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Lower limb fractures and dislocation

Learn about the types, radiological findings, and treatment options for lower limb fractures and dislocations. Topics include hip, femur, knee, and tibia fractures, with detailed discussions on classifications, complications, and management techniques.

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Lower limb fractures and dislocation

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  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

  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. Left side Radiograph shows left hip dislocation

  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 Proximal 1/3 supracondyalar

  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

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

  40. Complications • Compartment syndrome • Joint stiffness • Deformity • arthrosis

  41. 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

  42. 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

  43. Complications • Joint stiffness • Patellofemoral arthrosis • reduced knee extensor mechanism

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

  45. 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 #

  46. Radiographs show tibial shaft fracture

  47. Complications • Compartment syndrome • Malunion (leading to shortening and arthrosis) • Nonunion

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

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