Lower Limb Trauma😊

Normal Hip X-ray Landmarks:

Shenton's Line:

• Definition:
• continuous curved line
• drawn from the
• lower border of the superior pubic ramus,
• laterally towards the head and neck of the femur.

• Clinical Significance:
• Disturbances in its continuity indicate pathology of the hip.

Neck-Shaft Angle (Angle of Inclination):

• Normal Range: 120°-135°.

• Coxa Vara:
• Angle is < 120°
• Problems:
1. Limb shortening.
2. Trendelenburg gait.

• Coxa Valga:
• Angle is > 135° (less common in trauma).

Trendelenburg Test:

• Purpose: To assess the abductor mechanism of the hip.

• Mnemonic: Sound side sinks

Principle Abductors of Hip:

• Gluteus medius

• Gluteus minimus

• Supplied by the superior gluteal nerve.

Function of Abductors:

• Maintain gait by stabilizing the pelvis.

• Ipsilateral (I/L) abductors help swing the contralateral (C/L) limb.

Abductor Failure (Causes):

• Gluteus medius weakness.

• Gluteus minimus weakness.

• Superior gluteal nerve palsy.

• Coxa vara

Test Procedure:

• Ask the patient to stand on each limb for 30 seconds.

• Observe the ASIS

• Positive Test:
• When the patient stands on the pathological side (affected limb),
• the sound (unaffected) side sinks.
• ASIS/PSIS of the other side goes down.

• Note:
• Bilateral (B/L) abductor
• waddling gait.
• Mnemonic: No abductor → add(uctor) → wadd → waddling gait

Thomas Test:

• Iliopsoas contracture

ANS

3

• AKA: Hugh Owen Thomas well leg raise test.

• Positive if Contracture +

• Purpose:
• Used to assess flexion contracture/flexion deformity of the hip.

• Steps:
• Patient is asked to lay supine to check for exaggerated lumbar lordosis.
• Ask the patient to flex the hip gradually.
• If flexion of hip is done beyond normal limit:
• It will result in overcorrection of the normal side in the form of lifting up of pelvis.
• This can be avoided by ensuring both the ischial tuberosities touch the ground.
• When the ischial tuberosities touch the ground:
• The affected hip will come to lie in its deformed diseased position of flexion deformity.
• Measure the angle between the affected thigh and ground to obtain actual degree of flexion of deformity.

• Mnemonic: Thomas nte flex adich vachekkunn

Ober Test

• ITB contracture is common in polio.

• Leads to deformities:
• Hip Joint:
• FABER position
• Flexion
• Abduction
• External rotation
• Knee Joint:
• FER
• Flexion
• External rotation of tibia

Hip Dislocation

Mechanism of Injury:

• Posterior Dislocation (Most Common):
• Dashboard injury.

• Anterior Dislocation:
• Deceleration injury,
• fall from height.

Attitude of Limb:

• Posterior Dislocation (F, AD, IR):



• Flexion at hip.
• Adduction at thigh.
• Internal rotation.

• Anterior Dislocation (F, AB, ER):



• Flexion at hip.
• Abduction at thigh.
• Externally rotated limb.

Length of Limb:

• Posterior Dislocation:
• Shortened.

• Anterior Dislocation:
• Lengthened.

X-ray Features:

• Posterior Dislocation:



• Posterior dislocation visible.
• Shenton's line is broken.
• Adduction and internal rotation of limb.
• Lesser trochanter is not visible.

• Anterior Dislocation:



• Head lies outside acetabulum.
• Shenton's line is broken.
• Abduction and external rotation of limb.

Palpation:

• Posterior Dislocation:
• Head palpable in the gluteal region.

• Anterior Dislocation:
• Head palpable in the femoral triangle.

Management:

• First Attempt:
• Closed reduction.

• If not reducing due to muscle spasm:
• Closed reduction under anesthesia.

• If no reduction after anesthesia:
• Open reduction + apply skeletal traction.

Complications:

• Avascular necrosis (Most Common):
• If not reduced within 6-12 hours post-injury.

• Sciatic nerve injury:
• Especially in posterior dislocation,
• foot drop/high stepping gait
• due to common peroneal nerve component.

In AVN:

• Femur is relatively flat i.e. collapse of the head.

• Appears more dense due to dead bone.

Crescent sign.

• FICAT score → 2b → Crescent sign

Proximal Femur Fractures

Anatomy of Proximal Femur Blood Supply:

• Head of femur.

• Mnemonic: Proximally → Profunda → medial and lateral

• Intracapsular neck
• supplied by medial circumflex artery
• commonly disrupted

• Extracapsular neck
• supplied by
• profunda femoris,
• medial circumflex femoral artery
• lateral circumflex femoral artery

• Capsule.

