Fracture of lower limb

Types Ankle Tibia plateau Neck of femur Intertrochanteric femur

Description Occurs due to twisting or axial loading Twisting force -> spiral # of both legs in different levels Fall directly into greater # from the extracapsular part of the neck to a point 5
mechanism *alert for compartment s(x) trochanter cm distal to the lesser trochanter
* Always check both malleolus TRO ligamental I-III : low energy
injury IV-VI : high energy
Features -H/O twisting Associated injuries : -History of fall -History of fall , pain, cant stand
-swollen ankle 1.Meniscus injury -Pain in the hip -Limb is shortened
-deformity 2.Cruciate&collateral injury -Lies in the external rotation
-cant stand 3.Arterial ijnury
Grading Denis Weber Schatzker Garden Evan
name A - Fibula # below level of tibia I – lateral plateau , split # I – incomplete , no I – Stable , Non displaced
Adduction injury II - lateral plateau , split depression displacement II- Stable , Displaced
B - Oblique/spiral # fracture of # II – complete with no III – Unstable , reverse obliquity
fibula near level of syndesmosis III – lateral plateau ,depression # displacement IV – Unstable ,s ubtrochanteric
Eversion injury IV III - complete with spike
C - Fibula # above level of A:medial plateau partial displacement
syndemosis B:split # IV - complete with Stable : intact posterior medical cortex . will resist
Medical mallelous injury C:depression # fully with medical comprehensive loads once reduced
Torn tibiofibular ligament V – bicondylar plateau displacement
Maisonneuve injury = ankle VI - # with separation of Unstable :comminuation of the posteromedial
injury with proximal 1/3rd fibula metaphysic from diaphysis cortex . Frature will collapse into varus and
Syndesmosis – made up of anterior-inferior retroversion when loaded
tibiofibular ligament, interosseous ligament, - Early external fixation :
and posterior-inferior fibular ligaments,
to get patient up and walkinG ASAP
Management Principles : Principles :
Weber A – below knee cast 1.Limit soft tissue damage 1.Accurate reduction
2.Obtain and hold ligament 2.Secure fixation
Weber B with no talar shift – non weight 3.Detect compartment s(x) 3.Early activity – patient should
bearing below knee cast for 6-8 weeks 4.Start early weight bearing and joint movement ASAP sit up on the bed and walk with
Weber B with talar shift – ORIF T(X): crutches ASAP .
Low energy High energy Old people : athroplasty
*Talar shift is lateral subluxation of the talus 1.Undisplaced- 1.External
due to loss mortise stability Full length cast fixation
from upper 2.Intramedullary
thigh to nailing
metatarsal
Weber C – ORIF + Stabilization of the necks
syndemosis with screws / transosseous 2Displaced :
suture device reduction

Complication 1.Joint stiffness Early : compartment syndrome , infection , vascular injury , 1.AVN Early :Thromboembolism , pressure sores
2.Complex regional pain syndrome nerve injury , 2.Non union Late :Failure of fixation , malunion
3.OA Late : malunion , joint stiffness , OA , Osteoperosis 3.OA
Fracture of upper limbs
Types Distal radius Humerus Montegia Galeazzi Supracondylar
Classification Colles Smith’s -Proximal 1/3 rd ulnar -distal 1/3 radius B>G
fracture fracture Proximal humerus # fracture with proximal radio - shaft AND -Extraarticular
-radial shift -fall on the ulnar joint injury / radial head -associated
-radial back of the *low-energy falls dislocation distal radioulnar Gartland classification :
shortening hand -elderly with osteoporotic bone Bado classification : joint (DRUJ)
-2.5cm from *high-energy trauma Type I injury Extension Flexion
the wrist -young individual -# of proximal or middle Type Undisplaced Undisplaced
-outstrech -concomitant soft tissue and third ulna with anterior I
hand neurovascular injuries dislocation of the radial Type Displaced , Displaced ,
head II posterior anterior
Neer classification : Type II cortex cortex intact
-# of proximal or middle intact
third ulna with posterior Type Completely Completely
Dosal Volar dislocation of the radial III displaced , displaced
displacement displacement head posterior anterolateral
Dorsal Volar Type III cortex not
angulation angularion -# of the ulnar metaphsis intact
Dinner fork Garden with lateral dislocation of
deformity spade the head
deformity -# of proximal or middle
third ulna and radius with
dislocation of the radial
head in any direction
 Humeral shaft #
-distal to the surgical neck & proximal
to the supracondylar ridge

