PELVIS AND LOWER LIMB Grant Kennedy

PELVIS AND LOWER LIMB Grant Kennedy

Objectives To cover this huge topic adequately in just over an hour.
Special thanks to Tintinalli, UTDOL, Dr. Buckley, Rob and Shawn’s REMERGS web page.

Pelvic Fractures: Epidemiology
Majority due to high impact blunt trauma (MVA, pedestrian vs. vehicle etc.) but also secondary to falls in frail elderly Mortality overall = 10% Mortality 50% if open # Mortality quoted tends to be all cause mortaltiy; less than 1% will die as a direct consequence of their pelvis fracture.

Pelvic Anatomy Pelvis = sacrum, coccyx + 2 innominate bones
Innominate bones = ilium, ischium, pubis Sacrum + innominate bones form a ring Strength from ligamentous supports (largely posterior aspect of ring)

Pelvic Anatomy 5 joints: Lumbosacral Sacroiliac (x2) Sacrococcygeal
Symphysis

Pelvic Anatomy

Anterior Support: Posterior Support: Symphysis pubis Pubic rami
Fibrocartilaginous joint covered by ant & post symphyseal ligaments Pubic rami Posterior Support: ~majority of stability Iliolumbar ligaments Sacroiliac ligaments Sacrospinous ligament Sacrotuberous ligament Sacrospinous resists external rotation Sacrotuberous resists rotational and vertical shearing forces

Vascular Anatomy Vessels lie close to posterior pelvic walls
Venous bleeding most common (sacral plexus) Most commonly injured arteries are superior gluteal and internal pudendal Venous bleeding is most common because of relative deficiency in protective vasospasm, and lack of valves in pelvis with extensive collateral anastomoses.

Pelvic Anatomy Nerve supply through the pelvis derived from lumbar and sacral plexuses Other structures: lower GI/GU

History & Physical AMPLE Hx Mechanism/Ambulating at Scene
Numbness/Weakness/Bowel + Bladder Dysfxn Inspect: Destot’s sign: Hematoma above inguinal ligament or over scrotum Blood at urethral meatus (urologic injury?)—if so, ED cystourethrogram. Insert foley a small amount (and lightly put up the balloon). Inject cc of dye into bladder and have x-ray taken at same time. Flank ecchymoses Similar sensitivity in physical exam in kids has been reported elsewhere

History + Physical Examine pelvis only once!
AP compression on ASIS AP compression on symphysis Lateral compression on iliac crests Distal neurovascular exam! Bimanual should be performed on all women w/ pelvic # If blood, do speculum to assess for vaginal laceration (open #) DRE in everyone (High riding prostate? Lack of tone?) Earle’s sign: Presence of bony prominence, palpable hematoma, or tender # line on DRE

Imaging Plain films are NOT necessary in stable trauma patient with no lower abdo-pelvic complaints, normal exam and GCS >13 X Rays: AP Inlet/Outlet Judet CT Scan: Evaluates extent of posterior injuries and retroperitoneal bleeding, superior imaging of sacrum and acetabulum, associated injuries

Imaging AP VIEW: Identifies most fractures
Look for disruption in iliopubic and ilioischial lines, sacral foramina, radiographic U, Shenton’s Lines Following are abnormal: Symphysis >5mm Vertical offset left vs. right rami (>1-2mm) SI joint > 5mm

6 lines of the pelvis: 1. Iliopubic (arcuate) line – disruption indicates ant column injury 2. Ilioischial line which defines the posterior column 3. Teardrop or Roentgenographic U formed by roof of acetabaulum and ilioischial spine defines quadrangular plate – disruption means intraplevic penetration 4. Roof of acetabulum 5. Post rim of acetabulum 6. Ant rim of acetabulum 7. Shenton’s line = medial femoral shaft  obturator foramen: disruption in hip dislocation or femoral neck #’s

Inlet view X-ray beam at 60o to plate directed towards feet Used to look for AP displacement of ring fractures. Outlet view Beam aimed 30o towards head Used to see Sup-Inf displacement.

Imaging Look for any evidence of damage to the posterior pelvic structures Clues on X-rays: L5 transverse process avulsion (iliolumbar ligament) Ischial spine avulsion (sacrospinous ligament) Unable to clearly make out sacral foramina Assymmetry of sacral foramina Avulsion at lower lip of lateral sacrum (sacrotuberous ligament) Ist 2 always denote mechanical instability

Pelvic Fracture Complications
Hemorrhage: up to 6L of blood can collect in retroperitoneal space! Open #: high mortality if not recognized; communication to rectum, vagina, skin examine posterior skin carefully, do not probe wounds, perineal wounds = operative debridement/irrigation, rectum = diverting colostomy

Urologic Injury: (15%) # of symphysis have highest incidence of urologic injury, Microhematuria = no need for cystourethrogram Gross hematuria = cystourethrogram + CT Neurologic Injury: with sacral #, sx of cauda equina, plexopathy, radiculopathy

