylar Femur Fractures


  • Occur just proximal to the knee joint, in the terminal 9 cm of the femur between the metaphyseal-diaphyseal junction and the femoral condyles
  • Present in younger patients due to high-energy injuries, and in elderly patients due to low-energy injury mechanisms like simple falls
  • May extend proximally into the diaphysis or distally in the knee joint

  
• Complications of Supracondylar Femur Fractures

  • Early: vascular injury
  • Late: joint stiffness & non-union

  
• Knee Joint


  • Four bones come together at the knee: femur, tibia, fibula, and patella
  • Stability of the knee joint is maintained by four ligaments: MCL, LCL, ACL, PCL
  • Inside the knee, there are two shock-absorbing menisci that sit on the top surface of the tibia

  
• Acute Knee Injuries


  • Can cause pain and swelling with difficulty bending the knee and weight-bearing
  • Pain can be felt with specific activities like climbing stairs (meniscus injury) or walking down stairs (patellar pain)
  • Immediate swelling may suggest a ligament tear or fracture, while swelling over hours may suggest meniscal or cartilage injuries
  • Giving way, popping or grinding in the knee is associated with cartilage or meniscus tears
  • Locking is when the knee joint refuses to completely straighten
• Treatment of Acute Knee Injuries

  1. Strains of ligament: RICE (rest, ice, compression, and elevation) with some strengthening exercises and physical therapy

  2. Torn ACL usually requires surgery in young athletes or active individuals, but may be treated non-operatively in less active elderly

  3. Meniscus injury with chronic pain, swelling, and signs of giving way usually needs Arthroscopic menisectomy

  4. MCL, LCL, and PCL alone rarely need surgery in acute stage unless associated with meniscal or ACL injuries
• Knee Dislocation


  • Always causes severe pain in the knee, sometimes with no feeling below the knee
  • Very serious symptoms include loss of pulse below the knee or loss of feeling/movement below the knee
• Treatment of Knee Dislocation

  1. X-ray to check for bone breaks

  2. Examination of pulses to detect arterial injury

  3. Arteriogram or Doppler to assess blood flow

  4. Examination of nerves to detect nerve injury

  5. Relocation by closed reduction, usually done in emergency unit

  6. If arterial injury, immediate surgery to repair the injured vessel(s)

  7. Immobilization of the entire knee joint in a splint or immobilizer

  
• Complications of Knee Dislocation

  • Vascular injury: popliteal artery
  • Nerve injury: mostly common peroneal or tibial nerves
  • Associated fracture: femoral condyles, shaft, or tibial plateau
  • Ligament injuries
• Late Complications of Knee Dislocation

  • Joint instability
  • Joint stiffness
  • Osteoarthritis
  • Recurrent dislocation
• Fracture Patella


  • Occur due to direct blow producing undisplaced crack, fall producing comminuted fracture, or indirect traction injury producing transverse fracture
  • Knee is swollen, painful, and gap can be felt sometimes associated with haemoarthrosis

  
• Treatment of Patella Fracture

  1. Undisplaced or minimally displaced: aspiration of haemoarthrosis & POP cylinder holding the knee straight for 6 weeks & quadriceps exercise

  2. Comminuted fracture: patellectomy is advocated, or preserve patella if fragments undisplaced and newly replace patella (prosthetic patella)

  3. Displaced transverse fracture: open reduction & internal fixation by tension band wiring & repair of the extensor mechanism (quadriceps), back slab for 4-6 weeks then start exercise

  
• Tibial plateau fractures


  Fractures of the top part of the shin bone

  
• Mechanism of injury for tibial plateau fractures

  1. Varus or valgus force combined with axial loading

  2. Car striking a pedestrian

  3. Fall from a height with knee forced into valgus or varus
• Schatzker classification of tibial plateau fractures

  • Type 1 - Vertical split of lateral condyle
  • Type 2 - Vertical split of lateral condyle with depression
  • Type 3 - Depression of articular surface with intact condylar rim
  • Type 4 - Fracture of medial tibial condyle
  • Type 5 - Fracture of both condyles
  • Type 6 - Combined condylar and subcondylar fractures