Lower Limb Trauma

1
Lower Limb Trauma

• Mr Matthew Barry MS FRCS(Orth)
• Consultant Orthopaedic Surgeon

2
Overview

• Femoral shaft fractures
• Intra-articular fractures of the knee
• Ankle fractures

3
Femoral shaft fractures

• Epidemiology
• Management

4
Femoral shaft fracturesEpidemiology

• Boys 72
• Age bimodal distribution

Hinton et al JBJS 1999 81A 500
5
Femoral shaft fracturesEpidemiology

• Mechanism of injury

Hinton et al JBJS 1999 81A 500
6
Femoral shaft fractures - Management

• Traction
• Traction hip spica
• Immediate hip spica
• ORIF
• Ex-fix
• Elastic nail

7
Femur - Traction

• Common method of treatment
• ? in hospital
• ? until united
• ? convert to POP cast

Spica
Skeletal traction
ORIF
Ex-fix
Skin traction
Al-Habdan, Int Surg 2004
n261 LOS 32 days
8
Femur - immediate hip spica
Immediate next available list

• Advantages
• Short hospital stay
• Cost

• Disadvantages
• GA required
• ? malunions

Indication Younger child lt5
Coyte, CORR 1997 Buckley, CORR 1997 Infante,
CORR 2000
9
Femur - ORIF

• Advantages
• Anatomical reduction
• Early mobilisation
• Short hospital stay

• Disadvantages
• Scars
• Neuro-vascular injury
• 2nd GA to remove plate
• Re-fracture

10
Femur im nail

• Why not treat the fracture like an adult and use
  a standard intramedullary nail?

11
im nail

• Entry point piriformis fossa
• damage to piriformis anastomosis
• AVN femoral head in 5
• unsalvagable
• ? use trochanteric entry point

Orler, Unfallchirurg 1998
12
Femur Ex-Fix

• Advantages
• Early mobilisation
• Good for open or infected cases

• Disadvantages
• Scars
• Large device
• Pin site problems
• Re-fracture 10

Kesemenli, Acta Orthop Belg 2004 Wright, Lancet
2005
13
Femur Elastic Nail

• Advantages
• Excellent stability
• Early mobilisation
• Early weight bearing
• Short hospital stay
• Small scars
• V.low re-fracture rate

• Disadvantages
• Wound problems
• 2nd GA to remove nails
• Cost

Ligier, JBJS 1988 Bar-On, JBJS 1997 Vransky,
JPO 2000 Flynn, JPO 2001
14
Intra-articular fractures of the knee

• ACL avulsion fractures

15
ACL avulsion fracture

• Mechanism of injury
• ACL rupture vs avulsion fracture
• Classification
• Management
• Prognosis

16
ACL avulsion fractures

• Mechanism of injury
• Hyperextension injury
• Fall of bicycle
• Sport

17
Fracture vs ACL rupture

• ACL rupture is uncommon in children lt 14 years
• bone is weaker than the ligament

Clanton et al JBJS 1979 61A 1195
18
Classification of ACL fracture
I
II
III
Meyers McKeever JBJS 1959 41A 209
19
ACL avulsion fracture

• Management
• Type I long leg cast with knee in extension
• ? aspirate haemarthrosis

20
ACL avulsion fracture

• Management
• Type II and III

EUA and aspirate knee Extend knee II screen
Not reduced
Reduced
ORIF ? scope
Long leg cast Check xray 1 week
Long leg cast
21
ACL avulsion fractures

• Prognosis
• Good. Bone unites
• Malunion of Type III fracture may result in
  impingement

22
Ankle Fractures

• Ottawa ankle rules
• Classification
• Management

23
Ottawa Ankle Rules
Stiell et al. Ann Emerg Med 1992 21384 Stiell
et al JAMA 1994271827-32.

• Initially applied to ADULT ankle injuries
• Determines the need for an X-ray
• Xray if bone tenderness at
• A post edge lat mall
• B post edge med mall
• C base of 5th MT
• D navicular
• unable to wt bear
• Reduces number of x-rays by 35

24
Ottawa Ankle Rules

• Subsequently validated in children
• 25 reduction in number of x-rays obtained
• No fractures missed

Chande. Arch Pediatr Adolesc Med 1995149
255 Boutis et al. Lancet 2001 358 2118 Clarke
et al. Pediatr Emerg Care. 2003 19 73
25
Classification of Ankle Fractures

• Modification of Lauge-Hansen classification of
  adult fractures
• Dias Tachdjian CORR 1978 136 230

26
Management

• Undisplaced conservative Rx
• Displaced
• Reduce and hold the physeal fracture
• Non physeal fracture will probably follow and
  may not need any Rx
• Consider the periosteum as a block to reduction

27
Special ankle fractures

• Tillaux
• Triplane

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Tillaux

• Older child nearing skeletal maturity
• External rotation injury

29
Tillaux

• Why does it occur ?
• Related to physeal closure
• Last part to close is antero-medial part

30
Tillaux

• Management
• ORIF for displaced fracture
• ? percutaneous k wire

31
Triplane

• 1 - 2 years younger than Tillaux fracture
• Usually 2 part fracture
• Occasionally 3 or 4 part
• ORIF for displaced fracture

32
Conclusions

• Femur fracture
• Immediate hip spica for younger child
• Elastic nails in older children
• ACL avulsion fracture
• ORIF for displaced fractures
• Ankle fracture
• Get the physis right
• Remember special fractures n older children