Gynecologic Injury: laceration, abruption, uterine perforation Intra-abdominal Injury: rectum, colon, small bowel Injuries by Association: due to high force mechanism… thoracic aortic rupture, diaphragmatic rupture

Pelvic Fractures 5 General Categories: 1. Pelvic Ring 2. Acetabular
3. Sacral 4. Avulsion type 5. Single bone

Pelvic Ring Fractures Young Classification System:
Differentiates fracture patterns based on mechanism of injury/direction of causative force 3 major fracture patterns: 1. lateral compression (50%) 2. antero-posterior compression (25%) 3. vertical shear (5%)

Young Classification:
Lateral Compression (50%) – transverse # of pubic rami, ipsilateral or contralateral to posterior injury LC I – sacral compression on side of impact LC II – iliac wing # on side of impact LC III – LC-I or LC-II on side of impact w/ contralateral APC injury

AP Compression (25%) Symphyseal and / or Longitudinal Rami Fractures
APC I –diastasis of the pubic symphysis and/or anterior SI joint APC II – disrupted anterior SI joint, sacrotuberous, and sacrospinous ligaments (intact post SI ligs) APC III – complete SI joint disruption w/ lateral displacement and disruption of sacrotuberous and sacrospinous ligaments

Tile B1 / Young APC II

Young Classification System:
Vertical Shear (5%) Symphyseal diastasis or vertical displacement anteriorly and posteriorly; usually through SI joint, occasionally through iliac wing

Tile C1/ Young VS

Pelvic Fracture Management
Stable vs. Unstable Young Classification: LC I, APC I = several days bedrest +/- external fixator, followed by progressive weight bearing as tolerated LC II and III, APC II and III, VS = surgery

Pelvic Fracture Management
Buckley: Full weight bearing for lateral compression #s that lack significant deformity, isolated pubic rami fractures Indications for surgery: ongoing hemorrhage, displaced posterior pelvic injury, symphysis diastasis >2.5 cm

Pelvic Fracture Management of the Unstable Patient
ABC’s & initial stabilization (IV access, crystalloid, blood products) Application of Pelvic Sheet/Binder/External fixator (open-book with intact posterior ligaments has most potential for benefit) Adjuncts: Foley (but not if blood at meatus) FAST to assess for intraperitoneal injury (and help with disposition—laparotomy vs. angio) AP pelvis ABX (ancef) and Tetanus if open.

Pelvic Fracture Management of the Unstable Patient
FAST +, Unstable = Laparotomy first FAST -, Unstable = Angio STABLE but with significant # = CT. If ‘brash’ on CT = ongoing bleed, needs angio

PELVIC BINDER Benefits: Reduces pelvic volume (tamponade effect)
Stabilizes # fragments Improves patient comfort

PELVIC BINDER Application: Apply at level of greater trochanters
Avoid over-reduction (esp lateral compression #) as can increase internal rotation deformity, increase bleeding Aim for anatomical reduction (legs, trochanters, patellae should be neutral)

Acetabulum Forms the ‘socket’ for the femoral head Fusion of 3 bones:
1. iliac (superior dome—chief weight-bearing surface) 2. pubis (anterior-inferior—thin, easily fractured) 3. ischium (posterior-inferior-thick)

Acetabulum

Acetabulum Also classically described as having 2 columns:
1. Anterior column (anterior iliac wing, superior pubic ramus, anterior wall of acetabulum) 2. Posterior column (ischium, ischial tuberosity, posterior wall of acetabulum)

Acetabular Fractures Nearly all associated with hip dislocations
Sciatic nerve injury common MVA most common mechanism Imaging: Judet views (AP, 45 degree iliac oblique, 45 degree obturator oblique) CT scan (x-ray negative but suspicious; clarifying operative or non-operative) Judet-Letournel Classification System: Simple (5 types) vs. Complex (combos)

Acetabular Fractures Judet Classification Simple Fractures:
1. Posterior Wall 2. Posterior Column 3. Anterior Wall 4. Anterior Column 5. Transverse

Acetabular Fracture Management
ABCs Neurovascular exam Reduction of hip dislocation Ortho consult Admission Buckley: Non-Displaced = non weight bearing x 6-8 weeks Displaced >2mm intra-articular = surgery

Sacral Fractures Mechanism:
Direct trauma or forced flexion Key distinction is Vertical (high energy/unstable) vs. Transverse O/E: pain on DRE Dx: AP pelvis, CT Neuro deficits are cauda equina injuries, radiculopathies, or plexopathies L5  weak dorsiflexors (ant tibial compartment), sensoru deficit in dorsum of foot / lat calf S1/S2  weak hip extensors, knee flexors, and plantar flexors; sensory deficit to post leg and sole and lat foot and genitalia S3-S5 sexual and bowel/bladder dysfuntion; saddle anesthesia

