OCCO 4014: INTRODUCTION TO CLINICAL

ORTHOPAEDIC

MANAGEMENT OF PATIENT WITH

TRAUMATIC INJURIES
(PELVIS AND LOWER LIMB)
KUMPULAN 7 ADOC 1/2023
MOHD HAFIZ BIN ABDULLAH RIJAL
NUR ALWANNI BINTI YUSOFF
NAFIZAH BINTI ISMAIL
 PELVIS
The pelvis is a stable circular base that supports the
trunk and forms an attachment for the lower
extremities. It is a massive, irregular bone created by
the fusion of three separate bones. The largest and
uppermost of the three bones is the ilium, the strongest
and lowermost is the ischium, and the anterior-most is
the pubis.
 MECHANISMS
• Low-energy mechanisms (falls from standing height)
• Typically result in stable pelvic injuries
• Often result in isolated pelvic fractures without other
traumatic injuries
• Especially in elderly patients, may result in avulsion
fractures and acetabular fractures
• High-energy mechanisms (motor vehicle accidents, falls
from heights)
• Associated with significant hemorrhage from bone
fractures as well as vascular injury, multiorgan injuries,
and deformity
• Increased risk of mortality, primarily owing to
hemorrhage
 TYPE OF FRACTURE AND DISLOCATION

•Stablepelvic fracture: only one break in your pelvis and the

broken parts of the bones aren’t displaced. Pelvic fractures
that happen from low impact events (minor fall or running)
•Unstable pelvic fracture: two or more breaks and the ends
of broken parts of the bones are displaced. Caused by high-
impact events (car crash)
•Avulsion pelvic fracture: happens when a tendon or ligament
tears away from the bone that’s attached and taking small
fragment of bone with it.
Hip dislocation
 CLASSIFICATION OF PELVIS FRACTURE
1. Tile classification
2. Young and burgess classification

YOUNG AND BURGESS TILE CLASSIFICATION

 YOUNG AND BURGESS CLASSIFICATION

Based on mechanism of
injury

1.Anteroposterior
compression fractures (APC)
2.Lateral compression
fractures (LC)
3.Vertical shear fractures
MANAGEMENT

INITIAL MANAGEMENT GOALS (PRE HOSPITAL CARE)

Control haemorrhage and associated

life threatening injuries

Pelvic stabilization
Begin resuscitation with crystalloid fluids via

large bore IV access

Bind pelvis with rolled sheet or pelvic binder for

immediate external stabilization

HOSPITAL MANAGEMENT

1) For Stable fracture (Tile type A)

Typically
managed conservatively on outpatient basis with rest, pain
management, and functional rehabilitation
Eg: superior or inferior pubic rami fracture

2) For Unstable fracture (Tile type B and C)

Initiate
conservative resuscitation with IV crystalloid infusion (1-2 L for adults and 20
mL/kg for children)
Physiologicfailure to respond to crystalloids suggests need for transfusion of blood
and blood products
Ifintra-abdominal source of bleeding is identified on FAST (focused assessment
with sonography for trauma) or diagnostic peritoneal lavage, transport patient to
operating room for exploratory laparotomy with pelvic stabilization (eg, internal
fixation, external pelvic fixation, pelvic c-clamp)
Administer iv antibiotic for open freacture to reduce risk of infection
 Pelvic C-
clamp
External fixation
frame

Pelvic ring after pelvic binder application

HIP DISLOCATION
DEFINITION

a painful event in which the ball joint of your hip

comes out of its socket. It usually occurs from a
significant traumatic injury.
CLASSIFICATION

Posterior dislocation – common case in

hip dislocation (80%-90%)
Anterior dislocation
Central dislocation
POSTERIOR DISLOCATION

 Known as ‘dashboard injury’

 Usually happens when someone
seated in car
 When accident happens, body will
thrown forward and striking the
knee against dashboard
 Femur is thrust upwards and
femoral head is forced out of its
socket (acetabulum)
CLINICAL FEATURES

 will be in flexion, adduction

and medial rotation deformity
to the affected limb.
 Unable to walk
 Vascular injury and sciatic
nerve injury sign
 Pain over the hip and posterior
lim
 Loss of sensation in posterior
leg and foot
MANAGEMENT
Allis maneuver

Stimson maneuver
AFTER CMR MANAGEMENT

 Skin traction applied for 2weeks and to start mobilize

after traction with physiotherapist
 Pain management- analgesic as needed
 Avoid adduction and internal rotation of lower limb
 To repeat xray after traction before allow full weight
bearing
CLASSIFICATION OF
FRACTURE
FEMUR
FEMUR
 Type of long bone
 Longest

 Heaviest

 Strongest

 A part of appendicular skeletal

 Consist of 3 major segment
 Proximal

 Midshaft

 Distal
Classified of fracture (in general)

