Lower Extremity
Trauma
Makhzum R. Bentaher
The Knee Joint
Bones:
– Femur
– Tibia
– Fibula
– Patella
Menisci ACL PCL
– Medial Meniscus Medial
– Lateral Meniscus LCL Meniscus
Ligaments:
Lateral
– MCL- Medial Collateral Meniscus
Ligament MCL
– LCL- Lateral Collateral
Ligament
– ACL- Anterior Cruciate
Ligament
– PCL- Posterior Cruciate
Ligament
Knee Anatomy – Soft
Tissues
Ligaments of Knee
Medial Collateral (MCL)
– Resists valgus forces
Lateral Collateral (LCL)
– Resists varus forces
Anterior Cruciate (ACL)
– Resists anterior
translation of the tibia
Posterior Cruciate
(PCL)
– Resists posterior
translation of the tibia
Knee Anatomy – Soft
Tissues
Major Tendons
– Patellar Tendon –
attaches the
quadriceps muscles
to the tibia
Knee Anatomy – Soft
Tissues
Menisci of the knee
– Lateral Meniscus –
Joint cartilage that
deepens the knee joint.
– Medial Meniscus –
Joint cartilage that
deepens the knee
joint . Has a deep
attachment to the MCL.
– Outer 1/3 has a blood
supply, rest is
avascular.
Meniscal Blood Supply
Meniscal Tear
Cause: A weight bearing combined with a
rotational force while extending of flexing
the knee. Medial more common than lateral.
Acute vs. Chronic
Effusion on joint line, loss of motion, joint
locking, and pain when squatting.
TX: RICE
quad sets
Surgery possible
ST: McMurray’s, Apley’s compression test
The Anterior Cruciate Ligament
and the Posterior Cruciate
Ligament
o ACL- located internally in the
front of the knee , prevents
the knee from sliding forward
Signs and Symptoms of injury:
o Swelling in the knee occurs within
minutes
o Athlete may be in mild to severe pain
o Walking is difficult
- Anterior Drawer test, Lachman test
PCL- located behind the
knee and forms an "X"
on the inside of the knee
and prevent the knee
from sliding backward.
Signs and Symptoms of
injury:
o Swelling in the knee occurs
within minutes
o Athlete may be in mild to
severe pain
o Walking is difficult
- Posterior Drawer test
Sag Sign
The Medial Collateral
Ligament
MCL- ligament on the inside of the knee, prevents knee
from sliding side to side.
- valgus force from lateral side .
- Valgus Stress Test
The Lateral Collateral
Ligament
LCL- ligament
located on the
outside of the knee,
prevents knee from
sliding side to side
- varus force from the
medial side or from
internal rotation of
the tibia.
- Varus Stress Test
Distal Femur Fractures
Distal Metaphyseal
Fractures
Look for intra-articular
involvement
Plain films
CT
Distal Femur Fractures
Treatment:
– Retrograde IM Nail
– ORIF open vs.
MIPO
– Above depends on
fracture type,
bone quality, and
fracture location
Knee Dislocations
High association of injuries
– Ligamentous Injury
ACL, PCL, Posterolateral Corner
LCL, MCL
– Vascular Injury
Intimal tear vs. Disruption
Obtain ABI’s (+) Arteriogram
Vascular surgery consult with
repair within 8hrs
– Peroneal >> Tibial N. injury
Patella Fractures
History
– MVA, fall onto knee,
eccentric loading
Physical Exam
– Ability to perform straight
leg raise against gravity (ie,
extensor mechanism still
intact?)
– Pain, swelling, contusions,
lacerations and/or abrasions
at the site of injury
– Palpable defect
Patella Fractures
Radiographs
– AP/Lateral/Sunrise views
Treatment
– ORIF if ext mechanism
is incompetent
– Non-operative
treatment with brace if
ext mechanism remains
intact
Tibia Fractures
Proximal Tibia Fractures (Tibial
Plateau)
Tibial Shaft Fractures
Distal Tibia Fractures (Tibial
Pilon/Plafond)
Tibial Plateau Fractures
MVA, fall from height, sporting injuries
Mechanism and energy of injury plays a
major role in determining orthopedic care
Examine soft tissues, neurologic exam
(peroneal N.), vascular exam (esp with
medial plateau injuries)
Be aware for compartment syndrome ( 5p
pain, pallor, parasthesia, pulseless,
paralysis).