Vertical Sacral Fractures
Denis Classification: Zone 1—lateral to sacral neural foramina (6% L5 root injury) Zone 2—through sacral neural foramina (28% sciatic injury) Zone 3—medial to sacral neural foramina (50% bowel/bladder, sexual dysfunction)

Transverse Sacral Fractures
Potential for neurologic injury depends on level of # line Nerve root injury uncommon below S4 High incidence of neuro deficit if # line above S2

Sacral Fractures Treatment of High-Energy Vertical: ABCs etc. Surgical stabilization Treatment of Transverse: Neuro deficits  urgent spine consult No neuro deficits  ice, bed rest, analgesia & ortho f/u in 1 week

Coccyx Fractures Mechanism: Presentation: Dx: Tx:
Fall in seated position Presentation: Pain w/ sitting, standing, or defecating Local tenderness Dx: Clinical. X-rays not needed! (pain on compression during DRE) Tx: --rest, ice, donut-ring cushion, stool softeners Coccygectomy if persistent chronic pain These guys hurt while trying to take a crap b/c of contraction of the levator ani and anococygeal muscles which atttach to coccyx. Gluteus maximus also has coccygeal insertions so when they get up it hurts. Takes a long time to heal

CASE 13 yo boy presents with pain in his hip after kicking a soccer ball…

Avulsion Fractures Mechanism: Most common types: Tx:
Forced contraction of muscle avulsing bony fragment (soccer & gymnastics) Most common types: Ischial tuberosity  hamstring ASIS avulsion  sartorius AIIS  rectus femoris Tx: RICE, crutches (for comfort), f/u w/ family MD IT= hip ext; ASIS + AIIS = hip flex >2 cm displacement = surgery Ischial tuberosity avulsion is most common & presents with pain on thigh flexion with knee extension / tender on DRE; happens in hurdlers, pole vaulters and cheerleaders; tx w/ bed rest w/ hip in extension, esternal rotation and slight abduction for 3-4 wks ASIS avulsion presents with pain on thigh flexion + abduction; happens in sprinters + soccer players, usually in teens – tx w/ bed rest for 3-4 weeks w/ hip in flexion and abduction – resume N activity in 8 weeks AIIS avulsion presents with pain on hip flexion or inability to flex hip /happens in field goal kickers + soccer players. tx w/ bed rest for 3-4 weeks– resume N activity in 8 weeks

CASE 53 year old German female presents with pain in her groin after having fallen skiing. Mechanism: landed and fell back onto buttocks/’tail bone’.

Isolated Ramus Fracture
Mechanism: Fall in elderly; stress # in young athlete Presentation: Inability to ambulate, local pain TX: Ice, rest, analgesics, crutches with progressive weight bearing.

Sup and Inf Rami # (unilateral)
Generally Stable Conservative management Look for complicating associated injuries: posterior pelvic impaction, SI joint injury, acetabular # (may need CT to identify these)

Sup and Inf Rami # (bilateral)
Straddle # GU injuries common! CT pelvis needed to plan surgical mgmt Consult ORTHO Tx: SURGERY

What is the name of this type of #??

Duverney (Iliac Wing) Fracture
Mechanism: Direct trauma Presentation: Localized pain, swelling, tenderness abdominal tenderness Associated acetabular # Dx: AP pelvis Tx: Minimally displaced  ortho f/u in 1 week, rest, ice, strapping Severely displaced  ORIF Concerning abdo exam CT abdo/pelvis Instruct to return if s or s of an ileus

Hip Dislocations 3 Types:
Posterior (80%)>>Anterior>>Central Associated injuries: #-dislocation with femoral head or acetabulum Sciatic nerve (posterior); Femoral nerve/vessels (anterior) Mechanism: Adults: MVA (high energy), polytrauma (assoc knee injuries) Elderly/Prosthetics/Kids: low energy

Hip Dislocations--Presentations
Anterior Dislocation: extremity in abduction/external rotation (similar to fem neck #) Posterior Dislocation: extremity shortened, internally rotated, adducted DX: AP/Lateral Pelvis.

Hip Dislocations Treatment: Orthopedic Emergency!
ABCs/initial stabilization R/O associated life threatening injuries Risk of AVN increases in direct proportion to delay in adequate reduction Simple (ie. no #) Ant/Post dislocations should be reduced urgently in ED using Allis, Stimson or Whistler maneuvers

Post Reduction: Allis Method

Post Reduction: Stimson Method

Hip Dislocations Call Ortho for irreducible dislocations (incarcerated tendon, intra-articular osteochondral fragment) Post Reduction… Obtain post reduction films (including CT if associated acetabular # or other pelvic injury) Check ROM to ensure stability of the hip, neurovascular status Simple dislocation w/out # = zimmer x 1wk, crutches w/ weight bearing as tolerated and ortho f/u

Hip Dislocations-Special Circumstances
Associated Femoral Head #: More common w/ anterior Can still attempt closed reduction Consult ortho Hip Prosthesis: No time urgency as AVN not an issue

Injuries to the Femur Anatomy:
Fem Head + Acetabulum = Ball and socket joint Fibrous capsule extends from acetabulum to intertrochanteric line Blood supply to femoral head from med and lat femoral circumflex arteries, branch of obturator Vessels course beneath reflection of capsule and along ligamentum teres (less important) Easily disrupted with # leading to AVN

Injuries to the Femur History: AMPLE Hx of Osteoporosis?
Hx of Steroids? (RF for AVN) Hx of Cancer, Radiation, Chemo? (pathologic #) Medical causes for falls? (syncope etc.)

