Title: Lower Limb Trauma
1Lower Limb Trauma
- Mr Matthew Barry MS FRCS(Orth)
- Consultant Orthopaedic Surgeon
2Overview
- Femoral shaft fractures
- Intra-articular fractures of the knee
- Ankle fractures
3Femoral shaft fractures
4Femoral shaft fracturesEpidemiology
- Boys 72
- Age bimodal distribution
Hinton et al JBJS 1999 81A 500
5Femoral shaft fracturesEpidemiology
Hinton et al JBJS 1999 81A 500
6Femoral shaft fractures - Management
- Traction
- Traction hip spica
- Immediate hip spica
- ORIF
- Ex-fix
- Elastic nail
7Femur - Traction
- Common method of treatment
- ? in hospital
- ? until united
- ? convert to POP cast
Spica
Skeletal traction
ORIF
Ex-fix
Skin traction
Al-Habdan, Int Surg 2004
n261 LOS 32 days
8Femur - immediate hip spica
Immediate next available list
- Advantages
- Short hospital stay
- Cost
- Disadvantages
- GA required
- ? malunions
Indication Younger child lt5
Coyte, CORR 1997 Buckley, CORR 1997 Infante,
CORR 2000
9Femur - ORIF
- Advantages
- Anatomical reduction
- Early mobilisation
- Short hospital stay
- Disadvantages
- Scars
- Neuro-vascular injury
- 2nd GA to remove plate
- Re-fracture
10Femur im nail
- Why not treat the fracture like an adult and use
a standard intramedullary nail?
11im nail
- Entry point piriformis fossa
- damage to piriformis anastomosis
- AVN femoral head in 5
- unsalvagable
- ? use trochanteric entry point
Orler, Unfallchirurg 1998
12Femur Ex-Fix
- Advantages
- Early mobilisation
- Good for open or infected cases
- Disadvantages
- Scars
- Large device
- Pin site problems
- Re-fracture 10
Kesemenli, Acta Orthop Belg 2004 Wright, Lancet
2005
13Femur Elastic Nail
- Advantages
- Excellent stability
- Early mobilisation
- Early weight bearing
- Short hospital stay
- Small scars
- V.low re-fracture rate
- Disadvantages
- Wound problems
- 2nd GA to remove nails
- Cost
Ligier, JBJS 1988 Bar-On, JBJS 1997 Vransky,
JPO 2000 Flynn, JPO 2001
14Intra-articular fractures of the knee
15ACL avulsion fracture
- Mechanism of injury
- ACL rupture vs avulsion fracture
- Classification
- Management
- Prognosis
16ACL avulsion fractures
- Mechanism of injury
- Hyperextension injury
- Fall of bicycle
- Sport
17Fracture vs ACL rupture
- ACL rupture is uncommon in children lt 14 years
- bone is weaker than the ligament
Clanton et al JBJS 1979 61A 1195
18Classification of ACL fracture
I
II
III
Meyers McKeever JBJS 1959 41A 209
19ACL avulsion fracture
- Management
- Type I long leg cast with knee in extension
- ? aspirate haemarthrosis
20ACL avulsion fracture
- Management
- Type II and III
EUA and aspirate knee Extend knee II screen
Not reduced
Reduced
ORIF ? scope
Long leg cast Check xray 1 week
Long leg cast
21ACL avulsion fractures
- Prognosis
- Good. Bone unites
- Malunion of Type III fracture may result in
impingement
22Ankle Fractures
- Ottawa ankle rules
- Classification
- Management
23Ottawa Ankle Rules
Stiell et al. Ann Emerg Med 1992 21384 Stiell
et al JAMA 1994271827-32.
- Initially applied to ADULT ankle injuries
- Determines the need for an X-ray
- Xray if bone tenderness at
- A post edge lat mall
- B post edge med mall
- C base of 5th MT
- D navicular
- unable to wt bear
- Reduces number of x-rays by 35
24Ottawa Ankle Rules
- Subsequently validated in children
- 25 reduction in number of x-rays obtained
- No fractures missed
Chande. Arch Pediatr Adolesc Med 1995149
255 Boutis et al. Lancet 2001 358 2118 Clarke
et al. Pediatr Emerg Care. 2003 19 73
25Classification of Ankle Fractures
- Modification of Lauge-Hansen classification of
adult fractures - Dias Tachdjian CORR 1978 136 230
26Management
- Undisplaced conservative Rx
- Displaced
- Reduce and hold the physeal fracture
- Non physeal fracture will probably follow and
may not need any Rx - Consider the periosteum as a block to reduction
27Special ankle fractures
28Tillaux
- Older child nearing skeletal maturity
- External rotation injury
29Tillaux
- Why does it occur ?
- Related to physeal closure
- Last part to close is antero-medial part
30Tillaux
- Management
- ORIF for displaced fracture
- ? percutaneous k wire
31Triplane
- 1 - 2 years younger than Tillaux fracture
- Usually 2 part fracture
- Occasionally 3 or 4 part
- ORIF for displaced fracture
32Conclusions
- Femur fracture
- Immediate hip spica for younger child
- Elastic nails in older children
- ACL avulsion fracture
- ORIF for displaced fractures
- Ankle fracture
- Get the physis right
- Remember special fractures n older children