Lower Extremity Trauma

PELVIC INJARIES INTRODUCTION

 they are particularly important because of the high incidence of associated soft tissue injuries
and the risks of severe blood loss, shock, sepsis and (ARDS).

 Degloving injuries to the surrounding soft tissues, both open and closed, also may accompany
these fractures and complicate their treatment.

 Reported mortality from severe pelvic fracture ranges from 10% to as high as 50% in some
earlier series of open pelvic fractures.

Early mortality most commonly results from hemorrhage or closed head injury; late mortality
occurs from sepsis or multiple system organ failure
Mortality rate 15-25% for closed fractures, as much as 50% for open fractures
 hemorrhage is leading cause of death overall
closed head injury is the most common for lateral compression injuries

 increased mortality associated with

 systolic BP <90 on presentation
 age >60 years
 increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
 need for transfusion > 4 units
 PALVIC ANATOMY
 An understanding of the anatomy of the pelvis is key to the management and treatment of
pelvic injuries

 The pelvis should be viewed as a ring structure. Therefore, any break in this ring can lead to
stability issues, which may require operative intervention

The pelvic ring is composed of the sacrum and two innominate bones joined anteriorly at the
symphysis and posteriorly at the paired sacroiliac joints

The stability of the pelvic ring depends upon the rigidity of the bony parts and the integrity of
the strong ligaments

 As long as the bony ring and the ligaments are intact, load-bearing is unimpaired.
• Pelvic ligamnets may be divided into two groups according to the ligamentous attachments:
A. Sacrum to ilium
B. Pubic to Pubic Ligaments

 The strongest and most important ligamentous structures occur in the posterior aspect of the pelvis
connecting the sacrum to the innominate bones

 The sacroiliac ligamentous complex is divided into posterior (short and long) and anterior ligaments. Posterior
ligaments provide most of the stability.

 : Symphyseal ligaments.. Resist external rotation

 The transversely placed ligaments resist rotational forces and include:- short posterior sacroiliac, anterior
sacroiliac, iliolumbar, and sacrospinous ligaments.
 The vertically placed ligaments resist shear forces (vertical shear, VS) and include the long posterior
sacroiliac, sacrotuberous, and lateral lumbosacral ligaments.
 The bladder lies behind the symphysis pubis. The trigone is held in position by the lateral
ligaments of the bladder and, in the male, by the prostate.
In the female the trigone is attached also to the cervix and the anterior vaginal fornix.
 Consequently in females the urethra is much more mobile and less prone to injury.
 
The pelvic colon, with its mesentery, is a mobile structure and therefore not readily injured.
However, the rectum and anal canal are more firmly tethered to the urogenital structures and
the muscular floor of the pelvis and are therefore vulnerable in pelvic fractures.
 
Mechanism of Injury
A. low-energy injuries, which typically result in fractures of individual bones,
• it may also result from sudden muscular contractions in young athletes that cause an avulsion
injury, a low energy fall, or a straddle-type injury (motorcycle or horse).

B. high-energy fractures, which may result in pelvic ring disruption.

• typically result from a motor vehicle accident, pedestrian-struck mechanism, motorcycle
accident, fall from heights, or crush mechanism.
Associated injuries :
o chest injury in up to 63%
o long bone fractures in 50%
o sexual dysfunction up to 50%
o head and abdominal injury in 40%
o spine fractures in 25%
 CLINICAL EVALUATION
 

 Often the patient complains of severe pain and feels as if he has fallen apart, and there may
be swelling or bruising of the lower abdomen, the thighs, the perineum, the scrotum or the
vulva

 Pelvic instability may result in a leg-length discrepancy involving shortening on the involved
side or a markedly internally or externally rotated lower extremity
 Palpation of the posterior aspect of the pelvis may reveal a large hematoma

A palpable hematoma over the perineum (Destot sign), above the inguinal ligament, or the
proximal thigh may be indicative of a pelvic ring fracture with concomitant bleeding.
 Digital rectal in all and a vaginal exam in women should be performed in all trauma patients
 Bilateral functional motor testing of the lower extremities should be performed in all trauma
patients.
Imaging
 AP Pelvis :
 part of initial ATLS evaluation
 look for asymmetry, rotation or •
displacement of each hemipelvis
 evidence of anterior ring injury needs
further imaging