 Open fracture
 Fracture bone and/or fracture hematoma are exposed
to the external environment via a puncture of the soft
tissue and skin
 Closed fracture
 The bone is broken, but do not penetrating the skin and
not exposed to the external
 Open fracture

 Closed fracture
Common fracture of proximal of femur
and its classification
 Russel taylor classification of subtrochanteric fracture
 Evan classification of intertrochanteric fracture
 Garden classification of femoral neck of fracture
 Pipkin classification of femoral head fracture
Common fracture for midshaft (body of
femur) and its classification
 Transverse
 Linear
 Oblique non-displaced
 Oblique displaced
 Spiral
 Greenstick
 Comminuted
 Segmental
 Butterfly (Winquist
fracture)
 BUTTERFLY (WINQUIST FRACTURE)
SEGMENTAL FRACTURE
Fracture for distal end of femur and its
calssification
 Also known as supracondylar fracture

 There are three type of supracondylar fracture

 Transverse fracture
 Comminuted fracture
 Intra-articular fracture
SUPRACONDYLAR FRACTURE
Management of femur fracture
 Initial management :
 putinto skin traction (10% of body weight) + pain
management
 Iftransferred to another hospital, should be
immobilized with Thomas Splint or backslab
 In ward, there are two kind of treatment :
 Conservative treatment
 Surgery treatment
 Conservative treatment include :
Closed manipulative reduction (CMR)
skin traction ( 10% of bodyweight )
Skeletal traction
Pain management
Thomas Splint

 Surgery treatment include :

Open Reduction and Internal Fixation ( ORIF )
Interlocking Nail of femur ( ILN )
Proximal Femoral Nail ( PFN )
Bipolar Hemiarthroplasty
External Fixation
SKIN TRACTION

THOMAS SPLINT
OPEN REDUCTION AND
INTERNAL FIXATION (ORIF)

PROXIMAL FEMORAL NAIL

OF FEMUR (PFN)

INTERLOCKING NAIL
BIPOLAR HEMIARTHROPLASTY EXTERNAL FIXATION
CLASSIFICATION OF FRACTURE

TIBIA
 Fracture of tibia plateau
 Injuriesof the proximal end of tibia including
metaphysis and epiphysis region as well as articular
surfaces
 Mechanism of injury

 Axial loading:
 -Valgus or varus forces such as fall from a height.
 Lateral tibia plateau fracture is more than medial.
 Presented with knee effusion
 Lead to early OA
 Mechanism of injury

 Direct forces such as cause by falls and MVA.

 More soft tissue injury.

 Indirect forces or rotational forces.

 Less soft tissue injury.
 CLASSIFICATION
 Schatzker classification of tibia plateau fracture
 Type 1-lateral tibia plateau fracture without depression
Type II
-Lateral Split-depressed fracture
-most common
Type III
- Lateral Pure depression fracture with no associated split
- uncommon, elderly osteoporotic
Type IV
- Medial plateau fracture with or without depression
- associated fx-dislocation
- high rate of NV and ligamentous injuries
Type V
- Bicondylar fracture
- tibial spines remain continuous with shaft
Type VI
- Metaphyseal-diaphyseal discontinuity
- significant soft-tissue injury
 Management
 CONSERVATIVE:
- Non weight bearing
 Closed
reduction/immobilization –
use of knee immobilizer
 Eg : above knee cast
- Physiotherapy

 OPERATIVE :
- Open Reduction Internal
Fixation(ORIF)
- External Fixator(Ilizarof)
TIBIAL SHAFT FRACTURE

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Mechanism of injury

 Direct injury: RTA ( Road Traffic Accident ) commonest

cause of these fracture,mostly due to direct violence.
 frequently the object cuasing the fracture lacerates the skin
over it,resulting in open fracture.

 Indirect injury: bending or torsional force on the tibia may

result in an oblique or spiral fracture.
 the sharp edge of fracture fragment may pierce the skin
from within,resulting in an open fracture.

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management

NON OPERATIVE:
 Application of long leg cast with
progressive weight bearing for
fractures with minimal
displacement.
 cast with the knes in 0-5
degrees of flexion to allow for
weight bearing with crutches
as soon as tolerated by patient
 FWB by 2nd to 4th week.

OPERATIVE :
 intramedullary (IM) nail

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 Plate fixation
- suitable for metaphyseal
fractures
 External fixation
- used to treat severe open
fractures
also use in closed fractures
complicated by compartment
syndrome
- union rates :90% with about
4-6 months for union.
plate fixation external fixation

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 Plates and screws
- suitable for fractures extend
ing into metaphysis or
epiphysis

Plate and screws

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Distal Tibia Fracture

 Distal tibia fractures are primarily

located within a square based on
the width of the distal metaphysis.

