Lower Limb Trauma: Injuries and Management Overview
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February 2019
February 2019
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Secondary survey?
Secondary survey?
Hip to Toes
Hip to Toes
Bones / Soft tissues
Bones / Soft tissues
Open / Closed injuries
Open / Closed injuries
Local / distal
Local / distal
Early / Late
Early / Late
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Look
Look
Feel
Feel
Move
Move
Neurovascular
Neurovascular
Other occult injuries?
Other occult injuries?
Treatment
Treatment
?Pathological (# or cause)
?Pathological (# or cause)
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Common / important lower limb injuries:
Common / important lower limb injuries:
–
NOF #
NOF #
–
Femoral #
Femoral #
–
Knee
Knee
–
Tibial plateau
Tibial plateau
–
Fibula head
Fibula head
–
Tibia
Tibia
–
Ankle
Ankle
–
Foot
Foot
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Common / important lower limb injuries:
Common / important lower limb injuries:
–
NOF #
NOF #
–
Femoral #
Femoral #
–
Knee
Knee
–
Tibial plateau
Tibial plateau
–
Fibula head
Fibula head
–
Tibia
Tibia
–
Ankle
Ankle
–
Foot
Foot
•
Look
Look
•
Feel
Feel
•
Move
Move
•
Neurovascular
Neurovascular
•
Other occult injuries?
Other occult injuries?
•
Treatment
Treatment
•
?Pathological
?Pathological
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Common / important lower limb injuries:
Common / important lower limb injuries:
–
NOF #
NOF #
–
Femoral #
Femoral #
–
Knee
Knee
–
Tibial plateau
Tibial plateau
–
Fibula head
Fibula head
–
Tibia
Tibia
–
Ankle
Ankle
–
Foot
Foot
•
Look
Look
•
Feel
Feel
•
Move
Move
•
Neurovascular
Neurovascular
•
Other occult injuries?
Other occult injuries?
•
Treatment
Treatment
•
?Pathological
?Pathological
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!
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Typically due to a fall in the elderly.
Typically due to a fall in the elderly.
Leg
Leg
deformity?
deformity?
Other signs?
Other signs?
Blood supply
Blood supply
Delayed presentation (impaction)
Delayed presentation (impaction)
N
N
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k
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O
O
f
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Fast track orthopaedics
Fast track orthopaedics
Bloods, analgesia, ivi, ECG
Bloods, analgesia, ivi, ECG
Block
Block
Rememb
Rememb
e
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r – why have they fallen?
r – why have they fallen?
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Typically due to significant trauma
Typically due to significant trauma
in
in
young
young
.
.
Signs
Signs
Tender, palpable bone, abnormal
Tender, palpable bone, abnormal
movements.
movements.
Other injuries –
Other injuries –
mechanism.
mechanism.
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ABC
ABC
iv access, fluids, bloods (inc. x-match)
iv access, fluids, bloods (inc. x-match)
Analgesia
Analgesia
Thomas splint
Thomas splint
Orthopaedics
Orthopaedics
Fat Embolus
•
Suspect the unexpected
•
Long bone fractures - and others
•
Looks like a PE
•
CxR changes
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Fractures / dislocation
Fractures / dislocation
Ligamentous injuries
Ligamentous injuries
Cartilage injuries
Cartilage injuries
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Swelling / effusion, bruising, deformity
Swelling / effusion, bruising, deformity
Tenderness
Tenderness
Full ROM? SLR?
Full ROM? SLR?
Abnormal movements / ligamentous
Abnormal movements / ligamentous
injury
injury
Neurovascular
Neurovascular
Investigation
Investigation
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XRAY Only required if:
XRAY Only required if:
Age 55 or over
Age 55 or over
Isolated tenderness of the patella (no bone tenderness
Isolated tenderness of the patella (no bone tenderness
of the knee other than the patella)
of the knee other than the patella)
Tenderness at the head of the fibula
Tenderness at the head of the fibula
Inability to flex to 90 degrees
Inability to flex to 90 degrees
Inability to weight bear both immediately and in the
Inability to weight bear both immediately and in the
department (4 steps - unable to transfer weight twice
department (4 steps - unable to transfer weight twice
onto each lower limb regardless of limping).
onto each lower limb regardless of limping).
