INJURY OF LOWER EXTREMITIES

 

HIP  FX

 

  1. Hip can be broken at the level of head, neck (subcapital), intertrochanteric (fx located as a line between grater and lesser trochanters), trochanter.
     
  2. Fx can be simple, displaced, impacted, comminuted.
     
  3. X-rays required are  AP pelvis, AP hip, Lateral cross table hip.
     
  4. Occasionally  x-ray may be negative but pt still unable to bear weight. Occult fx may be present and MRI, Bone scan or CT can be used for diagnosis.
     
  5. Examination may  vary from pain only  to shortening and external rotation. Pt with non-displaced fx of the neck may even be  ambulatory.
     
  6. Monitor Hg/Hct in Neck and Intertrocanteric  fx. Fx of the neck with displacement is an orthopedic emergency.
     
  7. Sciatic nerve injury, artery or vein injury and  pelvic fx are all possible associated injuries. Femoral and distal pulses must be assessed.
     
  8. Most pts are treated surgically, unless non-displaced trochanteric or simple hairline subcapital  fx in young pt (yet surgery is optional).

 

HIP  DISLOCATION

 

  1. Occurs 2ry to frontal injury with knee flexed e.g. dashboard injury while driving a car. Posterior dislocation is the most common.
     
  2. X-rays requested are AP pelvis, AP hip, Lateral cross table hip, Judet view.
     
  3. The incidence of acetabular fx is so common that if this is not seen by the X-ray, one should order CT. femoral head injury is also commonly associated
     
  4. On exam pt holds leg flexed at knee level and adducted. Nerve that could be involved is sciatic.
     
  5. If not reduced within 4-6 hrs the risk of avascular necrosis is >50% as compare to <5% when reduced in time.

     

PELVIC INJURY / TRAUMA

  1. Occurs as a result of mechanical insult (MVA, high  or low energy  trauma such as fall from height or elderly  with osteoporotic bone respectively).
     
  2. Possible associated injuries are urethra, bladder, abdominal and vascular hemorrhage (  the femoral and iliac vessels as well as pelvic plexus), spinal trauma, sciatic injury.
     
  3. Anatomy of pelvis is tri-dimensional. Schematically imagine a big ring with attached wing on each side. The wings are composed of iliac bone (iliac crest & iliac spine), acetabulum, pubic rami and ischial bone. The ring is composed of  arcuate line of  iliac bone and superior aspect of  pubic rami. Secrum and coccyx are part of pelvis and are in anatomical vicinity with nerves.
     
  4. Assessment of pelvic fx includes looking for gross deformities, palpating femoral pulse, "rocking" from lateral-to-medial  of pelvis at iliac crest, ascertain that prostate is not high riding and r/o blood at urethral meatus in men and inspection  of  vagina for laceration/bleeding in women. Document rectal tone. See for leg length discrepancy.
     
  5. In addition to above physical examination radiographic studies are performed. AP pelvic films are always part of  "Trauma Series" along with C-spine and Chest. What do we look for on the pelvic Xray? Here are the Xray findings that are considered normal:
     
        1. the width  of sacro-iliac joint is 2-4 mm.
           
        2. the width of pubic symphysis joint is 5 mm.
           
        3. alignment of symphysis.
           
        4. do not ignore hip and acetabulum just because only pelvic films were ordered (get Judet view if  PA film is not satisfactory  to r/o acetabular fx).
           
        5. look if any fx along iliac bone, ischial  tuberosity,  pubic rami.
           
    • At  times CT is needed to better assess and "reconstruct" the image. CT is also appropriate since not infrequently pelvic injury 2ry to posterior mechanism can be associated with retroperitoneal bleed.
       
  6. In case of  hemodynamic instability, MAST device in addition to routine ATLS protocol is employed. If  MAST is not available, wrap a sheet around the pelvis.
     
