PELVIS AND LOWER LIMB Grant Kennedy

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PELVIS AND LOWER LIMBGrant Kennedy
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Objectives

• To cover this huge topic adequately in just over
  an hour.
• Special thanks to Tintinalli, UTDOL, Dr. Buckley,
  Rob and Shawns REMERGS web page.

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Pelvic Fractures Epidemiology

• Majority due to high impact blunt trauma (MVA,
  pedestrian vs. vehicle etc.) but also secondary
  to falls in frail elderly
• Mortality overall 10
• Mortality 50 if open

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Pelvic Anatomy

• Pelvis sacrum, coccyx 2 innominate bones
• Innominate bones ilium, ischium, pubis
• Sacrum innominate bones form a ring
• Strength from ligamentous supports (largely
  posterior aspect of ring)

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Pelvic Anatomy

• 5 joints
• Lumbosacral
• Sacroiliac (x2)
• Sacrococcygeal
• Symphysis

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Pelvic Anatomy
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• Anterior Support
• Symphysis pubis
• Fibrocartilaginous joint covered by ant post
  symphyseal ligaments
• Pubic rami
• Posterior Support
• majority of stability
• Iliolumbar ligaments
• Sacroiliac ligaments
• Sacrospinous ligament
• Sacrotuberous ligament

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Vascular Anatomy

• Vessels lie close to posterior pelvic walls
• Venous bleeding most common (sacral plexus)
• Most commonly injured arteries are superior
  gluteal and internal pudendal

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Pelvic Anatomy

• Nerve supply through the pelvis derived from
  lumbar and sacral plexuses
• Other structures lower GI/GU

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History Physical

• AMPLE Hx
• Mechanism/Ambulating at Scene
• Numbness/Weakness/Bowel Bladder Dysfxn
• Inspect
• Destots sign Hematoma above inguinal ligament
  or over scrotum
• Blood at urethral meatus (urologic injury?)if
  so, ED cystourethrogram. Insert foley a small
  amount (and lightly put up the balloon). Inject
  100-150 cc of dye into bladder and have x-ray
  taken at same time.
• Flank ecchymoses

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History Physical

• Examine pelvis only once!
• AP compression on ASIS
• AP compression on symphysis
• Lateral compression on iliac crests
• Distal neurovascular exam!
• Bimanual should be performed on all women w/
  pelvic
• If blood, do speculum to assess for vaginal
  laceration (open )
• DRE in everyone (High riding prostate? Lack of
  tone?)
• Earles sign
• Presence of bony prominence, palpable hematoma,
  or tender line on DRE

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Imaging

• Plain films are NOT necessary in stable trauma
  patient with no lower abdo-pelvic complaints,
  normal exam and GCS gt13
• X Rays
• AP
• Inlet/Outlet
• Judet
• CT Scan
• Evaluates extent of posterior injuries and
  retroperitoneal bleeding, superior imaging of
  sacrum and acetabulum, associated injuries

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Imaging

• AP VIEW
• Identifies most fractures
• Look for disruption in iliopubic and ilioischial
  lines, sacral foramina, radiographic U, Shentons
  Lines
• Following are abnormal
• Symphysis gt5mm
• Vertical offset left vs. right rami (gt1-2mm)
• SI joint gt 5mm

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• Inlet view
• X-ray beam at 60o to plate directed towards feet
• Used to look for AP displacement of ring
  fractures.
• Outlet view
• Beam aimed 30o towards head
• Used to see Sup-Inf displacement.

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Imaging

• Look for any evidence of damage to the posterior
  pelvic structures
• Clues on X-rays
• L5 transverse process avulsion (iliolumbar
  ligament)
• Ischial spine avulsion (sacrospinous ligament)
• Unable to clearly make out sacral foramina
• Assymmetry of sacral foramina
• Avulsion at lower lip of lateral sacrum
  (sacrotuberous ligament)

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Pelvic Fracture Complications

• Hemorrhage up to 6L of blood can collect in
  retroperitoneal space!
• Open high mortality if not recognized
  communication to rectum, vagina, skin
• examine posterior skin carefully, do not probe
  wounds,
• perineal wounds operative debridement/irrigation
  ,
• rectum diverting colostomy

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Pelvic Fracture Complications

• Urologic Injury (15) of symphysis have
  highest incidence of urologic injury,
• Microhematuria no need for cystourethrogram
• Gross hematuria cystourethrogram CT
• Neurologic Injury with sacral , sx of cauda
  equina, plexopathy, radiculopathy

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Pelvic Fracture Complications

• Gynecologic Injury laceration, abruption,
  uterine perforation
• Intra-abdominal Injury rectum, colon, small
  bowel
• Injuries by Association due to high force
  mechanism thoracic aortic rupture, diaphragmatic
  rupture

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Pelvic Fractures

• 5 General Categories
• 1. Pelvic Ring
• 2. Acetabular
• 3. Sacral
• 4. Avulsion type
• 5. Single bone

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Pelvic Ring Fractures

• Young Classification System
• Differentiates fracture patterns based on
  mechanism of injury/direction of causative force
• 3 major fracture patterns
• 1. lateral compression (50)
• 2. antero-posterior compression (25)
• 3. vertical shear (5)