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#
#
Analgesia, immobilisation.
Analgesia, immobilisation.
May need ORIF (esp transverse
May need ORIF (esp transverse
fractures)
fractures)
Bipartite patella
Bipartite patella
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#
#
Analgesia
Analgesia
Long leg backslab
Long leg backslab
Orthopaedics
Orthopaedics
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Reduce under analgesia e.g. entonox
Reduce under analgesia e.g. entonox
Use thumbs to lever patella back into
Use thumbs to lever patella back into
place
place
Cylinder POP / cricket pad splint
Cylinder POP / cricket pad splint
Quads exercises
Quads exercises
Fracture clinic
Fracture clinic
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ACL – prevents tibia sliding forward
ACL – prevents tibia sliding forward
relative to femur.
relative to femur.
+ve anterior draw
+ve anterior draw
PCL – prevents tibia sliding back relative
PCL – prevents tibia sliding back relative
to the femur.
to the femur.
+ve posterior draw
+ve posterior draw
Effusion, instability.
Effusion, instability.
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MCL –
MCL –
valgus
valgus
load
load
Localised swelling, bruising,
Localised swelling, bruising,
tenderness.
tenderness.
J
J
oint
oint
opens
opens
up when stressed.
up when stressed.
LCL may be damaged in a similar way.
LCL may be damaged in a similar way.
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Usually due to twisting the knee while
Usually due to twisting the knee while
weight bearing
weight bearing
Painful (especially on knee extension)
Painful (especially on knee extension)
Locking / giving
Locking / giving
Effusion
Effusion
Special tests
Special tests
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May be secondary to direct blow, tibial
May be secondary to direct blow, tibial
plateau #, ankle twisting injury.
plateau #, ankle twisting injury.
Bruising, swelling, tenderness.
Bruising, swelling, tenderness.
Look for common peroneal nerve injury
Look for common peroneal nerve injury
– inability to dorsiflex and evert,
– inability to dorsiflex and evert,
decreased sensation dorsum of foot and
decreased sensation dorsum of foot and
lateral calf
lateral calf
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#
#
Usually due to direct blow
Usually due to direct blow
(transverse/oblique #)
(transverse/oblique #)
or twisting injury
or twisting injury
(spiral #)
(spiral #)
May be visible swelling, deformity,
May be visible swelling, deformity,
bruising.
bruising.
Tender, often palpable bone edges.
Tender, often palpable bone edges.
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Analgesia
Analgesia
Long leg backslab
Long leg backslab
Orthopaedics
Orthopaedics
Children?
Children?
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A
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Usually due to inversion / eversion
Usually due to inversion / eversion
injuries
injuries
Inability to weight bear:?
Inability to weight bear:?
Swelling, bruising, deformity.
Swelling, bruising, deformity.
Tenderness – bony or ligamentous
Tenderness – bony or ligamentous
Ottawa Rules
•
Site of bony tenderness
•
Ankle
•
Foot
•
Neck of fibula
•
Unable to weight bear
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A
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n
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:
:
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W
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A
A
:
:
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v
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r
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s
s
e
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f
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a
a
a
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v
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s
s
i
i
o
o
n
n
,
,
b
b
e
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v
v
e
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f
f
t
t
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s
s
y
y
n
n
d
d
e
e
s
s
m
m
o
o
s
s
i
i
s
s
.
.
Should be stable.
Should be stable.
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W
e
e
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b
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r
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B
B
:
:
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h
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v
v
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l
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f
f
s
s
y
y
n
n
d
d
e
e
s
s
m
m
o
o
s
s
i
i
s
s
.
.
May be unstable.
May be unstable.
W
W
e
e
b
b
e
e
r
r
C
C
:
:
H
H
i
i
g
g
h
h
f
f
i
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b
b
u
u
l
l
a
a
f
f
r
r
a
a
c
c
t
t
u
u
r
r
e
e
,
,
s
s
y
y
n
n
d
d
e
e
s
s
m
m
o
o
t
t
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c
c
d
d
i
i
s
s
r
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u
u
p
p
t
t
i
i
o
o
n
n
a
a
n
n
d
d
m
m
e
e
d
d
i
i
a
a
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m
m
a
a
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o
l
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a
r
r
f
f
r
r
a
a
c
c
t
t
u
u
r
r
e
e
.
