1. Lower Extremity Trauma

2. Lower Extremity Trauma
Hip Fractures / Dislocations
Femur Fractures
Patella Fractures
Knee Dislocations
Tibia Fractures
Ankle Fractures
Foot Fracture

3. Hip Fractures Hip Dislocations Femoral Head Fractures
Femoral Neck Fractures
Intertrochanteric Fractures
Subtrochanteric Fractures

4. Hip Dislocations Significant trauma, usually MVA
Posterior: Hip flexion, IR, Add
Anterior: Extreme ER, Abd/Flex

5. Anatomic classification
posterior dislocation (90%)
occur with axial load on femur, typically with hip flexed and adducted
axial load through flexed knee (dashboard injury) 
associated with
osteonecrosis
posterior wall acetabular fracture
femoral head fractures
sciatic nerve injuries 
ipsilateral knee injuries (up to 25%) 
anterior dislocation 
associated with femoral head impaction or chondral injury
occurs with the hip in abduction and external rotation

6. Anterior Dislocation 7-10% of hip dislocations Mechanism:
Forced abduction with external rotation of hip.
Anterior hip capsule is torn or avulsed.
Femoral head is levered out anteriorly.

7. Epstein Classification of Anterior Hip Dislocations
Type I Superior (pubic and subspinous) Type II Inferior (obturator and perineal) A No associated fracture B Associated fracture of the femoral head/neck C Associated fracture of the acetabulum

8. Thompson and Epstein Classification of Hip Dislocations
Type I Pure dislocation with at most a small posterior wall Type II Dislocation with large posterior wall Type III Dislocation with comminuted posterior wall Type IV Dislocation with “acetabular floor” fracture Type V Dislocation with femoral head fracture

9. Hip Dislocations Emergent Treatment: Closed Reduction
Dislocated hip is an emergency
Goal is to reduce risk of AVN and DJD
Allows restoration of flow through occluded or compressed vessels
Literature supports decreased AVN with earlier reduction
Requires proper anesthesia
Requires “team” (i.e. more than one person)

10. Hip Dislocations Emergent Treatment: Closed Reduction
General anesthesia with muscle relaxation facilitates reduction, but is not necessary
Conscious sedation is acceptable
Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, cause muscle spasm, and make subsequent attempts at reduction more difficult

11. Hip Dislocations Emergent Treatment: Closed Reduction Allis Maneuver
Assistant stabilizes pelvis with pressure on ASIS
Surgeon stands on stretcher and gently flexes hip to 90deg, applies progressively increasing traction to the extremity with gentle adduction and internal rotation
Reduction can often be seen and felt
Insert hip
Reduction
Picture

12. Hip Dislocations Following Closed Reduction
Check stability of hip to 90deg flexion
Repeat AP pelvis
Judet views of pelvis (if acetabulum fx)
CT scan with thin cuts through acetabulum
R/O bony fragments within hip joint (indication for emergent OR trip to remove incarcerated fragment of bone)

13. Hip Dislocations Following Closed Reduction
No flexion > 60deg (Hip Precautions)
Early mobilization with
P.W.B. for 4-6 weeks
MRI at 3 months (follow risk of AVN)

14. Complications Post-traumatic arthritis
up to 20% for simple dislocation, markedly increased for complex dislocation
Femoral head osteonecrosis
5-40% incidence
Increased risk with increased time to reduction
Sciatic nerve injury
8-20% incidence
associated with longer time to reduction
Recurrent dislocations
less than 2%

15. Femoral Head Fractures
Concurrent with hip dislocation due to shear injury

16. Femoral Head Fractures
Pipkin Classification
I: Fracture inferior to fovea
II: Fracture superior to fovea
III: Femoral head + acetabulum fracture
IV: Femoral head + femoral neck fracture

17. Femoral Head Fractures
Treatment Options
Type I
Nonoperative: non-displaced
ORIF if displaced
Type II: ORIF
Type III: ORIF of both fractures
Type IV: ORIF vs. hemiarthroplasty

18. Epidemiology 250,000 Hip fractures annually At risk populations
Expected to double by 2050
At risk populations
Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition
Young: high energy trauma

19. Femoral Neck Fractures
Garden Classification
I Valgus impacted
II Non-displaced
III Complete: Partially Displaced
IV Complete: Fully Displaced
Functional Classification
Stable (I/II)
Unstable (III/IV) I II
III IV

