This document provides an overview of lower extremity fractures, focusing on pelvic fractures, fractures of the neck of the femur, and intertrochanteric fractures of the femur. Key points include the relevant anatomy, mechanisms of injury, clinical evaluation, classification systems, treatment approaches, and potential complications for each type of fracture. Radiographic evaluation and the importance of assessing hemodynamic status and associated injuries are also discussed.

1. Lower Extremities
Fractures (Part I)
Dr. Apoorv Jain
D’Ortho, DNB Ortho
drapoorvjain23@gmail.com
+91-9845669975

2. • Pelvic Fractures
• Fracture Neck Of
Femur
• Intertrochanteric
Fracture Femur
• Fracture Shaft Of
Femur

3. Pelvic Fractures

4. Pelvic Fractures
Relevant Anatomy:
• The pelvic ring is composed of the sacrum and
two innominate bones joined anteriorly at the
symphysis and posteriorly at the paired
sacroiliac joints.
• The innominate bone is formed at maturity by
the fusion of three ossification centers:
– the ilium
– the ischium, and
– the pubis

5. The pelvic brim is formed by the arcuate lines
that join the sacral promontory posteriorly and
the superior pubis anteriorly.

6. Mechanism Of Injury
• Low-energy injuries:
– As in sudden muscular contractions in young
athletes that cause an avulsion injury, a low-energy
fall, or a straddle-type injury
• High-energy injuries:
– Motor vehicle accidents, fall from heights, or crush
mechanism
– Impact injuries result when a moving victim strikes
a stationary object or vice versa
– Crush injuries occur when a victim is trapped
between the injurious force

7. Avulsion Fractures:
• Common in Athletes
• Pull Of Sartorius will cause?
– Anterior Superior Iliac Spine avulsion
• Pull Of Rectus femoris will cause?
– Anterior Inferior Iliac Spine avulsion
• Pull of Hamstrings?
– Ischial Tuberosity avulsion
• Pull Of Adductor Longus?
– Pubic avulsion fracture

8. Clinical evaluation
• Perform patient primary assessment
(ABCDE):
–Airway Maintenance with C-spine protection
–Breathing and Ventilation
–Circulation with hemorrhage control
–Disability: Neurologic status
–Exposure/Environment Control

9. • Initiate resuscitation: Address life-
threatening injuries
• Evaluate injuries to head, chest,
abdomen, and spine.
• Identify all injuries to extremities and
pelvis, with careful assessment of distal
neurovascular status

10. • Pelvic Compression Test:
–The Antero-Posterior and Lateral Compression
test for pelvic instability should be performed
once only and involves rotating the pelvis
internally and externally.

11. Remember: “The first clot is the best clot” Once
disrupted, subsequent thrombus formation of a
retroperitoneal hemorrhage is difficult because
of hemodilution by administered intravenous
fluid and exhaustion of the body’s coagulation
factors by the original thrombus
To be done
once only

12. • Massive flank or buttock contusions are
indicative of significant bleeding
• The perineum must be carefully inspected for
the presence of a lesion representing an open
fracture

13. Hemodynamic status
• Retroperitoneal hemorrhage/ a large-vessel injury,
such as external or internal iliac disruption
• Causes rapid, massive hemorrhage and marked
hemodynamic instability
• Pelvic Binder, Rapid Fluid Resuscitation, Monitoring
(Pulse, BP, Urinary Output) are crucial
• Often, immediate surgical exploration to control
bleeding is required

15. Associated Injuries
• Neurologic injury:
–Lumbosacral plexus and nerve root injuries
• Genitourinary and gastrointestinal
injury
–Bladder injury: 20% incidence
–Urethral injury: 10% incidence
• Look for blood at the urethral meatus or on
catheterization
–Perforations in the rectum or anus, entrapment
of bowel with GI obstruction may occur

16. Radiographic evaluation
• Standard trauma radiographs include:
– AP view of the chest
– Lateral view of the cervical spine
– AP view of the pelvis
• In an AP view of the pelvis look for:
– Anterior lesions: pubic rami fractures and symphysis
displacement
– Sacroiliac joint and sacral fractures
– Iliac fractures
– L5 transverse process fractures

18. • Special views of the pelvis include:
– Obturator and iliac oblique views (Judet Views): For
suspected acetabular fractures
– Inlet and Outlet views
• Computed tomography
• Magnetic resonance imaging

19. Classifications

20. Young-Burgess classification

22. AP Compression Type

24. Treatment
• Nonoperative (Conservative) for
– Undisplaced/ Minimally displaced, Stable fractures
– Gaping of pubic symphysis <2.5 cm
– Isolated pubic rami fractures
• Includes Bed Rest, Traction, in bed
mobilisation followed by Gradual assisted
weight bearing

25. • Operative Techniques
–External fixation
–Internal fixation
• Open reduction and stable internal
fixation are performed using lag screws
and neutralization plates.

