Lower Limb Injuries

1. February 2019 Lower Limb Injuries

2. Lower Limb Trauma Secondary survey? Hip to Toes Bones / Soft tissues Open / Closed injuries Local / distal Early / Late

3. Lower Limb Trauma Look Feel Move Neurovascular Other occult injuries? Treatment ?Pathological (# or cause)

4. Lower Limb Trauma Common / important lower limb injuries: NOF # Femoral # Knee Tibialplateau Fibula head Tibia Ankle Foot

5. Lower Limb Trauma Common / important lower limb injuries: NOF # Femoral # Knee Tibial plateau Fibula head Tibia Ankle Foot • Look • Feel • Move • Neurovascular • Other occult injuries? • Treatment • ?Pathological

6. Lower Limb Trauma Common / important lower limb injuries: NOF # Femoral # Knee Tibial plateau Fibula head Tibia Ankle Foot • Look • Feel • Move • Neurovascular • Other occult injuries? • Treatment • ?Pathological Pitfalls!

7. Neck of Femur Typically due to a fall in the elderly. Leg deformity? Other signs? Blood supply Delayed presentation (impaction)

8. Neck Of Femur Fast track orthopaedics Bloods, analgesia, ivi, ECG Block Remember – why have they fallen?

9. Femoral Fracture Typically due to significant trauma in young. Signs Tender, palpable bone, abnormal movements. Other injuries –mechanism.

10. Femoral Fracture ABC iv access, fluids, bloods (inc. x-match) Analgesia Thomas splint Orthopaedics

11. Fat Embolus • Suspect the unexpected • Long bone fractures - and others • Looks like a PE • CxR changes

12. Knee Injuries Fractures / dislocation Ligamentous injuries Cartilage injuries

13. Knee Injuries Swelling / effusion, bruising, deformity Tenderness Full ROM? SLR? Abnormal movements / ligamentous injury Neurovascular Investigation

14. Ottowa Knee Rules XRAY Only required if: Age 55 or over Isolated tenderness of the patella (no bone tenderness of the knee other than the patella) Tenderness at the head of the fibula Inability to flex to 90 degrees Inability to weight bear both immediately and in the department (4 steps - unable to transfer weight twice onto each lower limb regardless of limping).

15. Patella # Analgesia, immobilisation. May need ORIF (esp transverse fractures) Bipartite patella

16. Tibial Plateau # Analgesia Long leg backslab Orthopaedics

17. Patella dislocation Reduce under analgesia e.g. entonox Use thumbs to lever patella back into place Cylinder POP / cricket pad splint Quads exercises Fracture clinic

18. Ligament injuries ACL – prevents tibia sliding forward relative to femur. +ve anterior draw PCL – prevents tibia sliding back relative to the femur. +ve posterior draw Effusion, instability.

19. Ligament injuries MCL – valgus load Localisedswelling, bruising, tenderness. Joint opensup when stressed. LCL may be damaged in a similar way.

20. Meniscal injuries Usually due to twisting the knee while weight bearing Painful (especially on knee extension) Locking / giving Effusion Special tests

21. Fibula Head May be secondary to direct blow, tibial plateau #, ankle twisting injury. Bruising, swelling, tenderness. Look for common peroneal nerve injury – inability to dorsiflex and evert, decreased sensation dorsum of foot and lateral calf

22. Tibial # Usually due to direct blow (transverse/oblique #) or twisting injury (spiral #) May be visible swelling, deformity, bruising. Tender, often palpable bone edges.

23. Tibial Fracture Analgesia Long leg backslab Orthopaedics Children?

24. Ankle Fractures Usually due to inversion / eversion injuries Inability to weight bear:? Swelling, bruising, deformity. Tenderness – bony or ligamentous

25. Ottawa Rules • Site of bony tenderness • Ankle • Foot • Neck of fibula • Unable to weight bear

26. Ankle fractures Classification: Weber A: transverse fibula avulsion, below the level of the syndesmosis. Should be stable. Weber B:Lateralmalleolar fracture at the level of syndesmosis. May be unstable. Weber C:Highfibula fracture, syndesmotic disruption and medial malleolar fracture. Usually unstable.

27. Ankle fractures Stable unimalleolar fractures – B/KPOP and fracture clinic Unstable fractures will need orthopaedics for ORIF Indications for ED reduction…

28. Maisonneuve Fracture Proximal fibular fracture coexisting with a medial malleolar fracture or disruption of the deltoid ligament. Partialor complete syndesmosis disruption. Always check joint above & joint below

29. Foot Fractures Deformity, swelling, bruising. Tenderness Ottawa rules for x-rays

30. 5th Metatarsal Fracture Commonest # metatarsal Base of 5th: Twistingof foot / ankle: avulsion fracture. Direct blow may break it anywhere.

31. Analgesia, support Fracture clinic follow up Direct discharge?

32. Calcaneal fracture Swelling, bruising, tenderness around heel. Usually due to high energy impact e.g. fall. Look for other injuries

33. Calcaneal fracture Bohler’s angle should be 35-40° Refer to orthopaedics as most will need admission for analgesia, elevation +/- CT and ORIF

34. More likely to be tibial May not be! Prognosis depending on tissue loss Principles the same Open fractures

35. Control haemorrhage with direct pressure Analgesia, splintage Remove obvious contaminants if possible Photo wound ID, verbal consent, photograph card Iodine dressings and i.v. ABX +/- tetanus

36. Finally… • POP: • Backslab • Compartment syndrome • VTE • Risk assess: # clinic forms • Dalteparin

38. Summary • Mechanism of injury • Look Feel Move ?xray • Analgesia, analgesia, analgesia