.
Usually unstable.
Usually unstable.
A
A
n
n
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k
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l
e
e
f
f
r
r
a
a
c
c
t
t
u
u
r
r
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s
s
Stable unimalleolar fractures – B
Stable unimalleolar fractures – B
/
/
K
K
POP
POP
and fracture clinic
and fracture clinic
Unstable fractures will need orthopaedics
Unstable fractures will need orthopaedics
for ORIF
for ORIF
Indications for ED reduction…
Indications for ED reduction…
M
M
a
a
i
i
s
s
o
o
n
n
n
n
e
e
u
u
v
v
e
e
F
F
r
r
a
a
c
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t
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u
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e
e
Proximal fibular fracture coexisting with a
Proximal fibular fracture coexisting with a
medial malleolar fracture or disruption of
medial malleolar fracture or disruption of
the deltoid ligament.
the deltoid ligament.
P
P
artial or complete
artial or complete
syndesmosis d
syndesmosis d
isruption.
isruption.
Always check joint above & joint below
Always check joint above & joint below
F
F
o
o
o
o
t
t
F
F
r
r
a
a
c
c
t
t
u
u
r
r
e
e
s
s
Deformity, swelling, bruising.
Deformity, swelling, bruising.
Tenderness
Tenderness
Ottawa rules for x-rays
Ottawa rules for x-rays
5
5
t
t
h
h
M
M
e
e
t
t
a
a
t
t
a
a
r
r
s
s
a
a
l
l
F
F
r
r
a
a
c
c
t
t
u
u
r
r
e
e
Commonest #
Commonest #
metatarsal
metatarsal
Base of 5
Base of 5
th
th
: T
: T
wisting
wisting
of
of
foot / ankle
foot / ankle
:
:
avulsion fracture.
avulsion fracture.
Direct blow may break it anywhere.
Direct blow may break it anywhere.
Analgesia, support
Analgesia, support
Fracture clinic follow up
Fracture clinic follow up
Direct discharge?
Direct discharge?
C
C
a
a
l
l
c
c
a
a
n
n
e
e
a
a
l
l
f
f
r
r
a
a
c
c
t
t
u
u
r
r
e
e
Swelling, bruising, tenderness around
Swelling, bruising, tenderness around
heel.
heel.
Usually due to high energy impact e.g.
Usually due to high energy impact e.g.
fall.
fall.
Look for other injuries
Look for other injuries
C
C
a
a
l
l
c
c
a
a
n
n
e
e
a
a
l
l
f
f
r
r
a
a
c
c
t
t
u
u
r
r
e
e
Bohler’s angle should be 35-40
Bohler’s angle should be 35-40
Refer to orthopaedics as most will
Refer to orthopaedics as most will
need admission for analgesia,
need admission for analgesia,
elevation +/- CT and ORIF
elevation +/- CT and ORIF
More likely to be tibial
More likely to be tibial
May not be!
May not be!
Prognosis depending on tissue loss
Prognosis depending on tissue loss
Principles the same
Principles the same
O
O
p
p
e
e
n
n
f
f
r
r
a
a
c
c
t
t
u
u
r
r
e
e
s
s
Control haemorrhage with direct pressure
Control haemorrhage with direct pressure
Analgesia, splintage
Analgesia, splintage
Remove obvious contaminants if possible
Remove obvious contaminants if possible
Photo wound
Photo wound
ID, verbal consent, photograph card
ID, verbal consent, photograph card
Iodine dressings and i.v. ABX +/- tetanus
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
This collection of images and descriptions covers common lower limb injuries, such as neck of femur, femoral fractures, and knee injuries. It provides insights into the assessment, treatment, and potential complications associated with lower limb trauma, emphasizing the importance of prompt evaluation and appropriate management.
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Presentation Transcript
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 Common / important lower limb injuries: NOF # Femoral # Knee Tibial plateau Fibula head Tibia Ankle Foot Pitfalls! Look Feel Move Neurovascular Other occult injuries? Treatment ?Pathological
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 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