Mechanism :
1.Fall on the hand may twist the
humerus  spiral #
2.Fall on the elbow with arm
abducted may hinge the bone
transverse or oblique #
3.Direct blow to the arm 
transverse /comminuted #

Management Conservative Operative Proximal Humeral shaft 1.CMR of radial head Operative: OPERATIVE NON
immolization Unstable # 1.Arm in a sling 1.Cast & elbow 2.ORIF +ulnar plating ORIF +plating +/- OPERATIVE
in a cast for Should be 2.Active exercise 90 3.Open reduction + annular K wire (DRUJ) -Cast -ORIF
3weeks fixed with k 3.Closed reduction 2. Internal ligament repaired if failed immobilization using k
wires of 4.Internal fixation fixation head CMR for 3 weeks WRE
plate -Three 4.Radial head fixation if -Dunlop
part fracture traction
5.Prosthetic
replacement
-Four part
Complication 1.Circulatory impairment 1.Fracture of shaft of humerus  radial Early : PIN neuropathy 1.compartment Early – vascular and nerve injury ,
2.Nerve injury nerve palsy ( wrist drop ) Late : malunion syndrome compartment syndrome,infection
3.Joint stiffness 2.Fracture of proximal  shoulder Non union 2.neurovascular Late- Malunion , joint stiffness ,
4.malunion dislocation , vascular and nerve injuries , injury volkman ischaemic contracture
stiffnesss 3.Non union
Dislocation
Shoulder Elbow
Anterior dislocation -90 % Terrible triad injury :
1.Posterior elbow dislocation
-Fall on back stretching hand 2.Radial head #
-Forced abduction and external rotation of the shoulder 3.Radial head # + coronoid #

Symptom Sign Presentation :

-severe pain until support the arm with -Lateral outline shoulder is flattened and a Symptoms Signs
opposite hand small budge is may be seen and felt just above -elbow deformity & swelling -Inspection & palpation
the clavicle -elbow pain varus or valgus deformity
Posterior dislocation -forearm or wrist pain may be a sign of ecchymosis & swelling
associated injuries diffuse tenderness
-trauma with the arm in a flexed, adducted, and internally rotated position
-range of motion & instability
Symptom Sign
document flexion-extension and pronation-
-pain with flexion, adduction, and internal inspection
supination
rotation of the arm -prominent posterior shoulder and coracoid
crepitus should be noted
motion
varus/valgus instability stress test
-limited external rotation
-neurovascular exam
-shoulder locked in an internally rotated
position common in undiagnosed posterior
dislocation
Regan and Morrey classification
Type I – Avulsion of tip
Type II – Single or comminuted # involving < 50%
Type III – Single or comminuted # involving > 50 %

Investigation : Normal ROM Functional ROM

Xray of the shouder 0-150 ° Flexion 30-130°
- True AP 85° Supination 50°
- Scapula Y
80° Pronation 50°
- Axillary
 overlapping shadow of the humeral head an glenoid fossa ( head usually lying below and medial to the
socket )
Management :
-CMR
Treatment :
- If failed CMR  Open reduction
- Reduction
Complications :
Complication :
-nerurovascular injury
1.Rotator cuff tear
-Compartment syndrome
2.Nerve injury
-Heteroscopic ossification
3.Vascular injury
-Instability / redislocation
4.Fracture – dislocation
-Elbow osteoarthritis
5.Recurrent dislocation – depression seen in posterosuperior part of humeral head