FRACTURES OF THE LOWER LIMBS

AND THEIR MANAGEMENT

Dr Tom Sough
Orthopaedic and Trauma Surgeon
Dept. Of Surgery
University of Abuja
 Learning objectives
• To define the anatomical region of the lower
limb
• To understand fractures of the lower limbs
and their mechanisms
• To differentiate between various types of
fractures possible in the lower limb
• To outline treatment of the common ones
What region of the body is the lower
limb?
• For the sake of this lecture, we will focus on
fractures of the:
- Femur
- Tibia/fibular
- Foot
 Review of General Principles of
fracture management
• First aid
• Resuscitation
• Clinical assessment
• Classification of fracture
• Reduction of fracture
• Immobilization of fracture
• Rehabilitation
• Watch out for complications
 Fractures of the femur
• Divisions of the • Methods of
bone treatment
• Proximal • Cast
femur:Neck and • Traction
head • External fixation
• Shaft • Internal fixation
• Distal femur • Why your
Decision???
 Fracture Neck of femur
• Relatively common • Will discuss
• Most common in important aspects
the elderly of the fracture
• Clinical assessment
and early
treatment very
important
 Anatomy of the proximal femur
• Physeal closure age 16
• Neck-shaft angle
130° ± 7°
• Anteversion
10° ± 7°
• Calcar Femorale
Posteromedial
dense plate of bone
 Blood Supply
• Lateral epiphysel artery
– terminal branch MFC artery
– predominant blood supply to
weight bearing dome of head
• Artery of ligamentum teres
– from obturator artery
– supplies anteroinferior head
• Lateral femoral circumflex a.
– less contribution than MFC
 Blood Supply
• fracture displacement=vascular disruption
• revascularization of the head
– intact vessels
– vascular ingrowth across fracture site
• importance of quality of reduction
– metaphyseal vessels
 Classification fractures of the
femoral neck
• Pauwels [1935]
– Angle describes vertical shear vector
 Classification
• Garden [1961]
I Valgus impacted or
incomplete
II Complete I II
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement
** Portends risk of AVN and
Nonunion III IV
 Classification
• Functional Classification
– Stable
• Impacted (Garden I)
• Non-displaced (Garden II)
– Unstable
• Displaced (Garden III and IV)
 Treatment
• Goals
– Improve outcome over natural history
– Minimize risks and avoid complications
– Return to pre-injury level of function
– Provide cost-effective treatment
 Treatment
• Options
– Non-operative
• very limited role
• Activity modification
• Skeletal traction
– Operative
• ORIF
• Hemiarthroplasty
• Total Hip Replacement
 Treatment
Decision Making Variables
• Patient Characteristics
– Young (arbitrary physiologic age < 65)
• High energy injuries
– Often multi-trauma
• High Pauwels Angle (vertical shear pattern)
– Elderly
• Lower energy injury
• Comorbidities
• Pre-existing hip disease
• Fracture Characteristics
– Stable
– Unstable
 Treatment
Young Patients
(Arbitrary physiologic age < 65)

– Non-displaced fractures
• At risk for secondary displacement
• Urgent ORIF recommended
– Displaced fractures
• Patients native femoral head best
• AVN related to duration and degree of
displacement
• Irreversible cell death after 6-12 hours
• Emergent ORIF recommended
 Treatment
Elderly Patients
• Operative vs. Non-operative
– Displaced fractures
• Unacceptable rates of mortality, morbidity, and poor outcome
with non-operative treatment
– Non-displaced fractures
• Unpredictable risk of secondary displacement
– AVN rate 2X
– Standard of care is operative for all femoral neck fractures
 Hemi

ORIF
THR
 Intertrochanteric Femur
• Intertrochanteric
Femur
– Extra-capsular
femoral neck
– To inferior border
of the lesser
trochanter
 Incidence

• 50% are Intertrochanteric Fractures

Demographics

• 90% >65y/o

• F>M

• Peak @ 80y/o
 Etiology

• Osteoperosis

• Low energy fall

– Common

• High Energy
– Rare
 Prevention

• Prevention & Active

Treatment of Osteoporosis

• Fall Prevention

• Minimize Fall Impact

Physical Presentation

• Involved Extremity

– Short

– External Rotated
 Radiographs

• Plain Films
– AP Pelvis
– Cross
Table Lateral
 Radiographs
• Plain Films
– AP Pelvis
– Cross
Table Lateral
Perioperative Medical Management

