Transcript pelvis and lower limb - Calgary Emergency Medicine

PELVIS AND LOWER
LIMB
Grant Kennedy
Objectives

To cover this huge topic adequately in just
over an hour.

Special thanks to Tintinalli, UTDOL, Dr.
Buckley, Rob and Shawn’s REMERGS web
page.
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 #

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)
Pelvic Anatomy
5 joints:
 Lumbosacral
 Sacroiliac (x2)
 Sacrococcygeal
 Symphysis

Pelvic Anatomy

Anterior Support:
– Symphysis pubis
 Fibrocartilaginous joint
covered by ant & post
symphyseal ligaments
– Pubic rami

Posterior Support:
– ~majority of stability
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Iliolumbar ligaments
Sacroiliac ligaments
Sacrospinous ligament
Sacrotuberous ligament
Vascular Anatomy

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Vessels lie close
to posterior
pelvic walls
Venous bleeding
most common
(sacral plexus)
Most commonly
injured arteries
are superior
gluteal and
internal pudendal
Pelvic Anatomy

Nerve supply through the pelvis derived
from lumbar and sacral plexuses

Other structures: lower GI/GU
History & Physical
AMPLE Hx
 Mechanism/Ambulating at Scene
 Numbness/Weakness/Bowel + Bladder Dysfxn

Inspect:
 Destot’s 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

History + Physical
Examine pelvis only once!

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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?)

Earle’s sign:
– Presence of bony prominence, palpable hematoma, or tender # line on
DRE
Imaging
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Plain films are NOT necessary in stable trauma
patient with no lower abdo-pelvic complaints,
normal exam and GCS >13
X Rays:
AP
Inlet/Outlet
Judet
CT Scan:
Evaluates extent of posterior injuries and
retroperitoneal bleeding, superior imaging of
sacrum and acetabulum, associated injuries
Imaging
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AP VIEW:
Identifies most fractures
Look for disruption in iliopubic and ilioischial
lines, sacral foramina, radiographic U, Shenton’s
Lines
Following are abnormal:
Symphysis >5mm
Vertical offset left vs. right rami (>1-2mm)
SI joint > 5mm

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.
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)
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

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

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

Pelvic Fractures
5 General Categories:
 1. Pelvic Ring
 2. Acetabular
 3. Sacral
 4. Avulsion type
 5. Single bone

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%)

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

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
Tile B1 / Young APC II
Young Classification System:

Vertical Shear (5%)
– Symphyseal diastasis or
vertical displacement
anteriorly and
posteriorly; usually
through SI joint,
occasionally through iliac
wing
Tile C1/ Young VS
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

Pelvic Fracture Management
Buckley:
 Full weight bearing for lateral compression
#s that lack significant deformity, isolated
pubic rami fractures
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Indications for surgery: ongoing
hemorrhage, displaced posterior pelvic
injury, symphysis diastasis >2.5 cm
Pelvic Fracture Management of
the Unstable Patient
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ABC’s & 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 disposition—laparotomy vs. angio)
AP pelvis
ABX (ancef) and Tetanus if open.
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
PELVIC BINDER
Benefits:
 Reduces pelvic volume (tamponade effect)
 Stabilizes # fragments
 Improves patient comfort

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)

Acetabulum
Forms the ‘socket’ for the femoral head
Fusion of 3 bones:
 1. iliac (superior dome—chief weightbearing surface)
 2. pubis (anterior-inferior—thin, easily
fractured)
 3. ischium (posterior-inferior-thick)

Acetabulum
Acetabulum
Also classically described as having 2
columns:
 1. Anterior column (anterior iliac wing,
superior pubic ramus, anterior wall of
acetabulum)
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2. Posterior column (ischium, ischial
tuberosity, posterior wall of acetabulum)
Acetabular Fractures
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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)
Acetabular Fractures
Judet Classification
 Simple Fractures:
 1. Posterior Wall
 2. Posterior Column
 3. Anterior Wall
 4. Anterior Column
 5. Transverse

Acetabular Fracture
Management
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ABCs
Neurovascular exam
Reduction of hip dislocation
Ortho consult
Admission
Buckley:
 Non-Displaced = non weight bearing x 6-8
weeks
 Displaced >2mm intra-articular = surgery
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
Vertical Sacral Fractures
Denis Classification:
 Zone 1—lateral to sacral neural foramina
(6% L5 root injury)
 Zone 2—through sacral neural foramina
(28% sciatic injury)
 Zone 3—medial to sacral neural foramina
(50% bowel/bladder, sexual dysfunction)

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
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
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
CASE

13 yo boy presents with pain in his hip
after kicking a soccer ball…
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
– >2 cm displacement = surgery
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’.
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.

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)

Sup and Inf Rami #
(bilateral)
Straddle #
 GU injuries common!
 CT pelvis needed to plan surgical mgmt
 Consult ORTHO
 Tx: SURGERY

What is the name
of this type of #??

