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PELVIS AND LOWER LIMB Grant Kennedy

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Title: PELVIS AND LOWER LIMB Grant Kennedy


1
PELVIS AND LOWER LIMBGrant Kennedy
2
Objectives
  • To cover this huge topic adequately in just over
    an hour.
  • Special thanks to Tintinalli, UTDOL, Dr. Buckley,
    Rob and Shawns REMERGS web page.

3
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

4
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)

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

6
Pelvic Anatomy
7
  • Anterior Support
  • Symphysis pubis
  • Fibrocartilaginous joint covered by ant post
    symphyseal ligaments
  • Pubic rami
  • Posterior Support
  • majority of stability
  • Iliolumbar ligaments
  • Sacroiliac ligaments
  • Sacrospinous ligament
  • Sacrotuberous ligament

8
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

9
Pelvic Anatomy
  • Nerve supply through the pelvis derived from
    lumbar and sacral plexuses
  • Other structures lower GI/GU

10
History Physical
  • AMPLE Hx
  • Mechanism/Ambulating at Scene
  • Numbness/Weakness/Bowel Bladder Dysfxn
  • Inspect
  • Destots 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
    100-150 cc of dye into bladder and have x-ray
    taken at same time.
  • Flank ecchymoses

11
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?)
  • Earles sign
  • Presence of bony prominence, palpable hematoma,
    or tender line on DRE

12
Imaging
  • Plain films are NOT necessary in stable trauma
    patient with no lower abdo-pelvic complaints,
    normal exam and GCS gt13
  • X Rays
  • AP
  • Inlet/Outlet
  • Judet
  • CT Scan
  • Evaluates extent of posterior injuries and
    retroperitoneal bleeding, superior imaging of
    sacrum and acetabulum, associated injuries

13
Imaging
  • AP VIEW
  • Identifies most fractures
  • Look for disruption in iliopubic and ilioischial
    lines, sacral foramina, radiographic U, Shentons
    Lines
  • Following are abnormal
  • Symphysis gt5mm
  • Vertical offset left vs. right rami (gt1-2mm)
  • SI joint gt 5mm

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15
  • 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.

16
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)

17
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

18
Pelvic Fracture Complications
  • 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

19
Pelvic Fracture Complications
  • 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

20
Pelvic Fractures
  • 5 General Categories
  • 1. Pelvic Ring
  • 2. Acetabular
  • 3. Sacral
  • 4. Avulsion type
  • 5. Single bone

21
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)

22
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

23
  • 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

24
Tile B1 / Young APC II
25
Young Classification System
  • Vertical Shear (5)
  • Symphyseal diastasis or vertical displacement
    anteriorly and posteriorly usually through SI
    joint, occasionally through iliac wing

26
Tile C1/ Young VS
27
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

28
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 gt2.5 cm

29
Pelvic Fracture Management of the Unstable Patient
  • ABCs 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 dispositionlaparotomy vs. angio)
  • AP pelvis
  • ABX (ancef) and Tetanus if open.

30
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

31
PELVIC BINDER
  • Benefits
  • Reduces pelvic volume (tamponade effect)
  • Stabilizes fragments
  • Improves patient comfort

32
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)

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34
Acetabulum
  • Forms the socket for the femoral head
  • Fusion of 3 bones
  • 1. iliac (superior domechief weight-bearing
    surface)
  • 2. pubis (anterior-inferiorthin, easily
    fractured)
  • 3. ischium (posterior-inferior-thick)

35
Acetabulum
36
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)

37
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38
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)

39
Acetabular Fractures
  • Judet Classification
  • Simple Fractures
  • 1. Posterior Wall
  • 2. Posterior Column
  • 3. Anterior Wall
  • 4. Anterior Column
  • 5. Transverse

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41
Acetabular Fracture Management
  • ABCs
  • Neurovascular exam
  • Reduction of hip dislocation
  • Ortho consult
  • Admission
  • Buckley
  • Non-Displaced non weight bearing x 6-8 weeks
  • Displaced gt2mm intra-articular surgery

42
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43
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

