Lower limb fractures

and dislocation

DR. MOHAMAD KHAIRUDDIN BIN ABDUL WAHAB

M.B.B.S (Univ. Malaya), MS Ortho (UKM)
ORTHOPAEDIC SURGEON
FACULTY OF MEDICINE
CUCMS
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
Contents:
 FRACTURE NECK OF FEMUR
 INTERTROCHANTERIC FRACTURE
 HIP JOINT DISLOCATION
 FEMUR SHAFT FRACTURE
 DISTAL FEMUR FRACTURE
 KNEE JOINT DISLOCATION
 PATELLA FRACTURE
 TIBIAL PLATEAU FRACTURE
CONT’:

 TIBIA SHAFT FRACTURE

 MALLEOLI FRACTURE
 TALUS FRACTURE
 CALCANEUM FRACTURE
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
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)
Garden’s classification

Stage I Incomplete # (impacted)

Stage II Complete and undisplaced

Stage III Complete and moderately

displaced
Stage IV Severely displaced
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
Radiological features of neck of femur fracture

Shenton’s line
Complication:

 Avascular necrosis of the femur head

 Non-union of the fracture
 General complications following prolong
bedridden for conservative treatment
(bedsore, DVT, pneumonia, stiffness)
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
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)
Intertrochanteric fracture

 Commonly occur in elderly patient

(osteoporosis) following trivial fall
 Extension to subtrochanteric region
 May presented as comminuted fracture
pattern
Radiograph shows intertrochanteric
fracture of the femur
Complications:

 Mal-union of the fracture

 Failure in fixation for the fracture due to
osteoporotic bone
 General complications following prolong
bedridden
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)
Fixation of fracture intertrochanteric fracture
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
 Left side

Radiograph shows left hip dislocation

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
Treatment

 Emergency CMR under sedation

 Failure in CMR  open reduction

 Failure in CMR to obtain acceptable

reduction is due to:
 Inverted limbus of the acetebular rim
 Intra-articular fracture fragment
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
 Radiographs show femur shaft fractures

Distal 1/3

supracondyalar Proximal 1/3

Complication

 Vascular injury (femoral artery)

 Fat embolism
 Delayed and non-union of the fracture
 Mal-union of the fracture
 Joint stiffness (knee)
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)
Intramedullary locking
nail
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
Complications

 Joint stiffness and arthrosis if involve the

articular region
 Risk of femoral artery injury
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)
Angled blade plate for fixation
of supracondylar fracture
of the femur
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
Radiographs show anterior
dislocation of the knee
Risk of vascular injury

 Transected or thrombosis (following

intimal injury)
 Vascular assessment or surveillance
 Angiogram as indicated
Directions of dislocation

 Reference to the position of tibia

 Anteromedial dislocation (risk of
associated intimal injury of popliteal
artery)
 Posterolateral dislocation (highly
associated with transected popliteal
artery)
artery
Complications

 Neurovascular injury
 Knee ligaments injury (result in joint
instability)
 Stiffness of the joint
 Arthrosis formation following cartilage
damage
Treatment
 Immediate reduction and immobilization
 Artery exploration and repair in the
evidence of arterial injury
 Immobilization in cast (FLPOP) or
external fixation
 Ligaments repair or reconstruction for
multiple ligaments injury resulting in
instability
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
Types of TP #

 Simple split lateral condyle

 Depressed, comminuted lateral condyle
 Crushed comminuted lateral condyle
 Split medial condyle
 Bicondylar fractures
 Bicondylar and subcondylar
Complications

 Compartment syndrome
 Joint stiffness
 Deformity
 arthrosis
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
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
Complications

 Joint stiffness
 Patellofemoral arthrosis
 reduced knee extensor mechanism
Treatment
Undisplaced fracture
 Cylinder cast immobilization for 6 weeks

Displaced fracture
 ORIF (tension band wiring)

Severely comminuted
 Cerclage wiring or patellectomy
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 #
Radiographs show tibial shaft fracture
Complications

 Compartment syndrome
 Malunion (leading to shortening and
arthrosis)
 Nonunion
Treatment
Acceptable displacement with less
comminuted (stable)
 Apply Full Length POP immobilization for
6 weeks

