1. Lower Limb Injuries
February 2019

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

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

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

5. 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

6. 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!

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

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

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

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

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

12. Knee Injuries Fractures / dislocation Ligamentous injuries
Cartilage injuries

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

14. 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).

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

16. Tibial Plateau #
Analgesia
Long leg backslab
Orthopaedics

17. 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

18. 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.

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

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

21. 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

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

23. Tibial Fracture
Analgesia
Long leg backslab
Orthopaedics
Children?

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

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

26. 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.

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

28. 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

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

30. 5th Metatarsal Fracture
Commonest # metatarsal
Base of 5th: Twisting of foot / ankle: avulsion fracture.
Direct blow may break it anywhere.

31. Analgesia, support
Fracture clinic follow up
Direct discharge?

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

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

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

35. 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

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

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