Injuries to the Femur O/E: Inspect pelvis/hip/knee
Neurovascular status (fem nerve/artery in subtrochanteric or shaft #; sciatic nerve in hip # or dislocations) Assess for open # Imaging: AP Lateral

Injuries to the Femur General Management:
ABCs and initial stabilization Type and Crossmatch (can lose 3L of blood w/ shaft #) Pre-hospital Hare or Sager traction splints for shaft or subtrochanteric # Contraindications to traction: open #, nerve injury, femoral neck (may further compromise blood flow)

Injuries to the Femur Open Fractures: Type I = < 1cm (Ancef)
Type II = > 1 – 10 cm (Ancef + Gent) Type III = > 10 cm (Ancef + Gent) Irrigate and cover w/ saline guaze Tetanus Splint + Consult

Injuries to the Femur Classification of Hip Fractures:
1. Intracapsular: Femoral head Femoral neck 2. Extracapsular: Greater or Lesser Trochanter Intertrochanteric Subtrochanteric

Injuries to the Femur

Femoral Head Fractures
Infrequently in isolation Usually in conjunction w/ dislocation Types: capital, depression, shear Consult Ortho Treatment: If associated dislocation—attempt reduction in ED ORIF if failure to reduce

Femoral Head Fractures
Treatment: (Buckley) Non-displaced, stable # = limited weight bearing with crutches for 6 weeks Displaced (>2mm) head fragment, or associated femoral neck or acetabular # = ORIF

# of left femoral head

Femoral Neck Fractures
Garden Classification Types: Subcapital vs. Transcervical All are intracapsular (precarious blood supply)

Mechanism: minor trauma in elderly (osteoporosis); high energy in young Presentation: ranges from limp and mild groin pain (non-displaced #) to unable to weight bear w/ externally rotated, abducted and shortened limb

Dx: AP/Lateral—look for disruption of Shenton’s Line, Trabecular network, Normal and Reverse S Significant hip pain w/ weight bearing and normal radiographs = possible occult fem neck #, may need CT or MR to diagnose Treatment: Analgesia in ED, ORIF Complications: AVN, non-union, osteomyelitis, emboli

What type of # is this? Donk Sign Greater troch #

Trochanteric Fractures
Greater Trochanter: Direct trauma vs. avulsion of gluteus medius Pain with abduction/extension Tender to palp over greater troch TX: Conservative, gradual weight-bearing until asymptomatic >1cm displaced: ortho consult for fixation

Trochanteric Fractures
Lesser Trochanter: Avulsion of iliopsoas Pain w/ flexion/internal rotation TX: Conservative, gradual weight bearing >2cm displaced: ortho for screw fixation

What type of # is this? Intertrochanteric #

Intertrochanteric Fractures
Extracapsular, thus less risk of AVN Fall in elderly High energy force in young TX: ABCs; analgesia Exclude other life threatening injuries ORTHO for Dynamic Hip Screw fixation Complications: non-union, infection, blood loss

Type Of #?

Subtrochanteric Fractures
Occur b/w the lesser trochanter and proximal 5 cm of femoral shaft Elderly: fall in osteoporotic bone, pathological #s Young: high energy trauma Comminution and deformity common TX: ABCs, Ortho for ORIF Complications: hemodynamic instability, fat embolus, non-union

Femoral Shaft Fractures
Young w/ high energy trauma (falls, MVAs, gunshot etc.) Classification: transverse, oblique, spiral, wedge, comminuted 50% have assoc. ligamentous damage to knee TX: ABCs (significant hemorrhage can occur) Look for other life threatening injuries Traction splints in pre-hospital setting Ortho for ORIF (IM rod) vs. plating for comminuted (union rates approach 100%)

Case 68y male injured in MVC c/o left leg pain

Case continued Type of #?

