Lower limb fractures

1. Lower limb fractures
and dislocation
PRESENTED BY
JASIM HASAN

2. Learning outcome:
The student should be able to:
 Discuss on the mechanism, clinical
presentation, classification, radiological
findings, and its complications of fractures
and joint dislocation
 Derive treatment option of the common
lower limb fractures and joint dislocation

3. Contents:
 FRACTURE NECK OF FEMUR
 INTERTROCHANTERIC FRACTURE
 HIP JOINT DISLOCATION
 FEMUR SHAFT FRACTURE
 DISTAL FEMUR FRACTURE
 KNEE JOINT DISLOCATION
 PATELLA FRACTURE
 TIBIAL PLATEAU FRACTURE

4. CONT’:
 TIBIA SHAFT FRACTURE
 MALLEOLI FRACTURE
 TALUS FRACTURE
 CALCANEUM FRACTURE

5. Fracture neck of femur
 Common in elderly following fall (osteoporosis)
 Young adult is due to high energy impact such as
road traffic accident
 May accompanied hip joint dislocation (high
impact injury)
Demonstrated radiological (AP view of hip joint) as:
 Loss of Shenton’s line
 Disruption of proximal femur trabecula

6. Classification:
 Garden’s classification (4 stages) for
femur neck fracture
 Help to determine the management and
predict the prognosis on complication
(avascular necrosis of the femoral head)

7. Garden’s classification
Stage I Incomplete # (impacted)
Stage II Complete and undisplaced
Stage III Complete and moderately
displaced
Stage IV Severely displaced

8. Anatomical classification:
 Also can describe the pattern of neck
fracture
 Subcapital region
 Transcervical region
 Basal region
 Prognosis for AVN worsen in subcapital
and transverse fracture

9. Radiological features of neck of femur fracture
Shenton’s line

10. Complication:
 Avascular necrosis of the femur head
 Non-union of the fracture
 General complications following prolong
bedridden for conservative treatment
(bedsore, DVT, pneumonia, stiffness)

11. Treatment:
 Depend on the age of the patient,
patient’s health and fracture stages &
duration
Non-operative reserve for:
 Poor health (unfit for surgery) patient
 Require on Traction for 3 – 6 weeks then
start ambulate

12. Cont’:
Operative treatment is the main goal:
 Younger age group with acute # and elderly
with impacted # (preserved the head) usage of
fracture fixation devices eg. Screw fixation,
Dynamic Hip Screw
 Elderly patient with displaced # or chronic #
subjected to hip replacement (hemiarthroplasty
or total arthroplasty of the hip joint)

13. Intertrochanteric fracture
 Commonly occur in elderly patient
(osteoporosis) following trivial fall
 Extension to subtrochanteric region
 May presented as comminuted fracture
pattern

14. Radiograph shows intertrochanteric
fracture of the femur

15. Complications:
 Mal-union of the fracture
 Failure in fixation for the fracture due to
osteoporotic bone
 General complications following prolong
bedridden

16. Treatment
 Operative is the main goal except unfit
patient for anaesthesia or extreme
osteoporotic bone
Choices of implant for fracture fixation:
 Dynamic Hip Screw
 Proximal femoral nail (PFN)

17. Fixation of fracture intertrochanteric fracture

18. Hip joint dislocation
 Direction: posterior is more common than
anterior
 Mechanism: ‘dash-board’ injury
 Limb attitude:
 Posterior dislocation (flexed, adducted,
internally rotated, short limb)
 Anterior dislocation (flexed, externally
rotated, abducted)
 Association with acetebular fractures of
femoral head fractures

19. Radiograph shows left hip dislocation
Left side

20. Complications:
 Sciatic nerve injury leading muscle
paralysis and loss of sensory below the
knee
 Prolong dislocation can also result in
avascular necrosis of the femoral head

21. Treatment
 Emergency CMR under sedation
 Failure in CMR  open reduction

22. Femoral shaft fractures
 Area that is well padded with muscles
leading to fracture displacement and
difficulty in CMR and maintain the reduction
 Associated with soft tissue injury due to
high-energy injury risk of getting
compartment syndrome
 Long bones – segmental #
 Occasionally associated with # neck of
femur

23. Radiographs show femur shaft fractures
Distal 1/3
supracondyalar Proximal 1/3

24. Complication
 Vascular injury (femoral artery)
 Fat embolism
 Delayed and non-union of the fracture
 Mal-union of the fracture
 Joint stiffness (knee)

25. Treatment
 Less preference for non-operative
treatment (as the bone is weight bearing
region) in adult
Operative fracture fixation used :
 Intramedullary-Locking-Nail
 Plating (DCP)

26. Intramedullary locking
nail

27. Distal femur #: Supracondylar
& intercondylar
 Supracondylar # can be isolated or
combination with intercondylar #
 Result from high energy force
 Risk of vascular injury (femoral artery)
 Intercondylar extension may involved
articular region of the knee

28. Complications
 Joint stiffness and arthrosis if involve the
articular region
 Risk of femoral artery injury

29. Treatment
 Open Reduction Internal Fixation is a goal
standard treatment
Fixation devices:
 Angled blade plate
 CDS (condylar dynamic screw)
 Supracondylar inter-locking nail
 Buttress plating (locking plate)

30. Angled blade plate for fixation
of supracondylar fracture
of the femur

31. Knee joint dislocation
 Result from violence injury force
 Involve more than two of knee ligaments
injury
 Can presented as ‘self-reduction’ joint
dislocation
 Associated with popliteal vessel injury
and common peroneal nerve injury
 Urgent attention for vascular assessment

