This document provides an overview of lower limb fractures, including fractures of the tibia (proximal, shaft, and distal), ankle, and foot. Key points discussed include the anatomy and mechanisms of injury for each fracture type. Classification systems and approaches to clinical examination, imaging, and management are described. Common complications are also outlined. The level of detail provided is intended for medical students to gain foundational knowledge on evaluating and treating lower limb fractures.

1. Lower limb
fractures
Tibia, Ankle, Foot.
Given Sishekano
201404386
MBChB IV
Feb 17,2017
14h00

2. Table of content
▪ Fractures of the tibia
▪ Fractures of the ankle
▪ Fractures of the foot

3. Tibial fractures
▪ 1. Anatomy
▪ 2. Proximal tibia fractures
▪ 3. Tibial shaft fractures.
▪ 4. Distal tibia fractures

4. Anatomy
• Long & Tubular w/ a triangular cross
section.
• Subcutaneous anteromedial border.

5. Fractures of the proximal tibia.
1. Fractures of tibial plateau
▪ Usually caused by forcible Valgus or Varus strain.
▪ Low energy fractures common in older females due to osteoporotic bone
changes.
▪ High energy fractures are commonly the result of motor vehicle
accidents, falls or sports related injuries
▪ Strong bending forces combined with an axial load e.g. bumper fractures
▪ A fall from a height in which the knee is forced into valgus or varus
position
▪ Lateral tibial plateu is commonly affected but medial may also be
affected

6. Epidemiology & presentation
▪ 50% of presenting pts are over 50 y/o (females commonly)
▪ Patients present with severe tenderness on side of fracture and on
opposing side if tendon damaged.
▪ Swollen tendon with doughy feel due to haemarthrosis

7. Classification (Schatzker Classification)

8. Imaging
▪ X-rays are vital
▪ CT scan not always done but help in evaluating extent of fracture
and planning management.
▪ MRI scan if soft tissue damage is suspected
▪ CT angiography if concerns of vascular compromise

9. Management
▪ Treatment is aimed at achieving a stable, aligned, mobile and
painless joint and to minimize the risk of posttraumatic
osteoarthritis.
▪ Undisplaced & minimally displaced(Lc): conservative
management.
▪ Marked displacement/ comminuted(Lc): ORIF
▪ Medial condyle fractures: ORIF
▪ Bicondylar fractures: internal fixation w/ Plates and screws

10. Tibial Shaft Fractures
▪ Commonest long bone fractures.
▪ Men>women
▪ Often Open fractures w/ contaminated wound.

11. Mechanism of Injury
▪ 1.Direct: High energy: MVA, sporting injury
-Transverse, comminuted, displaced fractures commonly occur.
-Incidence of soft tissue trauma is high
▪ Penetrating: gunshot-The injury pattern is variable.
▪ Bending-Short oblique or transverse fractures occur, with a
possible butterfly fragment.
-Crush injury.

12. ▪ 2. Indirect
▪ Torsional mechanisms
-twisting with foot fixed, falls from low height.
-minimal soft tissue damage.
▪ Stress fractures
-e.g in Ballet dancers.

14. Clinical Exam
▪ Neurovascular status
▪ Assess soft tissue injury
▪ Examine knee ligament(commonly damaged)
▪ Examine for signs of compartment syndrome.

15. Imaging
▪ X-ray is usually sufficient
-Two views
-Two joints
-Two occasions
▪ Oblique X-ray to characterise pattern of injury if necessary.
▪ Post reduction X-ray must be done.

16. Classification
▪ None Universal.
▪ If open-Gustillo Anderson
▪ If closed- Tscherne Classification
of closed fractures.

17. Management
▪ Low energy
-Gastillo I, II: Conservatively
▪ Undisplaced/minimally displaced
- full length cast from upper thigh
to metatarsal neck, knee is
slightly flexed and the ankle at a
right angle
▪ Displaced fracture
- reduction under general
anaesthesia
▪ High energy
-External fixation is the method of
choice
-intramedullary nailing is an
alternative
-- Open operations should be
avoided unless there is already an
open wound

18. Complications
▪ Vascular injuries
▪ Compartment syndrome
▪ Infection
▪ Malunion
▪ Delayed union and non union
▪ Joint stiffness

19. 3. Distal Tibial fractures
▪ Injury occurs when a large axial force drives the talus upwards
against the tibial plafond
▪ Usually high Energy
▪ Can be rotational with lower energy
▪ Articular Surface is Involved
▪ Can have severe comminution and severe soft tissue injury

