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Slide 1-

Lower Extremity Trauma M4 Student Clerkship UNMC Orthopaedic Surgery Department of Orthopaedic Surgery and Rehabilitation
Slide 2-

Lower Extremity Trauma Hip Fractures / Dislocations Femur Fractures Patella Fractures Knee Dislocations Tibia Fractures Ankle Fractures
Slide 3-

Hip Fractures Hip Dislocations Femoral Head Fractures Femoral Neck Fractures Intertrochanteric Fractures Subtrochanteric Fractures
Slide 4-

250,000 Hip fractures annually Expected to double by 2050 At risk populations Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition Young: high energy trauma Epidemiology
Slide 5-

Hip Dislocations Significant trauma, usually MVA Posterior: Hip flexion, IR, Add Anterior: Extreme ER, Abd/Flex
Slide 6-

Hip Dislocations Emergent Treatment: Closed Reduction Dislocated hip is an emergency Goal is to reduce risk of AVN and DJD Allows restoration of flow through occluded or compressed vessels Literature supports decreased AVN with earlier reduction Requires proper anesthesia Requires “team” (i.e. more than one person)
Slide 7-

Hip Dislocations Emergent Treatment: Closed Reduction General anesthesia with muscle relaxation facilitates reduction, but is not necessary Conscious sedation is acceptable Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, cause muscle spasm, and make subsequent attempts at reduction more difficult
Slide 8-

Hip Dislocations Emergent Treatment: Closed Reduction Allis Maneuver Assistant stabilizes pelvis with pressure on ASIS Surgeon stands on stretcher and gently flexes hip to 90deg, applies progressively increasing traction to the extremity with gentle adduction and internal rotation Reduction can often be seen and felt Insert hip Reduction Picture
Slide 9-

Hip Dislocations Following Closed Reduction Check stability of hip to 90deg flexion Repeat AP pelvis Judet views of pelvis (if acetabulum fx) CT scan with thin cuts through acetabulum R/O bony fragments within hip joint (indication for emergent OR trip to remove incarcerated fragment of bone)
Slide 10-

Hip Dislocations Following Closed Reduction No flexion > 60deg (Hip Precautions) Early mobilization with PT/OT TTWB for 4-6 weeks MRI at 3 months (follow risk of AVN)
Slide 11-

Femoral Head Fractures Concurrent with hip dislocation due to shear injury
Slide 12-

Femoral Head Fractures Pipkin Classification I: Fracture inferior to fovea II: Fracture superior to fovea III: Femoral head + acetabulum fracture IV: Femoral head + femoral neck fracture
Slide 13-

Treatment Options Type I Nonoperative: non-displaced ORIF if displaced Type II: ORIF Type III: ORIF of both fractures Type IV: ORIF vs. hemiarthroplasty Femoral Head Fractures
Slide 14-

Femoral Neck Fractures Garden Classification I Valgus impacted II Non-displaced III Complete: Partially Displaced IV Complete: Fully Displaced Functional Classification Stable (I/II) Unstable (III/IV) I II III IV
Slide 15-

Treatment Options Non-operative Very limited role Activity modification Skeletal traction Operative ORIF Hemiarthroplasty (Endoprosthesis) Total Hip Replacement Femoral Neck Fractures
Slide 16-

ORIF Hemi THR
Slide 17-

Femoral Neck Fractures Young Patients Urgent ORIF (<6hrs) Elderly Patients ORIF possible (higher risk AVN, non-union, and failure of fixation) Hemiarthroplasty Total Hip Replacement
Slide 18-

Intertrochanteric Hip Fx Intertrochanteric Femur Fracture Extra-capsular femoral neck To inferior border of the lesser trochanter
Slide 19-

Intertrochanteric Hip Fx Intertrochanteric Femur Fracture Physical Findings: Shortened / ER Posture Obtain Xrays: AP Pelvis, Cross table lateral
Slide 20-

Classification # of parts: Head/Neck, GT, LT, Shaft Stable Resists medial & compressive Loads after fixation Unstable Collapses into varus or shaft medializes despite anatomic reduction with fixation Reverse Obliquity Intertrochanteric Hip Fx
Slide 21-

Stable Reverse Obliquity Unstable Intertrochanteric Hip Fx
Slide 22-

Intertrochanteric Hip Fx Treatment Options Stable: Dynamic Hip Screw (2-hole) Unstable/Reverse: IM Recon Nail
Slide 23-

