This document discusses various orthopedic injuries to the lower limb, including fractures of the femoral neck, intertrochanteric fractures, femoral shaft fractures, distal femur fractures, patella fractures, tibial fractures, ankle fractures, and knee dislocations. For each injury, the document discusses epidemiology, mechanism of injury, clinical presentation, treatment options including operative and non-operative management, and potential complications. Surgical treatment involves procedures like open reduction internal fixation, intramedullary nailing, and arthroplasty, while non-operative care includes casting and bracing with restricted weight bearing.

1. ORTHOPEDIC SURGERY
Dr. Rami Abo Ali
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2. INJURIES TO THE LOWER LIMB ( 2 )
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3. FEMORAL NECK FRACTURES
 Epidemiology
 increasingly common due to aging
population
 women > men
 whites > blacks
 most expensive fracture to treat
 Mechanism
 high energy in young patients
 low energy falls in older patients
 Healing potential
 femoral neck is intracapsular, bathed in
synovial fluid
 lacks periosteal layer
 callus formation limited, which affects healing
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4.  Blood supply to femoral head
 major contributor is medial femoral circumflex (lateral epiphyseal
artery)
 some contribution to anterior and inferior head from lateral femoral
circumflex
 some contribution from inferior gluteal artery
 small and insignificant supply from artery of ligamentum teres
 displacement of femoral neck fracture will disrupt the blood supply and
cause an intracapsular hematoma
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5. FEMORAL NECK FRACTURES
 Symptoms
 impacted and stress fractures
 slight pain in the groin or pain referred
along the medial side of the thigh and
knee
 displaced fractures
 pain in the entire hip region
 Physical exam
 impacted fractures
 no obvious clinical deformity
 minor discomfort with active or passive
hip range of motion, muscle spasms at
extremes of motion
 pain with percussion over greater
trochanter
 displaced fractures
 leg in external rotation and abduction,
with shortening
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6. FEMORAL NECK FRACTURES
 Treatment
 Nonoperative
 observation alone
 may be considered in some patients who
are non-ambulators, have minimal pain,
and who are at high risk for surgical
intervention
 Operative
 ORIF
 Cannulated screw fixation (<50 yo)
 Sliding hip screw
 Hemiarthroplasty (for elders )
 total hip arthoplasty (for active elders ) 6
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8. FEMORAL NECK FRACTURES
 Prognosis
 mortality
 ~25-30% at one year (higher than vertebral compression
fractures)
 predictors of mortality
 pre-injury mobility is the most significant determinant for
post-operative survival
 in patients with chronic renal failure, rates of mortality at
2 years postoperatively, are close to 45%
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9. INTERTROCHANTERIC FRACTURES
 Extracapsular fractures of the proximal femur between the
greater and lesser trochanters
 Female : male ratio between 2:1 and 8:1
 typically older age than patients with femoral neck fractures
 Risk factors: osteoporosis, prior hip fracture, risk of
falls
 More common than femoral neck fracture in patients
with preexisting hip arthritis
 In contrast to intracapsular fractures, extracapsular trochanteric
fractures unite quite easily and seldom cause avascular
necrosis
 Physical Exam : painful, shortened, externally rotated lower
extremity 9
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11. INTERTROCHANTERIC FRACTURES
 Treatment
 Nonoperative
 nonweightbearing with early out of bed to chair
 Operative
 Intertrochanteric fractures are almost always treated by early
internal fixatio because :
 to obtain the best possible position And
 to get the patient up and walking as soon as possible and
thereby reduce the complications associated with prolonged
recumbency
 sliding hip compression screw
 intramedullary hip screw
 arthroplasty
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12. INTERTROCHANTERIC FRACTURES
 Complications
 Implant failure and cutout
 most common complication
 usually occurs within first 3 months
 Nonunion <2%
 treatment
 revision ORIF with bone grafting
 proximal femoral replacement
 Malunion
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13. FEMORAL SHAFT FRACTURES
 high energy injury that is associated with life-threating conditions
 Fracture patterns
 transverse
 spiral
 oblique
 segmental
 comminuted
 Blood loss in closed femoral shaft fractures is 1000-1500ml
 Must record and document distal neurovascular status
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14. FEMORAL SHAFT FRACTURES
 Treatment
 Nonoperative
 long leg cast or hip spica cast
 nondisplaced femoral shaft fractures in patients with
multiple medical comorbidities
 pediatric patients
 Operative
 antegrade intramedullary nail ( gold standard for
treatment of diaphyseal femur fractures )
 retrograde intramedullary nail
 external fixation with conversion to intramedullary nail
within 2-3 weeks
 open reduction internal fixation with plate
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16. FEMORAL SHAFT FRACTURES
 Complications
 Heterotopic ossification 25%
 Pudendal nerve injury
 Femoral artery or nerve injury
 Malunion and rotational
malalignment
 Delayed union
 Nonunion
 Infection
 Fat embolism
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Heterotopic ossification

17. DISTAL FEMUR FRACTURE
 Distal femur fractures are fractures extending from
the distal metaphyseal-diaphyseal junction of the femur
to the articular surface of the femoral condyles.
