Common injuries of lower limbs

Definition:_

Fracture:_ is a break in the structural continuity of bone. Dislocation: means that the joint surfaces are completely displaced

and are no longer in contact. Subluxation: a lesser degree of displacement, such that the articular

surfaces are still partly apposed

Types of displacement:_ 1.Translation(shfit): sideways ,forward ,or backward. 2.Angulation(tilt): malaligment lead to deformity. 3.Rotation(twist):end up with rotational deformity. 4.Shortening: Proximal migration of the distal fracture component

results in shortening of the overall bone length.

Hip Dislocation

Hip Dislocation: Mechanism of Injury

Almost always due to high-energy trauma. Most commonly involve unrestrained

occupants in RTAs. Can also occur in falls from heights, industrial

accidents and sporting injuries

Classification

Simple vs complex

Complex associated with fractures.

3 main patterns in relation to acetabulum

Posterior, Anterior, Central

Posterior hip dislocation

Posterior dislocation

Mostly posterior dislocation (80-90% of dislocations) Occurs with axial load on femur, typically with hip

flexed and adducted. Dashboard Injury is an example of axial load on flexed hip.

Posterior Dislocation Clinical features: - The hip is flexed, internally rotated, and adducted.

Diagnosis1.X_ray: AP view show the femoral head out of its sockets&above acetabulum asegment ofacetabular rim or femoral head may broken &displaced so do obligue view to see the size of fragment.2.CT-scan: best way to see the acetabular #.

*Thomas and Epstein Classificationof Posterior Hip Dislocations:

Type DescriptionI with or without a minor fractureII with a large single fracture of the posterior acetabular rimIII with comminution of the acetabular ringIV with a fracture of the acetabular floorV with a fracture of the femoral head

TREATMENT

Closed reduction under G.A Immobilization : by skeletal traction through a pin

applied in femoral condyles for 3-6 weeks . Rehabilitation: active exercise & gradual wt. b. by

using crutches.

This x-ray, taken from the front, shows a patient with a posterior dislocation

of the left hip.

Normal alignment after the hip has been reduced.

COMPLICATION Early Complications :- 1.Sciatic n. injury ; occur in 10_20% of cases but usually

recovers ,so nerve function should tested before reduction;if after reduction is diagnosed ,then. should be explored.

2.Vascular injury;(superior gluteal A.) is torn & bleeding may be profuse

Arteriogram should performed ; Treated by ligation 3.Associated # :of femoral shaft when occur at the same time

the dislocation is missed (it should be a rule with every femoral shaft # by X-ray)

Treatment : by OR. Of dislocation then IF. Of #.

Late Complication:-

1.Avascular Necrosis of femoral head: occur in 10% of traumatic dislocation & if reduction delay more than 12 hrs the % increase more than 40%;DX ,by MR I& isotope bone scan. X-ray show increase density of f. head Tx ;small necrotic segment treated by realignment ; Bif extensive collapse treated by joint replacement.2.Myositis ossificans:_its un common ;related to severity of injury ;so the period of rest &non wt. bearing need to be prolonged.3. POST TRAUMATIC O.A: 2nd OA not un common due to ; A) Cartilage damage at time of dislocation. B)presence of

retained fracture In the joint. C)Ischemic necrosis of femoral head

4. STIFFNESS.

Anterior Hip Dislocation

Anterior Dislocation

Femoral head situated anterior to acetabulum

Hyperextension force against an abducted leg that levers head out of acetabulum.

Also force against posterior femoral head or neck can produce dislocation

10 % to 15% of traumatic hip dislocation

Clinical features: The hip is minimally flexed, externally rotated and markedly abducted

Central Hip dislocation

Central dislocation

ALWAYS fracture dislocation Lateral force against an adducted femur

FRACTURE OF FEMORAL NECK

FRACTURE OF FEMORAL NECK It is intracapsular # of elderly osteoporotic individual ; majority

occur in Caucasian women in 7th &8th decades of life. Other risk factor: bone losing or bone weakening dis. As

osteomalacia , stroke, alcoholism,& chronic debilitating dis. It result from simple fall in elderly. fall from height or blow in RTA in young . stress # in runners &military personnel.