 Distal tibia forms an inferior

quadrilateral surface and pyramid-
shaped medial malleolus articulates
with the talus and fibula laterally via
the fibula notch

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Mechanism

 high energy axial load (most common)

 talus is driven into the plafond resulting in articular
impaction of the distal tibia
 falls from height
 motor vehicle accidents

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Tibial plafond fracture (also known as a
pilon fracture
 Is a fracture distal end of the tibia,involving its articular surface at
the ankle joint.
 occurs when a large force drives the talus upwards against the
tibial plafond,like a pestle (pilon) being struck into a motar.
 damage to the articular cartilage and the subchondral bone may
be broken into several pieces.in severe cases the comminution
extends some way up the shaft of tibia.

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43-B - Partial Articular
43- C Complete articular
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Ruedi and Allgower Classification

 Type I- Nondisplaced
 Type II - Simple
displacement with
incongruous joint

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 Type II - Simple
TYPE I Type III -
displacement with
Nondisplaced Comminuted
incongruous joint
articular surface

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TREATMENT
 Non-operative :
 cast immobilization
 indications
 stable fracture patterns without
articular surface displacement
 critically ill or non-ambulatory
patients
 significant risk of skin problems
(diabetes, vascular disease,
peripheral neuropathy)
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 Operative
 open reduction and internal
fixation (ORIF)
 external fixation/circular frame
fixation alone
 intramedullary nailing with
percutaneous screw fixation Circular frame fixation
 primary ankle arthrodesis
 Circular frame fixation
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Fibular Fracture
 The fibula is often
fractured, 2-5 cm proximal
to the distal end of the
lateral malleolus.It's
commonly related to
fracture dislocation of the
'ankle joint'

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Mechanism of Injury
Mechanisms of injury for tibia-fibula fractures can be divided
into 2 categories:

 low-energy injuries such as ground level falls and athletic

injuries
 high-energy injuries such as motor vehicle injuries,
pedestrians struck by motor vehicles, and gunshot wounds.
 Patients may report a history of direct (motor vehicle crash
or axial loading) or indirect (twisting) trauma and may
complain of pain, swelling, and inability to ambulate with
tibia fracture.
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 Classification
 Ankle fractures are classified
according to the Danis-Weber
classification system
 Type A is a transverse fibular
fracture caused by adduction
and internal rotation.
 A fracture of the lateral
malleolus distal to the
syndesmosis (the connection
between the distal ends of the
tibia and fibula).

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 Usually stable: but sometimes in need of an open
reduction and internal fixation (ORIF) especially if the
medial malleolus is fractured. Typical features :

 Below the level of the tibial plafond (syndesmosis)

 Tibiofibular syndesmosis intact
 Deltoid ligament intact
 Occasional oblique or vertical medial malleolus fracture
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 Type B, is caused by external
rotation, it is shown as a short
oblique fibular fracture directed
mediolaterally upward from the
tibial plafond.
 There are two type C fractures:
Type C 1 is an oblique medial-
to-lateral fibular fracture which is
caused by abduction. Type C 2
fractures result from a
combination of abduction and
external rotation, producing
more extensive syndesmotic
injury and a higher fibular
fracture.

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Management

 cast or splint for several weeks.

 ORIF fibula

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CLASSIFICATION OF
FRACTURE
TARSAL
TYPE OF FRACTURE

Calcaneum fracture
Talus fracture
CALCANEUM

also known as the heel bone, is found

at the back of the foot near the
ankle, just below the talus,
tibia and fibula bones of the lower leg.
It also plays an important role

in weight bearing and stability.

Most common tarsal

bone fractured
CALCANEUM FRACTURE

The calcaneus is most often fractured during a fall

from a height or a motor vehicle collision
•Ifyou land on your feet from a fall, your body's weight is
directed downward. This drives the talus bone directly
into the calcaneus.
•In a motor vehicle crash, the calcaneus
is driven up against the talus if the heel
is crushed against the floorboard
 SANDERS CLASSIFICATION
 Based on the number and location of articular fracture fragments
 Useful in determining both treatment methods and prognosis after
surgical fixation
MANAGEMENT

1. NON SURGICAL TREATMENT

A cast, splint, or brace will hold the bones in proper position while
they heal ( eg: boot cast)
May have to wear from 6 to 8 weeks
For non weight bearing until healed
2. SURGICAL TREATMENT
Surgical intervention will be done after swelling subsided or no infection over wound (open
wound)
Percutaneous screw fixation- Special screws are inserted through small incisions to
hold the fracture together.
Open reduction and internal fixation - an open incision is made to reposition
(reduce) the bones into their normal alignment. They are held together with wires or
metal plates and screws.
3. PAIN MANAGEMENT
Pain management after operation to reduce the pain recover from surgery
faster