  7. If pt is hemodynamically stable, pt is treated on the basis of  fx type.
      1. A single fx in any of  the bones composing the "wing" except acetabulum is considered stable and pt is treated with pain meds and rest.
         
      2. A fx of iliac bone near sacro-iliac joint only or only a fx of pubic rami +  ischial bone (i.e. only  one section of  the pelvic ring is disrupted. Also considered stable and treated as above.
         
      3. Fx of sacrum and coccyx  unless  present with neurological deficit also treated as above.
         
      4. If fx occurs in a way to disrupt two sections of  the "ring" i.e. one or both iliac bones and a fx of one or both ischeopubic rami or  separation of symphysis occurs on the same or opposite side, fx is considered unstable and temporizing external stabilization must be provided.
         
      5. Fx of acetabulum also requires surgical intervention.

Another Classification used based on AP  x-ray  film are as follows:

  1. Inlet view: look for anterior-to-posterior displacement and rotational displacement
     
  2. Outlet view: look for vertical displacement.

On the basis of  the above x-ray  findings fx is classified into:

  1. Stable: Intact posterior elements, i.e. no vertical or rotational displacement.
     
  2. Partially Stable: posterior elements partially intact, i.e. rotational displacement without vertical displacement. Partially  stable injury with pubic symphysis diastasis > 2.5 cm requires operative intervention.
     
  3. Unstable: posterior elements disrupted i.e. vertical and rotational displacement. Needs operative intervention.

 

ACETABULAR  FX

 

  1. Associated with pelvic and  hip fx
     
  2. To dx get AP and Judet view. If these are (-)ve but still strong suspicion on basis of mechanism, obtain CT.

 

FEMORAL  SHAFT  FX

 

  1. Occur 2ry to direct trauma.
     
  2. On exam shortening is present.
     
  3. Arterial injury may occur and is suspected if pulses, hematoma or compartment syndrome are  evident. Monitor Hct frequently
     
  4. Another complication is fat embolism.
     
  5. In the ER pt is put in Hare Traction device and early Ortho evaluation.

 

DISTAL  FEMUR

 

  1. Can be broken above condyle (supracondylar)  or  within  it (intercondylar). Fx can be non-displaced, displaced or comminuted.
     
  2. Distal pulses must be examined
     
  3. Sensory  deficit between 1st and  2d toe as well as motor deficit with  dorsiflexion / extension of  the toes (tibial and peroneal  nerve respectively ) must be examined.
     
  4. See "Knee Injury" below for other associated injuries
     
  5. Treatment in ER if NV compromise is present c/o traction and early orthopedic consultation.

 

KNEE  INJURY

 

  1. Diagnostic studies are: AP, lateral and "sunrise" views.
     
  2. Commonly effusion occurs with knee injury whether there is a bony and/or ligament/meniscus fx.
     
  3. Arthrocentesis is optional and generally done to provide comfort to the pt if effusion is big.
     
  4. In cases of ligament / meniscus injury  pt can be DC  with knee immobilizer and orthopedic referral.
     
  5. Patella Dislocation - is reduced by flexing the hip and applying pressure medially  while extending the knee. Pt then treated with immobilizer.
     
  6. In case of Patella Fx pt is treated as above unless comminuted fx,  incompetent extension, displaced fx ae present.
     
  7. Knee Dislocation : Deformity is evident. Popliteal artery injury and tibial/peroneal nerve injury can  occur. Treatment c/o immediate closed reduction and obtaining angiogram.

 

TIBIAL FX

 

  1. Tibial  Plateau ( injury  to proximal  articular  tibia ), Tibial Spine, Tibial Tubercle, Tibial Shaft - are all possibly involved in fx.
     
  2. Neurovascular assessment as above plus dorsiflexion  of the toes (tibial nerve).
     
  3. Look for compartment syndrome especially in case of shaft fx.
     
  4. Treatment depends if  the fx is non-displaced  - long leg  cast in full extension (unless it is shaft fx - long cast with knee flexed at 30) and non-weight bearing or displaced (surgery).