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Young Classification

• Lateral Compression
• (50) transverse of pubic rami, ipsilateral
  or contralateral to posterior injury
• LC I sacral compression on side of impact
• LC II iliac wing on side of impact
• LC III LC-I or LC-II on side of impact w/
  contralateral APC injury

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• AP Compression (25)
• Symphyseal and / or Longitudinal Rami Fractures
• APC I diastasis of the pubic symphysis and/or
  anterior SI joint
• APC II disrupted anterior SI joint,
  sacrotuberous, and sacrospinous ligaments (intact
  post SI ligs)
• APC III complete SI joint disruption w/ lateral
  displacement and disruption of sacrotuberous and
  sacrospinous ligaments

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Tile B1 / Young APC II
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Young Classification System

• Vertical Shear (5)
• Symphyseal diastasis or vertical displacement
  anteriorly and posteriorly usually through SI
  joint, occasionally through iliac wing

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Tile C1/ Young VS
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Pelvic Fracture Management

• Stable vs. Unstable
• Young Classification
• LC I, APC I several days bedrest /- external
  fixator, followed by progressive weight bearing
  as tolerated
• LC II and III, APC II and III, VS surgery

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Pelvic Fracture Management

• Buckley
• Full weight bearing for lateral compression s
  that lack significant deformity, isolated pubic
  rami fractures
• Indications for surgery ongoing hemorrhage,
  displaced posterior pelvic injury, symphysis
  diastasis gt2.5 cm

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Pelvic Fracture Management of the Unstable Patient

• ABCs initial stabilization (IV access,
  crystalloid, blood products)
• Application of Pelvic Sheet/Binder/External
  fixator (open-book with intact posterior
  ligaments has most potential for benefit)
• Adjuncts Foley (but not if blood at meatus)
• FAST to assess for intraperitoneal injury (and
  help with dispositionlaparotomy vs. angio)
• AP pelvis
• ABX (ancef) and Tetanus if open.

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Pelvic Fracture Management of the Unstable Patient

• FAST , Unstable Laparotomy first
• FAST -, Unstable Angio
• STABLE but with significant CT. If brash on
  CT ongoing bleed, needs angio

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PELVIC BINDER

• Benefits
• Reduces pelvic volume (tamponade effect)
• Stabilizes fragments
• Improves patient comfort

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PELVIC BINDER

• Application
• Apply at level of greater trochanters
• Avoid over-reduction (esp lateral compression )
  as can increase internal rotation deformity,
  increase bleeding
• Aim for anatomical reduction (legs, trochanters,
  patellae should be neutral)

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Acetabulum

• Forms the socket for the femoral head
• Fusion of 3 bones
• 1. iliac (superior domechief weight-bearing
  surface)
• 2. pubis (anterior-inferiorthin, easily
  fractured)
• 3. ischium (posterior-inferior-thick)

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Acetabulum
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Acetabulum

• Also classically described as having 2 columns
• 1. Anterior column (anterior iliac wing, superior
  pubic ramus, anterior wall of acetabulum)
• 2. Posterior column (ischium, ischial tuberosity,
  posterior wall of acetabulum)

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Acetabular Fractures

• Nearly all associated with hip dislocations
• Sciatic nerve injury common
• MVA most common mechanism
• Imaging
• Judet views (AP, 45 degree iliac oblique, 45
  degree obturator oblique)
• CT scan (x-ray negative but suspicious
  clarifying operative or non-operative)
• Judet-Letournel Classification System
• Simple (5 types) vs. Complex (combos)

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Acetabular Fractures

• Judet Classification
• Simple Fractures
• 1. Posterior Wall
• 2. Posterior Column
• 3. Anterior Wall
• 4. Anterior Column
• 5. Transverse

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Acetabular Fracture Management

• ABCs
• Neurovascular exam
• Reduction of hip dislocation
• Ortho consult
• Admission
• Buckley
• Non-Displaced non weight bearing x 6-8 weeks
• Displaced gt2mm intra-articular surgery

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Sacral Fractures

• Mechanism
• Direct trauma or forced flexion
• Key distinction is Vertical (high
  energy/unstable) vs. Transverse
• O/E pain on DRE
• Dx
• AP pelvis, CT

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Vertical Sacral Fractures

• Denis Classification
• Zone 1lateral to sacral neural foramina (6 L5
  root injury)
• Zone 2through sacral neural foramina (28
  sciatic injury)
• Zone 3medial to sacral neural foramina (50
  bowel/bladder, sexual dysfunction)

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Transverse Sacral Fractures

• Potential for neurologic injury depends on level
  of line
• Nerve root injury uncommon below S4
• High incidence of neuro deficit if line above
  S2

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Sacral Fractures

• Treatment of High-Energy Vertical ABCs etc.
  Surgical stabilization
• Treatment of Transverse
• Neuro deficits ? urgent spine consult
• No neuro deficits ? ice, bed rest, analgesia
  ortho f/u in 1 week

