1. 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

2. 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

3. Contents: FRACTURE NECK OF FEMUR INTERTROCHANTERIC FRACTURE
HIP JOINT DISLOCATION
FEMUR SHAFT FRACTURE
DISTAL FEMUR FRACTURE
KNEE JOINT DISLOCATION
PATELLA FRACTURE
TIBIAL PLATEAU FRACTURE

4. CONT’: TIBIA SHAFT FRACTURE MALLEOLI FRACTURE TALUS FRACTURE
CALCANEUM FRACTURE

5. 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

6. 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)

7. Garden’s classification
Stage I
Incomplete # (impacted)
Stage II
Complete and undisplaced
Stage III
Complete and moderately displaced
Stage IV
Severely displaced

8. 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

9. Radiological features of neck of femur fracture
Shenton’s line

10. Complication: Avascular necrosis of the femur head
Non-union of the fracture
General complications following prolong bedridden for conservative treatment (bedsore, DVT, pneumonia, stiffness)

11. 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

12. 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)

13. Intertrochanteric fracture
Commonly occur in elderly patient (osteoporosis) following trivial fall
Extension to subtrochanteric region
May presented as comminuted fracture pattern

14. Radiograph shows intertrochanteric
fracture of the femur

15. Complications: Mal-union of the fracture
Failure in fixation for the fracture due to osteoporotic bone
General complications following prolong bedridden

16. 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)

17. Fixation of fracture intertrochanteric fracture

18. 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

19. Left side
Radiograph shows left hip dislocation

20. 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

21. 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

22. 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

23. Radiographs show femur shaft fractures
Distal 1/3
supracondyalar
Proximal 1/3

24. Complication Vascular injury (femoral artery) Fat embolism
Delayed and non-union of the fracture
Mal-union of the fracture
Joint stiffness (knee)

25. 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)

26. Intramedullary locking
nail

27. 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

28. Complications
Joint stiffness and arthrosis if involve the articular region
Risk of femoral artery injury

29. 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)

30. Angled blade plate for fixation
of supracondylar fracture
of the femur

31. 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

32. Radiographs show anterior
dislocation of the knee

33. Risk of vascular injury
Transected or thrombosis (following intimal injury)
Vascular assessment or surveillance
Angiogram as indicated

34. 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)

35. artery

36. Complications Neurovascular injury
Knee ligaments injury (result in joint instability)
Stiffness of the joint
Arthrosis formation following cartilage damage

37. 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

38. 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

40. Types of TP # Simple split lateral condyle
Depressed, comminuted lateral condyle
Crushed comminuted lateral condyle
Split medial condyle
Bicondylar fractures
Bicondylar and subcondylar

41. Complications
Compartment syndrome
Joint stiffness
Deformity
arthrosis

42. 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

43. 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

44. Complications Joint stiffness Patellofemoral arthrosis
reduced knee extensor mechanism

45. Treatment Undisplaced fracture
Cylinder cast immobilization for 6 weeks
Displaced fracture
ORIF (tension band wiring)
Severely comminuted
Cerclage wiring or patellectomy

46. 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 #

47. Radiographs show tibial shaft fracture

48. Complications Compartment syndrome
Malunion (leading to shortening and arthrosis)
Nonunion

49. Treatment Acceptable displacement with less comminuted (stable)
Apply Full Length POP immobilization for 6 weeks
Comminuted, segmental (unstable
reduction alignment)
Internal fixation (ILN, Plating)

50. Intramedullary
Locking nail for
Tibia shaft fracture

51. Malleoli fractures Forces to the ankle region
External rotation, abduction, adduction,
Ankle joint dislocation or subluxation
Ankle ligaments injury including syndesmosis

52. 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

53. Cont’: Type B: # level with syndesmosis Oblique fibular #
External rotation force
Disrupted medial structures
Syndesmosis intact

54. 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

55. Fracture of lateral
malleolus

56. Complications Dislocated or subluxated ankle joint Stiffness
Arthrosis of ankle joint
Ankle instability
Nonunion fracture (displaced medial malleolus)
Malunion of the fracture

57. 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)

58. Plating of the lateral malleolus fracture
with 1/3 tubular plate

59. 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

60. Talus fractures Dome of talus fracture showed Through CT-scan
Neck of talus fracture

61. 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)

62. Treatment Undisplaced #: cast immobilization (boot POP)
Displaced # +/- dislocation: ORIF screw fixation
If AVN developed later may consider arthrodesis of the ankle joint

63. Screw fixation of the talus fracture at the neck region

64. 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

65. Extra-articular fracture of calcaneum

66. Complications Skin necrosis (intense swelling)
Malunion of the fracture
Peroneal tendon impingement
Flat and broad foot (shoe fitting)
Subtalar arthrosis

67. 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

68. 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 (address:

69. 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.

70. 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

71. Enjoy reading…..
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