20. Femoral Neck Fractures
Treatment Options
Operative
ORIF
Hemiarthroplasty (Endoprosthesis)
Total Hip Replacement

21. Femoral Neck Fractures
Young Patients
Urgent ORIF (<6hrs)
Elderly Patients
ORIF possible (higher risk AVN, non-union, and failure of fixation)
Hemiarthroplasty
Total Hip Replacement

22. Hemi
ORIF
THR

23. Intertrochanteric Hip Fx
Intertrochanteric Femur Fracture
Extra-capsular femoral neck
To inferior border of the lesser trochanter

24. Intertrochanteric Hip Fx
Intertrochanteric Femur Fracture
Physical Findings: Shortened / ER Posture
Obtain Xrays: AP Pelvis, Cross table lateral

25. Intertrochanteric Hip Fx
Classification
# of parts: Head/Neck, GT, LT, Shaft
Stable
Resists medial & compressive Loads after fixation
Unstable
Collapses into varus or shaft medializes despite anatomic reduction with fixation
Reverse Obliquity

26. Intertrochanteric Hip Fx
Reverse
Obliquity
Stable
Unstable

27. Intertrochanteric Hip Fx
Treatment Options
Stable: Dynamic Hip Screw
Unstable/Reverse: IM Recon Nail

28. Subtrochanteric Femur Fx
Classification
Located from LT to 5cm distal into shaft
Intact Piriformis Fossa?
Treatment
IM Nail
Cephalomedullary IM Nail
ORIF

29. Femoral Shaft Fx Winquist
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
Type 4 - Segmental comminution

30. Femoral Shaft Fx Treatment Options IM Nail with locking screws
ORIF with plate/screw construct
External fixation
Consider traction pin if prolonged delay to surgery

31. Distal Femur Fractures
Distal Metaphyseal Fractures
Look for intra-articular involvement
Plain films CT

32. Distal Femur Fractures
Treatment:
Retrograde IM Nail
ORIF open vs. MIPO
Above depends on fracture type, bone quality, and fracture location

33. Knee Dislocations High association of injuries Ligamentous Injury
ACL, PCL, Posterolateral Corner
LCL, MCL
Vascular Injury
Intimal tear vs. Disruption
Obtain ABI’s  (+)  Arteriogram
Vascular surgery consult with repair within 8hrs
Peroneal >> Tibial N. injury

34. KNEE DISLOCATION
Devastating injury resulting from high or low energyhigh-energy
usually from MVC or fall from height
commonly a dashboard injury resulting in axial load to flexed knee
low-energy
often from athletic injury
generally has a rotational component 
morbid obesity is a risk-facto

35. Associated Injuries vascular injury 5-15% in all dislocations
40-50% in anterior/posterior dislocations 
due to tethering at the politeal fossa
proximal - fibrous tunnel at the adductor hiatus
distal - fibrous tunnel at soleus muscle
nerve injury
usually common peroneal nerve injury (25%)
tibial nerve injury is less common
fractures
present in 60%
tibia and femur most common

36. Classification Anterior most common type of dislocation (30-50%)
due to hyperextension injury
arterial injury is generally an intimal tear due to traction
posterior
2nd most common type (25%) highest rate of complete tear of popliteal artery
lateral 
13% of knee dislocations due to varus or valgus force
highest rate of peroneal nerve injury
Medial
rotational

37. Schenck Classification
KD I
Multiligamentous injury with involvement of ACL or PCL
KD II
Injury to ACL and PCL only (2 ligaments)
KD III
Injury to ACL, PCL, and PMC or PLC (3 ligaments)
KD IV
Injury to ACL, PCL, PMC, and PLC (4 ligaments)
KD V
Multiligamentous injury with periarticular fracture

38. vascular exam
Rule out vascular injury on exam both before and after reduction
palpate the dorsalis pedis and posterior tibial pulses
if pulses are present and normal 
measure Ankle-Brachial Index (ABI)    
if ABI >0.9   then monitor with serial examination (100% Negative Predictive Value)
if ABI <0.9 perform arterial duplex ultrasound or CT angiography
if arterial injury confirmed then consult vascular surgery
If pulses are absent or diminished 
confirm that the knee joint is reduced or perform immediate reduction and reassessment
immediate surgical exploration if pulses are still absent following reduction
ischemia time >8 hours has amputation rates as high as 86%
if pulses present after reduction angiography

39. Initial Treatment reduce knee and re-examine vascular status
considered an orthopedic emergency
splint knee in degrees of flexion 
confirm reduction is held with repeat radiographs in brace/splint
vascular consult indicated if