     

FIBULAR  FX

 

  1. Peroneal nerve assessment (extension of toes) and r/o other injuries (ankle, tibia, knee)
     
  2. Associated injury could be knee, tibia, ankle (Masoneuve's fx)
     
  3. Treatment c/o  posterior splint  for comfort.

 

ANKLE  SPRAIN

 

Etiology:

  1. Inversion motion gives injures to 90% of ankle sprains. Most commonly , the anterior talofibular ligament on the lateral side is affected.
     
  2. Eversion will cause 5-10% of ankle sprains and ligament affected is daltoid (on the medial aspect).

S & S:

  1. Pain, swelling, +/- hearing of popping, +/- deformity
     
  2. Neurovascular status must be assessed
     
  3. See if pt has pain along fibula especially if medial ankle (daltoid ligament) is swollen.
     
  4. Pain may indicate Maissonneuve's fx, i.e. fx of fibula 2ry to daltoid injury.

DX:

  1. X-ray: AP, lateral, 45 internally oblique and stress view (if needed). Following are the possibilities:
     
    1. I ankle sprain = on exam no swelling and X-ray is (-)ve for  mortise abnormality, i.e. a space between tib-fib and talus posteriorly.
        
    2. II ankle sprain = moderate to significant swelling and (-)ve standard X-ray  for mortise abnormality. Stress view, however,  will be positive.
       
    3. II ankle sprain = significant swelling and (+) ve standard X-ray

Treatment:

  1. I ankle sprain - ACE band and ambulate as tolerated. Ice and elevation are also indicated.
     
  2. II ankle sprain -as above plus Air cast x 2-4 wks. and crutches prn.
     
  3. III ankle sprain - in ER treated as II sprain, but for long term pt is referred to orthopods for possible surgical repair.

 

FOOT  INJURY

 

Overview:

  1. Obtain AP, Lateral, Oblique, Harris (axial), Broden views
     
  2. Associated injuries are: lumbar spine, other LE fractures.

 

  1. Calcanear  fx
     
    1. Occurs after fall ("jumpers" injury) and associated injuries to lumbar spine pelvis, hip, knees are present  in 10-25%. Thus, in ER, "jumper's view" X-rays, splinting and  ortho consult are standard of care. If this is an isolated fx - bulky dressing and short leg splint are appropriate.
       
  2. Talus, Navicular, Cuboid and Cuneiform  fx
     
    1. If no associated injuries, isolated talus fx is treated with short-leg splint.
  3. Metatarsal fx
     
    1. 2d metatarsal bone and midfoot is a relatively  stable joint. Thus, when  one sees fx of the base of  2d  metatarsal, Lisfranc's fx  (hyperextension of forefoot on midfoot) should be suspected. This is an unstable fx and Ortho must be  consulted ASAP. 
    2. Fx of 5th metatarsal  base, Ballet's fx, is treated with ice, elevation, NWB and hard-sole-shoe  or short leg cast. Jone's fx is a fx of  the proximal 5th metatarsal at junction  of diaphysis and metaphysis (1. 5 cm from the tip of proximal 5th metatarsal).  Posterior splint, NWB and  ortho  referral. Vascular supply to this area is not very good, thus conservative treatment is warranted. This is treated with short-leg cast.
    3. When  shaft of the metatarsal bone is broken, posterior splint is applied after attempting close reduction if displaced by more than 3-4 mm or > 10 of angulation, NWB (Non Weight Bearing), referral to ortho. If no displacement, hard-sole-shoe and comfort are sufficient.
       
  4. Phalanx fx
     
    1. If fx is not displaced, buddy taping & hard-sole-shoe.
       
    2. If displaced, after close reduction in addition  to above, NWB is suggested.
       
  5. Stress fx
    1. May not be visible on initial X-ray. MRI or Bone scan ( 3 or more days after the injury) are alternatives. Treatment is rest and pain meds. Immobilization is rarely needed.

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