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Coccyx Fractures

• Mechanism
• Fall in seated position
• Presentation
• Pain w/ sitting, standing, or defecating
• Local tenderness
• Dx
• Clinical. X-rays not needed! (pain on compression
  during DRE)
• Tx
• --rest, ice, donut-ring cushion, stool softeners
• Coccygectomy if persistent chronic pain

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CASE

• 13 yo boy presents with pain in his hip after
  kicking a soccer ball

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Avulsion Fractures

• Mechanism
• Forced contraction of muscle avulsing bony
  fragment (soccer gymnastics)
• Most common types
• Ischial tuberosity ? hamstring
• ASIS avulsion ? sartorius
• AIIS ? rectus femoris
• Tx
• RICE, crutches (for comfort), f/u w/ family MD
• IT hip ext ASIS AIIS hip flex
• gt2 cm displacement surgery

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CASE

• 53 year old German female presents with pain in
  her groin after having fallen skiing.
• Mechanism landed and fell back onto
  buttocks/tail bone.

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Isolated Ramus Fracture

• Mechanism
• Fall in elderly stress in young athlete
• Presentation
• Inability to ambulate, local pain
• TX
• Ice, rest, analgesics, crutches with progressive
  weight bearing.

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Sup and Inf Rami (unilateral)

• Generally Stable
• Conservative management
• Look for complicating associated injuries
  posterior pelvic impaction, SI joint injury,
  acetabular (may need CT to identify these)

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Sup and Inf Rami (bilateral)

• Straddle
• GU injuries common!
• CT pelvis needed to plan surgical mgmt
• Consult ORTHO
• Tx SURGERY

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• What is the name
• of this type of ??

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Duverney (Iliac Wing) Fracture

• Mechanism
• Direct trauma
• Presentation
• Localized pain, swelling, tenderness
• abdominal tenderness
• Associated acetabular
• Dx
• AP pelvis
• Tx
• Minimally displaced ? ortho f/u in 1 week, rest,
  ice, strapping
• Severely displaced ? ORIF
• Concerning abdo exam? CT abdo/pelvis

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Hip Dislocations

• 3 Types
• Posterior (80)gtgtAnteriorgtgtCentral
• Associated injuries
• -dislocation with femoral head or acetabulum
• Sciatic nerve (posterior) Femoral nerve/vessels
  (anterior)
• Mechanism
• Adults MVA (high energy), polytrauma (assoc knee
  injuries)
• Elderly/Prosthetics/Kids low energy

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Hip Dislocations--Presentations

• Anterior Dislocation
• extremity in abduction/external rotation (similar
  to fem neck )
• Posterior Dislocation
• extremity shortened, internally rotated, adducted
• DX AP/Lateral Pelvis.

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Hip Dislocations

• Treatment
• Orthopedic Emergency!
• ABCs/initial stabilization
• R/O associated life threatening injuries
• Risk of AVN increases in direct proportion to
  delay in adequate reduction
• Simple (ie. no ) Ant/Post dislocations should be
  reduced urgently in ED using Allis, Stimson or
  Whistler maneuvers

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Post Reduction Allis Method
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Post Reduction Stimson Method
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Hip Dislocations

• Call Ortho for irreducible dislocations
  (incarcerated tendon, intra-articular
  osteochondral fragment)
• Post Reduction
• Obtain post reduction films (including CT if
  associated acetabular or other pelvic injury)
• Check ROM to ensure stability of the hip,
  neurovascular status
• Simple dislocation w/out zimmer x 1wk,
  crutches w/ weight bearing as tolerated and ortho
  f/u

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Hip Dislocations-Special Circumstances

• Associated Femoral Head
• More common w/ anterior
• Can still attempt closed reduction
• Consult ortho
• Hip Prosthesis
• Consult ortho
• No time urgency as AVN not an issue

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Injuries to the Femur

• Anatomy
• Fem Head Acetabulum Ball and socket joint
• Fibrous capsule extends from acetabulum to
  intertrochanteric line
• Blood supply to femoral head from med and lat
  femoral circumflex arteries, branch of obturator
• Vessels course beneath reflection of capsule and
  along ligamentum teres (less important)
• Easily disrupted with leading to AVN

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Injuries to the Femur

• History
• AMPLE
• Hx of Osteoporosis?
• Hx of Steroids? (RF for AVN)
• Hx of Cancer, Radiation, Chemo? (pathologic )
• Medical causes for falls? (syncope etc.)