• Optimize Medical Problems

• DVT Prevention
• Perioperative Antibiotics
• UTI Treatment
• Nutritional Optimization
– Decrease 1yr Mortality
 Classification

• Multiple Classifications
– Stable vs Unstable
 Classification
• Stable
• Resists Medial &
Compressive Loads
• With Anatomic
reduction and
fixation
 Classification
• Unstable
• Collapses in varus
or shaft
medializes
despite anatomic
reduction with
fixation
 Treatment options
• Non-operative
• Operative
 Implant Options

• Compression Hip
Screw & Side Plate
– Controlled Impaction
of Fracture
– Higher Angles Greater
Tendency for
Impaction
 Implant Options
• Intramedullary Sliding
Hip Screw
– Decreased Implant
Bending Strain
– Potential Percutaneus
Technique
– Inter Troch Shaft
– Reverse Obliquity
– Pathologic Shaft
Fracture
Femoral Shaft Fractures
 Femur Fractures
• Common injury due to major violent trauma
• 1 femur fracture/ 10,000 people
• More common in people < 25 yo or >65 yo
• Femur fracture leads to reduced activity for 107
days, the average length of hospital stay is 25 days
• Motor vehicle, motorcycle, auto-pedestrian,
aircraft, and gunshot wound accidents are most
frequent causes
 Anatomy
• Long tubular bone, anterior bow, flair at femoral
condyles
• Blood supply
– Metaphyseal vessels
– Single nutrient artery in diaphysis enters through the
linea aspera
– Nutrient artery communicates with medullary arteries
in intramedullary canal
– Medullary arteries supply 2/3 of endosteal blood
supply
 Femur Fractures
Gluteal muscles
Iliopsoas leads to
flexion of the
proximal fragment

These muscle forces

must be overcome to
Adductor reduce and
muscles shorten intramedullary nail the
the femur femur
 Femur Fracture
Classification
• 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
Axial and
• Type 4 - Segmental comminution rotational
» Winquist and Hansen 66A, 1984 stability
 Femur Fracture Management
• Non-operative

• Operative choice

• Piriformis fossa intact, lesser trochanter

intact

• Can you nail this ?

• Should you nail this ?

 Femur Fracture
Management
• Initial traction with portable traction splint or
transosseous pin
• Timing of surgery is dependent on:
– Resuscitation of patient
– Other injuries - abdomen, chest, brain
– Isolated femur fracture
 Femur Fracture
Management
• Diaphyseal fractures are managed by
intramedullary nailing through an antegrade
or retrograde insertion site
• Proximal or distal 1/3 fractures MAY be
managed best with a plate or an
intramedullary nail depending on the location
and morphology of the fracture
F = Force Bending moment = F x D F = Force

IM Nail Plate

D D

D = distance
from force to
implant The bending moment for
the plate is greater due to
the force being applied
over a larger distance
 Femur Fracture
Management
• Antegrade nailing is still the gold standard
– Highest union rates with reamed nails
– Extraarticular starting point
– Refined technique
• Antegrade nailing problems:
– Varus alignment of proximal fractures
– Trendelenburg gait
– Can be difficult with obese or multiply injured patients
 Femur Fracture
Complications
• Hardware failure
• Nonunion - less than 1-2%
• Malunion - shortening, malrotation,
angulation
• Infection
• Neurologic, vascular injury
• Heterotopic ossification
 Femur Fracture
Nonunion

Femoral
nonunion
with broken
IM Nail

Union after
exchange,
reamed
IM nail
Subtrochanteric fractures
are from the base of the
lesser trochanter to 5 cm
distal
Low Subtroch Fx’s

Most low subtrochanteric

fractures with an intact piriformis
fossa can be treated with a 1st
gen IM Nail
Nail or… Plate
Supracondylar Femur Fractures:
Plate vs Nail
Supracondylar Femur Fractures
 Supracondylar femur fractures

• Distal femur
anatomy
• Trapezoidal shape
• Intercondylar notch
• Lateral Epicondyle
larger
Supracondylar Femur Fractures