Garden classification

Anatomical Classification

Subcapital region Transcervical region Basal region

Diagnosis: 1.Stress #:_in elderly with unexplained pain in hip also in

athletes & military personnel(X-ray is normal& MRI show the lesion.

2.Undisplaced #: impacted difficult to see on X-ray but MRI & bone scan show the lesion.

3.Painless #:_in bed ridden pt. develop silent #. 4.Multiple #:_pt. with f. shaft # may have hip #.

Treatment: Pain relieving measure Simple splintage of the limb.

DEFENTIVE treatment:_

Garden type I&II : treated by closed reduction. Garden type III&IV: operation is almost mandatory &done urgently

either closed R. under GA then hold by screw & side plate through lat. Incision then do X-ray

if failed or pt. under 60 years old ;OR is indicated.

In pt. older than 70 yrs. Do prosthetic replacement . THR indicated only in case of (a)Tx have been delayed for some wks. (b) in pt with metastatic dis. Or pagets dis. Post op.: exercise & early mobility are important.

COMPLICATION 1.General complication:_DVT , pulmunary Embolism, pneumonia, bed

sore. 2.Avascular necrosis :_occur in 30 % of displaced&10% of undisplaced

..Dx by isotope .C.F :pain &progressive loss of function. Tx :by THR in pt. more than 45 yrs. &arthrodesis or realignment osteotomy in young. 3.Nonuonin : occur in more than 30 % of all neck # in severly displaced

#C. F : pain ,shortening, difficulty with walking.X-ray show # line. 4.Osteoarithritis: treated by THR.

Intracapsular fracture. Non-union:

Femoral head necrosis:

Intertrochanteric Hip Fractures

The intertrochanteric area of the femur is distal to the femoral neck and proximal to the femoral shaft; it is the area of the femoral trochanters, the lesser and the greater trochanters .

Caused by:_

1. fall directly onto the greater trochanter 2.or by an indirect twisting injury. Divided in to stable & unstable.

C.F: pt. is old, unable to stand , more shorter &externally rotated than with trans cervical ,& can not lift his\her leg.

TREATMENT Intertrochanteric fractures are almost always treated

by early internal fixation. (a) to obtain the best possible positionand (b) to get the patient up and walking as soon as possible and thereby reduce the complications associated with prolonged recumbency.

Most intertrochanteric fractures are managed with either a compression hip screw or an intramedullary nail

COMPLICATION: EARLY:DVT , pneumonia ,bed sore…. LATE:_ 1.Failed fixation: Screws may cut out of the

osteoporotic bone if reduction is poor or if the fixation device is incorrectly positioned. In either event, reduction and fixation may have to be re-done

2. Malunion : Varus and external rotation deformities are common.

3.Nonunion :rarely occur , if healing delayed beyond 6 months…..Treated by OR&IF with bone graft.

Subtrochanteric Fractures:

Subtrochanteric typically defined as area from lesser trochanter to 5cm distaly:

usually in younger patients with a high-energy mechanism may occur in elderly patients from a low-energy mechanism

CLINICAL FEATURES &DIAGNOSIS The leg lies in neutral or external rotation and looks short; the

thigh is markedly swollen, Movement is very painful. In X-ray the # may be transverse , oblique or spiral.

Treatment Non operative: observation with pain managementOperative:.OR&IF is the treatment of choice.Two main type of implant are used:1.Intramedullary nail with proximal interlocking screw.2.95 degree hip screw & side plate.

Treatment:

Complication:

1. Nonunion : can be treated with plating, , good fixation & bone graft.

2, malunion: Rotational & varus are common prevented by accurate

reduction ,if it cause symptoms…. op.is indicated.

FEMORAL SHAFT RRACTURE

FEMORAL SHAFT RRACTURE

High energy injuries frequently associated with life-threatening conditions.

most common in younger population low-energy: More common in elderly.