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Injuries to the Femur

• O/E
• Inspect pelvis/hip/knee
• Neurovascular status (fem nerve/artery in
  subtrochanteric or shaft sciatic nerve in hip
  or dislocations)
• Assess for open
• Imaging
• AP
• Lateral

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Injuries to the Femur

• General Management
• ABCs and initial stabilization
• Type and Crossmatch (can lose 3L of blood w/
  shaft )
• Pre-hospital Hare or Sager traction splints for
  shaft or subtrochanteric
• Contraindications to traction open , nerve
  injury, femoral neck (may further compromise
  blood flow)

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Injuries to the Femur

• Open Fractures
• Type I lt 1cm (Ancef)
• Type II gt 1 10 cm (Ancef Gent)
• Type III gt 10 cm (Ancef Gent)
• Irrigate and cover w/ saline guaze
• Tetanus
• Splint Consult

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Injuries to the Femur

• Classification of Hip Fractures
• 1. Intracapsular
• Femoral head
• Femoral neck
• 2. Extracapsular
• Greater or Lesser Trochanter
• Intertrochanteric
• Subtrochanteric

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Injuries to the Femur
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Femoral Head Fractures

• Infrequently in isolation
• Usually in conjunction w/ dislocation
• Types capital, depression, shear
• Consult Ortho
• Treatment
• If associated dislocationattempt reduction in ED
• ORIF if failure to reduce

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Femoral Head Fractures

• Treatment (Buckley)
• Non-displaced, stable limited weight bearing
  with crutches for 6 weeks
• Displaced (gt2mm) head fragment, or associated
  femoral neck or acetabular ORIF

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Femoral Neck Fractures

• Garden Classification
• Types
• Subcapital vs. Transcervical
• All are intracapsular (precarious blood supply)

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Femoral Neck Fractures

• Mechanism minor trauma in elderly
  (osteoporosis) high energy in young
• Presentation ranges from limp and mild groin
  pain (non-displaced ) to unable to weight bear
  w/ externally rotated, abducted and shortened
  limb

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Femoral Neck Fractures

• Dx AP/Laterallook for disruption of Shentons
  Line, Trabecular network, Normal and Reverse S
• Significant hip pain w/ weight bearing and normal
  radiographs possible occult fem neck , may
  need CT or MR to diagnose
• Treatment Analgesia in ED, ORIF
• Complications AVN, non-union, osteomyelitis,
  emboli

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• What type
• of is
• this?
• Donk Sign

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Trochanteric Fractures

• Greater Trochanter
• Direct trauma vs. avulsion of gluteus medius
• Pain with abduction/extension
• Tender to palp over greater troch
• TX
• Conservative, gradual weight-bearing until
  asymptomatic
• gt1cm displaced ortho consult for fixation

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Trochanteric Fractures

• Lesser Trochanter
• Avulsion of iliopsoas
• Pain w/ flexion/internal rotation
• TX
• Conservative, gradual weight bearing
• gt2cm displaced ortho for screw fixation

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• What
• type of
• is this?

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Intertrochanteric Fractures

• Extracapsular, thus less risk of AVN
• Fall in elderly
• High energy force in young
• TX
• ABCs analgesia
• Exclude other life threatening injuries
• ORTHO for Dynamic Hip Screw fixation
• Complications non-union, infection, blood loss

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• Type
• Of
• ?

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Subtrochanteric Fractures

• Occur b/w the lesser trochanter and proximal 5 cm
  of femoral shaft
• Elderly fall in osteoporotic bone, pathological
  s
• Young high energy trauma
• Comminution and deformity common
• TX ABCs, Ortho for ORIF
• Complications hemodynamic instability, fat
  embolus, non-union

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Femoral Shaft Fractures

• Young w/ high energy trauma (falls, MVAs, gunshot
  etc.)
• Classification transverse, oblique, spiral,
  wedge, comminuted
• 50 have assoc. ligamentous damage to knee
• TX ABCs (significant hemorrhage can occur)
• Look for other life threatening injuries
• Traction splints in pre-hospital setting
• Ortho for ORIF (IM rod) vs. plating for
  comminuted (union rates approach 100)

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Case

• 68y male injured in MVC
• c/o left leg pain

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Case continued

• Type of ?

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Distal Femur Fractures

• Supracondylar, Intracondylar (intra-articular),
  Condylar (intra-articular)
• Isolated, T or Y pattern

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Distal Femur Fractures
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Distal Femur Fractures

• Tx ABCs
• Check neurovascular exam.
• ( in close proximity to femoral and popliteal
  arteries!may need angio if in question)
• Splint and consult Ortho
• All require ORIF (per Buckley)

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Distal Femur Fractures

• Complications
• thrombophlebitis
• fat embolus syndrome
• delayed union or malunion if reduction is
  incomplete or not maintained
• intraarticular or quadriceps adhesions if the
  fracture is intraarticular
• angulation deformities
• osteoarthritis

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Knee Injuries

• Fractures
• 1. distal femur (covered already)
• 2. patellar
• 3. proximal tibia
• 4. proximal fibula
• Soft Tissue Injuries
• Dislocations (patellar, tib-fem), Ligamentous and
  Meniscal injuries

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Anatomy

• Main joints
• Patellofemoral
• Tibiofemoral
• Main bones
• Distal Femur
• Patella
• Proximal tibia
• (fibula head)

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Knee Anatomy

• Medial Stabilizers of the Knee
• MCL, joint capsule, semimembranosus, pes
  anserinus
• Lateral Stabilizers of the Knee
• LCL, joint capsule, IT band, biceps tendon,
  popliteal arcuate complex

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Knee Injuries

• DDX of Anterior Knee Pain
• Plateau/Patellar
• Pre-patellar Bursitis
• Quads/Patellar Tendonitis
• Patellofemoral Pain Syndrome
• Chondromalacia Patellae
• Osgood Schlatters
• Plica
• Meniscal injury
• Ligamentous injury
• Osteochondritis Dessicans
• Synovial Chondrinosis

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Knee Injuries

• DDX of Hemarthrosis
• ACL
• PCL
• Meniscal tear
• Osteochondral
• Capsular tear
• BUT NOT MCL nor LCL!

