1. Common lower limb fracture
Dr Tarif Alakhras
Orthopedic surgeon
kfmc

2. Common lower limb fracture
Fracture of the proximal femur (hip fracture)
Fracture of the shaft of the femur
Fracture of the distal femur
Fracture of the proximal tibia
Fracture the shaft of the tibia
Ankle fractures

3. Blood Supply to Femoral Head
Artery of Ligamentum Teres
Most important in children.
Its contribution decreases with age, and is probably insignificant in elderly patients.
Ascending Cervical Branches.
formed by branches of medial and lateral circumflex femoral arteries.
Penetrate capsule near its femoral attachment and Highly susceptible to injury with hip dislocation.

4. Hip fracture Intracapsular v extracapsular
The capsule envelopes the femoral head and neck
Intertrochanteric and subtrochanteric fractures do not involve the neck of femur

5. Hip fracture Capsule Area Intracapsular femoral head femoral neck
Subcabital
Transcervical
Basicervical
Extracapsular
Intrtrochanteric
subtrochanteric

6. Femoral Head Fractures
A rare fracture pattern.
requires high amounts of energy.
The classic mechanism of injury for femoral head fracture is traumatic posterior dislocation of the hip

7. Femoral Head Fractures
Examination of the injured hip often reveal hip pain & shortened lower extremity
 neurologic examination is important to rule out sciatic nerve injury
an ipsilateral knee examination is also required with attention paid to ligamentous stability (dashboard injury)

8. Femoral Head Fractures
 The CT scan is not only important for assessing the femoral head fracture pattern (size, location, comminution), but also to evaluate the congruity of the hip joint and determine the presence or absence of intra-articular loose fragments.

9. Femoral Head Fractures
Treatment
Fracture-dislocation of the hip is a true orthopaedic emergency.
The goals of definitive treatment of femoral head fractures are to achieve an anatomic reduction, achieve and maintain joint stability, and remove any interposed bone fragments. decision-making process.

10. Femoral Head Fractures
Nonoperative treatment
closed reduction and skeletal traction
 if close reduction is possible and the hip joint is stable for fracture with less than 1 mm of displacement on CT scan. 
Operative treatment
The indications for surgical management include nonanatomic reduction of the femoral head articular surface, an unstable hip joint, and the presence of intra-articular incarcerated fragments that are preventing a congruent joint reduction

11. Femoral Neck Fractures
These injuries occur in 2 distinct populations,
(1) young, active individuals
(2) elderly individuals with osteoporosis
It is more common in the elderly and female.
Whites > blacks

12. Femoral Neck Fractures
Mechanism of injury:
Elderly osteoporotic people :simple fall, with twisting the hip into external rotation.
young, active individuals: usually caused by a high-energy impact (fall from height or RTA).
Stress fracture of the femoral neck occur in runner or military personnel.

13. Femoral Neck Fractures
Presentation
Hip pain may radiate to the knee.
inability to bear weight.
The affected leg may be shortened, adducted and externally rotated.
Pain over the hip may be particularly aggravated by rotation of the leg.

14. Femoral Neck Fractures
Garden classification - Simulation
I - Incomplete or impacted bone injury
II - Complete (across whole neck) - undisplaced
III - Complete - partially displaced
IV - Complete - totally displaced

15. Femoral Neck Fractures
Surgery should be performed on the day of, or the day after, admission.
Internal fixation with screws if undisplaced
 displaced intracapsular fractures may be treated either by reduction and internal fixation in younger fit patient<50 years, or by replacement of the femoral head in older less fit patients.
Internal fixation is associated with less initial operative trauma but has an increased risk of reoperation on the hip.

16. Femoral Neck Fractures

17. Femoral Neck Fractures
Complications
Nonunion
5% of non-displaced
25% of displaced fractures
Osteonecrosis
0% of non-displaced
27% of displaced fractures

18. Intertrochanteric fractures
trochanteric hip fracture occurs between the greater trochanter, where the gluteus medius and the gluteus minimus (hip abductors) attach, and the lesser trochanter, where the iliopsoas (hip flexor) attaches

19. Intertrochanteric fractures
Frequency
Among individuals older than 60 years, intertrochanteric fractures occur more than twice as often in women as in men.
elderly, osteoporotic women
In the age group between 11 and 60 years, however, males sustain more fractures than females. Due to high-energy trauma

20. Intertrochanteric fractures
Etiology
Increased bone fragility of the intertroch area
from osteoporosis and osteomalacia secondary to a lack of adequate ambulation or antigravity activities, as well as decreased hormone levels, decreased intake of calcium or vitamin D, and other aging processes.
Benign and malignant tumors, along with metastases such as multiple myeloma and other malignancies, can also lead to weakened bony structure.

21. Intertrochanteric fractures
Clinical evaluation
Inability to bear-weight
Limb is short, abducted and externally rotated
Radiological evaluation
AP ,Lateral ,pelvic ,chest
Joint above and joint below should be included

22. Intertrochanteric fractures
Coexisting or preexisting conditions
Pulmonary insufficiency
Cardiac insufficiency
Cardiovascular insufficiency
Hypertension
Dehydration & Malnutrition
metabolic diseases or endocrine diseases, (diabetes and hypothyroidism)
A younger patient with a high-energy fracture has the potential for multiple other injuries to the remainder of the body, especially the head, chest and abdomen.