44
Vertical Sacral Fractures
  • Denis Classification
  • Zone 1lateral to sacral neural foramina (6 L5
    root injury)
  • Zone 2through sacral neural foramina (28
    sciatic injury)
  • Zone 3medial to sacral neural foramina (50
    bowel/bladder, sexual dysfunction)

45
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46
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

47
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

48
Coccyx Fractures
  • Mechanism
  • 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

49
CASE
  • 13 yo boy presents with pain in his hip after
    kicking a soccer ball

50
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51
Avulsion Fractures
  • Mechanism
  • 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
  • gt2 cm displacement surgery

52
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.

53
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55
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.

56
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)

57
Sup and Inf Rami (bilateral)
  • Straddle
  • GU injuries common!
  • CT pelvis needed to plan surgical mgmt
  • Consult ORTHO
  • Tx SURGERY

58
  • What is the name
  • of this type of ??

59
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

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61
Hip Dislocations
  • 3 Types
  • Posterior (80)gtgtAnteriorgtgtCentral
  • 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

62
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.

63
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

64
Post Reduction Allis Method
65
Post Reduction Stimson Method
66
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

67
Hip Dislocations-Special Circumstances
  • Associated Femoral Head
  • More common w/ anterior
  • Can still attempt closed reduction
  • Consult ortho
  • Hip Prosthesis
  • Consult ortho
  • No time urgency as AVN not an issue

68
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

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70
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.)

71
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

72
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)

73
Injuries to the Femur
  • Open Fractures
  • Type I lt 1cm (Ancef)
  • Type II gt 1 10 cm (Ancef Gent)
  • Type III gt 10 cm (Ancef Gent)
  • Irrigate and cover w/ saline guaze
  • Tetanus
  • Splint Consult

74
Injuries to the Femur
  • Classification of Hip Fractures
  • 1. Intracapsular
  • Femoral head
  • Femoral neck
  • 2. Extracapsular
  • Greater or Lesser Trochanter
  • Intertrochanteric
  • Subtrochanteric

75
Injuries to the Femur
76
Femoral Head Fractures
  • Infrequently in isolation
  • Usually in conjunction w/ dislocation
  • Types capital, depression, shear
  • Consult Ortho
  • Treatment
  • If associated dislocationattempt reduction in ED
  • ORIF if failure to reduce

77
Femoral Head Fractures
  • Treatment (Buckley)
  • Non-displaced, stable limited weight bearing
    with crutches for 6 weeks
  • Displaced (gt2mm) head fragment, or associated
    femoral neck or acetabular ORIF

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79
Femoral Neck Fractures
  • Garden Classification
  • Types
  • Subcapital vs. Transcervical
  • All are intracapsular (precarious blood supply)

80
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81
Femoral Neck Fractures
  • 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

82
Femoral Neck Fractures
  • Dx AP/Laterallook for disruption of Shentons
    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

83
  • What type
  • of is
  • this?
  • Donk Sign

84
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
  • gt1cm displaced ortho consult for fixation

85
Trochanteric Fractures
  • Lesser Trochanter
  • Avulsion of iliopsoas
  • Pain w/ flexion/internal rotation
  • TX
  • Conservative, gradual weight bearing
  • gt2cm displaced ortho for screw fixation

86
  • What
  • type of
  • is this?

87
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

88
  • Type
  • Of
  • ?

89
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

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91
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)

92
Case
  • 68y male injured in MVC
  • c/o left leg pain

93
Case continued
  • Type of ?

94
Distal Femur Fractures
  • Supracondylar, Intracondylar (intra-articular),
    Condylar (intra-articular)
  • Isolated, T or Y pattern

95
Distal Femur Fractures
96
Distal Femur Fractures
  • 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)

97
Distal Femur Fractures
  • 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

98
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

99
Anatomy
  • Main joints
  • Patellofemoral
  • Tibiofemoral
  • Main bones
  • Distal Femur
  • Patella
  • Proximal tibia
  • (fibula head)

100
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

101
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

102
Knee Injuries
  • DDX of Hemarthrosis
  • ACL
  • PCL
  • Meniscal tear
  • Osteochondral
  • Capsular tear
  • BUT NOT MCL nor LCL!