Distal Femur Fractures
Supracondylar, Intracondylar (intra-articular), Condylar (intra-articular) Isolated, T or Y pattern

Tx: ABCs Check neurovascular exam. (# in close proximity to femoral and popliteal arteries!—may need angio if in question) Splint and consult Ortho All require ORIF (per Buckley)

Complications: thrombophlebitis fat embolus syndrome delayed union or malunion if reduction is incomplete or not maintained intraarticular or quadriceps adhesions if the fracture is intraarticular angulation deformities osteoarthritis

Knee Injuries Fractures: 1. distal femur (covered already) 2. patellar
3. proximal tibia 4. proximal fibula Soft Tissue Injuries: Dislocations (patellar, tib-fem), Ligamentous and Meniscal injuries

Anatomy Main joints: Main bones: Patellofemoral Tibiofemoral
Distal Femur Patella Proximal tibia (fibula head)

Knee Anatomy Medial Stabilizers of the Knee:
MCL, joint capsule, semimembranosus, pes anserinus Lateral Stabilizers of the Knee: LCL, joint capsule, IT band, biceps tendon, popliteal arcuate complex

Knee Injuries DDX of Anterior Knee Pain: Plateau/Patellar #
Pre-patellar Bursitis Quads/Patellar Tendonitis Patellofemoral Pain Syndrome Chondromalacia Patellae Osgood Schlatters Plica Meniscal injury Ligamentous injury Osteochondritis Dessicans Synovial Chondrinosis

Knee Injuries DDX of Hemarthrosis: ACL PCL Meniscal tear
Osteochondral # Capsular tear BUT NOT MCL nor LCL!

Knee Injuries--History
AMPLE Mechanism particularly important Hx of prior knee injuries, surgeries Inability to weight bear Locking (meniscus vs. intra-articular body) Giving Way (ligamentous vs. meniscus) “Pop”! (ACL)

Knee Injuries--Examination
COMPARE TO HEALTHY KNEE Inspection (swelling, bruising, deformity) Palpation: (joint line tenderness? effusion? point tenderness?) ROM Ligamentous/Meniscal Stress Testing

Ligament/Meniscal Stress Testing
Anterior Drawer (ACL): not reliable. FN = effusion, hamstring spasm, technique FP = PCL injury Lachman’s Test (ACL): reliable, even in acute. Posterior Drawer (PCL) McMurray’s Test (Meniscal): int rotation stresses lateral meniscus, ext rotation stresses medial meniscus Collateral Ligament Stress (MCL, LCL):

Knee Injuries--Imaging
Standard XR Views: AP Lateral (fat fluid level = lipohemarthrosis = intra-articular #) Oblique (tibial plateau) Special XR Views: Tunnel (intercondylar region, tibial spines) Skyline (patellar) CT: helps fully delineate extent of tib plateau # MR: meniscal, ligamentous U/S: popliteal cysts, popliteal aneurysms

CASE 28 year old MOBHOB (Huffman, 2007)
Beaten about legs by some jerk yielding a bat. Tender in several places. X-ray shows…

Fractures of the Patella
Mech: direct blow vs. avulsion (forceful contraction of quads) Classification: transverse (most common), vertical, comminuted, avulsion-type O/E-focal tenderness, swelling. NEED to check extensor mechanism via straight-leg XR- watch for normal variants (bipartite)

Fractures of the Patella
TX: extra-articular, non-displaced, in-tact extensor mechanism = Zimmer splint (vs. long-leg cast) x 4 wks, progressive wt bearing, isometric exercises, passive ROM displaced >3mm and involving articular surface, inadequate extensor mechanism, comminuted = ORIF (tension band wire w/ suturing of retinaculum)

CASE 65 year old female from Japan presents post fall skiing.
Had collided with a snowboarder. Knee had twisted (external rotation of leg) Felt ‘pop’.

Fractures of the Tibial Spines
Tib spine = intercondylar eminence = consists of medial and lateral tubercle Anteriorly: ACL, ant horns of menisci Posteriorly: PCL, post horns of menisci Anterior injury 10x more common than posterior Results in cruciate ligament instability/tear Mech: AP force against the proximal tibia while in flexion (MVA, sports), twisting, hyperflexion, hyperextension

Fractures of the Tibial Spines
Type I--incomplete avulsion, no displace Type II--incomplete avulsion, displace of anterior but not post Type III--complete displacement (+/- rotation)

Fractures of Tibial Spines
O/E: hemarthrosis, inability to extend fully Lachman + if anterior spine XR: AP/Lateral/may need tunnel view TX: incomplete or non-displaced = immobilize in full extension (competitor), protected weight bearing, ortho f/u Complete, displaced = ortho consult for ORIF vs. arthroscopic to restore normal ACL function

CASE 35 yo woman presents with pain in her knee, unable to weight bear after having gone off a jump skiing, landed on flat surface… XR shows the following…

Fractures of the Tibial Plateau
Mech: valgus/varus force combined with axial load, driving femoral condyles into articulating surface of tibia VS. direct blow Lateral plateau > medial plateau May have assoc. ligamentous injury O/E: pain, swelling, decrease ROM, assess neurovascular (high incidence of popliteal a. inj) XR: often # is difficult to detect, may only show lipohemarthrosis on lateral, CT if needed

Fracture of the Tibial Plateaus
Segond fracture: Bony avulsion off the lateral tib plateau (lateral capsular sign) Strong association w/ ACL disruption

Fractures of the Tibial Plateau
TX: Non-displaced, no depression of articular surface = knee immobilizer, elevation x hrs, ortho f/u, non-weight bearing x 6-8 weeks Displaced >2mm, depressed articular surface = surgery

Ligamentous Injuries of the Knee
Grading of Ligamentous Sprains: Grade I: Pain but no laxity Grade II: Laxity w/ firm end point Grade III: Laxity w/out firm end point Cruciate ligament injuries often accompany collateral ligament injuries!