Classification: Winquist and Hansen Classification:

Type 0 • No comminution Type I • Insignificant amount of comminution Type II • Greater than 50% cortical contact Type III • Less than 50% cortical contact Type IV • Segmental fracture with no contact between

proximal and distal fragment

Presentation

Initial evaluation Advanced Trauma Life Support (ATLS) should be initiated Symptoms pain in thigh. There is swelling, deformity of the limb & movement is painful,

bleeding is sever, more than 1 liter may be lost in the soft tissue , one must exclude neurovascular injury & other lower

limb or pelvic #. # of the femoral shaft & tibial shaft on the same side produce floating knee.

X ray: Determine # pattern, one must x ray the hip & knee

as well as base line chest x ray because of the risk of ARDS in those with multiple injuries.

Treatment Emergency treatment: 1- treat the shock. 2- splint the #either by

tying the limb to the other leg. Or by the use of Thomas splint, this will control pain, reduce bleeding & make

transfer easier.* Definitive treatment: to reduce the systemic complications the # must be stabilized either by: (1)- Traction& bracing: Traction can reduce & hold most #s. in reasonable alignment except

those in the upper 1/3 of the femur

(2)- Intramedullary nailing : Is the method of choice for most femoral shaft #, if locking

screw used it will control even subtrocanteric & distal 1/3 #

(3)- External fixation: indicated for: 1- sever open injury. 2- multiple injury. 3- deal with bone

loss.

Complications of femoral shaft #:

Early: 1- shock: 1-2 liters of blood can be lost even in closed #. 2- fat embolism & ARDS: because # through large marrow filled

cavity result in small shower of fat emboli being swept to the lung.

3- thromboembolism: prolong traction in bed predispose to thrombosis.

4- infection: risk occur in open injury & follow internal fixation & should be treated as for acute osteomyelitis.

Late:

1- delayed & nonunion: when union delayed > 3-4 months & this should be treated by rigid fixation & bone graft.

2- malunion: no more than 15 degree angulation should be accepted & if shortening occur can be accommodated by building up the shoe.

3- joint stiffness: may be caused by soft tissue adhesion or the joint injured at the same time of initial trauma.

4- refracture.

SUPRACONDYLAR FRACTURES OF THE FEMUR

SUPRACONDYLAR FRACTURES OFTHE FEMUR It needs sever trauma to happen in young adult, or miner trauma in

osteoporotic bone in elderly. It happen from a fall from height The fracture line just above the condyle and may extend in between

either in form of Y or T shape fracture. The most dangerous acute complication is popliteal A. injury. C.F :the knee is swollen ,movement is painful ,tibial pulses should

always checked. X-Ray: The fracture line above condyle ,either TV or comminuted, there is shift and tilt back –ward due to gasterocnimous origin.

Classification of supracondylar # Type A: # not involve the joint surface. Type B: # involve the joint surface(one condyle)but leave the

supracondylar region intact. Type C: # have supracondylar&condylar component.

Treatment

1. Reduction by manipulation under general anasthesia &2. skeletal traction with semi flex knee to counteract muscle.

3.Immobilization: By the same traction with 9 Kgms for 12 wks. 4.Check X-ray after 2-3 days. Failure of conservative R indicate open reduction and I.F .

Complication: Early—skin damage and arterial damage Late---knee stiffness, non-union & malunion

Knee joint dislocation

Knee joint dislocation Result from violence injury force Involve more than two of knee ligaments injury Associated with popliteal vessel injury and common peroneal

nerve injury Urgent attention for vascular assessment.

Directions of dislocation: Reference to the position of tibia Anteromedial dislocation (risk of associated intimal injury

of popliteal artery) Posterolateral dislocation (highly associated with

transected popliteal artery)

Treatment 1. Immediate reduction and immobilization 2. Artery exploration and repair in the evidence of arterial

injury 3. Immobilization in cast (POP) or external fixation for

12wks. 4. Ligaments repair or reconstruction for multiple

ligaments injury in instability Complications: 1. Stiffness : is most common complication (38%), more

common with delayed mobilization. 2. Arthrosis formation following cartilage damage. 3. Knee ligaments injury (result in joint instability) 4. Neurovascular injury.