 They occur both in younger patients (as the result of high
energy trauma) or in older patients (from low energy
trauma as a pathological fracture secondary to
osteoporosis or malignancy).
 The classification is commonly used to classify distal
femur fractures into
 extra-articular (type A),
 partial articular (type B),
 and complete articular (type C). 17
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Floating knee is a flail knee joint
resulting from fractures of the shafts
or adjacent metaphyses of the femur
and ipsilateral tibia

19. DISTAL FEMUR FRACTURE
 The majority of distal femur fractures are managed
surgically.
 retrograde nailing or open reduction internal
fixation (ORIF).
 Non-operative management requires a long period of
immobilisation and non-weight bearing, however is
sometimes indicated for fractures with minimal
displacement in a non-ambulatory or very co-
morbid patient.
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20. PATELLA FRACTURE
 A patella (kneecap) fracture is a traumatic injury caused by
direct trauma or rapid contracture of the quadriceps with a
flexed knee
 most fractures occur in 20-50 year olds
 male to female 2:1
 Mechanism of injury
 direct impact injury occurs from fall or dashboard injury
 indirect eccentric contraction occurs from rapid knee
flexion against contracted quads muscle
 Osteology
 patella is largest sesamoid bone in body
 superior 3/4 of posterior surface covered by articular cartilage
 articular cartilage thickest in body (up to 1cm)
 posterior articular surface comprised of medial and lateral
facets
 lateral facet is larger
 facets separated by vertical ridge 20
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22. PATELLA FRACTURE
 Treatment
 Nonoperative
 knee immobilized in extension (brace or cylinder cast) and full weight
bearing
 Operative :depending on displacement and knee extension
function
 ORIF
 partial patellectomy
 total patellectomy
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23. DISLOCATION OF THE PATELLA
 Anatomy
 Static stability
 medial patellofemoral ligament
(MPFL)
 is primary restraint in first 20
degrees of knee flexion
 patellar-femoral bony structures
account for stability in deeper
knee flexion
 trochlear groove morphology,
patella height, patellar
tracking
 Dynamic stability
 provided by vastus medialis
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24. DISLOCATION OF THE PATELLA
 The patella can be dislocated by a sharp twisting movement of
the knee in very slight flexion
 It is common in adolescents, particularly girls with loose
ligament
 On examination soon after a dislocation, the knee will be
swollen because of the haemarthrosis and there will be
tenderness on the medial side of the patella because the medial
structures are torn (medial patella femoral ligament)
 Treatment
 All blood should be aspirated to help reduce pain.
 Immobilization of the knee and early rehabilitation
 If the patella has dislocated more than three times a
stabilizing operation will probably be required
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26. DISLOCATION OF THE PATELLA
 Recurrent dislocation of patella :
 In over 70% of cases an underlying abnormality is found.