Check for knee ligamentous instability
Tibial Plateau Fractures
Xrays:AP/Lateral +/- traction films
CT scan (after ex-fix if appropriate)
Schatzker Classification of Plateau
Fxs
Lower Energy
Higher Energy
Tibial Plateau Fractures
Treatment
– Spanning External
Insert blister
Fixator may be Pics of ex-fix here
appropriate for
temporary
stabilization and to
allow for resolution
of soft tissue
injuries
Tibial Plateau Fractures
Treatment
– Definitive ORIF for
patients with
varus/valgus
instability, >5mm
articular stepoff
– Non-operative in
non-displaced stable
fractures or patients
with poor surgical
risks
Tibial Shaft Fractures
Mechanism of Injury
– Can occur in lower energy, torsion type
injury (e.g., skiing)
– More common with higher energy
direct force (e.g., car bumper)
– Open fractures of the tibia are more
common than in any other long bone
Tibial Shaft Fractures
Open Tibia Fx
Priorities
– ABC’S
– Associated Injuries
– Tetanus
– Antibiotics
– Fixation
Tibial Shaft Fractures
Gustilo and Anderson Classification of
Open Fx
– Grade 1
<1cm, minimal muscle contusion, usually
inside out mechanism
– Grade 2
1-10cm, extensive soft tissue damage
– Grade 3
3a: >10cm, adequate bone coverage
3b: >10cm, periosteal stripping requiring
flap advancement or free flap
3c: vascular injury requiring repair
Tibial Shaft Fractures
Management of Open Fx
Soft Tissues
– ER: initial evaluation
wound covered with
sterile dressing and leg
splinted, tetanus
prophylaxis and
appropriate antibiotics
– OR: Thorough I&D
undertaken within 6 hours
with serial debridements
as warranted followed by
definitive soft tissue
cover
Tibial Shaft Fractures
Definitive Soft Tissue Coverage
– Proximal third tibia fractures can be covered
with gastrocnemius rotation flap
– Middle third tibia fractures can be covered
with soleus rotation flap
– Distal third fractures usually require free flap
for coverage
Tibial Shaft Fractures
Treatment Options
– IM Nail
– ORIF with Plates
– External Fixation
– Cast or Cast-Brace
Tibial Shaft Fractures
Advantages of IM nailing
– Lower non-union rate
– Smaller incisions
– Earlier weightbearing and
function
– Single surgery
Tibial Shaft Fractures
IMnailing of
distal and
proximal fx
– Can be done but
requires
additional
planning, special
nails, and
advanced
techniques
Tibial Pilon Fractures
Fractures involving distal tibia
metaphysis and into the ankle joint
Soft tissue management is key!
Often occurs from fall from height or
high energy injuries in MVA
“Excellent” results are rare, “Fair to
Good” is the norm outcome
Multiple potential complications
Tibial Pilon Fractures
Initial Evaluation
– Plain films, CT scan
– Spanning External Fixator
– Delayed Definitive Care to protect soft
tissues and allow for soft tissue swelling
to resolve
Tibial Pilon Fractures
Treatment Goals
– Restore Articular Surface
– Minimize Soft Tissue Injury
– Establish Length
– Avoid Varus Collapse
Treatment Options
– IM nail with limited ORIF
– ORIF
– External Fixator
Tibial Pilon Fractures
Complications
– Mal or Non-union (Varus)
– Soft Tissue Complications
– Infection
– Potential Amputation
Ankle Fractures
Most common weight-
bearing skeletal injury
Incidence of ankle fractures
has doubled since the
1960’s
Highest incidence in elderly
women
– Unimalleolar 68%
– Bimalleolar 25%
– Trimalleolar 7%
– Open 2%
Osseous Anatomy
Lateral
Ligamentous
Anatomy
Medial Ligamentous Anatomy
Syndesmosis Anatomy
Ankle Fractures
History
– Mechanism of injury
– Time elapsed since the injury
– Soft-tissue injury
– Has the patient ambulated on
the ankle?
– Patient’s age / bone quality
– Associated injuries
– Comorbidities (DM, smoking)
Ankle Fractures
Physical Exam
– Neurovascular exam
– Note obvious deformities
– Pain over the medial or lateral
malleoli
– Palpation of ligaments about the
ankle
– Palpation of proximal fibula,
lateral process of talus, base of
5th MT
– Examine the hindfoot and
forefoot
Ankle Fractures
Radiographic Studies
– AP, Lateral, Mortise of Ankle (Weight
Bearing if possible)
– AP, Lateral of Knee (Maissaneve injury)
– AP, Lateral, Oblique of Foot (if painful)
Ankle Fractures
AP Ankle
– Tibiofibular overlap
<10mm is abnormal
and implies
syndesmotic injury
– Tibiofibular clear
space
>5mm is abnormal -
implies syndesmotic
injury
– Talar tilt
>2mm is considered
abnormal
Ankle Fractures
Ankle Mortise View
– Foot is internally
rotated and AP
projection is performed
– Abnormal findings:
Medial joint space
widening
Talocural angle <8 or
>15 degrees (compare to
normal side)
Tibia/fibula overlap
<1mm
Ankle Fractures
Lateral View
– Posterior malleolar
fractures
– Anterior/posterior
subluxation of the
talus under the tibia
– Displacement/
Shortening of distal
fibula
– Associated injuries
Ankle Fractures
Classification Systems (Weber-Danis)
– A: Fibula Fracture distal to mortise
– B: Fibula Fracture at the level of the
mortise
– C: Fibula Fracture proximal to mortise
Ankle Fractures
Initial Management
– Closed reduction (conscious
sedation may be necessary)
– AO splint
– Delayed fixation until soft
tissues stable
– Pain control
– Monitor for possible
compartment syndrome in high
energy injuries
Ankle Fractures
Indications for non-operative care:
– Nondisplaced fracture with intact syndesmosis
and stable mortise
– Less than 3 mm displacement of the isolated
fibula fracture with no medial injury
– Patient whose overall condition is unstable and
would not tolerate an operative procedure
Management:
– NWB in short leg cast for 6 weeks
– Repeat x-ray at 7–10 days to r/o interval
displacement
Ankle Fractures
Indications for operative
care:
– Bimalleolar fractures
– Trimalleolar fractures
– Talar subluxation
– Articular impaction injury
– Syndesmotic injury
Beware the painful ankle with
no ankle fracture but a
widened mortise… check
knee films to rule out
Maissoneuve Syndesmosis
injury.
Ankle Fractures
ORIF:
– Fibula
Lag Screw if possible + Plate
Confirm length/rotation
– Medial Malleolus
Open reduce
4-0 cancellous screws vs. tension
band
– Posterior Malleolus
Fix if >30% of articular surface
– Syndesmosis
Stress after fixation
Fix with 3 or 4 cortex screws
Thank’s