■ Anterior lesions:
pubic rami fractures and symphysis
displacement
■ Sacroiliac joint and sacral fractures
■ Iliac fractures
■ L5 transverse process fractures.
 Initial Management of Pelvic Ring Fractures
• Pre hospital management of multiply injured patients includes immobilization of the spine
with the use ofcervical collars and back boards and various ready-made splints for extremity
injuries.
• Airway protection as needed and appropriate circulatory support with intravenous fluids
• Initial management of the trauma patient should be dictated by Advanced Trauma Life
Support (ATLS) protocols
• In the last decade, as an adjunct to resuscitative measures, the use of external pelvic
compression devices (binders; sheets) has become increasingly.
■ Options for immediate hemorrhage control or pelvic bleeding include:
1. Application of military antishock trousers (MAST). This is typically performed in the field.
2. Wrapping of a pelvic binder (or sheet if a binder is not available) the level of the trochanters
to provide access to the abdomen.
3. Consider application of a bean bag.
4. Consider angiography or embolization if the hemorrhage continues despite closing of the
pelvic volume.
5. Consider application of a pelvic C-clamp (posterior).
6. Consider an anterior external fixator.
7. Open reduction and internal fixation (ORIF): pts emergency laparotomy for other indications;
it is frequently contraindicated by itself
8. Open packing of the retroperitoneum is an option in the unstable patient who is brought to
the operating room for laparotomy and exploration.
The purpose of external compression is the following:
(a) To close the open-book pelvic injury, which reduces the pelvic volume there by allowing for a
tamponade effect;
(b) to stabilize the pelvic ring injury, which allows for clot formation; and
(c) allow for auto transfusion by returning the blood from the lower extremities to the vascular
system
 Complications
 Neurologic injury
o L5 nerve root runs over sacral ala joint
o may be injured if SI screw is placed to anterior
o anterior subcutaneous pelvic fixator may give rise to LFCN injury (most common)
 DVT and PE
o DVT in ~ 60%, PE in ~ 27%
o prophylaxis essential
 mechanical compression
 pharmacologic prevention (LMWH or Lovenox)
 vena caval filters (closed head injury)
 Chronic instability
o rare complication; can be seen in nonoperative cases
o presents with subjective instability and mechanical symptoms
o diagnosed with alternating single-leg-stance pelvic radiographs
 FEMORAL NECK FRACTURES.
 factors, such as physiologic age, bone quality, activity level, fracture pattern, and medical
comorbidity, play an important role in deciding whether to perform ORIF versus arthroplasty.
 Most fractures of the femoral neck are intracapsular and may compromise the tenuous blood
supply to the femoral head
 Femoral neck fractures occur most frequently in elderly female Patients
 They are uncommon in patients younger than 60 years. 
They are less common in black races
 Nonmodifiable risk factors include increasing age, female sex, positive family history of
osteoporotic fractures, and ethnic origin.
 
Modifiable lifestyle risk factors increasing the risk of hip fractures include a low body mass
index (<18.5), low sunlight exposure, low recreational activity, smoking, and alcohol abuse.
Chronic disease in general tends to increase fracture risk. There is good evidence of increased
hip fracture risk in association with diabetes mellitus (type 1 in particular), chronic renal
disease, celiac disease, and primary hyperparathyroidism

Certain medications are associated with alteration of bone metabolism and increase fracture
risk. Steroids are most commonly implicated, but other medications are also now well
recognized risk factors. These include antiepileptic medication, certain antidepressants
a(selective serotonin reuptake inhibitor), proton pump inhibitors, and HIV medications.

 The risk of falling increases with age due to the increasing muscle weakness, abnormal gait or
balance, neurologic disease, deteriorating eyesight, and medication with sedative or
cardiovascular side effects
 Vitamin A in high doses likely increases the risk of fracture

Nutritional status of the elderly fracture patient must be assessed

 Prevention
 The risk of hip fracture in women may be minimized by maintaining body weight, walking for
exercise, performing high-intensity resistive exercises, avoiding long-acting benzodiazepines,
minimizing caffeine intake, using appropriate footwear, ceasing smoking, and treating impaired
visual function and obesity.