Subtrochanteric Femur Fx Classification Located from LT to 5cm distal into shaft Intact Piriformis Fossa? Treatment IM Nail Cephalomedullary IM Nail ORIF
Slide 24-

Femoral Shaft Fx Type 0 - No comminution Type 1 - Insignificant butterfly fragment with transverse or short oblique fracture Type 2 - Large butterfly of less than 50% of the bony width, > 50% of cortex intact Type 3 - Larger butterfly leaving less than 50% of the cortex in contact Type 4 - Segmental comminution Winquist and Hansen 66A, 1984
Slide 25-

Treatment Options IM Nail with locking screws ORIF with plate/screw construct External fixation Consider traction pin if prolonged delay to surgery Femoral Shaft Fx
Slide 26-

Distal Femur Fractures Distal Metaphyseal Fractures Look for intra-articular involvement Plain films CT
Slide 27-

Distal Femur Fractures Treatment: Retrograde IM Nail ORIF open vs. MIPO Above depends on fracture type, bone quality, and fracture location
Slide 28-

High association of injuries Ligamentous Injury ACL, PCL, Posterolateral Corner LCL, MCL Vascular Injury Intimal tear vs. Disruption Obtain ABI’s  (+)  Arteriogram Vascular surgery consult with repair within 8hrs Peroneal >> Tibial N. injury Knee Dislocations
Slide 29-

Patella Fractures History MVA, fall onto knee, eccentric loading Physical Exam Ability to perform straight leg raise against gravity (ie, extensor mechanism still intact?) Pain, swelling, contusions, lacerations and/or abrasions at the site of injury Palpable defect
Slide 30-

Patella Fractures Radiographs AP/Lateral/Sunrise views Treatment ORIF if ext mechanism is incompetent Non-operative treatment with brace if ext mechanism remains intact
Slide 31-

Tibia Fractures Proximal Tibia Fractures (Tibial Plateau) Tibial Shaft Fractures Distal Tibia Fractures (Tibial Pilon/Plafond)
Slide 32-

Tibial Plateau Fractures MVA, fall from height, sporting injuries Mechanism and energy of injury plays a major role in determining orthopedic care Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with medial plateau injuries) Be aware for compartment syndrome Check for knee ligamentous instability
Slide 33-

Tibial Plateau Fractures Xrays: AP/Lateral +/- traction films CT scan (after ex-fix if appropriate)
Slide 34-

Schatzker Classification of Plateau Fxs Lower Energy Higher Energy
Slide 35-

Tibial Plateau Fractures Treatment Spanning External Fixator may be appropriate for temporary stabilization and to allow for resolution of soft tissue injuries Insert blister Pics of ex-fix here
Slide 36-

Tibial Plateau Fractures Treatment Definitive ORIF for patients with varus/valgus instability, >5mm articular stepoff Non-operative in non-displaced stable fractures or patients with poor surgical risks
Slide 37-

Tibial Shaft Fractures Mechanism of Injury Can occur in lower energy, torsion type injury (e.g., skiing) More common with higher energy direct force (e.g., car bumper) Open fractures of the tibia are more common than in any other long bone
Slide 38-

Tibial Shaft Fractures Open Tibia Fx Priorities ABC’S Associated Injuries Tetanus Antibiotics Fixation
Slide 39-

Johner and Wruh’s Classification
Slide 40-

Tibial Shaft Fractures Gustilo and Anderson Classification of Open Fx Grade 1 <1cm, minimal muscle contusion, usually inside out mechanism Grade 2 1-10cm, extensive soft tissue damage Grade 3 3a: >10cm, adequate bone coverage 3b: >10cm, periosteal stripping requiring flap advancement or free flap 3c: vascular injury requiring repair
Slide 41-

Tibial Shaft Fractures Tscherne Classification of Soft Tissue Injury Grade 0- negligible soft tissue injury Grade 1- superficial abrasion or contusion Grade 2- deep contusion from direct trauma Grade 3- Extensive contusion and crush injury with possible severe muscle injury
Slide 42-

Management of Open Fx Soft Tissues ER: initial evaluation  wound covered with sterile dressing and leg splinted, tetanus prophylaxis and appropriate antibiotics OR: Thorough I&D undertaken within 6 hours with serial debridements as warranted followed by definitive soft tissue cover Tibial Shaft Fractures
Slide 43-