» Reconstruction of the
articular surface and

» The goal is restoration

of the mechanical axis
 Operative treatment options
• Reduction and cast??
• Traction??
• External fixation
• Internal fixation
Percutaneous Screw Fixation
+ IM nail
 Tibia/Fibular, the leg bones
• Proximal: Plateau
• Shaft
• Distal: Plafond
Fractures of the Tibial Plateau
 Osseous Anatomy
• Proximal Tibia
– widens into lateral and medial tibial flares
– flares lead to medial and lateral plateau
(condyles)
– intercondylar eminence
– tibial tubercle (patellar tendon)
– proximal tib/fib joint
 Osseous Anatomy
• Medial Plateau • Lateral Plateau
VS – smaller
– larger – convex: frontback
– concave: frontback – sideside
– sideside – higher than medial
– lower than lateral side – slopes posteriorly 7°
– slopes posteriorly 10° – cartilage 4 mm
– cartilage 3mm – softer bone
– medial condyle stronger
bone
– bears 75% of weight
 Meniscus
• Fibrocartilage
• lateral meniscus
– more circular than medial
– covers more of articular surface than
medial
– attached to PCL via ligaments
• Humphry (anterior)
• Wrisberg (posterior)
– no attachment to LCL
– bears most of joint reactive force
 Meniscus
• Medial meniscus
– “C” shaped
– intimately attached to MCL
– bears equal joint reactive force as bone
 Mechanism of Injury
• Mechanism of injury is fall from standing
height in most patients
– MVA is increasing as % of fractures
– High energy fracture patterns increasing in
this age group!
• Most common fracture pattern is split-
depressed fracture of lateral tibial
plateau (80% of fractures)
 Demographics of
Plateau Fractures
• 1% of all fractures
• 8% of all fractures in the elderly
• lateral plateau involved 55-70%
• medial plateau involved 10-20%
• both involved 10-30%
 Evaluation
• Trauma Evaluation
– ABCs
– Associated Injuries
• Evaluation of Limb
– Gentle exam for knee stability
– Observation of soft tissues
– Neurovascular evaluation
– Evaluate for compartmental syndrome
• Imaging Evaluation
 Physical Exam
• Soft Tissue Assessment
– Tscherne & Goetzen (closed injury)
• grade 0: minimal soft tissue damage/ indirect force
• grade 1: superficial abrasion/contusion via pressure from
within
• grade 2: deep, contaminated abrasion with localized
skin/muscle contusion: impending comp. syn.
• Grade 3: extensive skin contusion/crush: sobq avusion;
underlying muscle damage; decompensated cs
– Gustilo and Anderson (open injury)
 Physical Exam
• Neurologic exam
– peroneal nerve!
• Vascular exam
– popliteal artery and medial plateau injuries
– beware the of the knee dislocation posing
as a fracture
– beware of posteriorly displaced fracture
fragments
– ABI <0.9 urgent arterial study
 Physical Exam
• Compartment syndrome
• KNEE STABILITY
– varus/valgus in full extension
– may require premedication
• aspiration of knee effusion/hematoma
• replace with lidocaine+marcaine
 Evaluation
• Plain radiographs
– AP, lateral, ? oblique of knee on 17-inch cassettes
– AP and lateral of entire tibia
– Traction radiographs
• Very helpful for complex fractures
• Traction can be applied by temporary spanning ex-fix
– CT scan indications
• Fractures for which you are considering nonsurgical care
• Complex fractures to assist in surgical planning
• Always obtain CT after applying traction
AP and Lateral Radiographs
AP and Lateral Radiographs
AP and Lateral Radiographs
Pre-traction
Post-traction
Computed Tomography
Computed Tomography
 Classification:
Schatzker

III

II
 Classification:
Schatzker

IV
VI
V
 Urgent Management
• Rule out compartmental syndrome
• Provide temporary external stabilization
– Relieves pain
– Stabilizes bone and soft tissues
• Consider spanning external fixation if:
– Complex fracture pattern
– Large amount of shortening
– Soft tissue conditions or other injuries make
immediate ORIF unsafe
 Surgical Indicatons
• Open Fracture – I&D, spanning ex-fix
• Extensive soft tissue contusion – spanning ex-
fix
• Closed fracture
– Varus/valgus instability of the knee
– Varus or valgus tilt of the proximal tibia
– Meniscal injury/previous mensicectomy
– Articular displacement or gapping???
 Should You Operate on These
Fractures?