 Postmenopausal estrogen replacement protects against hip fracture in women younger than
75 years.
 
The bisphosphonates are a proven means of increasing bone.

 The same is seen with calcium and vitamin D supplementation and growth hormone therapy,
even for those patients in residential care
 APPLIED ANATOMY OF THE FEMAR NECK
 The upper femoral epiphysis closes by age 16 years

 Neck-shaft angle: 130 ± 7 degrees in the normal hip, so an angle less than this is referred to
as coxa vara, and an increased .angle is termed coxa valga.
 

 Femoral anteversion: 10 ± 7 degrees or range of 15—25 . Femoral neck anteversion describes

the angle subtended by the femoral neck to the transcondylar axis,
 MECHANISM OF INJURY

 A fall onto the greater trochanter (valgus impaction.

 An alternative mechanism is external rotation of the leg, with increasing tension in the
anterior capsule and iliofemoral ligaments. As the neck rotates, the head remains fixed and a
fracture occurs.

The usual site of the fracture is in the weakest part of the femoral neck, located just below the
articular surface

high energy in young patients
o low energy falls in older patients
 FEMUR NECK , HEAD BLOOD SUPPLY

 The femoral head gets its blood supply from three sources:
(1) intramedullary vessels in the femoral neck;  
(2) ascending cervical branches of the medial and lateral circumflex anastomoses, which run
within the capsular retinaculum before entering the bone at the articular margin of the femoral
head; and 
(3) the vessels of the ligamentum teres.
•
 RADIOGRAPHIC EVALUATION
• A physician-assisted internal rotation view of 10 to 15° to the injured hip is always helpful to
further clarify the fracture pattern and determine treatment plans and also to eliminate the
obliquity of anteversion
• The lateral radiograph may be difficult to acquire due to pain but is useful in determining
whether the fracture is present and whether it is displaced
 Presentation
o impacted and stress fractures
 slight pain in the groin or pain referred along the medial side of the thigh and knee
o displaced fractures
 pain in the entire hip region

Physical exam
o impacted and stress 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
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
 displaced fractures in young or physiologically young patients
 ORIF indicated for most pts <65 years of age
 hemiarthroplasty
 debilitated elderly patients
 metabolic bone disease

total hip arthoplasty

•  older active patients
•  patients with preexisting hip osteoarthritis
•  more predictable pain relief and better functional outcome than hemiarthroplasty
•  arthroplasty for Garden III and IV in patient < 85 years
 Intertrochanteric Fractures
• Extracapsular fractures of the proximal femur between the greater and lesser trochanters
• roughly the same as femoral neck fractures
•
• risk factors  proximal humerus fractures increase risk of hip fracture for 1 year
•
Stability of fracture pattern is arguably the most reliable method of classification
stable
 intact posteromedial cortex
 clinical significance
 will resist medial compressive loads once reduced
 unstable
 comminution of the posteromedial cortex
 clinical significance
 fracture will collapse into varus and retroversion when loaded
•
•
 4. Subtrochanteric Fractures

• Subtrochanteric typically defined as area from lesser trochanter to 5cm distal

•
 Femoral Shaft Fractures
• The femoral shaft is circumferentially padded with large muscles.
• This provides advantages and disadvantages:
• reduction can be difficult as muscle contraction displaces the fracture; however,
healing potential is improved by having this well-vascularized sleeve containing a
source of mesenchymal stem cells.
 Anatomy
• The femur is the longest bone in the human body. It is tubular and has an anterior bow with a
radius of curvature of approximately 120 cm.

