Common Lower Limb

Fractures and Dislocations

Muhammed Yesuf, MD

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Pelvic fracture
Epidemiology
• Under 35 more in men, above 35
more in women
Anatomy
• Pelvic ring – sacrum, two
innominate bones
• Pelvic brim – sacral promontory +
arcuate line + superior pubis
• Stability - ligaments

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Clinical finding
• ATLS
• Hemodynamic status
• Leg length discrepancy, rotation
• The AP–LC test for pelvic instability
• Soft tissue contusion
• Perineal lesions
• DRE, vaginal exam
• Neurologic exam
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Radio
• AP, inlet, outlet
• CT
Classification
• Young and Burgess
• Mechanism – APC, LC, VS, CM
• Tiles classification
A. stable
B. Rotationally unstable/ vertically stable
c. rotationally and vertically unstable
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Treatment
• ATLS
• Nonoperative
• APC I, LC I
• Operative
• Open, hemodynamic instability, unstable fracture, LLD>1.5CM, sacral
displacement>1cm, intractable pain, rotational deformity
• External fixation, internal fixation

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Acetabular Fracture
Epidemiology
• 30% associated neural injury
Clinical finding
• ATLS
• Neurovascular assessment
• Soft tissue

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Radiography
• AP, Judet views (iliac and
obturator oblique views)
• CT
Classification
• Judet –Letournel
• Primary
• Associated

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Treatment
• Non operative
• Nondisplaced, Maintained roof arc
angle, Distal anterior column fracture,
Small posterior wall (<20%), Elderly
low demand patients
• Operative
• Displaced, large posterior wall
fragment, posterior instability,
intrarticular fragment, irreducible
fracture dislocation

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Hip dislocation
Epidemiology
• 50% associated fracture
• Most posterior

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Clinical finding
• Trauma survey, concomitant injuries
• Posterior dislocation - hip flexion, internal rotation, and adduction
• Anterior dislocation - hip external rotation with mild flexion and abduction
• Sciatic nerve injury
Radiography
• AP pelvis, cross table lateral
• CT

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Treatment
• Closed reduction
• Allis method
• Stimson gravity method
• Open reduction
• Irreducible closed
• Nonconcentric reduction
• Femur neck, acetabulum
fracture

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Proximal Femur fracture
Epidemiology
• Femur neck, inter trochanteric and subtrochanteric
• Common In elderly women
Clinical finding
• ATLS
• Shortened, externally rotated limb

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Radiography
• AP, cross table lateral
• MRI, CT

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Treatment
• Cannulated screw
• Sliding hip screw
• Cephalomedullary nail
• Angled blade plate
• External fixation
• Arthroplasty

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Femoral shaft fracture
Epidemiology
• In young male and elderly female
Clinical finding
• ATLS
• Deformity, swelling, shortening
• Neurovascular
• Knee evaluation
• Hemodynamic status

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Treatment
• Non operative
• Skeletal traction
• Significant comorbidity,
temporary
• Operative
• IMN
• Ex fix
• Plate

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Distal femur fracture
Epidemiology
• Young males, elderly females
Clinical finding
• Pain, swelling, deformity
• Neurovascular exam – popliteal artery
Radiography
• AP, Lateral, oblique x-ray
• CT, MRI
• Arteriography
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Treatment
• Nonoperative
• Stable nondisplaced
• Advanced medical condition
• Cast, brace
• Operative
• Screw
• Plate
• Nail
• External fixator

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Knee dislocation
Epidemiology
• 20-50% spontaneous reduction
Clinical finding
• Knee distortion
• Arterial evaluation
• Neurologic evaluation
• Stability examination

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Radiography
• AP, Lateral, oblique x-ray –
after reduction
• Arteriography
• MRI

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Treatment
• Immediate closed reduction
• Splint at 20-30 degree
• Exfix
• Operative treatment
• Unsuccessful closed reduction
• Residual soft tissue interposition
• Open injuries
• Vascular injuries
• Associated fractures

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Patellar fracture
Epidemiology
• 20-50 yrs., M:F – 2:1
Clinical finding
• Pain, swelling, tenderness, palpable
defect,
• Active extension exam

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Radiography
• AP, lateral view,
sunrise(axial) x-ray view
• CT

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Treatment
• Nonoperative
• Nondisplaced or minimally displaced(2-3mm) with intact extensor mechanism
• Cylindrical cast or knee immobilizer
• Operative
• TBW
• Screw
• Patellectomy

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Tibial fracture
Epidemiology
• Proximal/plateau – lateral
• Shaft - Most common long bone
fractures
• Distal/pilon

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Clinical finding
• Pain, Swelling,
• Soft tissue assessment
• Neurovascular examination
• Compartment syndrome
• Ligament injury, meniscus injury

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Radiography
• AP, Lateral, oblique, Traction view, stress view
• CT, MRI, bone scan
• Angiography

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Treatment
• Nonoperative
• Acceptable Fracture Reduction – shaft
• Less than 5 degrees of varus/valgus angulation
• Less than 10 degrees of anterior/posterior angulation
• Less than 10 degrees of rotational deformity
• Less than 1 cm of shortening
• More than 50% cortical contact is recommended.

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• Operative treatment
• IMN
• EX FIX
• Plates and screws
• Screws

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Ankle Fracture
Epidemiology
• Common in elderly women
Clinical finding
• Pain, swelling, tenderness,
deformity
• Neurovascular evaluation
• Soft tissue evaluation

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Radiography
• AP, lateral, Mortise
• Stress view
• CT
• MRI

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Classification
• Denis-weber
• Based on level of fibular fracture
• Lauge Hansen
• Based on “pure” injury sequences

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Treatment
• Nonoperative
• Nondisplaced, acceptable
reduction, unfit patient
• Operative
• Screw
• Plate
• Exfix
• TBW
• IMN

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Calcaneus fracture
Epidemiology
• Most frequently fractured tarsal bone
• Most intrarticular fracture
Clinical finding
• Heel pain, tenderness, swelling, heel
widening and shortening, ecchymosis
• Neurovascular evaluation,
compartment syndrome

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Radiography
• AP, lateral view, harris axial
view, ankle series
• CT
Classification
• Extrarticular vs intrarticular

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Treatment
• Non operative
• Nondisplaced fracture
• Soft tissue trauma
• Comorbidities
• Operative
• Displaced
• Open
• Fracture dislocation

• ORIF

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TMT(Lisfranc) joint injury
Epidemiology
• May be overlooked initially
Clinical finding
• Deformity, pain, swelling, tenderness,
plantar ecchymosis
• Stress testing

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Radiography
• AP, lateral, oblique, stress, weight
bearing view
• CT, MRI

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Treatment
• Nonoperative
• Sprain, nondisplaced ligamentous
injuries, 1st to 3rd metatarsal base
fractures
• Operative
• Displaced injury
• ORIF
• arthrodesis

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Forefoot fracture
Metatarsal fracture
Clinical finding
• Pain, swelling, tenderness
Radiography
• AP, lateral, oblique
• MRI, bone scan

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Treatment
• Indications for operative mx
• 1St - unstable
• 2nd , 3rd, 4th - more than 10 degrees of deviation in the dorsal plantar plane or
3 to 4 mm translation in any plane
• 5th – zone 2 injuries

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Phalangeal fractures
• Epidemiology
• Proximal phalanx of the fifth toe is the most often involved
Treatment
• Nonoperatively with closed reduction for clinical deformity
• Operative reduction for fractures with gross instability or persistent
intra-articular discontinuity

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