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Knee Injuries--History

• AMPLE
• Mechanism particularly important
• Hx of prior knee injuries, surgeries
• Inability to weight bear
• Locking (meniscus vs. intra-articular body)
• Giving Way (ligamentous vs. meniscus)
• Pop! (ACL)

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Knee Injuries--Examination

• COMPARE TO HEALTHY KNEE
• Inspection (swelling, bruising, deformity)
• Palpation (joint line tenderness? effusion?
  point tenderness?)
• ROM
• Ligamentous/Meniscal Stress Testing

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Ligament/Meniscal Stress Testing

• Anterior Drawer (ACL) not reliable.
• FN effusion, hamstring spasm, technique
• FP PCL injury
• Lachmans Test (ACL) reliable, even in acute.
• Posterior Drawer (PCL)
• McMurrays Test (Meniscal) int rotation
  stresses lateral meniscus, ext rotation stresses
  medial meniscus
• Collateral Ligament Stress (MCL, LCL)

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Knee Injuries--Imaging

• Standard XR Views
• AP
• Lateral (fat fluid level lipohemarthrosis
  intra-articular )
• Oblique (tibial plateau)
• Special XR Views
• Tunnel (intercondylar region, tibial spines)
• Skyline (patellar)
• CT helps fully delineate extent of tib plateau
• MR meniscal, ligamentous
• U/S popliteal cysts, popliteal aneurysms

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CASE

• 28 year old MOBHOB (Huffman, 2007)
• Beaten about legs by some jerk yielding a bat.
• Tender in several places.
• X-ray shows

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Fractures of the Patella

• Mech direct blow vs. avulsion (forceful
  contraction of quads)
• Classification transverse (most common),
  vertical, comminuted, avulsion-type
• O/E-focal tenderness, swelling. NEED to check
  extensor mechanism via straight-leg
• XR- watch for normal variants (bipartite)

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Fractures of the Patella

• TX extra-articular, non-displaced, in-tact
  extensor mechanism Zimmer splint (vs. long-leg
  cast) x 4 wks, progressive wt bearing, isometric
  exercises, passive ROM
• displaced gt3mm and involving articular surface,
  inadequate extensor mechanism, comminuted ORIF
  (tension band wire w/ suturing of retinaculum)

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CASE

• 65 year old female from Japan presents post fall
  skiing.
• Had collided with a snowboarder.
• Knee had twisted (external rotation of leg)
• Felt pop.

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Fractures of the Tibial Spines

• Tib spine intercondylar eminence consists of
  medial and lateral tubercle
• Anteriorly ACL, ant horns of menisci
• Posteriorly PCL, post horns of menisci
• Anterior injury 10x more common than posterior
• Results in cruciate ligament instability/tear
• Mech AP force against the proximal tibia while
  in flexion (MVA, sports), twisting, hyperflexion,
  hyperextension

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Fractures of the Tibial Spines

• Type I--incomplete avulsion, no displace
• Type II--incomplete avulsion, displace of
  anterior but not post
• Type III--complete displacement (/- rotation)

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Fractures of Tibial Spines

• O/E hemarthrosis, inability to extend fully
• Lachman if anterior spine
• XR AP/Lateral/may need tunnel view
• TX incomplete or non-displaced immobilize in
  full extension (competitor), protected weight
  bearing, ortho f/u
• Complete, displaced ortho consult for ORIF vs.
  arthroscopic to restore normal ACL function

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CASE

• 35 yo woman presents with pain in her knee,
  unable to weight bear after having gone off a
  jump skiing, landed on flat surface
• XR shows the following

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Fractures of the Tibial Plateau

• Mech valgus/varus force combined with axial
  load, driving femoral condyles into articulating
  surface of tibia VS. direct blow
• Lateral plateau gt medial plateau
• May have assoc. ligamentous injury
• O/E pain, swelling, decrease ROM, assess
  neurovascular (high incidence of popliteal a.
  inj)
• XR often is difficult to detect, may only show
  lipohemarthrosis on lateral, CT if needed

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Fracture of the Tibial Plateaus

• Segond fracture
• Bony avulsion off the lateral tib plateau
  (lateral capsular sign)
• Strong association w/ ACL disruption

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Fractures of the Tibial Plateau

• TX
• Non-displaced, no depression of articular surface
  knee immobilizer, elevation x 24-48 hrs, ortho
  f/u, non-weight bearing x 6-8 weeks
• Displaced gt2mm, depressed articular surface
  surgery

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Ligamentous Injuries of the Knee

• Grading of Ligamentous Sprains
• Grade I Pain but no laxity
• Grade II Laxity w/ firm end point
• Grade III Laxity w/out firm end point
• Cruciate ligament injuries often accompany
  collateral ligament injuries!