Types of Proximal Femur Fractures:

Intertrochanteric/Extracapsular Fracture:

• Age: 70-80 years (Elderly).

• Sex: Female > males.

• EVANS CLASSFICATION → IT #

• Trauma: Moderate to severe fall.

• Pain: Moderate to severe pain.

• Location of Pain: Trochanteric region.

• Shortening: > 1 inch.

• Deformity/Attitude:
• External rotation > 45°



• lateral part of foot touches the bed

• Complication (No disruption of blood supply):
• Malunion.
• Shortening
• Coxa vara (decrease in neck-shaft angle).
• Trendelenberg limb

• X-ray: Fracture outside joint capsule.

Management:

• Goal:
• Maintain neck shaft angle (125°-130°) with devices and prevent coxa vara.

Surgical:

• Proximal Femoral Nail (PFN)



• with locking and stabilization screws
• Best Modality

• Dynamic Hip Screw (DHS):
• Sliding compression mechanism.

Conservative Management

• (in inoperable cases, e.g., due to age, comorbidities):
• Derotation boot:
• Allows healing in malunited position,
• prevents external rotation.

Neck of Femur Fracture:

• Age: 50-60 years (Elderly).

• Sex: Female >>> males.

• Trauma: Trivial fall.

• Pain: Mild pain.

• Location of Pain: Scarpa's triangle.

• Shortening: < 1 inch.

• Deformity/Attitude:
• External rotation < 45°
• (capsule limits it).

• Complication (Due to disruption of blood supply):
• AVN (Avascular Necrosis) (45%).
• Non-union (30%).

X-ray:

• Shenton's line broken,

• fracture within joint capsule.

Classification:

• Anatomical, Pauwels' & Garden's classifications.

• Pipkin classification

Treatment by Age:

< 65 years (Younger Patient):

• < 3 weeks from fracture:
• Closed reduction Internal Fixation (CRIF) +
• cannulated cancellous screws.

• > 3 weeks from fracture (delayed presentation):
• Perform MRI to assess viability.
• Non-viable Head of Femur (HOF):
• Fixation +
• Vascularisation procedures
• Meyers,
• Bakshi,
• Fibular vascular graft
• Mnemonic: Non viable neck → give to meyer for bhakshikkan
• Viable:
• Fixation +
• Osteotomy
• McMurray,
• Pauwel (better)
• Mnemonic: if viable → Otta itt Pole (Pauwel) nn murrich (Murray) kalayanam

• If both fail & young patient:
• Proceed to Hemiarthroplasty or
• Total arthroplasty as for older patients.

≥ 65 years (Older Patient):

Replacement:

Hemiarthroplasty (in previously normal hip):

• Replacement of only head and neck of femur.
• Implants:



• Austin Moore
• 2 thola
• Thompson,
• Tholayilla
• Bipolar
• Most Common & Best

Total Arthroplasty

• (in previously abnormal hip, e.g., Osteoarthritis):

• Replacement of head & neck of femur +

• Acetabular cup.

Heterotopic Bone Formation, After Hip Arthroplasty

• Post-traumatic arthritis

• Hypertrophic arthritis

• Diffuse idiopathic skeletal hyperostosis (DISH)

• Paget’s disease

• Ankylosing spondylitis

• Previous history of heterotopic ossification in either hip

Deformity Type	Description	Primary Nerve at Risk	Relative Risk during Total Knee Arthroplasty
Valgus	Knock-knee	Common Peroneal Nerve	Higher
Varus	Bow-legged	Tibial Nerve	Lower

Shaft of Femur Fracture

Fat Embolism Syndrome (FES):

• Pathogenesis: Leaking of intramedullary fat into circulation.

• Clinical Features:
• Not seen in children.
• Occur 24-48 hours after polytrauma:
• Cutaneous: Petechial rash.
• Cardiorespiratory: Dyspnoea/tachypnoea.
• CNS: Depression, coma, anxiety.

Diagnosis:

• Mnemonic: Fat → Good → Gurd

GURDS criteria

• Major Criteria (4):
• Axillary/Subconjunctival petechiae.
• PaO2 below 60 mmHg.
• CNS depression.
• Pulmonary edema.

• Minor Criteria (8):
• Fever.
• Tachycardia.
• Anemia.
• Thrombocytopenia.
• Fat globules in sputum.
• Fat globules in urine (Lipuria - Gurd test).
• Increased ESR.
• Retinal emboli.

• Diagnosis Criteria: 1 major + 4 minor = Fat embolism.