20. Clinical features
▪ Little swelling initially but this rapidly changes
▪ Fracture blisters are common
▪ Ankle may be deformed or dislocated

21. Classification(Rudi and Allgower)
▪ Type I – Fracture involving
minimal displacement
▪ Type II – Significant
displacement of the joint surface
▪ Type III – Impaction and
comminution of the articular
surface

22. Imaging
▪ X-ray(diagnostic)

23. Management
▪ Early management: SPAN, SCAN,
PLAN.
▪ Remember Life, Limb, Fracture.
▪ Manage soft tissue swelling.
▪ Once skin has recovered, do ORIF
▪ Closed reduction w/ a cast.
▪ External fixation if needed

24. 2. Ankle fractures
▪ Anatomy of the ankle ▪ Tibia and fibula form a mortise
which provides a constrained
articulation for the talus.
▪ Ankle stability is provided by 3
factors:
▪ Bony architecture, joint capsule and
ligamentous
▪ structures:
▪ Syndesmotic ligaments
▪ Medial collateral ligaments
▪ Lateral collateral ligaments

25. ▪ Stumbling and falling
-Foot is usually anchored to the ground and the body lounges
forward.
▪ Ankle twisting
-Talus tilts or rotates forcibly in mortise causing a low energy
fracture of one or both malleoli with associated injuries of the
ligaments.

26. ▪ Simple description:
▪ Joint can be injured on one side only
(single malleolus) or on both sides
(bi-malleolar fracture)
▪ Rotational injuries:
▪ 1/both sides may be injured.
▪ Posterior lip of the lower end of the
tibia (posterior malleolus) may be
fractured.
▪ Degree of instability depends on
how much of ankle complex is
damaged.

27. Classification
1. Weber classification

28. 2. LAUGE-HANSEN CLASSIFICATION:
Uses two terms:
First: describes position of the foot at time of injury, second: the motion of the talus relative to the tibia
Types:
1. supination – adduction
2. supination – external rotation
3. pronation – abduction
4. pronation – eversion
5. pronation – dorsiflexion
Description is used because most ankle injuries are caused by the weight of the falling person applying
force on the ankle with the foot in a fixed position.
Classification proposes that mechanism of injury can be deduced from the X-ray appearances and that
reduction involves applying the reverse movement.

29. 3. Fractures of the foot
▪ Anatomy of the foot.

30. Talus fracture
▪ Talus fracture is an injury of the hind
foot
▪ Rare, occur due to considerable
violence with axial loading or hyper
dorsiflexion.
▪ Injuries include fracture of the head,
neck, body, or bony processes of
talus.
▪ Patients present with painful and
swollen foot and ankle
▪ Obvious deformity if fracture is
displaced
▪ Skin overlaying the fracture or
dislocation may be tented or split

31. X-ray(Talus fracture)

32. Hawkins Classification & management
▪ Type I : non displaced fracture
▪ Type II : displaced fracture with
subluxation or dislocation of the
subtalar joint and a normal ankle
joint
▪ Type III : displaced fracture with
body of talus dislocated from both
subtalar and ankle joint.
▪ Type IV: in addition to features
describes in type III there is
dislocation or subluxation of the
head of the talus at the
talonavicular joint
Management
▪ Undisplaced #: Backslab until
swelling has subsided followed by
non-weight bearing below knee
CPOP (6-8 weeks)
▪ Displaced #: closed reduction
attempted first, if it fails, ORIF is
performed where the reduced # is
stabilised with 1 or 2 lag screws
Complications
-Malunion
-AVN
-Secondary Osteoarthritis

33. Calcaneal fractures
▪ Common mechanism axial loading
▪ Calcaneum driven up against talus and
is split or crushed.
▪ 10% of calcaneus #s associated with
compression injuries of spine, pelvis or
hip.
▪ Two types:
▪ Extra-articular #: involve calcaneal
processes or posterior part of bone.
Easy to manage and have good
prognosis.
▪ Intra-articular #: cleave bone obliquely
and run into superior articular surface.
Articular facet is split apart and there
may be severe comminution.

