Lower Limb

Pelvic Avulsion Fractures

• Sudden, violent muscle contraction of
  • ASIS – Sartorius
  • AIIS – Rectus Femoris
  • Posterior spine – erector spinae
  • Iliac Crest – abdominals
  • Ischial tuberosity - hamstrings

• ASIS, AIIS, Posterior spine of pelvis, Iliac Crest – Symptomatic management – Crutches, WBAT, strengthening and stretching (often caused by overuse and / or tight structures)
• Ischial Tuberosity – may need internal fixation

Isolated Fractures of the Pubic Rami

• Fall onto side

• Symptomatic – WBAT with gait aid

Fractures of the Acetabulum

• MVA
• Fall from height

• Variable depending on extent of damage – internal fixation, extensive bed rest / NWB

Fracture of the Neck of Femur

• Fall +/- onto hip

• Internal fixation or hip replacement

• Avascular necrosis

Fractures of the Femoral Shaft

• MVA
• Fall from height
• Crushing injuries

• Traction, internal fixation

Supracondylar Fractures of the Femur (distal third of femur)

• Motor Vehicle Accident
• Falls from height

• Children - If minimally displaced, full leg POP, NWB
• Adult, or Child if displaced - may need ORIF or reduction and then plastered into knee flexion

Condylar Fractures of the Femur

• Motor Vehicle Accident
• Falls from height

• ORIF

Patella Fractures

• Direct violence
• Sudden muscular contraction

• Undisplaced vertical or horizontal – plaster cylinder or ZKS for 6 weeks, WBAT
• Otherwise – ORIF or patellar excision

Avulsion Fractures of the Tibial Tubercle

• Sudden violent quadriceps contraction

• No or minimal displacement, or in skeletally immature – 6 weeks in plaster cylinder or ZKS
• Marked displacement – fixed with a screw

Fractures of the Head of the Fibula

• Varus force
• Sudden muscular contraction (biceps femoris)

• Undisplaced / displaced
  • If knee is clinically stable – symptomatic treatment
  • If knee unstable – operative repair unless there is a definite, undisplaced fracture which seems likely to go on to union, in which case an plaster cylinder or Zimmer Splint is applied for 6-8 weeks

• Common Peroneal Nerve palsy

Fractures of the Tibial Shaft

• Direct violence
• Torsional stress
• Fall from height
• Motor vehicle accidents

• Adults - usually internal fixation or manipulation
• Children
  • Undisplaced– managed in long leg plaster over generous layer of wool; admission is desirable for observation of circulation; NWB with crutches commenced at about 2-3 days.
  • Angulated – need to be reduced under general anaesthesia

• Often open injuries
• Compartment syndrome

Tibial Plateau Fractures

• Severe varus or valgus force
• Fall from height

• No ligament damage, no tibial subluxation, tibial depression < 10mm – traction or internal fixation
• >10mm tibial depression – internal fixation

Unicondylar and Bicondylar Tibial Fractures

• As per tibial plateau fractures

• Internal fixation
• Traction

Fractures of the Distal Fibula

• Hyperinversion
• Hypereversion

• Distal to syndesmosis (Weber A)
  • Undisplaced with normal talar alignment - below knee POP for 6 weeks,
  • Displaced or with talar tilting – manipulation or fixation
• Distal fibular, at level of syndesmosis (Weber B)
  • Undisplaced (no talar tilting) - symptomatic as above, or internal fixation
  • Displaced or with talar tilting – manipulation or fixation
• Distal fibular, above level of syndesmosis (Weber C)
  • undisplaced stable (where medial ligament and posterior tib/fib ligament are NOT involved – no talar tilting) – below knee POP or above knee POP
  • Unstable (posterior tib/fib ligament and/or medial ligament are involved – talar tilting) – internal fixation
• Epiphyseal
  • Type 1 and 2
    • No or minimal displacement – below knee POP
    • Displacement appreciable – reduction, below knee POP
  • Type 3 and 4 – reduction, likely internal fixation
  • Type 5 - orthopaedic review and below knee POP