Medial Collateral Ligament (MCL): Mech: valgus force Dx: pain or laxity w/ valgus stress TX: non-operative, knee immobilizer (2 wks) then hinge brace (8 wks), weight bearing as tolerated (will likely need crutches early on), RICE Ultimately physio/quad strengthening

Lateral Collateral Ligament (LCL): Mech: hyperextension + varus force DX: pain or laxity w/ varus stress TX: conservative as per MCL

Anterior Cruciate Ligament (ACL): Mech: pivoting, rotation w/ valgus stress, hyperextension DX: + Lachman; hemarthrosis in 70%; ‘pop’ in 70%; watch for assoc. injuries (50% have meniscal tears); Segond # TX: Initially conservative; ROM limiting brace; weight bearing as tolerated; long-term = hamstring strenghtening/brace vs. reconstruction

Posterior Cruciate Ligament (PCL): Mech: dashboard (MVA) w/ direct blow to anterior tibia; hyperflexion; hyperextension DX: + posterior drawer, posterior sag TX: non-operative unless persistent instability post rehab/quads strengthening or other associated injuries (meniscal tear, combined ligamentous injury etc.)

Meniscal Injuries Medial 2x more common (and posterior peripheral aspect) Damage associated with early OA Avascular except peripheral 1/3 MECH: twisting on weight-bearing knee Associated with MCL/ACL (Terrible Triad!)

Meniscal Injuries HX: painful locking that prevents further activity; ‘clicking’, ‘giving way’ DX: joint-line tenderness; McMurray’s (somewhat useless) TX: Conservative (RICE/NSAIDS);outpt f/u LOCKED KNEE (?attempt reduction w/ procedural sedation). Needs surgery w/ in 2 weeks: consult ortho.

CASE 40 year old obese male skier…
Fell and had immediate pain in his knee. Unable to weight bear.

Tibial-Femoral Knee Dislocation
Types: Anterior, Posterior, Medial, Lateral MECH: sporting accidents, falls High incidence of popliteal artery injury, peroneal nerve injury, compartment Normal pulses do not r/o vascular injury TX: Immediate reduction (longitudinal traction), Zimmer splint and Ortho consult for surgical stabilization

Tibial-Femoral Knee Dislocation
Check neurovascular pre- and post: Absent pulse (post) = Immediate Vascular Surgery Consult + reposition/relocate Decreased or absent pulse pre w/ return post = Angio Pulse present pre and post = serial exams vs. ANGIO ALL (per Betzner)

Patella Dislocation Patella displaced laterally over lateral condyle (most common) Mech: twisting on extended knee; TX: Reduction in ER (+/- under sedation) XR post reduction to r/o # Zimmer x 1 wk with crutches. Then knee sleeve x 3 weeks with progressive weight bearing, gentle ROM and isometric quad strengthening

Soft Tissue Injuries Patellar Tendonitis—overuse-pain to palp over inferior pole--tx conservative Osteochondritis Dissecans—idiopathic--articular cartilage and subchondral bone dislodged—tx epiphyses open = protective weight bearing. epiphyses closed = arthroscopy Quads/Patellar Tendon Rupture—violent contraction of quads—tx surgical repair Baker’s Cyst—aspiration, surgical, vs. resolution

Soft Tissue Injuries Chondromalacia Patellae—softening of articular cartilage secondary to patellofemoral malalignment/abrnormal tracking of patella. Tx= Rest/NSAIDS/quads+hip strengthening/brace Plica—redundant folds of synovium that become inflammed. Leads to pain/stiffness. Dx: clinical/exclusion Tx: conservative Osteonecrosis—bony infarction. Spontaneous vs. secondary causes (steroids, SLE, EtOH, Sickle etc). Dx-MRI (XR normal). Tx-Early=protected weight bearing/NSAIDS. Advanced=debridement/bone graft/TKA

Leg Injuries

Leg Injuries-Anatomy Bones: Tibia/Fibula 4 compartments:
1. Anterior--ant tib artery, deep peroneal nerve (dorsiflexion; sensory = web space of 1st and 2nd toes) 2. Lateral—superficial peroneal nerve (foot eversion; sensory = lateral dorsal foot) 3. Superficial Posterior—ankle plantar flexors (gastroc, soleus), sural nerve = lateral heel sensation 4. Deep Posterior—post tibial artery; tibial nerve = toe plantar flexors, sensation to sole of foot