 These include joint hypermobility, patella alta, patella maltracking and
axial malalignments
 Anatomical factors
 patella alta :causes patella to not articulate with sulcus, losing its
constraint effects
 trochlear dysplasia
 excessive lateral patellar tilt (measured in extension)
 lateral femoral condyle hypoplasia
 Treatment
 Nonoperative
 NSAIDS, activity modification, and physical therapy
 Operative
 Medial retinaculum and ligament repair
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27. KNEE DISLOCATION
 Complete separation of the tibia from the femur requires enough
trauma to tear at least two of the four major ligaments.
 Both vascular and neurological functions must be assessed carefully
and recorded so that any deterioration will be noticed.
 Damage to the popliteal vessels occurs in 50% of cases and an
angiogram is mandatory if there is doubt about the peripheral
vascularity.
 Exploration of the popliteal artery and repair should be performed as
an emergency as there is a high chance of an amputation if this is
delayed more than 6 hours from the time of the injury
 Types :
 Anterior (30-50%) (most common)
 Posterior (30-40%)
 Lateral
 Medial
 Rotational
 Treatment :
 Emergent reduction followed by vascular assessment/consult
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29. TIBIAL PLATEAU FRACTURES
 Fractures of the tibial plateau are caused by a varus or valgus force
combined with axial loading (a pure valgus force is more likely to rupture
the ligaments).
 Associated conditions
 meniscal tears
 ACL injuries
 compartment syndrome
 vascular injury
 Radiology :
 X-ray
 CT scan
 important to identify articular depression and comminution
 Treatment :
 Undisplaced fractures can be treated conservatively (splint).
 Displaced fractures need open reduction and internal fixation +/- bone
graft .
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31. TIBIAL SHAFT FRACTURES
 Most common long bone fracture
 account for 4% of all fracture seen in the Medicare population
 Mechanism of injury
 Indirect force: (low energy)
 Twisting: spiral fractures of both bones
 Angulation: oblique fractures with butterfly segment.
 Direct force:
 Transverse (low energy) or comminuted (high energy) fractures usually with skin and
soft tissue damage.
 Treatment
 Closed reduction / cast immobilization
 indications
 closed low energy fractures with acceptable alignment
 < 5 degrees varus-valgus angulation
 < 10 degrees anterior/posterior angulation
 > 50% cortical apposition
 < 1 cm shortening
 No rotational malalignment
 Open reduction internal fixation ( plate , IM nail)
 External fixation ( mostly for open fractures )
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33. TIBIAL SHAFT FRACTURES
 Complications :
 Knee pain
 Malunion
 Nonunion
 Malrotation
 Compartment syndrome
 can occur in both
closed and open tibia
shaft fractures
 Soft tissue damage.
 Skin loss
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34. DISTAL TIBIAL FRACTURES
 These fractures occur at the distal end of the
tibia.
 Tibial plafond fractures (Also known
as pilon fractures) are caused by high energy
axial load (motor vehicle accidents, falls from
height) and often characterized by articular
impaction and comminution with soft tissue
injury
 Check Dorsalis Pedis and Posterior Tibial pulses
 Ct scan is very important in planning for surgery
 Treatment :
 Undisplaced stable fractures can be treated
conservatively .
 Displaced fractures need
 open reduction and internal fixation (ORIF)
+/- bone graft .
 External fixation and delayed ORIF
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36. DISTAL TIBIAL FRACTURES
 Complications
 Wound slough (10%)
 Dehiscence (9-30%)
 Infection (5-15%)
 Varus malunion
 Nonunion
 Posttraumatic arthritis
 Chondrolysis
 Stiffness
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37. ANKLE FRACTURES
 Typically a low-energy mechanism of injury, rotational as opposed to
axial load
 Must always evaluate for deltoid or syndesmosis injury
 injury patterns
 isolated medial malleolus fracture
 isolated lateral malleolus fracture
 bimalleolar fractures
 posterior malleolus fractures
 syndesmotic injury
 Radiographs recommended views
 AP
 lateral
 Mortise (the leg internally rotated 15 degree ) for syndesmosis
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39. ANKLE FRACTURES
 Treatment
 Nonoperative
 short leg walking cast or cast boot for
nondisplaced stable fracture and tip
avulsions
 Operative
 ORIF for displaced unstable fractures
 Complications
 Wound problems surgery
 Deep infections
 up to 20% in diabetic patients
 Malunion
 Post-operative stiffness
 Post-traumatic arthritis
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40. ANKLE LIGAMENT INJURIES
 ankle sprains involve an injury to the
Anterior Talo-Fibular Ligament (ATFL)
and calcaneofibular ligament (CFL)
and are the most common reason for
missed athletic participation
 Types:
 Stretching of the ligament.