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Ligamentous Injuries of the Knee

• Medial Collateral Ligament (MCL)
• Mech valgus force
• Dx pain or laxity w/ valgus stress
• TX non-operative, knee immobilizer (2 wks) then
  hinge brace (8 wks), weight bearing as tolerated
  (will likely need crutches early on), RICE
• Ultimately physio/quad strengthening

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Ligamentous Injuries of the Knee

• Lateral Collateral Ligament (LCL)
• Mech hyperextension varus force
• DX pain or laxity w/ varus stress
• TX conservative as per MCL

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Ligamentous Injuries of the Knee

• Anterior Cruciate Ligament (ACL)
• Mech pivoting, rotation w/ valgus stress,
  hyperextension
• DX Lachman hemarthrosis in 70 pop in 70
  watch for assoc. injuries (50 have meniscal
  tears) Segond
• TX Initially conservative ROM limiting brace
  weight bearing as tolerated long-term
  hamstring strenghtening/brace vs. reconstruction

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Ligamentous Injuries of the Knee

• Posterior Cruciate Ligament (PCL)
• Mech dashboard (MVA) w/ direct blow to anterior
  tibia hyperflexion hyperextension
• DX posterior drawer, posterior sag
• TX non-operative unless persistent instability
  post rehab/quads strengthening or other
  associated injuries (meniscal tear, combined
  ligamentous injury etc.)

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Meniscal Injuries

• Medial 2x more common (and posterior peripheral
  aspect)
• Damage associated with early OA
• Avascular except peripheral 1/3
• MECH twisting on weight-bearing knee
• Associated with MCL/ACL (Terrible Triad!)

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Meniscal Injuries

• HX painful locking that prevents further
  activity clicking, giving way
• DX joint-line tenderness McMurrays (somewhat
  useless)
• TX Conservative (RICE/NSAIDS)outpt f/u
• LOCKED KNEE (?attempt reduction w/ procedural
  sedation). Needs surgery w/ in 2 weeks consult
  ortho.

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CASE

• 40 year old obese male skier
• Fell and had immediate pain in his knee.
• Unable to weight bear.

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Tibial-Femoral Knee Dislocation

• Types Anterior, Posterior, Medial, Lateral
• MECH sporting accidents, falls
• High incidence of popliteal artery injury,
  peroneal nerve injury, compartment
• Normal pulses do not r/o vascular injury
• TX Immediate reduction (longitudinal traction),
  Zimmer splint and Ortho consult for surgical
  stabilization

136
Tibial-Femoral Knee Dislocation

• Check neurovascular pre- and post
• Absent pulse (post) Immediate Vascular Surgery
  Consult reposition/relocate
• Decreased or absent pulse pre w/ return post
  Angio
• Pulse present pre and post serial exams vs.
  ANGIO ALL (per Betzner)

137
Patella Dislocation

• Patella displaced laterally over lateral condyle
  (most common)
• Mech twisting on extended knee
• TX Reduction in ER (/- under sedation)
• XR post reduction to r/o
• Zimmer x 1 wk with crutches. Then knee sleeve x 3
  weeks with progressive weight bearing, gentle ROM
  and isometric quad strengthening

138
Soft Tissue Injuries

• Patellar Tendonitisoveruse-pain to palp over
  inferior pole--tx conservative
• Osteochondritis Dissecansidiopathic--articular
  cartilage and subchondral bone dislodgedtx
  epiphyses open protective weight bearing.
  epiphyses closed arthroscopy
• Quads/Patellar Tendon Ruptureviolent contraction
  of quadstx surgical repair
• Bakers Cystaspiration, surgical, vs. resolution

139
Soft Tissue Injuries

• Chondromalacia Patellaesoftening of articular
  cartilage secondary to patellofemoral
  malalignment/abrnormal tracking of patella. Tx
  Rest/NSAIDS/quadship strengthening/brace
• Plicaredundant folds of synovium that become
  inflammed. Leads to pain/stiffness.
• Dx clinical/exclusion Tx conservative
• Osteonecrosisbony infarction. Spontaneous vs.
  secondary causes (steroids, SLE, EtOH, Sickle
  etc). Dx-MRI (XR normal). Tx-Earlyprotected
  weight bearing/NSAIDS. Advanceddebridement/bone
  graft/TKA

140
Leg Injuries
141
Leg Injuries-Anatomy

• Bones Tibia/Fibula
• 4 compartments
• 1. Anterior--ant tib artery, deep peroneal nerve
  (dorsiflexion sensory web space of 1st and 2nd
  toes)
• 2. Lateralsuperficial peroneal nerve (foot
  eversion sensory lateral dorsal foot)
• 3. Superficial Posteriorankle plantar flexors
  (gastroc, soleus), sural nerve lateral heel
  sensation
• 4. Deep Posteriorpost tibial artery tibial
  nerve toe plantar flexors, sensation to sole of
  foot

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Fibular Fractures

• Proximally attachment for LCL, biceps femoris
  tendon
• Common peroneal wraps around fibular head
• Usually in setting of to Tibia
• Mech direct trauma vs. twisting on planted foot,
  inversion or eversion of ankle
• Only bears 15 of body weight, thus pts can often
  ambulate with isolated