Comminuted, segmental (unstable

reduction alignment)
 Internal fixation (ILN, Plating)
Intramedullary
Locking nail for
Tibia shaft fracture
Malleoli fractures

 Forces to the ankle region

 External rotation, abduction, adduction,
 Ankle joint dislocation or subluxation
 Ankle ligaments injury including
syndesmosis
Classification
 Danis & Weber (Muller et al 1991):

Type A: # below the tibiofibular

syndesmosis
 abduction or adduction force
 Medial malleolus may #ed or rupture of
deltoid ligament
Cont’:

Type B: # level with syndesmosis

 Oblique fibular #
 External rotation force
 Disrupted medial structures
 Syndesmosis intact
Cont’:

Type C: # above the syndesmosis

 Abduction alone or combination of
abduction and external rotation force
 Disruption of syndesmosis and
interosseous membrane (widened
mortise)
 Unstable tibiofibular region
Fracture of lateral
malleolus
Complications

 Dislocated or subluxated ankle joint

 Stiffness
 Arthrosis of ankle joint
 Ankle instability
 Nonunion fracture (displaced medial
malleolus)
 Malunion of the fracture
Treatment

Undisplaced #
 Cast immobization (boot POP)

Displaced # with or without subluxation

joint or loss of normal ankle mortise
 ORIF (fibular plating, screw fixation of
medial malleoli, syndesmotic screw)
Plating of the lateral malleolus fracture
with 1/3 tubular plate
Talus fractures
 Rare injury
 Violence injury (following inversion force or
axial loading)
 +/- dislocation of the ankle joint or subtalar joint
 Regions affected: head, neck, body, and lateral
process
 Risk of developing avascular necrosis of talus
dome
 Talus fractures

Dome of talus fracture showed

Neck of talus fracture Through CT-scan
Complications

 Skin damage or necrosis due to pressure

from the underling bone
 Nonunion of the fracture
 AVN following fracture at the neck region
 Arthrosis (ankle and subtalar)
Treatment

 Undisplaced #: cast immobilization (boot

POP)
 Displaced # +/- dislocation: ORIF screw
fixation
 If AVN developed later may consider
arthrodesis of the ankle joint
Screw fixation of the talus fracture at the neck region
Calcaneum fractures

 Result from axial loading

 Traction through Achilles tendon lead to
avulsion fracture
 Can be extra-articular or intra-articular
fracture (referring to subtalar joint)
 Result in loss of foot arch (Bohler’s
angle: 25 –40 degrees) lead to flat foot
Extra-articular fracture of calcaneum
Complications

 Skin necrosis (intense swelling)

 Malunion of the fracture
 Peroneal tendon impingement
 Flat and broad foot (shoe fitting)
 Subtalar arthrosis
Treatment
 Extra-articular fractures or undisplaced
intra-articular fractures may require
Robert-Jones bandaging for 1 week then
followed by boot POP cast for 5 weeks
 No weight bearing is allowed

 Displaced intra-articular # or avulsion of

Achilles insertion: ORIF screw or recon
plate
Exercise for student:

After reviewing the lecture notes, you are

require to do some exercises.
The answers to the exercise need to be
submitted via e-mail (address:
mkhairuddin@salam.uitm.edu.com.my)
Questions:

 Briefly discuss on the classification used

to describe neck of femur fracture.
 With regards to dislocated knee,
describe the direction of dislocation in
relation to vascular injury pattern.
 Briefly discuss on the complications
following calcaneum fracture.
Reference for further
reading:
 Orthopaedic Surgery Essential: Trauma;
Charles Court-Brown, Lippincott Williams &
Wilkins; 2005
 Turek’s Orthopaedics: Principles & their
application; Stuart L. Wienstein, Joseph A.
Backwalter: 5th Edition Lippincott Williams &
Wilkins 2005
 Practical Fracture Treatment; Ronald McRae, Max
Esser; 4th Edition, Churchill Livingstone 2002
Enjoy reading…..

For further questions or enquiry , please contact through:

Handphone: 012-8976094
Email : mkhairuddin@slam.uitm.edu.com.my