Lower Limb Injuries February 2019

Lower Limb Trauma Secondary survey? Hip to Toes Bones / Soft tissues Open / Closed injuries Local / distal Early / Late

Lower Limb Trauma Look Feel Move Neurovascular Other occult injuries? Treatment ?Pathological (# or cause)

Lower Limb Trauma Common / important lower limb injuries: NOF # Femoral # Knee Tibial plateau Fibula head Tibia Ankle Foot

Lower Limb Trauma Common / important lower limb injuries: NOF # Femoral # Knee Tibial plateau Fibula head Tibia Ankle Foot Look Feel Move Neurovascular Other occult injuries? Treatment ?Pathological

Lower Limb Trauma Pitfalls! Common / important lower limb injuries: NOF # Femoral # Knee Tibial plateau Fibula head Tibia Ankle Foot Look Feel Move Neurovascular Other occult injuries? Treatment ?Pathological Pitfalls!

Neck of Femur Typically due to a fall in the elderly. Leg deformity? Other signs? Blood supply Delayed presentation (impaction)

Neck Of Femur Fast track orthopaedics Bloods, analgesia, ivi, ECG Block Remember – why have they fallen?

Femoral Fracture Typically due to significant trauma in young. Signs Tender, palpable bone, abnormal movements. Other injuries – mechanism.

Femoral Fracture ABC iv access, fluids, bloods (inc. x-match) Analgesia Thomas splint Orthopaedics

Fat Embolus Suspect the unexpected Long bone fractures - and others Looks like a PE CxR changes

Knee Injuries Fractures / dislocation Ligamentous injuries Cartilage injuries

Knee Injuries Swelling / effusion, bruising, deformity Tenderness Full ROM? SLR? Abnormal movements / ligamentous injury Neurovascular Investigation

Ottowa Knee Rules XRAY Only required if: Age 55 or over Isolated tenderness of the patella (no bone tenderness of the knee other than the patella) Tenderness at the head of the fibula Inability to flex to 90 degrees Inability to weight bear both immediately and in the department (4 steps - unable to transfer weight twice onto each lower limb regardless of limping).

Patella # Analgesia, immobilisation. May need ORIF (esp transverse fractures) Bipartite patella

Tibial Plateau # Analgesia Long leg backslab Orthopaedics

Patella dislocation Reduce under analgesia e.g. entonox Use thumbs to lever patella back into place Cylinder POP / cricket pad splint Quads exercises Fracture clinic

Ligament injuries ACL – prevents tibia sliding forward relative to femur. +ve anterior draw PCL – prevents tibia sliding back relative to the femur. +ve posterior draw Effusion, instability.

Ligament injuries MCL – valgus load Localised swelling, bruising, tenderness. Joint opens up when stressed. LCL may be damaged in a similar way.

Meniscal injuries Usually due to twisting the knee while weight bearing Painful (especially on knee extension) Locking / giving Effusion Special tests

Fibula Head May be secondary to direct blow, tibial plateau #, ankle twisting injury. Bruising, swelling, tenderness. Look for common peroneal nerve injury – inability to dorsiflex and evert, decreased sensation dorsum of foot and lateral calf

Tibial # Usually due to direct blow (transverse/oblique #) or twisting injury (spiral #) May be visible swelling, deformity, bruising. Tender, often palpable bone edges.

Tibial Fracture Analgesia Long leg backslab Orthopaedics Children?

Ankle Fractures Usually due to inversion / eversion injuries Inability to weight bear:? Swelling, bruising, deformity. Tenderness – bony or ligamentous

Ottawa Rules Site of bony tenderness Unable to weight bear Ankle Foot Neck of fibula Unable to weight bear

Ankle fractures Classification: Weber A: transverse fibula avulsion, below the level of the syndesmosis. Should be stable. Weber B: Lateral malleolar fracture at the level of syndesmosis. May be unstable. Weber C: High fibula fracture, syndesmotic disruption and medial malleolar fracture. Usually unstable.

Ankle fractures Stable unimalleolar fractures – B/K POP and fracture clinic Unstable fractures will need orthopaedics for ORIF Indications for ED reduction…

Maisonneuve Fracture Proximal fibular fracture coexisting with a medial malleolar fracture or disruption of the deltoid ligament. Partial or complete syndesmosis disruption. Always check joint above & joint below

Foot Fractures Deformity, swelling, bruising. Tenderness Ottawa rules for x-rays

5th Metatarsal Fracture Commonest # metatarsal Base of 5th: Twisting of foot / ankle: avulsion fracture. Direct blow may break it anywhere.

Analgesia, support Fracture clinic follow up Direct discharge?

Calcaneal fracture Swelling, bruising, tenderness around heel. Usually due to high energy impact e.g. fall. Look for other injuries

Calcaneal fracture Bohler’s angle should be 35-40° Refer to orthopaedics as most will need admission for analgesia, elevation +/- CT and ORIF

Open fractures More likely to be tibial May not be! Prognosis depending on tissue loss Principles the same

Control haemorrhage with direct pressure Analgesia, splintage Remove obvious contaminants if possible Photo wound ID, verbal consent, photograph card Iodine dressings and i.v. ABX +/- tetanus

Finally… POP: Backslab Compartment syndrome VTE Risk assess: # clinic forms Dalteparin

Summary Mechanism of injury Look Feel Move ?xray Analgesia, analgesia, analgesia