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
Hip Dislocations
3 Types:
Posterior (80%)>>Anterior>>Central
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
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.
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

Post Reduction: Allis Method
Post Reduction: Stimson Method
Hip Dislocations
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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
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

Injuries to the Femur
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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
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.)

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 #
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Imaging:
AP
Lateral
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)

Injuries to the Femur
Open Fractures:
 Type I = < 1cm (Ancef)
 Type II = > 1 – 10 cm (Ancef + Gent)
 Type III = > 10 cm (Ancef + Gent)

Irrigate and cover w/ saline guaze
 Tetanus
 Splint + Consult

Injuries to the Femur
Classification of Hip Fractures:
 1. Intracapsular:
 Femoral head
 Femoral neck
 2. Extracapsular:
 Greater or Lesser Trochanter
 Intertrochanteric
 Subtrochanteric

Injuries to the Femur
Femoral Head Fractures
Infrequently in isolation
 Usually in conjunction w/ dislocation
 Types: capital, depression, shear
 Consult Ortho
 Treatment:
 If associated dislocation—attempt
reduction in ED
 ORIF if failure to reduce

Femoral Head Fractures
Treatment: (Buckley)
 Non-displaced, stable # = limited weight
bearing with crutches for 6 weeks


Displaced (>2mm) head fragment, or
associated femoral neck or acetabular # =
ORIF
Femoral Neck Fractures

Garden Classification
Types:
 Subcapital vs. Transcervical


All are intracapsular (precarious blood
supply)
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
Femoral Neck Fractures

Dx: AP/Lateral—look for disruption of Shenton’s 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
What type
 of # is
 this?
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Donk Sign
Trochanteric Fractures
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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
>1cm displaced: ortho consult for fixation
Trochanteric Fractures
Lesser Trochanter:
 Avulsion of iliopsoas
 Pain w/ flexion/internal rotation

TX:
 Conservative, gradual weight bearing
 >2cm displaced: ortho for screw fixation

What
 type of
 # is this?

Intertrochanteric Fractures
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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
Type
Of
#?
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

Femoral Shaft Fractures
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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%)
Case
68y male injured in
MVC
 c/o left leg pain

Case continued

Type of #?
Distal Femur Fractures

Supracondylar, Intracondylar (intraarticular), Condylar (intra-articular)

Isolated, T or Y pattern
Distal Femur Fractures
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)

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
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
Anatomy

Main joints:
– Patellofemoral
– Tibiofemoral

Main bones:
–
–
–
–
Distal Femur
Patella
Proximal tibia
(fibula head)
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

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


Knee Injuries
DDX of Hemarthrosis:
 ACL
 PCL
 Meniscal tear
 Osteochondral #
 Capsular tear


BUT NOT MCL nor LCL!
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)

Knee Injuries--Examination
COMPARE TO HEALTHY KNEE
 Inspection (swelling, bruising, deformity)
 Palpation: (joint line tenderness?
effusion? point tenderness?)
 ROM
 Ligamentous/Meniscal Stress Testing

Ligament/Meniscal Stress
Testing
Anterior Drawer (ACL): not reliable.
 FN = effusion, hamstring spasm, technique
 FP = PCL injury
Lachman’s Test (ACL): reliable, even in acute.
Posterior Drawer (PCL)
McMurray’s Test (Meniscal): int rotation
stresses lateral meniscus, ext rotation stresses
medial meniscus
Collateral Ligament Stress (MCL, LCL):
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
CASE

28 year old MOBHOB (Huffman, 2007)
Beaten about legs by some jerk yielding a
bat.
Tender in several places.
X-ray shows…
Fractures of the Patella
Mech: direct blow vs. avulsion (forceful
contraction of quads)
 Classification: transverse (most
common), vertical, comminuted, avulsiontype
 O/E-focal tenderness, swelling. NEED to
check extensor mechanism via straight-leg
 XR- watch for normal variants (bipartite)

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 >3mm and involving articular
surface, inadequate extensor mechanism,
comminuted = ORIF (tension band wire
w/ suturing of retinaculum)
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’.

Fractures of the Tibial
Spines
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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
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)

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

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…
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 > 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
Fracture of the Tibial
Plateaus
Segond fracture:
 Bony avulsion off the lateral tib plateau
(lateral capsular sign)
 Strong association w/ ACL disruption

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 >2mm, depressed articular
surface = surgery
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!
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

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

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

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.)

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!)

Meniscal Injuries
HX: painful locking that prevents further
activity; ‘clicking’, ‘giving way’
 DX: joint-line tenderness; McMurray’s
(somewhat useless)
 TX: Conservative (RICE/NSAIDS);outpt f/u
 LOCKED KNEE (?attempt reduction w/
procedural sedation). Needs surgery w/ in
2 weeks: consult ortho.

CASE
40 year old obese male skier…
 Fell and had immediate pain in his knee.
 Unable to weight bear.