• The shaft of the femur is cylindrical anteriorly, medially, and laterally. The thickened posterior
cortex of the femur coalesces into the linea aspera in the central diaphysis of the femur.
• The linea aspera divides proximally to the lesser and greater trochanters, and distally to the
medial and lateral femoral condyles.
• The linea aspera serves as a muscle attachment site as well as a buttress along the concavity of
the femoral diaphysis.
• The medial cortex is under compression, whereas the lateral cortex is under tension.
• The isthmus of the femur is the region with the smallest intramedullary (IM) diameter
Classification
 Clinical Evaluation

• blood loss in closed femoral shaft fractures is 1000-1500ml

• blood loss in open fractures may be double that of closed fractures
• while for closed tibial shaft fractures, 500-1000ml

• AP and lateral views of ipsilateral hip important to rule-out coexisting femoral neck fracture
AP and lateral views of ipsilateral knee ( Important) !
 Emergency treatment
• Advanced Trauma Life Support (ATLS) should be initiated
• temporary stabilization to control pain, reduces ,bleeding and makes transfer
easier.
• Traction or a splint ( long posterior cast )
Definitive Treatment
pathologic Fracture
 Patella Fracture

• Represent 1% of all skeletal injuries.

• Male-to-female ratio 2:1
• Most common age group 20 to 50 years old
• Bilateral injuries uncommon
 Anatomy
• The patella is the largest sesamoid bone in the body.
• The quadriceps tendon inserts on the superior pole and the patellar ligament originates
from the inferior pole of the patella.
• There are seven articular facets; the lateral facet is the largest (50% of the articular
surface).
• The articular cartilage may be up to 1-cm thick.
• The medial and lateral extensor retinacula are strong longitudinal expansions of the
quadriceps and insert directly onto the tibia. If these remain intact in the presence of a
patella fracture, then active extension will be preserved
• The function of the patella is to increase the mechanical advantage and leverage of the
quadriceps tendon, aid in nourishment of the femoral articular surface, and protect the
femoral condyles from direct trauma.
• The blood supply arises from the geniculate arteries, which form an anastomosis
circumferentially around the patella.
 Mechanism Of Injury
 Direct: Trauma to the patella may produce incomplete, simple, stellate, or comminuted
fracturepatterns.
• Displacement is typically minimal owing to preservation of the medial and lateralretinacular
expansions.
• Abrasions over the area or open injuries are common. Active knee
• extension may be preserved.
■ Indirect (most common):
This is secondary to forcible eccentric quadriceps contraction while the knee is in a semiflexed
position (e.g., in a “stumble” or “fall”).
The intrinsic strength of the patella is exceeded by the pull of the musculotendinous and
ligamentous structures. A transverse fracture.
• degree of displacement of the fragments suggests the degree of retinacular disruption.
• Active knee extension is usually lost.
 Presentation

• palpable patellar defect

o significant hemarthrosis
o unable to perform straight leg raise indicates failure of extensor mechanism
 retinaculum disrupted

• It is important to rule out an open fracture because these constitute a surgical urgency; this
may require instillation of more than 100 mL of saline into the knee to determine
communication with overlying lacerations
Radiographs
o patella alta
o fracture displacement
best evaluated on lateral x-ray

degree of fracture displacement

correlates with degree of retinacular
disruption
 Management
• Treatment always operation :
• preserve patella whenever possible
•  extensor mechanism failure (unable to perform straight leg raise)
•  open fractures

•  fracture articular displacement >2mm

•  displaced patella fracture >3mm

•  patella sleeve fractures in children

 Tibia Shaft Fractures

• Epidemiology : most common long bone fx

• o account for 4% of all fx seen in the Medicare population
• Because of its subcutaneous position, the tibia is more commonly fractured, and more often
sustains an open fracture, than any other long bone.
• Diaphyseal tibia fractures have the highest rate of nonunion for all long bones.
 Clinical Anatomy
• Tibia is the 2nd largest bone in the body after femur .
• In adults, the length of the tibia ranges from 30 to 47 cm, and the minimal diameter of the
intramedullary canal varies between 8 mm or less to more than 15 mm at the junction of the
middle and distal tibial thirds