40. Complications Stiffness (arthrofibrosis)
is most common complication (38%)
more common with delayed mobilization
Laxity and instability (37%)
Peroneal nerve injury (25%)
most common in posterolateral dislocations
Vascular compromise
in addition to vessel damage, claudication, skin changes, and muscle atrophy can occur

41. Patella Fractures History Physical Exam
MVA, fall onto knee, eccentric loading
Physical Exam
Ability to perform straight leg raise against gravity (ie, extensor mechanism still intact?)
Pain, swelling, contusions, lacerations and/or abrasions at the site of injury
Palpable defect

42. Patella Fractures Radiographs Treatment AP/Lateral/Sunrise views
ORIF if ext mechanism is incompetent
Non-operative treatment with brace if ext mechanism remains intact

43. Tibia Fractures Proximal Tibia Fractures (Tibial Plateau)
Tibial Shaft Fractures
Distal Tibia Fractures (Tibial Pilon/Plafond)

44. Tibial Plateau Fractures
MVA, fall from height, sporting injuries
Mechanism and energy of injury plays a major role in determining orthopedic care
Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with medial plateau injuries)
Be aware for compartment syndrome
Check for knee ligamentous instability

45. Tibial Plateau Fractures
Xrays: AP/Lateral +/- traction films
CT scan (after ex-fix if appropriate)

46. Schatzker Classification of Plateau Fxs
Lower Energy
Higher Energy

47. Tibial Plateau Fractures
Treatment
Definitive ORIF for patients with varus/valgus instability, >5mm articular stepoff
Non-operative in non-displaced stable fractures or patients with poor surgical risks

48. Tibial Plateau Fractures
Treatment
Spanning External Fixator may be appropriate for temporary stabilization and to allow for resolution of soft tissue injuries
Insert blister
Pics of ex-fix here

49. Tibial Shaft Fractures
Mechanism of Injury
Can occur in lower energy, torsion type injury (e.g., skiing)
More common with higher energy direct force (e.g., car bumper)
Open fractures of the tibia are more common than in any other long bone

50. Tibial Shaft Fractures
Open Tibia Fx
Priorities
ABC’S
Associated Injuries
Tetanus
Antibiotics
Fixation

51. Tibial Shaft Fractures
Gustilo and Anderson Classification of Open Fx
Grade 1
<1cm, minimal muscle contusion, usually inside out mechanism
Grade 2
1-10cm, extensive soft tissue damage
Grade 3
3a: >10cm, adequate bone coverage
3b: >10cm, periosteal stripping requiring flap advancement or free flap
3c: vascular injury requiring repair

52. Tibial Shaft Fractures
Management of Open Fx Soft Tissues
ER: initial evaluation  wound covered with sterile dressing and leg splinted, tetanus prophylaxis and appropriate antibiotics
OR: Thorough I&D undertaken within 6 hours with serial debridements as warranted followed by definitive soft tissue cover

53. Tibial Shaft Fractures
Definitive Soft Tissue Coverage
Proximal third tibia fractures can be covered with gastrocnemius rotation flap
Middle third tibia fractures can be covered with soleus rotation flap
Distal third fractures usually require free flap for coverage

54. Tibial Shaft Fractures
Treatment Options
IM Nail
ORIF with Plates
External Fixation
Cast or Cast-Brace

55. Tibial Shaft Fractures
Advantages of IM nailing
Lower non-union rate
Smaller incisions
Earlier weightbearing and function
Single surgery

56. Tibial Shaft Fractures
IM nailing of distal and proximal fx
Can be done but requires additional planning, special nails, and advanced techniques

57. Tibial Pilon Fractures
Fractures involving distal tibia metaphysis and into the ankle joint
Soft tissue management is key!
Often occurs from fall from height or high energy injuries in MVA
“Excellent” results are rare, “Fair to Good” is the norm outcome
Multiple potential complications

58. Tibial Pilon Fractures
Initial Evaluation
Plain films, CT scan
Spanning External Fixator
Delayed Definitive Care to protect soft tissues and allow for soft tissue swelling to resolve

59. Tibial Pilon Fractures
Treatment Goals
Restore Articular Surface
Minimize Soft Tissue Injury
Establish Length
Avoid Varus Collapse
Treatment Options
IM nail with limited ORIF
ORIF
External Fixator

60. Tibial Pilon Fractures
Complications
Mal or Non-union (Varus)
Soft Tissue Complications
Infection
Potential Amputation

