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Lower Limb Trauma

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Type I: long leg cast with knee in extension. aspirate haemarthrosis. ACL avulsion fracture ... Long leg cast. ACL avulsion fractures. Prognosis. Good. Bone unites ... – PowerPoint PPT presentation

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Title: Lower Limb Trauma


1
Lower Limb Trauma
  • Mr Matthew Barry MS FRCS(Orth)
  • Consultant Orthopaedic Surgeon

2
Overview
  • Femoral shaft fractures
  • Intra-articular fractures of the knee
  • Ankle fractures

3
Femoral shaft fractures
  • Epidemiology
  • Management

4
Femoral shaft fracturesEpidemiology
  • Boys 72
  • Age bimodal distribution

Hinton et al JBJS 1999 81A 500
5
Femoral shaft fracturesEpidemiology
  • Mechanism of injury

Hinton et al JBJS 1999 81A 500
6
Femoral shaft fractures - Management
  • Traction
  • Traction hip spica
  • Immediate hip spica
  • ORIF
  • Ex-fix
  • Elastic nail

7
Femur - 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
8
Femur - 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
9
Femur - ORIF
  • Advantages
  • Anatomical reduction
  • Early mobilisation
  • Short hospital stay
  • Disadvantages
  • Scars
  • Neuro-vascular injury
  • 2nd GA to remove plate
  • Re-fracture

10
Femur im nail
  • Why not treat the fracture like an adult and use
    a standard intramedullary nail?

11
im nail
  • Entry point piriformis fossa
  • damage to piriformis anastomosis
  • AVN femoral head in 5
  • unsalvagable
  • ? use trochanteric entry point

Orler, Unfallchirurg 1998
12
Femur 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
13
Femur 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
14
Intra-articular fractures of the knee
  • ACL avulsion fractures

15
ACL avulsion fracture
  • Mechanism of injury
  • ACL rupture vs avulsion fracture
  • Classification
  • Management
  • Prognosis

16
ACL avulsion fractures
  • Mechanism of injury
  • Hyperextension injury
  • Fall of bicycle
  • Sport

17
Fracture 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
18
Classification of ACL fracture
I
II
III
Meyers McKeever JBJS 1959 41A 209
19
ACL avulsion fracture
  • Management
  • Type I long leg cast with knee in extension
  • ? aspirate haemarthrosis

20
ACL 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
21
ACL avulsion fractures
  • Prognosis
  • Good. Bone unites
  • Malunion of Type III fracture may result in
    impingement

22
Ankle Fractures
  • Ottawa ankle rules
  • Classification
  • Management

23
Ottawa 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

24
Ottawa 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
25
Classification of Ankle Fractures
  • Modification of Lauge-Hansen classification of
    adult fractures
  • Dias Tachdjian CORR 1978 136 230

26
Management
  • 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

27
Special ankle fractures
  • Tillaux
  • Triplane

28
Tillaux
  • Older child nearing skeletal maturity
  • External rotation injury

29
Tillaux
  • Why does it occur ?
  • Related to physeal closure
  • Last part to close is antero-medial part

30
Tillaux
  • Management
  • ORIF for displaced fracture
  • ? percutaneous k wire

31
Triplane
  • 1 - 2 years younger than Tillaux fracture
  • Usually 2 part fracture
  • Occasionally 3 or 4 part
  • ORIF for displaced fracture

32
Conclusions
  • 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
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