Tibial plateau fractures:

Tibial plateau fractures:

Mechanism of trauma by fall from height, the # and its degree depend upon the state of knee during trauma.

Presentation: haemathrosis, instability, associated neurovascular injure.

Classification: Type 1: a vertical split of the lateral condyle. Type 2: a vertical split of the lateral condyle

combined with depressionof an adjacent loadbearing part of the condyle

Type 3: depression of the articular surface with an intact condylar rim.

Type4: fracture of the medial tibial condyle. Type 5: fracture of both condyles. Type 6: combined condylar and subcondylar

fractures.

Type 1 Type 5Type 4Type 3Type 2 Type 6

Treatment: *by Reduction for most of the # especially with minimal

displacement. *Hold with same traction for 12 wks, the exercises started. *Failure of conservative R. is an indication of open reduction I.F. SURGICAL TREATMENT: *1st &4th with marked displacement treated by I.F with Buttress

plate or by screw. *3rd treated surgically by elevation of articular surface &B.G. *5TH treated either by screws or buttress plate. *6th reduction by manipulation & immobilization for 12 weeks.

Complication: Valgus deformity Joint stiffness.

Patella fractures:

Patella fractures: Direct injury (dash board, direct fall onto the knee)

produced ‘stellate’ fracture Indirect injury (forced flexion knee) produce avulsion

type or simple transverse pattern Loss of extensor mechanism Haemathrosis X-Ray: 1.one or more line of # is seen by x-ray. 2.multiple # line with irregular displacement.

Treatment:

Undisplaced fracture Cylinder cast immobilization for 6 weeksDisplaced fracture ORIF (tension band wiring)Severely comminuted Cerclage wiring or patellectomy

Complications: 1.Joint stiffness 2.Patellofemoral arthrosis 3.Reduced knee extensor mechanism

Ligaments injuries of knee joint:

Ligaments injuries of knee joint: The knee joint is synovial hinge j. The stability depend on the tendons&ligments. There are 4important ligements and 2 accissories:_ 1.Med. Collatral lig.:give stability to med. Compartment. 2.Lat. Collatral lig.:give inassociation with fascia lata&poplitus

m. insertion stability to lat. Compartment 3.Ant. Cruciate lig.:its injury giveway anteriorly 4.Post. Cruciate lig.:its important in stability of post. Aspect. Accissory lig.(aricuate&oblique):helps the post. Cruciate in

stability of med.&lat. Condyles of tibia.

Ligaments injury ;cont. Divided into:_ A)Acute B)Chronic Mechanism of injury: 1.Trauma. 2.Atheletes injury. Presentation: Acute can be divided into a)partial b)compelet. Partial: 1.more hemoarthrosis 2.sever pain 3.pt. can walk

normally. Compelet: 1.less hemoarthrosis 2.less or no pain at all 3.pt. can not walk (give way).

Diagnosis 1.X-ray. 2.MRI.

TreatmentPartial: a)aspiration oh hemoarthrosis b)double bandage of

knee then backslab for short period.Complete: almost always surgery by a)re-attachment b)re-inforcement

c)replacement

Meniscus Tears

The meniscus is a rubbery, C-shaped disc that cushions your knee. The menisci keep your knee steady By balancing your weight across the knee.

A meniscus tear is usually caused by twisting or turning quickly, often during sport. There are three types of meniscus tears:

minor tear, you may have slight pain and swelling. moderate tear can cause pain at the side or center of your

knee. Swelling slowly gets worse over 2 or 3 days severe tears, pieces of the torn meniscus can move into the

joint space. This can make your knee catch or lock. Your knee may feel give way. It may swell and become stiff right after the injury or within 2 or 3 days.

(3) IMPORTANT TESTS: 1. the McMurray test. Is a pathognomonic test..the doctor will bend your

knee, then straighten and rotate it. This puts tension on a torn meniscus. If you have a meniscus tear, this movement will cause a clicking sound.