29. Complications
• Infection
• Thromboembolism:
– Disruption of the pelvic venous vasculature and
immobilization constitute major risk factors for
the development of deep venous thromboses.
• Malunion
• Nonunion

30. Fractures Around Hip
• Includes:
–Acetabular Fractures
–Fracture Head Of Femur
–Fracture Neck Of Femur
–Intertrochanteric Fracture Femur
Frequently
Associated With
Hip Dislocation

31. Fracture Neck Of
Femur

32. Fracture Neck Of Femur
• Occurs usually in elderly population
• The average age of occurrence is 77 years
for women and 72 years for men
• 80% occur in women
• The incidence in younger patients is very
low and is associated mainly with high-
energy trauma

34. • Risk factors include:
–female sex
–white race
–increasing age
–poor health
–tobacco and alcohol use
–previous fracture/ fall history, and
–low estrogen level (Post Menopausal)

35. Mechanism of injury
• Low-energy trauma: Most common in older
patients:
– Direct: A fall onto the greater trochanter (valgus
impaction) or forced external rotation of the lower
extremity
– Indirect: Muscle forces overwhelm the strength of the
femoral neck.
• High-energy trauma: Such as motor-vehicle accident
or fall from a significant height
• Cyclical loading (Stress fractures): Seen in athletes,
military recruits, ballet dancers; patients with
osteoporosis and osteopenia are at particular risk.

36. Clinical evaluation
Typically are nonambulatory on presentation
(Patients with impacted or undisplaced fractures
may however demonstrate subtle findings and may
be able to bear weight)
External rotation of the lower extremity
Shortening
Painful range of movements
Pain on axial compression
Tenderness in the groin

37. Radiographic Evaluation
• An AP view of the pelvis
• an AP and a Cross-table Lateral view of the
affected hip
• A 15° Internal rotation view (True AP) of the
injured hip may be helpful to further clarify
the fracture pattern.
A True AP view is taken
with limbs in
15° Internal Rotation

38. A Cross-table Lateral
view of the affected
hip is obtained by
flexing the uninjured
hip and knee 90
degrees and aiming
the beam into the
groin, parallel to the
floor and
perpendicular to the
femoral neck

40. Technetium Bone Scan or preferably
Magnetic resonance imaging may be used
to identify undisplaced or occult fractures
that are not apparent on plain radiographs

41. Classification
• Anatomic Location
–Subcapital
–Transcervical
–Basicervical (Treated as ExtraCapsular)
Treated as IntraCapsular

42. Pauwel’s Classification:
• Based on the angle of fracture from the horizontal:
– Type I: <30 degrees
– Type II: 30-70 degrees
– Type III: >70 degrees
More the angle, more unstable the fracure

43. Garden Classification:
• Based on the degree of valgus displacement
Type I: Incomplete/valgus impacted
Type II: Complete and undisplaced
Type III: Complete with partial displacement;
trabecular pattern of the femoral head does not
line up with that of the acetabulum
Type IV: Completely displaced; trabecular pattern
of the head assumes a parallel orientation with
that of the acetabulum

46. Treatment Algorithm
(for fracture neck of Femur)

47. Undisplaced
Displaced
Hemiarthroplasty/
Total Hip Arthroplasty
OldYoung
Percutaneous Screw
or Arthroplasty
Percutaneous
Cancellous Screw
Open Reduction &
Internal Fixation

48. Internal Fixation For Fracture Neck Of
Femur (For Younger Patients)
Percutaneous Cancellous
Screw Fixation
Fixation With a DHS
and Derotation Screw

49. Elderly Patients
(Physiological age>60 years)
Hemireplacement
Arthroplasty
Total Hip
Replacement

50. Complications
• Non Union
• Osteonecrosis Of Femoral head:
–Seen in upto 10% of nondisplaced fractures
and upto 27% of displaced fractures
• Fixation failure
• Prominent Hardware/ Screw backout
• Infection