Tibial Shaft Fractures Definitive Soft Tissue Coverage Proximal third tibia fractures can be covered with gastrocnemius rotation flap Middle third tibia fractures can be covered with soleus rotation flap Distal third fractures usually require free flap for coverage
Slide 44-

Tibial Shaft Fractures Treatment Options IM Nail ORIF with Plates External Fixation Cast or Cast-Brace
Slide 45-

Advantages of IM nailing Lower non-union rate Smaller incisions Earlier weightbearing and function Single surgery Tibial Shaft Fractures
Slide 46-

IM nailing of distal and proximal fx Can be done but requires additional planning, special nails, and advanced techniques Tibial Shaft Fractures
Slide 47-

Fractures involving distal tibia metaphysis and into the ankle joint Soft tissue management is key! Often occurs from fall from height or high energy injuries in MVA “Excellent” results are rare, “Fair to Good” is the norm outcome Multiple potential complications Tibial Pilon Fractures
Slide 48-

Initial Evaluation Plain films, CT scan Spanning External Fixator Delayed Definitive Care to protect soft tissues and allow for soft tissue swelling to resolve Tibial Pilon Fractures
Slide 49-

Tibial Pilon Fractures Treatment Goals Restore Articular Surface Minimize Soft Tissue Injury Establish Length Avoid Varus Collapse Treatment Options IM nail with limited ORIF ORIF External Fixator
Slide 50-

Tibial Pilon Fractures Complications Mal or Non-union (Varus) Soft Tissue Complications Infection Potential Amputation
Slide 51-

Ankle Fractures Most common weight-bearing skeletal injury Incidence of ankle fractures has doubled since the 1960’s Highest incidence in elderly women Unimalleolar 68% Bimalleolar 25% Trimalleolar 7% Open 2%
Slide 52-

Osseous Anatomy
Slide 53-

Lateral Ligamentous Anatomy
Slide 54-

Medial Ligamentous Anatomy
Slide 55-

Syndesmosis Anatomy
Slide 56-

Ankle Fractures History Mechanism of injury Time elapsed since the injury Soft-tissue injury Has the patient ambulated on the ankle? Patient’s age / bone quality Associated injuries Comorbidities (DM, smoking)
Slide 57-

Ankle Fractures Physical Exam Neurovascular exam Note obvious deformities Pain over the medial or lateral malleoli Palpation of ligaments about the ankle Palpation of proximal fibula, lateral process of talus, base of 5th MT Examine the hindfoot and forefoot
Slide 58-

Ankle Fractures Radiographic Studies AP, Lateral, Mortise of Ankle (Weight Bearing if possible) AP, Lateral of Knee (Maissaneve injury) AP, Lateral, Oblique of Foot (if painful)
Slide 59-

AP Ankle Tibiofibular overlap <10mm is abnormal and implies syndesmotic injury Tibiofibular clear space >5mm is abnormal - implies syndesmotic injury Talar tilt >2mm is considered abnormal Ankle Fractures
Slide 60-

Ankle Mortise View Foot is internally rotated and AP projection is performed Abnormal findings: Medial joint space widening Talocural angle <8 or >15 degrees (compare to normal side) Tibia/fibula overlap <1mm Ankle Fractures
Slide 61-

Lateral View Posterior malleolar fractures Anterior/posterior subluxation of the talus under the tibia Displacement/Shortening of distal fibula Associated injuries Ankle Fractures
Slide 62-

Ankle Fractures Classification Systems (Lauge-Hansen) Based on cadaveric study First word refers to position of foot at time of injury Second word refers to force applied to foot relative to tibia at time of injury
Slide 63-

Ankle Fractures Classification Systems (Weber-Danis) A: Fibula Fracture distal to mortise B: Fibula Fracture at the level of the mortise C: Fibula Fracture proximal to mortise
Slide 64-

Ankle Fractures Initial Management Closed reduction (conscious sedation may be necessary) AO splint Delayed fixation until soft tissues stable Pain control Monitor for possible compartment syndrome in high energy injuries
Slide 65-