• The tibia is the main weight-bearing bone in the leg, carrying greater than 80% of load.
•   Compared to the tibial diaphysis, the distal and proximal metaphyseal bones are relatively
weaker
• The diaphysis becomes thinner distally and twisting injuries commonly result in a spiral
fracture at the junction of the middle and distal thirds of the bone
• The anteromedial surface is subcutaneous and devoid of muscular or ligamentous
• attachments and renders the bone susceptible to injury with a high incidence of open fractures
 Vascularity
• Osseous vascularity is of key importance in bone healing after fracture.
• The adult tibia has both a medullary and a periosteal blood supply. It is estimated that the
outer 25% to 30% of the tibial cortex derives its oxygenation primarily from the periosteal
• system, whereas the rest of the bone is predominantly supplied by the medullary system.
• The nutrient artery wich is single vessel entering the bone is derived from the posterior
tibial artery, and it enters the medullary cavity from the nutrient foramina located in the
posterior surface at the proximal portion of the middle third of the tibia and distal to the
origination of the soleus muscle.
• Once the vessel enters the intramedullary (IM) canal, it gives off three ascending branches
and one descending branch. These give rise to the endosteal vascular tree, which anastomose
with periosteal vessels arising from the anterior tibial artery

• The anterior tibial artery is particularly vulnerable to injury as it passes through a hiatus in
the interosseus membrane
 Compartments and Musculature
• It has a subcutaneous anteromedial border and is bounded by four tight fascial compartments
(anterior, lateral, posterior, and deep posterior
• The fibula is responsible for 6% to 17% of a weight-bearing load. Its major function is for
muscle attachment.
• The common peroneal nerve courses around the neck of the fibula, which is nearly
subcutaneous in this region; it is therefore especially vulnerable to direct blows or traction
injuries at this level
• The interosseous membrane connects the tibia and fibula and the fibers run downward and
laterally and provides intrinsic stability
• The lateral compartment muscles evert the foot and take origin from the lateral and posterior
aspects of the fibula diaphysis
• The posterior deep compartment can be difficult to assess for compartment syndrom
•
Mechanism
 low energy fx pattern
•  result of torsional injury
•  indirect trauma results in spiral fx
•  fibula fx at different level
•  Tscherne grade 0 / I soft tissue injury
 high energy fx pattern
•  direct forces often result in wedge or short oblique fx and sometimes significant
comminution
•  fibula fx at same level
•  severe soft tissue injury
•  Tscherne II / III
•  open fx
Associated conditions
• o soft tissue injury (open wounds) : critical to outcome
• o compartment syndrome
• o bone loss
• o ipsilateral skeletal injury
•  extension to the tibial plateau or plafond
•  posterior malleolar fracture
•  most commonly associated with spiral distal third tibia fracture
 Clinical Evaluation
• Evaluation of neurovascular status is critical. Dorsalis pedis and posterior tibial artery pulses
must be evaluated and documented, especially in open fractures in which vascular flaps may
be necessary.

• Common peroneal and tibial nerve integrity must be documented.

• Assess soft tissue injury. Fracture blisters may contraindicate early open reduction of
periarticular fractures.

• Monitor for compartment syndrome. Pain out of proportion to the injury is the most reliable
sign of compartment syndrome.
• Tibial fractures may be associated with knee ligament injuries.
• About 5% of all tibial fractures are bifocal, with two separate fractures of the tibia
Radiography
• The entire length of the tibia and fibula, as well as the knee and ankle joints, must be seen.

 look :
• The presence of comminution
• The distance that bone fragments have displaced from their anatomic location
• Osseous defects
• Fracture lines may extend proximally to the knee or distally to the ankle joints.
• ■ The quality of the bone
• Air in the soft tissues: These are usually secondary to open fracture but may also signify the
• presence of gas gangrene, necrotizing fasciitis, or other anaerobic infections
 Treatment of Closed Tibia Fractures

Nonoperative
 closed reduction / cast immobilization
•  closed low energy fxs with acceptable alignment
•  < 5 degrees varus-valgus angulation
•  < 10 degrees anterior/posterior angulation
•  > 50% cortical apposition
•  < 1 cm shortening
•  < 10 degrees rotational malalignment
•  if displaced perform closed reduction under general anesthesia