4. REHABILITATION
Below knee backslab applied with elevation to reduce swelling
STO day14
Early motion of ankle and foot
Non weight bearing for 12 weeks or more depends on surgeons
TALUS

 Contains of :
 Head
 Neck
 Body
 Lateral process
 Posterior process
TALUS FRACTURE

Second most common tarsal fracture after

calcaneal fracture
Most talus fracture is talar neck fracture
Usually caused by high energy trauma such as
a car collision or a fall from height
HAWKINS CLASSIFICATION

•Hawkins Type I: Nondisplaced talar neck fracture

•Hawkins Type II: Talar neck fracture with subtalar
dislocation
•Hawkins Type III: Talar neck fracture with subtalar and
ankle subluxation
•Hawkins Type IV: Talar neck fracture with subtalar and
ankle and talonavicular dislocation
HAWKINS CLASSIFICATION
MANAGEMENT
 For undisplaced fractures (hawkin type I)
 Applied below-knee cast with ankle at 90 degrees for 6 t0 8
weeks
 Advice for non weight bearing.
 If there is doubt about whether the fracture is truly non-
displaced, a CT may be required.

 For displaced fractures (hawkin type II,III,IV)

 apply a well-padded splint around the back of the foot and
leg to immobilize and protect the limb. The splint should
extend from the toe to the upper calf( above knee
backslab)
 Elevate the foot to minimize swelling an pain
 Surgical treatment will be given after swelling reduced. Eg:
open reduction and internal fixation
 Pain management after operation to reduce the pain
recover from surgery faster
 Start early motion as soon as the wound heals and specific
physical therapy exercises to improve the range of
motion of foot and ankle and strengthen supporting
muscles.
 Allow weightbearing as surgeon’s direction.
3) Pain management
- Includes the use of opioids and NSAIDs
4) Venous thrombosis prophylaxis
chemoprophylaxis (clexane/heparin) and mechanical
prophylaxis (TED stockings)
5) Functional rehabilitation
Early movement with physiotherapist (eg: weight bearing with
crutches)
Doughnut pillow for patients with stable coccyx and
sacral fractures
 COMPLICATIONS
EARLY COMPLICATIONS

Associated injuries with:

1) Vascular
Blood loss due to distruption of the pelvic venous plexus
2) Pelvic
Genitourinary and gastrointestinal that is injuries to bladder, rectum, vagina and urethra
3) Neurologic
damage to sacral roots, obturator nerve, and fifth lumbar roots
Acetabular fractures have significant risk for sciatic nerve injury

4) Thromboembolism
- high risk for deep vein thrombosis and pulmonary embolism
COMPLICATION

 Avascular necrosis (AVN) - the death of bone tissue due

to a lack of blood supply
 Osteoarthritis – pain , stiffness, audible clicking sound when
moving over the hip
 Sciatic nerve injury – sciatic nerve becomes pinched and
can cause foot drop
 Heterotrophic ossification - bone grows in tissues where
it typically wouldn't.
 COMPLICATION
 Post traumatic arthritis
 Compartment syndrome
 Infection
 Non union/malunion
 Knee stiffness
 Deep vein thrombosis
LONG TERM COMPLICATIONS

Prolonged pain/ post traumatic hip arthritis

Impaired mobility
Deformity

Sexual dysfunction due to nerve damage

HEALTH EDUCATION
Physiotherapy

Encourage ambulation with cruthes or walking frame and follow

physician’s order for partial/full weight bearing
Dressing and STO
- Dressing as physician’s order and follow sto date given
High protein and vitamin diet to speed up the wound healing
process
Keep the knees and toes pointed forward when sit on a chair,
walk or stand
Do not sit when your legs crossed
Do not lean forward while seated down or stand up and don’t
bend more than 90◦
Do not lift knee higher than hip
Do not sit on low chair, bed or toilet
 Health Education
REHABILITATION

- Encourage early ambulation.-how to use assistive device safely

Encourage to do passive and active ROM.
POP CARE (conservative)
Keep cast clean and dry all time to avoid infection
Do not scratch or put foreign body in the cast
Come stat to hospital if develop pain or swelling
DRESSING CARE
dressing followed physician’s order (OD/EOD dressing) and to come to hospital stat if develop
sign and symptoms of infection
Advice patient not to wet the dressing.
NUTRITION

Encourage adequate balanced diet to promote bone and soft tissue healing.
Care of External fixator –pin site
TCA

- Follow all TCA’s and medication prescribed by doctor

- TCA stat if worsening in condition, get any complication or worsening in symptoms such as
swollen, bleeding and infection