• “The objective of treatment of tibial

plateau fractures is precise reconstruction
of the articular surface and stable fragment
fixation allowing early motion”
 Surgical Treatment
Depressed Fractures (Schatzker 3)
 Surgical Treatment
Split Fractures (Schatzker 1)
 Surgical Treatment
Split Fractures (Schatzker 1)
 Surgical Treatment
Split Fractures (Schatzker 1)
 Surgical Treatment
Split Fractures (Schatzker 1)
 Surgical Treatment
Split Depression Fractures (Schatzker 2)
 Fixation Lateral Plateau
Fractures
• Traditional
– large fragment “L” or “T” buttress plate
– 6.5mm subchondral lag screws
– 4.5mm diaphyseal screw
• Current Recommendation
– small fragment fixation
– pre-contoured peri-articular plates
– clustered sudchondral k-wires
•
 Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Hybrid Ex-Fix
 Postoperative Management
• Immediate PROM/AROM of knee
• Shower beginning 48 hours after surgery
– Ok to shower with ex-fix in place
• Routine Pin site care (if ex-fix)
• TDWB for 8-12 weeks
• Sutures out in 2 weeks
• Xrays in 4-6 weeks
Closed Fractures of
the Tibial shaft
 Anatomy

• 4 compartments of leg
• Canal expands and
cortex thins
proximally and
distally at
metaphyseal-
diaphyseal junctions
• Blood supply via single
nutrient artery and periosteal
arteries
 Physical Exam
• Pain, inability to bear weight, and deformity may
be seen
• Local swelling and edema variable

• Careful inspection of soft tissue envelope

necessary, including compartment swelling
• Thorough neurovascular assessment including
motor/sensory exam and distal pulses
 Physical Exam
• Soft tissue injury with high-energy crush
mechanism may take several days to fully
declare itself

• Repeated exam often necessary to follow

compartment swelling
 Radiographic Evaluation
• AP and Lat views of entire tib/fib required
from knee to ankle
• Oblique views can be helpful in follow-up
to assess healing
 Associated Injuries
• Up to 30% of patients
with tibial fractures have
multiple injuries
• Fracture of the ipsilateral
fibula common
• Ligamentous injury of
knee common in high
energy tibia fractures
 Associated Injuries
• Ipsilateral femur fx, so
called “floating knee”, seen
in high energy injuries
• Neuro/vascular injury less
common than in proximal
tibia fx or knee dislocation
• Foot and ankle injury should
be assessed on physical
exam and x-ray if needed
 Classification
• Numerous classification systems have been
proposed

• Important variables are pattern and location

of fracture, associated fibula fracture, extent
of comminution, and degree of soft tissue
injury
 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
 Compartment Syndrome

• 5-15%
• HISTORY
– Hi-Energy
– Crush
Nerve is the Tissue most Sensitive to
Ischemia

• PAIN first Symptom

• PAIN with Passive Stretch first Sign
 Each Compartment
has Specific Innervation

• Ant Comp Deep- - Peroneal

• Lateral -Sup Peroneal N.
• Deep Post. - Tibial N.
• Sup Post. - Sural N.
Compartment Syndrome is a Clinical
Diagnosis
 Clinical Monitoring
• Need Close Observation
• Repetitive Exams
• Some instances repetitive Pressure
measurements
 Closed Tibial Shaft Fractures

• Broad Spectrum of Injures No Single

Treatment
• Dependent on Mechanism of Injury
 Nonoperative Treatment
• Casts
• Functional Bracing
• Nondisplaced & Low Energy Injuries
 Surgical Options

• Intramedullary nail

• ORIF with plate

• External Fixation
 Advantages of IM Nail
• Advantages include
less malunion and less
shortening than closed
treatment or ex-fix

• Earlier weight bearing

may be allowed with
insertion large nail
Stability
 Fractures of the foot
• Calcaneum • Ankle fractures
• Talus • Medial and lateral
• Tatarsal malleolli
• Metatarsals