51. Non Union Fracture Neck Of Femur:
• As per FDA, a fracture neck femur is said to be
non united if does’nt heal in 3 months
• Causes include:
– Intra-articular location
(Synovial fluid causes the lyses of the blood clot)
– Absence of Cambium layer
(Hence there is lack of callus and healing is only endosteal)
– Vascular Anatomy
– Inadequate reduction
– Loss of fixation

52. • Clinically,
–Shortening/ contractures
–Externally rotated limb
–Telescopy+
• Radiologically,
–Absorption of neck
–Roundening of fracture margins
–Evidence of hip arthritis may be present
in long standing cases

53. • Treatment options for Fracture Non-Union
Neck Of Femur:
–Elderly patient (Physiological age>60):
• Hemiarthroplasty (AMP/Bipolar)
• Total Hip Replacement (if Osteoarthritis+)
–Younger Patients:
• Open Reduction and Internal Fixation with
Cancellous Bone graft
• Muscle pedicle graft/ Vascularised grafts
• Osteotomy
• Purchase time for Total Hip Replacement if
evidence of Osteoarthritis+

54. Intertrochanteric
Fracture Femur

55. Intertrochanteric Fracture Femur
• Account for nearly 50% of all fractures of the
proximal femur
• Average patient age of incidence is 66 to 76
years
• Risk factors include
– Female sex (2-8 times commoner in females)
– Advancing age
– History of fragility fractures and
– Osteoporosis

56. Relevant Anatomy
• These are extracapsular fractures
• Occur in cancellous bone with an abundant blood
supply. As a result, nonunion and osteonecrosis are
not major problems, as in femoral neck fractures.

57. • Deforming muscle forces will usually produce
–Shortening
–Abduction of proximal femur
–Medial displacement, Adduction and proximal
migration of distal femur

58. Mechanism of injury
• 90% of intertochanteric fractures in the
elderly result from a simple fall
• Most fractures result from a direct impact
to the greater trochanter
• In younger individuals they usually occur as
a result of high-velocity injuries such as a
motor vehicle accident or a fall from height

59. Clinical Evaluation
• Patients are usually nonambulatory with
– Lower extremity shortening
– Externally rotated (>Fracture Neck Of Femur)
– Tenderness over Greater Trochanter
– Range of hip motion is typically painful
(Patients with undisplaced fractures may be
ambulatory and experience minimal pain)

60. • Commonly associated injuries include,
–Fractures of the Distal Radius
–Proximal Humerus and
–Spine (compression fractures)
• Must also evaluate for,
–Potential Dehydration
–Nutritional status
–Pressure ulceration
–Hemodynamic instability

61. Radiographic Evaluation
(similar to fracture neck of Femur)
• An AP view of the Pelvis
• An AP and a Cross-table Lateral View of the
involved Hip
• A 15° Internal Rotation View
• Technetium Bone Scan or preferably MRI may
be useful in identifying undisplaced or occult
fractures that are not apparent on plain
radiographs.

62. Fracture stability depends on the integrity
of the Posteromedial bony cortex

63. Evans Classification
Based On the Fracture Stability (Pre/Post
reduction)
• Stable:
– Intact or minimally comminuted Posteromedial
Cortex
• Unstable:
– Greater comminution of Posteromedial cortex
– Reverse Oblique Fractures
– Subtrochanteric Extension

64. Stable Fracture Pattern with Intact/
Minimally comminuted Posteromedial
Cortex

65. Unstable Fracture Pattern with,
Greater comminution of Posteromedial
cortex
Reverse Oblique Fractures
Subtrochanteric Extension

66. Treatment Options
1) Open Reduction/ Closed Reduction and Internal
Fixation with,
– Dynamic Hip Screw (For Stable Fractures)
– Intramedullary Nail
– Fixed Angle Blade Plate
2) External Fixation (For Open/ Infected Fractures)
3) Arthroplasty (For Associated Hip Osteoarthritis/
Fracture Neck Of Femur)
For Unstable Fractures

68. Dynamic Hip Screw (Sliding hip screw)

69. Intramedullary
Fixation

70. Complications
• Loss Of Fixation
• Malunion (Usually malrotation, varus/valgus)
• Non Union (Very rare, <2%)
• Infection
• Osteonecrosis Of femoral head (Rare)