Fractures of the Distal Tibia

• As above, usually with greater force

• Medial malleolus (Undisplaced or displaced) – internal fixation
• Medial malleolus (elderly) – may wish to try conservative management – manipulation if necessary and below knee POP, NWB for 6 weeks
• Isolated Posterior Malleolus, Bimalleolar and Trimalleolar – manipulation and/or internal fixation

Isolated Fractures of Navicular

• Inversion
• Avulsion of tibialis posterior

• Tuberosity
  • Undisplaced – below knee POP for 6 weeks
  • Displaced – internal fixation
• Other
  • Undisplaced – below knee POP for 6 weeks
  • Otherwise – internal fixation

Fractures of the Talus

• Forced dorsiflexion

• Avulsion fracture of ligamentous or capsular attachments – symptomatic treatment, eg 2-4 weeks in a below knee walking plaster
• Talar Dome
  • Undisplaced – padded below knee POP
  • Displaced - internal fixation or excision if small
• Talar Body
  • Undisplaced – padded below knee POP, NWB for 3 months
  • Displaced – internal fixation
  • Comminuted – bandaging, NWB for 8-10 weeks, AROM, isometrics ASAP
• Talar Neck
  • Undisplaced – padded below knee POP, NWB for 3 months
  • Displaced – manipulation or internal fixation
• Talar Head
  • Undisplaced – uncommon – opinion necessary
  • Comminuted – bandaging, NWB for 8-10 weeks, AROM, isometrics ASAP

• Often open injuries
• Avascular necrosis

Calcaneal Fractures

• Fall from height onto the heels
• Eversion (sustentaculum tali)

• Vertical fracture of the tuberosity – Compression, WBAT (initially sore++), heel cushion
• Avulsion of Sustentaculum tali (by deltoid ligament) – NWB 6 weeks or BK POP for 4 weeks, then WBAT
• Horizontal fractures
  • Avulsion type (including achilles tendon attachment) -  internal fixation
  • Posterior superior angle of the calcaneus (not involving achilles attachment) – manipulation if severely displaced and managed in below knee, padded plaster NWB for 1 week, then 5 weeks in a below knee walking plaster OR crepe bandage over wool, NWB for 6 weeks.

• Anterior fractures
  • No significant compression or shortening – as per sustentaculum tali
  • If calcaneal shortening – internal fixation and/or bone graft

• Body
  • Not involving subtalar joint
    • Minimally displaced – pressure bandage, rest, elevation, NWB for 6 weeks, calf exercises (stretch and strength) ASAP. May use Cam walker for position
    • Significantly displaced – internal fixation
  • Involving subtalar joint
    • Undisplaced – as per sustentaculum tali
    • Displaced – internal fixation

Fractures of the First Metatarsal

• Crushing accidents

• Undisplaced – below knee walking plaster for 5-6 weeks
• Displaced – reduction, then as above or internal fixation

Fractures of the Fifth Metatarsal base

• Inversion mechanism (pull of peroneus brevis)

• All fractures - Symptomatic – crepe bandage for 2-3 weeks; if marked pain – walking below knee plaster for 5-7 weeks

Jones Fracture (proximal Fifth Metatarsal shaft)

• Not usually associated with inversion; some features of a stress fracture

• Usually undisplaced - 7 weeks in below knee POP, NWB OR Internal fixation

• Non union

Metatarsal Shaft and Neck fractures (except the first metatarsal)

• Crushing accidents

• Undisplaced, without soft tissue damage – symptomatic treatment – bandage or walking plaster if pain severe
• Multiple fractures without much displacement – treat conservatively with below knee walking plaster for 6 weeks
• Multiple fractures with displacement - internal fixation

Fractures of the Phalanges

• Crushing

• Middle / Proximal Phalanges
  • Minimally displaced – Buddy strapping
  • Severely displaced – reduction and then buddy strapping
• Distal Phalanx - Buddy strapping, cut out for shoe or walking plaster for 2-4 weeks
• For first ray, may wish to consider walking plaster with toe platform