The document discusses lower limb fractures and dislocations, including the femur neck, intertrochanteric region, hip joint, femoral shaft, distal femur, knee joint, patella, tibial plateau, tibial shaft, malleoli, talus, and calcaneum. For each injury, the document outlines mechanisms of injury, clinical presentation, classification systems, radiological findings, complications, and treatment options. Conservative treatments include casting or traction, while operative options involve fixation devices like plates, screws, nails, or reconstruction as needed to stabilize fractures and restore joint alignment.

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 