2. GRINDING TEST. 3. DESTRUCTION TEST.

Treatment may include: Rest, ice, wrapping the knee with an elastic bandage, and propping up

the leg on pillows. Physical therapy. Surgery to repair the meniscus. Surgery to remove part of the meniscus.

FRACTURES OF TIBIA AND FIBULA

Because of its subcutaneous position, the tibia is more commonly fractured, and more often sustains an open fracture, than any other long bone.

Mechanism of injury Indirect injury is usually low energy; with a spiral or long

oblique#. Direct injury crushes or splits the skin over the fracture; this is usually a high-energy injury and the most common cause

is a motorcycle. It is either compound #(open) or close #.

CLOSED FRACTURE

*# of both bone is the important one & usually associated with displacement in form of shift, tilt or twist.

*The radiological findings are in form of T.V ,,butterfly ,oblique or spiral #.

TREATMENT

1. Reduction by MUA after examination of pulse . 2. Immobilization by above knee back slab then check x-ray. 3. If the # acceptable, change POP slab to cast for 10-12 wks. 4. Removal the cast & recheck x-ray, if consolidation is seen. 5. Exercise is proceed with active & passive exercise. 6. If conservative R. failed, open reduction & I.F is applied.

COMPOUND # (0PEN): It always contaminated. The grading depend on the severity of soft tissue injury, described by

Gustilo classification :

Treatment: • antibiotics • debridement • stabilization • prompt soft-tissue cover • rehabilitation. Wound toilet by mechanical washing to remove the foreign

bodies. Urgent wound excision: it is done systematically. skin, fascia,

muscles. nerve & tendon then bones. Fixation of # by external fixation & it is contraindicated to

internal fixation

complication Early complication:_ 1. VASCULAR INJURY 2. COMPARTMENT SYNDROME 3. INFECTION Late complication:_ 1. Malunion 2. Delayed union 3. Non-union 4. Joint stiffness 5. Osteoporosis 6. Regional complex pain syndrome

MALLEOLAR FRACTURES OF THEANKLE Fractures and fracture dislocations of the ankle are

common. Most are low-energy fractures of one or both

malleoli, usually caused by a twisting mechanism. The patient usually presents with a history of a twisting injury, usually with the ankle going into inversion, followed by immediate pain, swelling and difficulty weight bearing. Bruising often comes out soon after injury.

Classification

Danis & Weber: Type A: # below the tibiofibular syndesmosis ,Perhaps associated with an oblique or vertical fracture of the

medial malleolus; this is almost certainly an adduction (or adduction and internal rotation) injury.

Classification cont.

Type B:_ is an oblique fracture of the fibula in the sagittal plane at the level of the syndesmosis;

This is an external rotation injury and it may be associated with a tear of the anterior tibiofibular ligament

Classification cont. Type C:_ is a more severe injury, above the level of the syndesmosis, which means that the tibiofibular ligament and part of the interosseous membrane must have been torn. This is due to severe abduction or a combination of abduction and external rotation

Treatment:Undisplaced # : Cast immobilization (boot POP)

Displaced # with or without subluxation : ORIF (fibular plating, screw fixation of medial malleoli , syndesmotic screw).

Complications :

EARLY 1. Vascular injury 2. Wound breakdown and infection LATE 1. Incomplete reduction 2. Non-union 3. Joint stiffness 4. Algodystrophy

FRACTURES OF THE CALCANEUM

Result from axial loading Traction through Achilles tendon lead to avulsion

fracture Can be extra-articular or intra-articular fracture

(referring to subtalar joint) Result in loss of foot arch lead to flat foot

FRACTURES OF THE CALCANEUM Extra_articular # of calcenum

Intra_articular # of calcenum

Treatment

Extra-articular fractures or undisplaced fractures may require bandaging for 1 week then followed by boot POP cast for 5 weeks

No weight bearing is allowed

Displaced intra-articular # or avulsion of Achilles insertion: ORIF screw or recon plate

Complications

EARLY 1. Swelling and blistering 2. Compartment syndrome LATE 1. Malunion 2. Peroneal tendon impingement 3. Insufficiency of the tendo Achillis 4. Talocalcaneal stiffness and osteoarthritis