Musculoskeletal Trauma Cases in Lower Extremities and Its Management

Musculoskeletal Trauma Cases in Lower
Extremities and Its Management

OBJECTIVE
• Femoral Shaft Fracture
• Tibial Shaft Fracture
• Ankle Fracture
• Metatarsal Fracture
FEMORAL SHAFT FRACTURE
EPIDEMIOLOGY
• The highest age and gender specific incidences of
femoral shaft fracture are seen in males from 15 to
24 years of age and in females 75 years of age or
older.
• Femoral shaft fractures occur most frequently in
young men after high-energy trauma and elderly
women after a low-energy fall.
• The bimodal distribution peaks at 25 and 65 years of
age with an overall incidence of approximately 10 per
100,000 population per year.
ANATOMY
Deforming Muscle
Forces on the Femur
A. Abductors
B. Iliopsoas
C. Adductors
D. Gastronemius origin
E. Fascia lata
MECHANISM OF INJURY
• High-energy trauma
– motor vehicle accidents,
– gunshot injuries,
– falls from a height.
• Pathologic fractures
• Stress fractures (military recruits or runners)
– recent increase in training intensity just before the
onset of thigh pain
CLINICAL EVALUATION
Variable Gross
Pain Deformity
Patient
Non-ambulatory
Shortening of The
Swelling Affected Extremity
CLASSIFICATION
Winquist and Hansen
Type I: Minimal or no
comminution
Type II: Cortices of both
fragments at least 50% intact
Type III: 50% to 100% cortical
comminution
Type IV: Circumferential
comminution with no cortical
contact
TREATMENT
• Skeletal Traction
TREATMENT
• Intramedullary Nailing
REHABILITATION
• Early patient mobilization out of bed is
recommended.
• Early range of knee motion is indicated.
• Weight bearing on the extremity is guided by a
number of factors including the patient’s
associated injuries, soft tissue status, type of
implant, and the location of the fracture.
COMPLICATIONS
Nonunion -
Vascular Nerve
Delayed Malunion
Injury Injury
Union
Infection
(<1% Compartm Fixation
Refracture incidence ent device
in closed syndrome failure
fractures)
TIBIAL SHAFT FRACTURE
EPIDEMIOLOGY
Most Common Highest Rate of

Long Bone Non-union for
Fractures All Long Bones
EPIDEMIOLOGY
26 Tibial diaphyseal fractures per 100,000
population per year
Highest incidence seen in young males is between 15 and

19 years of age, (109 : 100,000 population per year)
Highest incidence seen in women is between 90 and 99

years of age, (49 per 100,000 population per year)
Average age of a patient sustaining a tibia

shaft fracture is 37 years
ANATOMY
MECHANISM OF INJURY
Direct Indirect
• High-energy bending • Torsional mechanisms
• Penetrating • Stress fractures
• Low-energy bending
CLINICAL EVALUATION
• Evaluation of
neurovascular status is
critical
• Assess soft tissue injury
• Monitor for
compartment syndrome
• Tibial fractures may be
associated with knee
ligament injuries
RADIOGRAPHIC EVALUATION
• The presence of comminution
• The distance that bone
fragments have displaced
from their anatomic location
• Osseous defects
• Fracture lines
• The quality of the bone
• Osteoarthritis or the
presence of a knee
arthroplasty
• Air in the soft tissues
TREATMENT
Nonoperative
• Long Leg Cast
– Reduction
– Casting
– Progressive Weight
Bearing
TREATMENT
Operative
• Intramedullary Nailing
• Flexible Nails (Enders, Rush Rods)
• External Fixation
• Plates and Screws
COMPLICATIONS
Stiffness at
Neurovas-
Soft tissue the knee
cular Nonunion Malunion
loss and/or
Injury
ankle
Infection is
more
Reflex
common Compartment Claw toe Hardware
sympathetic
dystrophy following syndrome deformity breakage
open
fracture
ANKLE FRACTURE
EPIDEMIOLOGY
• The highest incidence of ankle fractures occurs in
elderly women, although fractures of the ankle are
generally not considered to be “fragility” fractures.
• The incidence of ankle fractures is approximately
187 fractures per 100,000 people each year
• Open fractures are rare, accounting for just 2% of
all ankle fractures
• Increased body mass index is considered a risk
factor for sustaining an ankle fracture.
ANATOMY
MECHANISM
OF INJURY
CLINICAL EVALUATION
• From a limp to
nonambulatory
• Pain and discomfort,
with swelling,
tenderness, and
variable deformity
• A dislocated ankle
should be reduced and
splinted immediately
• AP, lateral, and mortise views of the
ankle should be obtained
TREATMENT
• The goal of treatment is
anatomic restoration of
the ankle joint
TREATMENT
Emergency Room
• Closed reduction should be • Post-reduction radiographs
performed for displaced should be obtained for
fractures fracture reassessment
• Open wounds and abrasions
should be cleansed and
dressed in a sterile fashion
TREATMENT
Nonoperative Short Leg Cast
Indications
• Nondisplaced, stable fracture
patterns with an intact
syndesmosis.
• Displaced fractures for which
stable anatomic reduction of the
ankle mortise is achieved.
• An unstable or multiple trauma
patient in whom operative
treatment is contraindicated
because of the condition of the
patient or the limb.
TREATMENT
Operative
Open Reduction Internal Fixation (ORIF)
Indications
• Failure to achieve or maintain
closed reduction with amenable
soft tissues
• Unstable fractures that may result
in talar displacement or widening
of the ankle mortise
• Fractures that require abnormal
foot positioning to maintain
reduction (e.g., extreme plantar
flexion)
• Open fractures
TREATMENT
Loss of Compartment
Malunion
Wound
Reduction Syndrome Problem
Reflex Post
Sympathetic Infection Non-union Traumatic
Dystrophy Arthritis
METATARSAL FRACTURE
EPIDEMIOLOGY
• This is a common injury; however, the true
incidence of metatarsal shaft fractures is
unknown, owing to the variety of physicians
treating such injuries.
MECHANISM OF INJURY
• Displaced fractures of the
metatarsals result in the
disruption of the major
weight-bearing complex of
the forefoot.
• Disruptions produce an
alteration in the normal
distribution of weight in
the forefoot and lead to
problems of metatarsalgia
and transfer lesions
MECHANISM OF INJURY
• Direct
• Twisting
• Avulsion
• Stress fractures
CLINICAL EVALUATION
• Patients typically
present with pain,
swelling, and
tenderness over the site
of fracture
• Neurovascular
evaluation is important,
as well as assessment of
soft tissue injury and
ambulatory capacity.
• In isolated injuries to the
foot, weight-bearing films
should be obtained in the
AP and lateral planes.
• The lateral radiographic
view of the metatarsals is
important for judging
sagittal plane
displacement of the
metatarsal heads.
TREATMENT
• short leg cast or
removable boot with
progressive weight
bearing as tolerated for
4 to 6 weeks
THANK YOU

Musculoskeletal Trauma Cases in Lower Extremities and Its Management

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Musculoskeletal Trauma Cases in Lower Extremities and Its Management

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Musculoskeletal Trauma Cases in Lower

Extremities and Its Management

Most Common Highest Rate of

Highest incidence seen in young males is between 15 and

Highest incidence seen in women is between 90 and 99

Average age of a patient sustaining a tibia

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