32. Radiographs show anterior
dislocation of the knee

33. Risk of vascular injury
 Transected or thrombosis.
 Vascular assessment or surveillance
 Angiogram as indicated

34. Directions of dislocation
 Reference to the position of tibia
 Anteromedial dislocation (risk of
associated injury of popliteal artery)
 Posterolateral dislocation (highly
associated with transected popliteal
artery)

35. artery

36. Complications
 Neurovascular injury
 Knee ligaments injury (result in joint
instability)
 Stiffness of the joint
 Arthrosis formation following cartilage
damage

37. Treatment
 Immediate reduction and immobilization
 Artery exploration and repair in the
evidence of arterial injury
 Immobilization in cast or external fixation
 Ligaments repair or reconstruction for
multiple ligaments injury resulting in
instability

38. Tibial plateau fractures
 Mechanism: varus or valgus force
combined with axial loading
 Also known as ‘bumper fracture’
 Tibial condyle can be crushed or split
 Presentation: haemathrosis, instability,
associated neurovascular injury

40. Types of TP #
 Simple split lateral condyle
 Depressed, comminuted lateral condyle
 Crushed comminuted lateral condyle
 Split medial condyle
 Bicondylar fractures
 Bicondylar and subcondylar

42. Complications
 Compartment syndrome
 Joint stiffness
 Deformity
 arthrosis

43. Treatment
Undisplaced or minimally displaced
 Traction until swelling subsided, apply cast
immobilization
Displaced and depressed
 Open reduction and internal fixation (buttress
plate, inter-fragmentary screw)
 May need bone grafting in depressed fractures

44. 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

45. Complications
 Joint stiffness
 Patellofemoral arthrosis
 reduced knee extensor mechanism

46. Treatment
Undisplaced fracture
 Cylinder cast immobilization for 6 weeks
Displaced fracture
 ORIF (tension band wiring)
Severely comminuted
 Cerclage wiring or patellectomy

47. Tibial shaft fractures
 Proximal, middle, distal region
 Compartment syndrome (proximal 1/3)
 Affecting union (distal 1/3)
 Spiral, oblique (indirect force)
 Transverse, comminuted (direct force)
 With or without fibular shaft #

48. Radiographs show tibial shaft fracture

49. Complications
 Compartment syndrome
 Malunion (leading to shortening and
arthrosis)
 Nonunion

50. Treatment
Acceptable displacement with less
comminuted (stable)
 Apply Full Length POP immobilization for
6 weeks
Comminuted, segmental (unstable
reduction alignment)
 Internal fixation (ILN, Plating)

51. Intramedullary
Locking nail for
Tibia shaft fracture

52. Malleoli fractures
(potts fracture)
 Forces to the ankle region
 External rotation, abduction, adduction,
 Ankle joint dislocation or subluxation
 Ankle ligaments injury including
syndesmosis

53. Classification
 Danis & Weber (Muller et al 1991):
Type A: # below the tibiofibular
syndesmosis
 abduction or adduction force
 Medial malleolus may #ed or rupture of
deltoid ligament

54. Cont’:
Type B: # level with syndesmosis
 Oblique fibular #
 External rotation force
 Disrupted medial structures
 Syndesmosis intact

55. Cont’:
Type C: # above the syndesmosis
 Abduction alone or combination of
abduction and external rotation force
 Disruption of syndesmosis and
interosseous membrane (widened
mortise)
 Unstable tibiofibular region

56. Fracture of lateral
malleolus

57. Complications
 Dislocated or subluxated ankle joint
 Stiffness
 Arthrosis of ankle joint
 Ankle instability
 Nonunion fracture (displaced medial
malleolus)
 Malunion of the fracture

58. Treatment
Undisplaced #
 Cast immobization (boot POP)
Displaced # with or without subluxation
joint or loss of normal ankle mortise
 ORIF (fibular plating, screw fixation of
medial malleoli, syndesmotic screw)

59. Plating of the lateral malleolus fracture
with 1/3 tubular plate

60. Talus fractures
 Rare injury
 Violence injury (following inversion force or
axial loading)
 +/- dislocation of the ankle joint or subtalar joint
 Regions affected: head, neck, body, and lateral
process
 Risk of developing avascular necrosis of talus
dome

61. Talus fractures
Dome of talus fracture showed
Through CT-scan
Neck of talus fracture

62. Complications
 Skin damage or necrosis due to pressure
from the underling bone
 Nonunion of the fracture
 AVN following fracture at the neck region
 Arthrosis (ankle and subtalar)

63. Treatment
 Undisplaced #: cast immobilization (boot
POP)
 Displaced # +/- dislocation: ORIF screw
fixation
 If AVN developed later may consider
arthrodesis of the ankle joint

64. Screw fixation of the talus fracture at the neck region

65. Calcaneum fractures
 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 (Bohler’s
angle: 25 –40 degrees) lead to flat foot

66. Extra-articular fracture of calcaneum

67. Complications
 Skin necrosis (intense swelling)
 Compartment syndrom
 Malunion of the fracture
 Peroneal tendon impairment
 Flat and broad foot
 Subtalar arthrosis

68. Treatment
 Extra-articular fractures or undisplaced
intra-articular fractures may require
Robert-Jones 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

69. Reference for further
reading:
 Orthopaedic Surgery Essential: Trauma;
Charles Court-Brown, Lippincott Williams &
Wilkins; 2005
 Turek’s Orthopaedics: Principles & their
application; Stuart L. Wienstein, Joseph A.
Backwalter: 5th Edition Lippincott Williams &
Wilkins 2005
 Practical Fracture Treatment; Ronald McRae, Max
Esser; 4th Edition, Churchill Livingstone 2002

70. 
 Thank you 