61. Ankle Fractures Most common weight-bearing skeletal injury
Incidence of ankle fractures has doubled since the 1960’s
Highest incidence in elderly women
Unimalleolar 68%
Bimalleolar 25%
Trimalleolar 7%
Open 2%

62. Osseous Anatomy

63. Lateral Ligamentous Anatomy

64. Medial Ligamentous Anatomy

65. Syndesmosis Anatomy

66. Ankle Fractures History Mechanism of injury
Time elapsed since the injury
Soft-tissue injury
Has the patient ambulated on the ankle?
Patient’s age / bone quality
Associated injuries
Comorbidities (DM, smoking)

67. Ankle Fractures Physical Exam Neurovascular exam
Note obvious deformities
Pain over the medial or lateral malleoli
Palpation of ligaments about the ankle
Palpation of proximal fibula, lateral process of talus, base of 5th MT
Examine the hindfoot and forefoot

68. Ankle Fractures AP Ankle Tibiofibular overlap Tibiofibular clear space
<10mm is abnormal and implies syndesmotic injury
Tibiofibular clear space
>5mm is abnormal - implies syndesmotic injury
Talar tilt
>2mm is considered abnormal

69. Ankle Fractures Ankle Mortise View
Foot is internally rotated and AP projection is performed
Abnormal findings:
Medial joint space widening
Talocural angle <8 or >15 degrees (compare to normal side)
Tibia/fibula overlap <1mm

70. Ankle Fractures Lateral View Posterior malleolar fractures
Anterior/posterior subluxation of the talus under the tibia
Displacement/Shortening of distal fibula
Associated injuries

71. Ankle Fractures Classification Systems (Lauge-Hansen)
Based on cadaveric study
First word refers to position of foot at time of injury
Second word refers to force applied to foot relative to tibia at time of injury

72. Ankle Fractures Classification Systems (Weber-Danis)
A: Fibula Fracture distal to mortise
B: Fibula Fracture at the level of the mortise
C: Fibula Fracture proximal to mortise

73. Ankle Fractures Initial Management
Closed reduction (conscious sedation may be necessary)
Splint
Delayed fixation until soft tissues stable
Pain control
Monitor for possible compartment syndrome in high energy injuries

74. Ankle Fractures Indications for non-operative care: Management:
Nondisplaced fracture with intact syndesmosis and stable mortise
Less than 3 mm displacement of the isolated fibula fracture with no medial injury
Patient whose overall condition is unstable and would not tolerate an operative procedure
Management:
WBAT in short leg cast or CAM boot for 4-6 weeks
Repeat x-ray at 7–10 days to r/o interval displacement

75. Ankle Fractures Indications for operative care: Bimalleolar fractures
Trimalleolar fractures
Talar subluxation
Articular impaction injury
Syndesmotic injury

76. Ankle Fractures ORIF: Fibula Medial Malleolus Posterior Malleolus
Lag Screw if possible + Plate
Confirm length/rotation
Medial Malleolus
Open reduce
4-0 cancellous screws vs. tension band
Posterior Malleolus
Fix if >30% of articular surface
Syndesmosis
Stress after fixation
Fix with 3 or 4 cortex screws

77. Hindfoot Fractures:
Talus
Calcaneus

79. Talar fractures: Rare Poor blood supply  high incidence of AVN
Can be major or minor

80. Major Talar fractures:
Neck, head, body (& lat process)
Talar neck fractures = 50%
Hawkins type1= non displaced + no joint inv.
Type II = displaced with subluxation or dislocation of the subtalar joint BUT ankle joint is OK
Type III = Type II +dislocation of ankle joint
Type IV = Type III + talar head dislocation

81. Talar Neck #

82. R calcaneus x-ray:

84. Bohler’s angle (30-40 deg)

85. Treatment: * Intraarticular= post facet involved
Extraarticular=
25-35%
Anterior process, tuberosity, medial process, sustenaculum tali, and body
If not displaced nor involving subtalar jt may treat with compressive dressings/casting
* Intraarticular= post facet involved
- well padded post splint or surgery

86. Calcaneal fractures:
More than 50% are associated with other extremity or spinal fractures

87. Midfoot Fractures:
Navicular
Cuboid
Lisfranc

90. Navicular fractures:
-Most common midfoot fracture but still rare -treatment= non-displaced=short-leg walking cast x6 wks displaced : surgery

91. Cuboid Fractures:
Treat as per navicular fractures
r/o Lisfranc injury

93. Lisfranc Joint:
Formed by the articulations of metatarsals 1-3 with the cuneiforms and metatarsals 4 & 5 with the cuboid
The metatarsal bases of digits 2-5 are joined by strong ligaments