103
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)

104
Knee Injuries--Examination
  • COMPARE TO HEALTHY KNEE
  • Inspection (swelling, bruising, deformity)
  • Palpation (joint line tenderness? effusion?
    point tenderness?)
  • ROM
  • Ligamentous/Meniscal Stress Testing

105
Ligament/Meniscal Stress Testing
  • Anterior Drawer (ACL) not reliable.
  • FN effusion, hamstring spasm, technique
  • FP PCL injury
  • Lachmans Test (ACL) reliable, even in acute.
  • Posterior Drawer (PCL)
  • McMurrays Test (Meniscal) int rotation
    stresses lateral meniscus, ext rotation stresses
    medial meniscus
  • Collateral Ligament Stress (MCL, LCL)

106
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

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108
CASE
  • 28 year old MOBHOB (Huffman, 2007)
  • Beaten about legs by some jerk yielding a bat.
  • Tender in several places.
  • X-ray shows

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111
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)

112
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 gt3mm and involving articular surface,
    inadequate extensor mechanism, comminuted ORIF
    (tension band wire w/ suturing of retinaculum)

113
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.

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116
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

117
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)

118
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

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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

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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 gt 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

123
Fracture of the Tibial Plateaus
  • Segond fracture
  • Bony avulsion off the lateral tib plateau
    (lateral capsular sign)
  • Strong association w/ ACL disruption

124
Fractures of the Tibial Plateau
  • TX
  • Non-displaced, no depression of articular surface
    knee immobilizer, elevation x 24-48 hrs, ortho
    f/u, non-weight bearing x 6-8 weeks
  • Displaced gt2mm, depressed articular surface
    surgery

125
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!

126
Ligamentous Injuries of the Knee
  • 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

127
Ligamentous Injuries of the Knee
  • Lateral Collateral Ligament (LCL)
  • Mech hyperextension varus force
  • DX pain or laxity w/ varus stress
  • TX conservative as per MCL

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Ligamentous Injuries of the Knee
  • 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

129
Ligamentous Injuries of the Knee
  • 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.)

130
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!)

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

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

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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

136
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)

137
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

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Soft Tissue Injuries
  • Patellar Tendonitisoveruse-pain to palp over
    inferior pole--tx conservative
  • Osteochondritis Dissecansidiopathic--articular
    cartilage and subchondral bone dislodgedtx
    epiphyses open protective weight bearing.
    epiphyses closed arthroscopy
  • Quads/Patellar Tendon Ruptureviolent contraction
    of quadstx surgical repair
  • Bakers Cystaspiration, surgical, vs. resolution

139
Soft Tissue Injuries
  • Chondromalacia Patellaesoftening of articular
    cartilage secondary to patellofemoral
    malalignment/abrnormal tracking of patella. Tx
    Rest/NSAIDS/quadship strengthening/brace
  • Plicaredundant folds of synovium that become
    inflammed. Leads to pain/stiffness.
  • Dx clinical/exclusion Tx conservative
  • Osteonecrosisbony infarction. Spontaneous vs.
    secondary causes (steroids, SLE, EtOH, Sickle
    etc). Dx-MRI (XR normal). Tx-Earlyprotected
    weight bearing/NSAIDS. Advanceddebridement/bone
    graft/TKA

140
Leg Injuries
141
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. Lateralsuperficial peroneal nerve (foot
    eversion sensory lateral dorsal foot)
  • 3. Superficial Posteriorankle plantar flexors
    (gastroc, soleus), sural nerve lateral heel
    sensation
  • 4. Deep Posteriorpost tibial artery tibial
    nerve toe plantar flexors, sensation to sole of
    foot

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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

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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

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

147
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 lt5mm,
    rotated lt10 degrees, angulated lt10 degrees and
    not shortened

148
Ankle Injuries
  • Anatomy of an Ankle
  • 3 Primary Joints
  • 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)

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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)

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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

153
  • Approach to Ankle
  • Go through complete approach (ABCs)
  • 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?