Ankle Fractures Indications for non-operative care: Nondisplaced fracture with intact syndesmosis and stable mortise Less than 3 mm displacement of the isolated fibula fracture with no medial injury Patient whose overall condition is unstable and would not tolerate an operative procedure Management: WBAT in short leg cast or CAM boot for 4-6 weeks Repeat x-ray at 7–10 days to r/o interval displacement
Slide 66-

Ankle Fractures Indications for operative care: Bimalleolar fractures Trimalleolar fractures Talar subluxation Articular impaction injury Syndesmotic injury Beware the painful ankle with no ankle fracture but a widened mortise… check knee films to rule out Maissoneuve Syndesmosis injury.
Slide 67-

Ankle Fractures ORIF: Fibula Lag Screw if possible + Plate Confirm length/rotation Medial Malleolus Open reduce 4-0 cancellous screws vs. tension band Posterior Malleolus Fix if >30% of articular surface Syndesmosis Stress after fixation Fix with 3 or 4 cortex screws
Slide 68-

Ankle Fractures Most common weight-bearing skeletal injury Incidence of ankle fractures has doubled since the 1960’s Highest incidence in elderly women Unimalleolar 68% Bimalleolar 25% Trimalleolar 7% Open 2%
Slide 69-

Osseous Anatomy
Slide 70-

Lateral Ligamentous Anatomy
Slide 71-

Medial Ligamentous Anatomy
Slide 72-

Syndesmosis Anatomy
Slide 73-

Ankle Fractures History Mechanism of injury Time elapsed since the injury Soft-tissue injury Has the patient ambulated on the ankle? Patient’s age / bone quality Associated injuries Comorbidities (DM, smoking)
Slide 74-

Ankle Fractures Physical Exam Neurovascular exam Note obvious deformities Pain over the medial or lateral malleoli Palpation of ligaments about the ankle Palpation of proximal fibula, lateral process of talus, base of 5th MT Examine the hindfoot and forefoot
Slide 75-

Ankle Fractures Radiographic Studies AP, Lateral, Mortise of Ankle (Weight Bearing if possible) AP, Lateral of Knee (Maissaneve injury) AP, Lateral, Oblique of Foot (if painful)
Slide 76-

AP Ankle Tibiofibular overlap <10mm is abnormal and implies syndesmotic injury Tibiofibular clear space >5mm is abnormal - implies syndesmotic injury Talar tilt >2mm is considered abnormal Ankle Fractures
Slide 77-

Ankle Mortise View Foot is internally rotated and AP projection is performed Abnormal findings: Medial joint space widening Talocural angle <8 or >15 degrees (compare to normal side) Tibia/fibula overlap <1mm Ankle Fractures
Slide 78-

Lateral View Posterior malleolar fractures Anterior/posterior subluxation of the talus under the tibia Displacement/Shortening of distal fibula Associated injuries Ankle Fractures
Slide 79-

Ankle Fractures Classification Systems (Lauge-Hansen) Based on cadaveric study First word refers to position of foot at time of injury Second word refers to force applied to foot relative to tibia at time of injury
Slide 80-

Ankle Fractures Classification Systems (Weber-Danis) A: Fibula Fracture distal to mortise B: Fibula Fracture at the level of the mortise C: Fibula Fracture proximal to mortise
Slide 81-

Ankle Fractures Initial Management Closed reduction (conscious sedation may be necessary) AO splint Delayed fixation until soft tissues stable Pain control Monitor for possible compartment syndrome in high energy injuries
Slide 82-

Ankle Fractures Indications for non-operative care: Nondisplaced fracture with intact syndesmosis and stable mortise Less than 3 mm displacement of the isolated fibula fracture with no medial injury Patient whose overall condition is unstable and would not tolerate an operative procedure Management: WBAT in short leg cast or CAM boot for 4-6 weeks Repeat x-ray at 7–10 days to r/o interval displacement
Slide 83-

Ankle Fractures Indications for operative care: Bimalleolar fractures Trimalleolar fractures Talar subluxation Articular impaction injury Syndesmotic injury Beware the painful ankle with no ankle fracture but a widened mortise… check knee films to rule out Maissoneuve Syndesmosis injury.
Slide 84-

Ankle Fractures ORIF: Fibula Lag Screw if possible + Plate Confirm length/rotation Medial Malleolus Open reduce 4-0 cancellous screws vs. tension band Posterior Malleolus Fix if >30% of articular surface Syndesmosis Stress after fixation Fix with 3 or 4 cortex screws