94. What to look for on x-ray:
Normally, medial aspect of metatarsals 1-3 should align with medial borders of cuneiforms
Metatarsals should be aligned dorsally with tarsals on lateral view
Medial 4th metatarsal should align with medial cuboid
Any fracture or dislocation of the navicular or cuneiforms or widening between metatarsals 1-3
Proximal 2nd metatarsal # is pathogpneumonic

95. Normal Lisfranc joint

96. Treatment:
May try closed reduction with traction but post reduction displacement of >2mm or tarso-metatarsal angle> 15 degrees requires surgery

97. Forefoot fractures:
Metatarsal
Phalangeal

98. Treatment:
Nondisplaced or min displaced fractures of metatarsal 2-4 stiff shoe, casting, or fracture brace.
Non displaced 1st metatarsal  NWB BK walking cast
Displaced 1st or 5th metatarsal
Attempt closed reduction if >3mm displacement or 10 degrees angulation

99. Treatment cont. Metatarsal base #  r/o LF injury
Jones Fracture=5th metatarsal base fracture.
Tx=non displaced  NWB BK cast x6-8 wks
= displaced  surgery

100. Jones #

101. Dislocations of the Upper Limb

102. Dislocation of the Shoulder
Mostly Anterior > 95 % of dislocations
Posterior Dislocation occurs < 5 %
True Inferior dislocation (luxatio erecta) occurs < 1%
Habitual Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is Painless

103. Mechanism of anterior shoulder dislocation
Usually Indirect fall on Abducted and extended shoulder
May be direct when there is a blow on the shoulder from behind

104. Anterior Shoulder dislocation
Usually also inferior
Bankart’s Lesion

105. Clinical Picture Patient is in pain
Holds the injured limb with other hand close to the trunk
The shoulder is abducted and the elbow is kept flexed
There is loss of the normal contour of the shoulder

106. Clinical Picture
Loss of the contour of the shoulder may appear as a step
Anterior bulge of head of humerus may be visible or palpable
A gap can be palpated above the dislocated head of the humerus

108. X Ray anterior Dislocation of Shoulder

109. Associated injuries of anterior Shoulder Dislocation
Injury to the neuro vascular bundle in axilla ( rare )
Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia )
Associated fracture

110. Axillary Nerve Injury Also called circumflex nerve
It is a branch from posterior cord of Brachial plexus
It hooks close round neck of humerus from posterior to anterior
It pierces the deep surface of deltoid and supply it and the part of skin over it

111. Axillary nerve injury

112. Management of Anterior Shoulder Dislocation
Is an Emergency
It should be reduced in less than 24 hours or there may be Avascular Necrosis of head of humerus
Following reduction the shoulder should be immobilised strapped to the trunk for 3-4 weeks and rested in a collar and cuff

113. Methods of Reduction of anterior shoulder Dislocation
Hippocrates Method ( A form of anesthesia or pain abolishing is required )
Stimpson’s technique ( some sedation and analgesia are used but No anesthesia is required )
Kocher’s technique is the method used in hospitals under general anesthesia and muscle relaxation

114. Hippocrates Method

115. Stimpson’s technique

116. Kocher’s Technique

117. SHOULDER REDUCTION Sedation Apply traction and counter traction
Lift humeral head into the glenoid

118. Complications of anterior Shoulder Dislocation : Early
Neuro vascular injury ( rare )
Axillary nerve injury
Associated Fracture of neck of humerus or greater or lesser tuberosities

119. Elbow Dislocation incidence
elbow dislocations are the most common major joint dislocation
posterolateral is the most common type of dislocation (80%)
demographics
predominantly affects patients between age years old

120. Simple 
no associated fracture 
account for 50-60% of elbow dislocations
complex  
associated fracture present
may take form of
terrible triad injury involves a disruption of the LUCL, a radial head fracture, a coronoid tip fracture and a dislocation of the elbow

121. Fracture dislocation

122. complications Varus Posteromedial instability Loss of motion
Neurovascular injuries (ulnar/median nerves)
Compartment syndrome
Damage to articular surface
Chronic instability
Heterotopic ossification
Contracture/stiffness
correlated with immobilization beyond 3 weeks

123. MONTEGGIA FRACTURE-DISLOCATION

124. MONTEGGIA FRACTURE-DISLOCATION

125. GALEAZZI FRACTURE-DISLOCATION