Fibular Fractures Proximally = attachment for LCL, biceps femoris tendon Common peroneal wraps around fibular head Usually in setting of # to Tibia Mech: direct trauma vs. twisting on planted foot, inversion or eversion of ankle Only bears 15% of body weight, thus pts can often ambulate with isolated #

Fibular Fractures ED Tx: ABCs; neurovascular; assess for knee/ankle injuries; stirrup splint to prevent varus/valgus stress x 3-4 wks; RICE; crutches if needed for pain; Consult Ortho for: lateral compartment syndrome/peroneal nerve injury; comminuted #, associated tibial #, badly displaced #, assoc knee/ankle joint injuries

Tibial Shaft Fractures
Major weight bearing bone! Open #s common due to superficial location Watch for compartment syndrome

Tibial Shaft Fractures
ED TX: ABCs, neurovascular exam; close inspection to r/o open #; analgesics; long-leg posterior splint and consult Ortho Definitive Tx: ORIF/IM rod VS. Consider long-leg cast (metatarsal heads to upper thigh) and non-weight bearing IF displaced <5mm, rotated <10 degrees, angulated <10 degrees and not shortened

Ankle Injuries Anatomy of an Ankle: 3 Primary Joints: 3 Bones:
Medial malleolus w/medial talus Tibial plafond w/ talar dome Lat malleolus w/ lat talus 3 Bones: Tibia, Fibula and Talus 3 sets of Ligaments: Lateral collaterals (ATFL, CFL, PTFL) Syndesmotic Ligaments Medial collaterals (Deltoid)

Ankle Injuries History: location of pain, swelling, ability to weight bear at time, audible ‘pop’ Exam: Neurovascular status! (Reduce prior to imaging if absent pulse!) Inspect: swelling, bruising, deformity Palp: location of tenderness (Ottawa Ankle/Foot Rules) ROM: active/passive Stress of Ligaments (after # r/o) Squeeze Test (checking syndesmotic ligs)

Ankle Injuries OTTAWA ANKLE RULES: X-ray if…
Pain in malleolar zone and 1 of… Inability to weight bear 4 steps both immediately and at time of evaluation Bony tenderness at post edge of distal 6 cm of either the lateral or medial malleolus

Approach to Ankle Go through complete approach (ABC’s)
3 views- AP, lat, Mortise (15-20° int rot) ankle, Direct evidence of injury: assess bones Indirect evidence of injuries: are all ankle measurements normal? Joint effusion?

Ankle Fractures What are stable fractures? Ankle forms a ring
Disruption of only 1 structure is stable Disruption of > 1 is unstable Assymetry in gap between talar dome and malleoli on mortis view= unstable

Ankle Fractures Management of Stable Fractures:
Chip/Avulsion #s <3mm = Tx as Sprain (ie. WBAT, RICE, NSAIDS, Early ROM/physio) Chip/Avulsion#s >3mm = splint and f/u with Ortho Non-displaced, non-intra-articular, stable #s: = 2 wks NWB cast, 3-5 wks WB cast. Ortho f/u in 1 wks to ensure # hasn’t slipped

Ankle Fractures Indications for Immediate Reduction Prior to X Ray:
Neurovascular compromise Gross Deformity Skin Tenting

Ankle Fractures Ortho Consultation for the Following: Open # Pilon #
Bimalleolar/Trimalleolar # Lateral Malleolar (Weber B and C) Lateral Malleolar Weber A2, A3 (some will fix/some will cast) Isolated Medial Malleolar with significant displacement Isolated Posterior Malleolar with significant displacement

Diagnosis. Classification. Treatment
Diagnosis?Classification?Treatment? Does it change you mgmt if they have a tender deltoid ligament?

Lateral Malleolar Fractures
Stability depends on location of # to tib-talar Danis-Weber Classification (A,B,C): A: # below tibiotalar joint A1: no deltoid (medial) tenderness, no post malleolar # A2: w/ deltoid (medial) tenderness A3: w/ post malleolar # B: # at the level of tibiotalar joint C: # above the tibiotalar joint

Treatment: Weber A1 (stable): NWB x 2 wks (below knee plaster, fiberglass, or air cast) then WBAT w/ air cast x 3 wks; f/u with Ortho in 1 wk Weber A2: Consult Ortho (some will fix surgically, some will cast). Do stress view to see if mortis opens up. Weber A3: Bimalleolar = Ortho for surgery

Treatment: Weber B: consult Ortho; 50% have injury to syndesmosis and widening of medial joint space Weber C: consult Ortho; frequent injury to syndesmosis

Type of Fracture?

Medial Malleolar Fractures
Commonly associated with lateral or posterior malleolar disruption = Ortho Significant displacement = Ortho R/O Maisonneuve’s # = Ortho Minimally displaced = NWB (below knee cast) x 2 wks; WBAT w/ walking boot x 3-5 wks; f/u w/ Ortho at 1 wk

TRIVIA TIME Name of the rare variation of a Maisonneuve Fracture in which the proximal fibula gets trapped behind the tibia?