144
Fibular Fractures

• ED Tx ABCs neurovascular assess for knee/ankle
  injuries stirrup splint to prevent varus/valgus
  stress x 3-4 wks RICE crutches if needed for
  pain
• Consult Ortho for lateral compartment
  syndrome/peroneal nerve injury comminuted ,
  associated tibial , badly displaced , assoc
  knee/ankle joint injuries

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Tibial Shaft Fractures

• Major weight bearing bone!
• Open s common due to superficial location
• Watch for compartment syndrome

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Tibial Shaft Fractures

• ED TX ABCs, neurovascular exam close inspection
  to r/o open analgesics long-leg posterior
  splint and consult Ortho
• Definitive Tx ORIF/IM rod VS.
• Consider long-leg cast (metatarsal heads to upper
  thigh) and non-weight bearing IF displaced lt5mm,
  rotated lt10 degrees, angulated lt10 degrees and
  not shortened

148
Ankle Injuries

• Anatomy of an Ankle
• 3 Primary Joints
• Medial malleolus w/medial talus
• Tibial plafond w/ talar dome
• Lat malleolus w/ lat talus
• 3 Bones
• Tibia, Fibula and Talus
• 3 sets of Ligaments
• Lateral collaterals (ATFL, CFL, PTFL)
• Syndesmotic Ligaments
• Medial collaterals (Deltoid)

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Ankle Injuries

• History location of pain, swelling, ability to
  weight bear at time, audible pop
• Exam Neurovascular status! (Reduce prior to
  imaging if absent pulse!)
• Inspect swelling, bruising, deformity
• Palp location of tenderness (Ottawa Ankle/Foot
  Rules)
• ROM active/passive
• Stress of Ligaments (after r/o)
• Squeeze Test (checking syndesmotic ligs)

152
Ankle Injuries

• OTTAWA ANKLE RULES
• X-ray if
• Pain in malleolar zone and 1 of
• Inability to weight bear 4 steps both immediately
  and at time of evaluation
• Bony tenderness at post edge of distal 6 cm of
  either the lateral or medial malleolus

153

• Approach to Ankle
• Go through complete approach (ABCs)
• 3 views- AP, lat, Mortise (15-20 int rot) ankle,
  
• Direct evidence of injury assess bones
• Indirect evidence of injuries are all ankle
  measurements normal? Joint effusion?

154
Ankle Fractures

• What are stable fractures?
• Ankle forms a ring
• Disruption of only 1 structure
• is stable
• Disruption of gt 1 is unstable
• Assymetry in gap between
• talar dome and malleoli
• on mortis view unstable

155
Ankle Fractures

• Management of Stable Fractures
• Chip/Avulsion s lt3mm Tx as Sprain (ie. WBAT,
  RICE, NSAIDS, Early ROM/physio)
• Chip/Avulsions gt3mm splint and f/u with Ortho
• Non-displaced, non-intra-articular, stable s
  2 wks NWB cast, 3-5 wks WB cast. Ortho f/u in 1
  wks to ensure hasnt slipped

156
Ankle Fractures

• Indications for Immediate Reduction Prior to X
  Ray
• Neurovascular compromise
• Gross Deformity
• Skin Tenting

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Ankle Fractures

• Ortho Consultation for the Following
• Open
• Pilon
• Bimalleolar/Trimalleolar
• Lateral Malleolar (Weber B and C)
• Lateral Malleolar Weber A2, A3 (some will
  fix/some will cast)
• Isolated Medial Malleolar with significant
  displacement
• Isolated Posterior Malleolar with significant
  displacement

158
Diagnosis?Classification?Treatment? Does it
change you mgmt if they have a tender deltoid
ligament?
159
Lateral Malleolar Fractures

• Stability depends on location of to tib-talar
• Danis-Weber Classification (A,B,C)
• A below tibiotalar joint
• A1 no deltoid (medial) tenderness, no post
  malleolar
• A2 w/ deltoid (medial) tenderness
• A3 w/ post malleolar
• B at the level of tibiotalar joint
• C above the tibiotalar joint

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Lateral Malleolar Fractures

• Treatment
• Weber A1 (stable) NWB x 2 wks (below knee
  plaster, fiberglass, or air cast) then WBAT w/
  air cast x 3 wks f/u with Ortho in 1 wk
• Weber A2 Consult Ortho (some will fix
  surgically, some will cast). Do stress view to
  see if mortis opens up.
• Weber A3 Bimalleolar Ortho for surgery

161
Lateral Malleolar Fractures

• Treatment
• Weber B consult Ortho 50 have injury to
  syndesmosis and widening of medial joint space
• Weber C consult Ortho frequent injury to
  syndesmosis

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Type of Fracture?
163
Medial Malleolar Fractures

• Commonly associated with lateral or posterior
  malleolar disruption Ortho
• Significant displacement Ortho
• R/O Maisonneuves Ortho
• Minimally displaced NWB (below knee cast) x 2
  wks WBAT w/ walking boot x 3-5 wks f/u w/ Ortho
  at 1 wk

164
TRIVIA TIME

• Name of the rare variation of a Maisonneuve
  Fracture in which the proximal fibula gets
  trapped behind the tibia?

