Lower limbs orthopedics

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Fifth stage 

Surgery-Ortho 

Lec-6

 .د

  مثنى

28/4/2016

Fractures of the tibia and fibula 

  Indirect force: (low energy) 

  Twisting: spiral fractures of both bones 

  Angulatory: oblique fractures with butterfly segment. 

  Direct force: 

  Transverse (low energy) or comminuted (high energy) fractures usually with skin 

and soft tissue damage. 

  Examine for: 

  Size of skin and soft tissue damage. 

  Distal pulses, sensation, movements. 

  Signs of compartment syndrome. 

  X-ray must include the knee and ankle. 

Management 

Objectives: 

  To limit soft tissue damage and preserve skin cover. 
  To obtain and hold fracture alignment. 
  To recognize compartment syndrome. 
  To start early weight bearing to promote healing. 
  To start joint movement as soon as possible. 

Treatment of low energy fractures 

  Including closed & Gustilo I & II fractures treated by non-operative methods; MUA for 

displaced fractures. 

  Full-length cast from upper thigh to metatarsal necks with the knee in slight flexion 

and the foot plantigrade. 

  Elevate the leg and observe for 2-3 days for compartment syndrome. 
  After 4-6 weeks change to below knee functional brace and allow weight bearing and 

knee movement. 

  Healing is complete in 8 wks in children and in 16 wks in adults. 

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Skeletal fixation 

  Locked intramedullary fixation is the method of choice for diaphyseal (shaft) fractures. 

  Plate  and  screws  for  fractures  near  bone  ends  (metaphyseal)  and  for  children  with 

closed unstable fractures. 

Open fractures: 

  Antibiotics & anti-tetanus. 
  Debridement; thorough wash with normal saline, removal of dead tissues and debris. 
  Stabilization preferably using external fixation. 
  Soft tissue cover using flaps or grafts. 
  Rehabilitation. 

Complications 

  Vascular  injury;  popliteal  A.  injury  with  proximal  tibial  frctures  requires  angiogram, 

exploration and repair. 

  Compartment syndrome; open fasciotomy done with minimum delay. 

  Infection after open fractures and open surgery. 

  Malunion: shortening >1.5cm, angulation > 7degrees or rotation should be corrected. 

  Delayed union and non-union; bone grafting and good fixation is required. 

  Joint stiffness. 

  Complex regional pain syndrome. 

Ankle ligament injuries 

Range from: 

  Stretching of the ligament. 

  Partial tear: healing restores full function. 

  Complete tear: joint instability. 

Usually  involves  lateral  ankle  ligaments  (ant.  Talofibular  lig.,  talocalcaneal  lig.,  and  post. 
Talofibular lig.). 

Medial calcaneal lig. (deltoid lig.) can result from abduction or eversion injury. 

Clinical features: 

Bruising,  swelling,  tenderness  (usually  distal  and  anterior  to  lat.  Maleolus  in  anterior 
talofebular lig. Injury). 

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Treatment 

  Partial tears: elastic bandage and gentle active exercise. 

  Complete tears: cast  immobilization  from  below  knee  to  toes  for  6  wks  then 

physiotherapy. 

  If this regime fails; operative repair is done. 

Complications: 

  Recurrent sprains. 
  Recurrent giving way or instability.  

FRACTURES AND FRACTURE- DISLOCATIONS OF THE ANKLE 

Injury may involve one or more of the following structures: 

  Lateral maleolus. 

  Medial maleolus. 

  Tibiofibular syndesmosis. 

  Lateral collateral ligament (ant. And posterior talofebular lig., and calcaneofibular lig.). 

  Medial collateral (deltoid) lig. 

  Tibial articular surface (tibial plafond). 

  Position of the talus. 

Clinical features 

  History of severe inj. In young athletes or simple inj. In elderly osteoporotic. 

  Ankle twist. 

  Intense pain, swelling, inability to stand and deformity. 

  Look for points of tenderness espetially over medial or lateral malleolus. 

Danis-Weber classification (based on the level of fibular fracture) 

  Type A: a fibular fracture below syndesmosis and oblique fracture medial maleolus. 

  Type B: fibular fracture at syndesmosis + disruption of ant. Fibers of tibiofibular lig. + 

fracture of medial malleolus or rupture of deltiod lig. 

  Type  C:  fibular  fracture  above  syndesmosis+  tibiofibular  lig.  (syndesmosis)  is  torn. 

Unstable fracture-subluxation of ankle mortise. 

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Principals of treatment 

  Treatment within hours or after several days until swelling subside by elevation and 

splintage. 

  Anatomical reduction is a must to avoid later osteoarthritis. 

  Fibular  fracture  below  tibiofibular  lig.  Ankle  jt.  is  stable;  reduce  the  fracture  and 

immobilize in a cast. 

  Fibular  fracture  above  tibiofibular  lig.  Ankle  jt.  is  unstable;  usually  need  internal 

fixation. 

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Postoperative management 

Below knee cast for 4 wks in low-level injuries, and 6-8 wks in fractures treated by surgery. 

Complictions  

  Joint stiffness and prolonged swelling. Treat by compression stocking and elevation. 

  Complex regional pain syndrome. 

  Osteoarthritis  

Comminuted fractures of the tibial plafond (Pilon fracture) 

  Severe axial compression of the ankle (FFH). 

  Shattering of ankle joint surface. 

  Swelling and blistering; treated by elevation and calcaneal traction. 

  Secondary Osteoarthritis is common. 

Fractures of Talus 

  Rare and usually due to considerable violence- FFH, car accidents,… 

  May involve the body, neck, head or dislocation of the talus. 

Clinical features 

  Pain, swelling, deformity. 

  Skin tented or split. 

  X-ray: difficult to diagnose. May need to repeat several days later to see the fracture. 

  C-T in difficult cases. 

Treatment  

  Trivial displacement: Below knee plaster with knee plantigrade for 6-8 wks 

  Displaced fractures or fracture dilocations: urgent reduction by closed manipulation; if 

fails, ORIF 

Complications  

  Non-union. 

  Avascular necrosis of body after fracture of neck. 

  Oseoarthritis. 

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Calcaneal fractures 

  Usually after FFH. 

  Associated injuries: spine, pelvis, hip or base of skull. 

  Extra-articular fractures: need closed treatment. Have good prognosis. 

  Intra-articular fractures: involve superior articular surface. May be comminuted. 

Special features 

  Foot painful, swollen, bruised and the heel look broad. Movement is painful. 

  Signs of compartment syndrome: intense pain and diminished sensation. 

  Necessary to X-ray the knees, spine, and pelvis. 

Treatment 

  Admit to hospital, elevate the leg and apply ice-packs until swelling subside. 

  Undisplaced fractures: closed treatment. 

  Displaced fractures: ORIF with screws.  

Complications  

  Broadening of the heel 

  Talocalcaneal stiffness and OA 

Metatarsal fractures 

Mechanism of injury: 

  Direct blow. 

  Twisting. 

  Repetitive stress. 

Treatment: 

  Walking plaster for 3 wks. 

  Displaced fractures; Kirschner wire fixation. 

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Stress injury (march fracture) 

  Young adult (often recruit or a nurse) 

  Painful foot after overuse. 

  Tender lump in shaft of metatarsal (usually 2

nd

). 

  X-ray: at first normal but later show hairline fracture and callus. 

  Radioisotope shows early increased activity. 

Avulsion of base of fifth metatarsal 

  Result from forefoot inversion injury. 

  Base of 5

th

 MT avulsed by peroneus brevis tendon. 

  Treatment: Below knee walking cast for 3wks.