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
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)

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

Soft Tissue Injuries
Patellar Tendonitis—overuse-pain to palp over
inferior pole--tx conservative
Osteochondritis Dissecans—idiopathic--articular
cartilage and subchondral bone dislodged—tx
epiphyses open = protective weight bearing.
epiphyses closed = arthroscopy
Quads/Patellar Tendon Rupture—violent
contraction of quads—tx surgical repair
Baker’s Cyst—aspiration, surgical, vs. resolution
Soft Tissue Injuries
Chondromalacia Patellae—softening of
articular cartilage secondary to patellofemoral
malalignment/abrnormal tracking of patella.
Tx= Rest/NSAIDS/quads+hip
strengthening/brace
 Plica—redundant folds of synovium that
become inflammed. Leads to pain/stiffness.
 Dx: clinical/exclusion Tx: conservative
 Osteonecrosis—bony infarction. Spontaneous
vs. secondary causes (steroids, SLE, EtOH,
Sickle etc). Dx-MRI (XR normal). TxEarly=protected weight bearing/NSAIDS.
Advanced=debridement/bone graft/TKA

Leg Injuries
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. Lateral—superficial peroneal nerve (foot eversion;
sensory = lateral dorsal foot)
3. Superficial Posterior—ankle plantar flexors
(gastroc, soleus), sural nerve = lateral heel sensation
4. Deep Posterior—post tibial artery; tibial nerve = toe
plantar flexors, sensation to sole of foot
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 #

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

Tibial Shaft Fractures

Major weight bearing bone!

Open #s common due to superficial
location

Watch for compartment syndrome
Tibial Shaft Fractures

ED TX: ABCs, neurovascular exam; close
inspection to r/o open #; analgesics; longleg 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 <5mm, rotated <10 degrees,
angulated <10 degrees and not shortened

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)
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)
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


Approach to Ankle
Go through complete approach (ABC’s)
 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?

Ankle Fractures
What are stable fractures?
 Ankle forms a ring

– Disruption of only 1 structure
is stable
– Disruption of > 1 is unstable
Assymetry in gap between
talar dome and malleoli
on mortis view= unstable

Ankle Fractures

Management of Stable Fractures:

Chip/Avulsion #s <3mm = Tx as Sprain (ie.
WBAT, RICE, NSAIDS, Early ROM/physio)

Chip/Avulsion#s >3mm = 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 # hasn’t slipped
Ankle Fractures

Indications for Immediate Reduction
Prior to X Ray:
Neurovascular compromise
 Gross Deformity
 Skin Tenting

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






Diagnosis?Classification?Treatment?
Does it change you mgmt if they
have a tender deltoid ligament?
Lateral Malleolar Fractures
Stability depends on location of # to tibtalar
 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
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

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

Type of Fracture?
Medial Malleolar Fractures
Commonly associated with lateral or
posterior malleolar disruption = Ortho
 Significant displacement = Ortho
 R/O Maisonneuve’s # = Ortho


Minimally displaced = NWB (below knee
cast) x 2 wks; WBAT w/ walking boot x 35 wks; f/u w/ Ortho at 1 wk
TRIVIA TIME

Name of the rare variation of a
Maisonneuve Fracture in which the
proximal fibula gets trapped behind
the tibia?
TRIVIA TIME

Name of the rare variation of a
Maisonneuve Fracture in which the
proximal fibula gets trapped behind
the tibia?

The Bosworth Fracture!
Posterior Malleolar
Fractures

Rarely in isolation

Isolated, non-displaced, <25% of joint
surface = cast + NWB x 2 wks; WBAT x 35 wks with air cast. Ortho f/u at 1 wk

Otherwise consult Ortho
Diagnosis? Stable or unstable?
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
Name of this type of fracture? Other
associated #s?
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!
The Foot (last section!)
HINDFOOT
talus
calcaneus
Medial
navicular cuboid
cuneiforms
metatarsals
FOREFOOT
sesamoids
phalanges
MIDFOOT
Choparts
Lisfrancs
MTP
IP
Type of #
Do you need to
speak to Ortho?
?ottawa ankle rules
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


Describe #?

At risk for??
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/ >2mm gapping, loose osteochondral body
10°
apex of
anterior process
Posterior
tuberosity
apex of
posterior facet
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
 But…non-displaced, extra-articular – NWB
cast x 6 wks
 Intra-articular, displaced ? ORIF

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

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, > 20% of articular
surface = ORIF

Describe injury.
 Name this injury.
 Management?

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
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



What type of #?

Treatment?

JONES #:

NWB cast (classic teaching) vs. weight
bearing (Buckley)
Describe.
Management
Walking cast x
2-3 weeks
Avulsion type #
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 (>3mm) or angulated >10 degrees =
closed reduction w/ toe traps; cast and NWB x
4-6 wks. Consult ortho in ED
Metatarsal #s
Great toe metatarsal shaft
 Non-displaced = NWB cast (it’s a major
WB surface!) x 6 wks; f/u with Ortho


Displaced = Attempt closed reduction and
consult Ortho in ED (will likely pin)
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

Phalangeal #’s

Indication for surgery: open #, displaced
intra-articular # of Great Toe

Otherwise: reduce, buddy taping,
protective orthosis, weight bearing as
tolerated