165
TRIVIA TIME

• Name of the rare variation of a Maisonneuve
  Fracture in which the proximal fibula gets
  trapped behind the tibia?
• The Bosworth Fracture!

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Posterior Malleolar Fractures

• Rarely in isolation
• Isolated, non-displaced, lt25 of joint surface
  cast NWB x 2 wks WBAT x 3-5 wks with air cast.
  Ortho f/u at 1 wk
• Otherwise consult Ortho

167
Diagnosis? Stable or unstable?
168
Bi or Tri-Malleolar s

• All unstable because of disruption of two or more
  elements of the ankle ring
• Syndesmosis injury is common
• All require Ortho consultation

169
Name of this type of fracture? Other associated
s?
170
Pilon Fractures

• Fall from height
• Talus driven into Tibial Plafond
• Distal Tibial Metaphysis s ( Fibula)
• 50 are open s!
• Associated s are common (calcaneus, tib-plateau,
  pelvis, C,T,L spine)
• ORTHO!

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The Foot (last section!)
172
HINDFOOT
talus
calcaneus
MIDFOOT
navicular
cuboid
Medial
cuneiforms
metatarsals
sesamoids
FOREFOOT
phalanges
173
Choparts
Lisfrancs
MTP
IP
174

• Type of
• Do you need to speak to Ortho?
• ?ottawa ankle rules

175
Talar s

• Osteochondral of Talar Dome
• X-rays commonly normal
• Ottawa Ankle Rules may miss these
• TX Cast or Splint and refer to Ortho as
  outpatient

176

• Describe ?
• At risk for??

177
Talar s

• At risk for AVN due to tenuous blood supply
• All talar fractures require Ortho f/u
• Minor (chip/avulsion of head,neck,body or
  osteochondral of talor dome) as outpatient
  after splinting (non-weight bearing Rigby)
• Major (the rest) in ED
• Per Buckley ORIF for any displaced , fractures
  w/ gt2mm gapping, loose osteochondral body

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10
180
Posterior tuberosity
apex of anterior process
apex of posterior facet
181
Calcaneal s

• Intra-articular vs. Extra-articular
• Calcaneus Management
• Order Harris (axial view), may need CT
• Probably should speak to Ortho for all since
  x-rays under-estimate extent of injury and tx
  varies considerably
• Butnon-displaced, extra-articular NWB cast x 6
  wks
• Intra-articular, displaced ? ORIF

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Sub-talar Dislocation

• Tibio-talar joint remains in tact
• Disruption of talonavicular and calcaneotalar
  joints
• Attempt reduction in ER and consult Ortho
• If successful, f/u x-rays (/- CT), short leg
  splint ortho f/u
• ORIF for irreducible dislocation, significant
  debris in joint space

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Navicular Fractures

• Rare
• Risk of AVN
• Tx
• Dorsal avulsion, tuberosity with minimal
  articular surface involvement walking cast x 6
  wks ortho f/u
• Body , displaced, gt 20 of articular surface
  ORIF

184

• Describe injury.
• Name this injury.
• Management?

185

• Describe injury.
• Name this injury
• Lisfranc
• Management?
• OR for any displacement of 1,2,3 metartarsal
  bases
• Fracture of the base of the 2nd metatarsal is
  pathognomonic

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Metatarsal Base s

• Metatarsal Base of Great Toe
• Consult Ortho
• Metatarsal Base s 2-4
• R/O Lisfranc injury.
• Recall 2nd metatarsal base is pathognomonic for
  Lisfranc.
• Non-displaced Below Knee Cast and f/u with
  Ortho
• Displaced Attempt reduction and consult Ortho

187

• What type of ?
• Treatment?

188

• JONES
• NWB cast (classic teaching) vs. weight bearing
  (Buckley)

189

• Describe.
• Management
• Walking cast x 2-3 weeks
• Avulsion type

190
Metatarsal Shaft Treatment

• Metatarsal Shaft s 2-5
• Nondisplaced or min displaced Treatments vary!
  stiff shoe, walking cast w/ WBAT, or cast w/ NWB
  x 4 wks.
• Displaced (gt3mm) or angulated gt10 degrees
  closed reduction w/ toe traps cast and NWB x 4-6
  wks. Consult ortho in ED

191
Metatarsal s

• Great toe metatarsal shaft
• Non-displaced NWB cast (its a major WB
  surface!) x 6 wks f/u with Ortho
• Displaced Attempt closed reduction and consult
  Ortho in ED (will likely pin)

192
Metatarsal Head and Neck s

• Non-displaced walking cast 4-6 wks
• Displaced (common) consult ortho re ? ORIF, as
  even if reduction achieved with toe traps they
  often slip

193
Phalangeal s

• Indication for surgery open , displaced
  intra-articular of Great Toe
• Otherwise reduce, buddy taping, protective
  orthosis, weight bearing as tolerated