154
Ankle Fractures
  • What are stable fractures?
  • Ankle forms a ring
  • Disruption of only 1 structure
  • is stable
  • Disruption of gt 1 is unstable
  • Assymetry in gap between
  • talar dome and malleoli
  • on mortis view unstable

155
Ankle Fractures
  • Management of Stable Fractures
  • Chip/Avulsion s lt3mm Tx as Sprain (ie. WBAT,
    RICE, NSAIDS, Early ROM/physio)
  • Chip/Avulsions gt3mm 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 hasnt slipped

156
Ankle Fractures
  • Indications for Immediate Reduction Prior to X
    Ray
  • Neurovascular compromise
  • Gross Deformity
  • Skin Tenting

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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

158
Diagnosis?Classification?Treatment? Does it
change you mgmt if they have a tender deltoid
ligament?
159
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

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Lateral Malleolar Fractures
  • 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

161
Lateral Malleolar Fractures
  • Treatment
  • Weber B consult Ortho 50 have injury to
    syndesmosis and widening of medial joint space
  • Weber C consult Ortho frequent injury to
    syndesmosis

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Type of Fracture?
163
Medial Malleolar Fractures
  • Commonly associated with lateral or posterior
    malleolar disruption Ortho
  • Significant displacement Ortho
  • R/O Maisonneuves 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

164
TRIVIA TIME
  • Name of the rare variation of a Maisonneuve
    Fracture in which the proximal fibula gets
    trapped behind the tibia?

165
TRIVIA TIME
  • Name of the rare variation of a Maisonneuve
    Fracture in which the proximal fibula gets
    trapped behind the tibia?
  • The Bosworth Fracture!

166
Posterior Malleolar Fractures
  • Rarely in isolation
  • Isolated, non-displaced, lt25 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

167
Diagnosis? Stable or unstable?
168
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

169
Name of this type of fracture? Other associated
s?
170
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!

171
The Foot (last section!)
172
HINDFOOT
talus
calcaneus
MIDFOOT
navicular
cuboid
Medial
cuneiforms
metatarsals
sesamoids
FOREFOOT
phalanges
173
Choparts
Lisfrancs
MTP
IP
174
  • Type of
  • Do you need to speak to Ortho?
  • ?ottawa ankle rules

175
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

176
  • Describe ?
  • At risk for??

177
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/ gt2mm gapping, loose osteochondral body

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10
180
Posterior tuberosity
apex of anterior process
apex of posterior facet
181
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
  • Butnon-displaced, extra-articular NWB cast x 6
    wks
  • Intra-articular, displaced ? ORIF

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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

183
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, gt 20 of articular surface
    ORIF

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  • Describe injury.
  • Name this injury.
  • Management?

185
  • Describe injury.
  • Name this injury
  • Lisfranc
  • Management?
  • OR for any displacement of 1,2,3 metartarsal
    bases
  • Fracture of the base of the 2nd metatarsal is
    pathognomonic

186
Metatarsal Base s
  • Metatarsal Base of Great Toe
  • Consult Ortho
  • Metatarsal Base s 2-4
  • 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

187
  • What type of ?
  • Treatment?

188
  • JONES
  • NWB cast (classic teaching) vs. weight bearing
    (Buckley)

189
  • Describe.
  • Management
  • Walking cast x 2-3 weeks
  • Avulsion type

190
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 (gt3mm) or angulated gt10 degrees
    closed reduction w/ toe traps cast and NWB x 4-6
    wks. Consult ortho in ED

191
Metatarsal s
  • Great toe metatarsal shaft
  • Non-displaced NWB cast (its a major WB
    surface!) x 6 wks f/u with Ortho
  • Displaced Attempt closed reduction and consult
    Ortho in ED (will likely pin)

192
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

193
Phalangeal s
  • Indication for surgery open , displaced
    intra-articular of Great Toe
  • Otherwise reduce, buddy taping, protective
    orthosis, weight bearing as tolerated
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