23. Intertrochanteric fractures
Current treatment of intertrochanteric fractures is surgical intervention. 
Proximal femoral nail Dynamic hip screw (DHS)

24. Intertrochanteric fractures
nonsurgical management
accompanied by unacceptable morbidity and mortality because of frequent complications associated with prolonged immobilization or inactivity.
Such complications included the following:
Pulmonary embolism (PE) from deep vein thrombosis(DVT)
Pressure ulcers 
Joints stiffness and muscle atrophy
Malunion, the fracture heals with unacceptable shortening, rotation, or angulation of the extremity

25. Femoral shaft fractures
High mechanism of energy
Inability to bear weight
AP & lateral radiographs
Two joints veiw
Bleeding:
Can easily loose 2L of blood
Risk of thromboembolism

26. Femoral shaft fractures
Treatment : always surgical
intramedullary nail is the best. Platting is another option

27. Distal Femur Fractures
Defined as fxs from articular surface to 5cm above metaphyseal flare
Supracondylar or intercondylar
Mechanism
young patients
high energy with significant displacement
older patients
low energy in osteoporotic bone with less displacement

28. Distal Femur Fractures
potential for injury to popliteal artery if significant displacement if no pulse after gross alignment restored then angiography is indicated

29. Distal Femur Fractures
Radiographs
obtain standard AP and Lat
AP, Lat CT
obtain with frontal and sagittal reconstructions
useful for
establish intra-articular involvement
identify separate osteochondral fragments in the area of the intercondylar notch
preoperative planning
Angiography
indicated when diminished distal pulses after gross alignment restored

30. Distal Femur Fractures
Treatment
Nonoperative
knee brace with NWB for 6 weeks
indications (rare)
nondisplaced fractures
nonambulatory patient
patient with significant comorbidities
Operative
open reduction internal fixation
indications
displaced fracture
intra-articular fracture
nonunion

31. Tibia and Fibula Fracture
Mechanism of injury
Direct forces such as those caused by falls and MVCs( transverse frx)
More soft tissues injury
Indirect or rotational forces (spiral frx)
less injury to the soft tissues

32. Most common open fracture
Most common long bone fracture
Most common open fracture
Bone immediately under skin
Significant cost
569,000 hospital days (USA)
Significant complications
Nonunions , compartment syndrome

33. Tibial shaft fracture : treatment
Conservative
Shortening <1cm
Angulation in varus/valgus plane< 5o
Angulation in antero-posterior plane <10o
Rotation neutral to slight external rotation
Bone apposition >50%

34. Tibial shaft fracture : treatment
Long leg cast (5 degrees of flexion) for 4-6 weeks
patella-bearing cast(Sarmiento) or fracture brace
The average union time is 16±4 weeks

35. Tibial shaft fracture : treatment
Surgical treatment
Intramedullary (IM) Nailing is the best treatment for mid shaft tibia fracture
The most complication is anterior knee pain!!

36. Surgical treatment Plate fixation 97% success rates Complication: i
infection,
wound breakdown,
nonunion i

37. Tibial plateau fractures
Occur from axial loading with valgus or varus forces, such as in a fall from a height. The lateral tibial plateau is fractured more frequently than the medial plateau.
Presented by knee effusion
lead to early OA in the knee joint.
Treated conservatively or surgically depending on the degree of displacement & joint surface disruption.

38. Ankle fracture
Together, the distal tibia and fibula form a concave mortis in which the talus is firmly held by the medial (deltoid) and lateral collateral lig.

39. Ankle fracture
Neer pointed out that the tibia, fibula, talus and connecting ligaments form a closed circle similar to the pelvic. Interruption at one side is usually associated with remote injury

40. Ankle fracture Most ankle fractures are isolated malleolar fractures.
Medial malleolus
Lateral malleolus
Posterior malleolus  
Mechanism of injury: position of the foot at time of injury, the magnitude, direction, and rate of loading

41. Ankle fracture Evaluation
- Common symptoms for a broken ankle include:
Immediate and severe pain
Swelling & Bruising
Tender to touch
Cannot put any weight on the injured foot
Deformity

42. Ankle fracture Radiographic Foot in 15o of internal rotation
AP & Lateral
Mortise views
Foot in 15o of internal rotation

43. Ankle fracture

44. Ankle fracture Denis –Weber classification Based on fibular fracture:
A. Infra-syndesmotic
B. Trans-syndesmotic
C. Supra-syndesmotic:
usually syndesmosis is torn

45. Ankle fracture
Denis –Weber classification
Bimalleolar feactur

47.  Maisonneuve fracture.

48. Ankle fracture Undisplaced: Indications for ORIF Below knee cast (NWB)
All fracture-dislocations
All type C fractures
Tri-malleolar fractures
Talar shift or tilt
Failure to achieve or/maintain closed reduction

49. Ankle fracture
Syndesmotic injury
With out syndesmotic injury