TRIVIA TIME Name of the rare variation of a Maisonneuve Fracture in which the proximal fibula gets trapped behind the tibia? The Bosworth Fracture!

Posterior Malleolar Fractures
Rarely in isolation Isolated, non-displaced, <25% of joint surface = cast + NWB x 2 wks; WBAT x 3-5 wks with air cast. Ortho f/u at 1 wk Otherwise consult Ortho

Diagnosis? Stable or unstable?

Bi or Tri-Malleolar #s All unstable because of disruption of two or more elements of the ankle ring Syndesmosis injury is common All require Ortho consultation

Name of this type of fracture? Other associated #s?

Pilon Fractures Fall from height Talus driven into Tibial Plafond
Distal Tibial Metaphysis #s (+ Fibula) 50% are open #s! Associated #s are common (calcaneus, tib-plateau, pelvis, C,T,L spine) ORTHO!

The Foot (last section!)

HINDFOOT talus calcaneus navicular cuboid MIDFOOT Medial cuneiforms metatarsals sesamoids FOREFOOT phalanges

Choparts Lisfrancs MTP IP

Type of # Do you need to speak to Ortho? ?ottawa ankle rules

Talar #s Osteochondral # of Talar Dome X-rays commonly normal
Ottawa Ankle Rules may miss these TX= Cast or Splint and refer to Ortho as outpatient

Describe #? At risk for??

Talar #s At risk for AVN due to tenuous blood supply
All talar fractures require Ortho f/u Minor (chip/avulsion of head,neck,body or osteochondral # of talor dome) = as outpatient after splinting (non-weight bearing –Rigby) Major (the rest) = in ED Per Buckley: ORIF for any displaced #, fractures w/ >2mm gapping, loose osteochondral body

Posterior tuberosity apex of anterior process apex of posterior facet

Calcaneal #s Intra-articular vs. Extra-articular
Calcaneus # Management Order Harris (axial view), may need CT Probably should speak to Ortho for all since x-rays under-estimate extent of injury and tx varies considerably But…non-displaced, extra-articular – NWB cast x 6 wks Intra-articular, displaced ? ORIF

Sub-talar Dislocation
Tibio-talar joint remains in tact Disruption of talonavicular and calcaneotalar joints Attempt reduction in ER and consult Ortho If successful, f/u x-rays (+/- CT), short leg splint; ortho f/u ORIF for irreducible dislocation, significant debris in joint space

Navicular Fractures Rare Risk of AVN Tx:
Dorsal avulsion, tuberosity # with minimal articular surface involvement = walking cast x 6 wks; ortho f/u Body #, displaced, > 20% of articular surface = ORIF

Describe injury. Name this injury. Management?

Describe injury. Name this injury Management? Lisfranc
OR for any displacement of 1,2,3 metartarsal bases Fracture of the base of the 2nd metatarsal is pathognomonic

Metatarsal Base #s Metatarsal Base of Great Toe: Consult Ortho
R/O Lisfranc injury. Recall 2nd metatarsal base is pathognomonic for Lisfranc. Non-displaced = Below Knee Cast and f/u with Ortho Displaced = Attempt reduction and consult Ortho

What type of #? Treatment?

JONES #: NWB cast (classic teaching) vs. weight bearing (Buckley)

Describe. Management Walking cast x 2-3 weeks Avulsion type #

Metatarsal Shaft # Treatment:
Metatarsal Shaft #s 2-5 Nondisplaced or min displaced = Treatments vary!: stiff shoe, walking cast w/ WBAT, or cast w/ NWB x 4 wks. Displaced (>3mm) or angulated >10 degrees = closed reduction w/ toe traps; cast and NWB x 4-6 wks. Consult ortho in ED

Metatarsal #s Great toe metatarsal shaft
Non-displaced = NWB cast (it’s a major WB surface!) x 6 wks; f/u with Ortho Displaced = Attempt closed reduction and consult Ortho in ED (will likely pin)

Metatarsal Head and Neck #s
Non-displaced = walking cast 4-6 wks Displaced (common) = consult ortho re ? ORIF, as even if reduction achieved with toe traps they often slip

Phalangeal #’s Indication for surgery: open #, displaced intra-articular # of Great Toe Otherwise: reduce, buddy taping, protective orthosis, weight bearing as tolerated

PELVIS AND LOWER LIMB Grant Kennedy

Similar presentations

Presentation on theme: "PELVIS AND LOWER LIMB Grant Kennedy"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

PELVIS AND LOWER LIMB Grant Kennedy

Similar presentations

Presentation on theme: "PELVIS AND LOWER LIMB Grant Kennedy"— Presentation transcript:

Similar presentations

About project

Feedback