34. Sanders Classification
▪ Type I: non-displaced fractures (displacement < 2 mm).
▪ Type II: consist of single intraarticular fracture dividing the
calcaneus into 2 pieces.
▪ Type IIA: occurs on lateral aspect of calcaneus.
▪ Type IIB: occurs on central aspect of calcaneus.
▪ Type IIC: occurs on medial aspect of calcaneus.
▪ Type III: consist of two intraarticular fractures that divide the
calcaneus into 3 pieces.
▪ Type IIIAB: two fracture lines are present, one lateral and one
central.
▪ Type IIIAC: two fracture lines are present, one lateral and one
medial.
▪ Type IIIBC: two fracture lines are present, one central and one
medial.
▪ Type IV fractures consist of fractures with more than three
intrarticular fractures.

35. Presentation
▪ Foot is painful, swollen and bruised.
▪ Wider, shortened, flatter heel when
viewed from behind + varus heel
▪ Tissues are thick and tender and
normal concavity below the lateral
malleolus is lacking.
▪ Subtalar joint cannot be moved but
ankle movement is possible.
▪ Always check for signs of
Compartment syndrome
X-ray views
▪ Lateral, oblique and AP views
▪ Extra-articular #: fairly obvious on
xray
▪ Intra-articular #: can be identified
on xray, if there is displacement of
fragments lateral view may show
reduced of Bohler’s angle

36. Management
▪ Undisplaced fractures: Closed non-surgical treatment (backslab,
CPOP), use crutches for 4-6 weeks.
▪ Displaced avulsion #: ORIF, Immobilise foot in slight equinus to
relieve tension on tendo Achillis. Non-weight bearing for 4-6 weeks.
▪ Displaced intra-articular #: ORIF with plates and screws.
▪ Bone grafts may be used to fill defects.
▪ Encourage exercise when pain subsides
▪ Pt allowed to use crutches 2-3 weeks after (non-weight bearing) ->
Partial weight bearing only when fracture has healed -> full weight
bearing only 4 weeks after that

37. Complications
▪ Early: swelling and blistering, Compartment Syndrome
▪ Late: Malunion, Insufficiency of Achilles tendon (due to loss of
heel height), talocalcaneal stiffness and osteoarthritis

38. Lisfranc fracture
▪ Lisfranc (midfoot) injuries result if bones in the midfoot are broken or
ligaments that support the midfoot are torn.
▪ Varies from minor sprains to severe fracture-dislocations
▪ m.o.i: simple twist and fall.
▪ This is a low-energy injury, commonly seen in football and soccer players.
▪ More severe injuries occur from direct trauma, such as a fall from a
height.
▪ These high-energy injuries can result in multiple fractures and
dislocations of the joints.
▪ It is often seen when someone stumbles over the top of a foot plantar
flexed.

39. Mechanism of injury
Symptoms
• Pain(worsened by
walking)
• Bruising
• Swelling

40. X-rays
▪ Full extent of injury hardly clear on plain x-ray; multiple vies of CT
may be needed.
▪ Look out for fractures of navicular and cuneiform bones.

41. Management
▪ Undisplaced sprain: cast immobilization for 4-6 weeks.
▪ Subluxation and dislocation: Traction and manipulation under
anaesthesia achieves reduction.
▪ Position is then held with K-wires or screws and cast
immobilization.
▪ Non-weight bearing for 6-8 weeks.

42. Metatarsal fractures
▪ Due to direct blow, severe
twisting injury or repetitive stress
▪ 5th metatarsal #s are usually
due to forced inversion of the
foot (the pot hole injury) which
then causes avulsion of the base
of the 5th metatarsal tuberosity
▪ Avulsion fracture occurs where a
tendon attaches to the bone
▪ When an avulsion fracture
occurs, the tendon pulls off a tiny
fragment of bone.

43. Presentation
▪ Patient often complains of
having sprained the ankle
▪ Tenderness marked over area of
fracture.
Management
▪ Fracture usually unites readily
▪ Immobilisation in a below knee
plaster for 4 weeks is advised
X-rays

44. Sesamoid fractures
▪ Fractures occur either due to a direct injury (i.e landing from a
height on the ball of the foot), sudden traction or;
▪ chronic repetitive stress as seen in dancers and runners
▪ Patient c/o pain over the sesamoids
▪ O/E: Tender spot in the same area and pain may be exacerbated
by passively hyperextending the hallux
Rx:Conservative treatment
▪ Use of local lignocaine injection for pain relief
▪ In cases of marked discomfort, immobilise leg in cast 2-3 weeks

45. References
1. Apley’s consice system of orthopaedics and fractures
2. Toronto notes 2016
3. Orthopaedics and fractures lecture notes(4th ed.), wiley-Blackwell.