 Partial tear: healing restores full
function.
 Complete tear: joint instability.
 Usually involves lateral ankle
ligaments (ant. Talofibular lig.,
talocalcaneal lig., and post. Talofibular
lig.).
 Medial calcaneal lig. (deltoid lig.) can
result from abduction or eversion
injury.
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41. ANKLE LIGAMENT INJURIES
 Clinical features:
 Bruising, swelling, tenderness (usually distal
and anterior to lat. Malleolus in anterior
talofebular lig. Injury).
 Treatment
 Partial tears: RICE , elastic bandage and
gentle active exercise.
 Complete tears: cast immobilization from
below knee to toes for 6 wks then
physiotherapy. if this regime fails; operative
repair is done.
 Complications:
 Recurrent sprains.
 Recurrent giving way or instability.
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42. FRACTURES OF TALUS
 Rare and usually due to fall from
height , car accidents,…
 May involve the body, neck, head
or dislocation of the talus.
 Clinical features
 Pain, swelling, deformity.
 Radiology :
 X-ray: difficult to diagnose.
May need to repeat several
days later to see the fracture.
 CT in difficult cases.
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43. FRACTURES OF TALUS
 Treatment
 Undisplaced : Below knee plaster
with knee plantigrade for 6-8 wks.
 Displaced fractures or fracture
dislocations: urgent reduction by
closed manipulation; if fails,
 ORIF
 Complications
 Non-union.
 Avascular necrosis of body after
fracture of neck.
 Secondary osteoarthritis. 43
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44. CALCANEAL FRACTURES
 Usually seen after fall from height .
 Lover's fracture, also known as Casanova fracture is a type of calcaneal
fracture
 Associated injuries: spine, pelvis, hip or base of skull.
 Types: ( CT scan is important )
 Extra-articular fractures: need closed treatment. Have good prognosis.
 Intra-articular fractures: involve superior articular surface.
 May be comminuted.
 Special features
 The foot swollen, bruised and the heel look broad. Movement is painful.
 Signs of compartment syndrome: intense pain and diminished sensation.
 Necessary to X-ray the knees, spine, and pelvis.
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45. CALCANEAL FRACTURES
 Treatment
 Admit to hospital, elevate the leg
and apply ice-packs until swelling
subside.
 Undisplaced fractures: closed
treatment.
 Displaced fractures: ORIF with
screws or calcaneal plate and
screws.
 Complications
 Broadening of the heel
 Stiffness
 Osteoarthritis
 Compartment syndrome 45
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46. METATARSAL FRACTURES
 Mechanism of injury:
 Direct trauma, Twisting, Repetitive stress.
 Treatment:
 Walking plaster for 3 weeks.
 Displaced fractures; Kirschner wire fixation.
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47. 5TH METATARSAL BASE FRACTURE
 5th metatarsal base fractures are among the most common
fractures of the foot.
 Some fractures may be predisposed to poor healing due to the
limited blood supply to the specific areas of the 5th metatarsal base.
 Treatment can include protected weight bearing, immobilization or
surgery depending on location of fracture, degree of displacement,
and athletic level of patient.
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48. 5TH METATARSAL BASE FRACTURE
 Jones fracture :is a zone 2 fracture (a transverse fracture at the base of
the fifth metatarsal, 1.5 to 3 cm distal to the proximal tuberosity )
 represents a vascular watershed area, making these fractures prone
to nonunion
 zone 2 (Jones fracture) in elite or competitive athletes treated
surgically to minimizes possibility of nonunion or prolonged restriction
from activity
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