71. Remember,
• For a displaced fracture neck of Femur or an
Intertrochanteric fracture Femur,
Surgery is the treatment of choice
• Non-operative treatment is associated with a
higher mortality rate than operative
treatment
• Non-operative treatment indicated only for
patients who are at extreme medical risk for
surgery or for demented/nonambulatory
patients with minimal hip pain

72. Fracture Shaft Of
Femur

73. Fracture Shaft Of Femur
• A femoral shaft
fracture is a fracture
of the femoral
diaphysis occurring
between 5 cm distal
to the lesser
trochanter and 5 cm
proximal to the
adductor tubercle

74. Age and Sex (Bimodal Distribution)
In Younger patients,
 More common in Men
 A High-velocity trauma
In Elderly patients,
 More common in Women
 A Low-energy fall

75. Mechanism Of Injury
• In Young Adults, almost always the result
of high-energy trauma,
– Motor vehicle accident
– Gunshot injury, or
– Fall from a height
• Pathologic fractures, especially in the
elderly, commonly occur following a trivial
fall
• Stress fractures occur mainly in military
recruits or runners

76. Clinical Evaluation
• A full trauma survey is indicated (ABCDE)
• The patient is
–Nonambulatory with pain
–Variable gross deformity
–Swelling, and
–Shortening of the affected extremity.
• A careful neurovascular examination is
essential

77. • A careful assessment of hemodynamic
stability is essential,
Average expected Blood loss of 750-1500ml
• Thorough examination of the ipsilateral hip
and knee should be performed
• Knee ligament injuries are common,
however, and need to be assessed after
fracture fixation

78. Thomas Splint Immobilisation
before shifting the patient

79. Associated Injuries
• Present in up to 5% to 15% of cases,
–Multisystem trauma,
–Spine,
–Pelvis, and
–Ipsilateral lower extremity injuries
• Ligamentous and meniscal injuries of the
ipsilateral knee are present in 50% of
patients with closed femoral shaft
fractures

80. Radiographic Evaluation
• AP and Lateral views of the femur,
hip, and knee
• AP view of the pelvis should be
obtained
• Look for evidence of an associated
femoral neck or intertrochanteric
fracture

81. Classification
• Descriptive Classification
–Open versus closed injury
–Location: Proximal, Middle, or Distal one-third
–Pattern: Spiral, Oblique, or Transverse
–Comminution: Segmental, or Butterfly fragment
–Displacement: Shortening or Translation,
Angulation or Rotational deformity

82. Winquist and Hansen Classification
• Based on fracture comminution,
–Type I: Minimal or No comminution
–Type II: Cortices of both fragments are 50% intact
–Type III: 50% to 100% cortical comminution
–Type VI: Circumferential comminution with no
cortical contact

83. Treatment
• Operative stabilization is the standard
of care for most femoral shaft fractures
• Surgical stabilization should occur
within 24 hours, if possible
• Early stabilization of long bone injuries
appears to be particularly important in
the multiply injured patient

84. For patients in whom surgery needs to be
delayed, temporary stabilisation with
Skeletal traction is required

85. Fixation Options
• Intramedullary Fixation
• Open Reduction and Plate Fixation
• External Fixation
(For Open/ Infected Fractures)

86. Intramedullary Fixation

87. Plate Fixation

88. External Fixation

89. Treatment Of Fracture Shaft Of
Femur In Children
As per AAOS guidelines,
• Age <6months:
– Pavlik Harness/ Early Spica Cast
• Age 6mts- 5 years:
– Early spica casting
– Traction with delayed spica casting
– ORIF with submuscular bridge plating
– Flexible nails (Ender’s / TENS)
– External fixator

90. Pavlik Harness for
Age<6months
Hip Spica Cast
for Age upto 5 years

91. Gallows
Traction
Paediatric
Thomas Splint

92. Flexible Intramedullary Nail Fixation

93. • Age 6-11 years,
–ORIF with submuscular bridge plating
–Flexible nails (Ender’s / TENS)
–External fixator
• Age>11 years,
–Antegrade Intramedullary Interlocking nail
–ORIF with submuscular bridge plating
–Flexible nails (Ender’s / TENS)
–External fixator

94. Complications
• Neurovascular injury
• Complartment Syndrome
• Infection
• Fixation Failure
• Non-Union/ Delayed Union
• Malunion
• Heterotopic Ossification

95. Thank You