Management of FES:

• Prevention: Immobilisation + early fixation of fracture.

• Treatment: Supportive O2 + IPPV

Treatment of Femur Shaft Fracture (by Age):

• Mnemonic: Pavam (Pawlik) Girl (Gallows) → Hip (Hip spica) Flexible (Flexible nail) arnnu → Enter (Ender) cheyyumbo tension (TENS) arnn → shaft fracture ayi

• If < 2 years/< 12 kg:
• Gallows traction



• Most Common
• Temporarily
• Once they start healing → Put a cast

• < 6 months:
• Pavlik harness.

• 6 months – 5 years:
• Hip spica cast.

• 5-10 years:
• Flexible nails (Ender's nail, TENS)/
• Plates if unstable.

• > 10 years (Adults):
• Intramedullary interlocking nails.

In > 65 yr old

Leg Injuries

Patella Fracture:

 

• History: Direct trauma to knee.

• Treatment (Rx):
• Tension band wiring with K-wires.
• Cylindrical cast → Compression → Distraction

• Special view for patella: Skyline view.

Bipartite Patella:

• Description:
• Congenital anomaly;
• accessory ossification centre.
• Small separated fragment
• due to incompletely fused patella at superolateral pole.

• Diagnosis:
• Incidental finding on X-ray.
• Rarely painful.

• Management: Conservative.

Tibial Shaft Fracture:

Management:

• Conservative:
• Patellar tendon bearing cast.

• Definitive Treatment:
• CRIF with intramedullary rod/nail with interlocking screws.

Runner's Fracture:

• Stress fracture of the fibula seen in marathon runners.

Ankle Joint Injuries

Ankle Anatomy (X-ray landmarks):

• Medial malleolus,

• lateral malleolus,

• posterior malleolus

Ankle Fractures:

OTTAWA RULES:

• When to take Xray in ankle trauma

• M/c injury → Anterior Talofibular Ligament tear

Ottawa Convention (Mine Ban Treaty)

• 1997 treaty.

• Bans use, stockpiling, production, transfer of anti-personnel landmines.

• Requires:
• Destruction of stockpiles within 4 years.
• Clearance of mined areas within 10 years.
• Assistance to victims.

• Not signed by:
• USA
• Russia
• China
• India
• Pakistan

Tillaux #

• Distal tibia → salter haris 3

• Avulsion fracture

DANIS- WEBER classification:

• For ankle #

Dancers # → Pseudo jones

Jumpers # → Sacrum

Denis classification

Judet and letournel: Acetabulum #

Young and Burgess: Pelvic #

Schatzker classification: Tibia #

EVANS CLASSFICATION → IT #

Types:

• Isolated Lateral Malleolus fracture:
• Involves only the lateral malleolus.

• Bimalleolar/Pott's Fracture:
• Involves both medial and lateral malleoli.
• Mnemonic: 2 malleoli potti (pots)

• Trimalleolar/Cotton's Fracture:
• Involves medial, lateral, and posterior malleoli.
• Mnemonic: cotton wrap when all 3 involved

Management:

• Initial:
• Closed reduction followed by slab application
• Neurovascular assessment before & after

• Post-reduction care:
• Manage neurovascular deficit/compartment syndrome.

• Definitive Surgical Treatment:
• Once swelling decreases.

Foot Fractures

Calcaneal Fracture: Lovers fracture

• Mechanism of Injury:
• Fall from height landing on feet.

Angles to Assess Reduction:

• Bohler's Angle: ↑↑
• Should be increased post-reduction.
• Mnemonic: Ankle pain bowl cheythapo kuudi

• Gissane's Angle: ↓↓
• Should be decreased post-reduction.
• Mnemonic: Ankle pain kiss cheythapo kurnaju

Aviator's Fracture:

• Mnemonic: Aviator (plane) and Hawk → both tala de mukalil kude

• Description:
• Fracture of the talar neck.

• Complication:
• ↑↑ risk of avascular necrosis of the body of talus.

• Classification:
• Hawkins classification → Talus Fracture



• Also in painful arc syndrome

• Blood Supply of Talus:
• Dorsalis pedis artery → Sinus Tarsi Artery.

Chopart's Fracture:

• Fracture of the intertarsal joint.

Lisfranc's Fracture:

• Fracture of the tarso-metatarsal joint.

Amputation:

• Intertarsal joint: Chopart's amputation.

• Tarsometatarsal joint: Lisfranc's amputation.

Robert Jones Fracture:

• Mnemonic: Robert jones the 5th → 3 zone bharichu → 1st zone il peru kochakki (peroneus brevis) pseudo () ayi bharichu → 2nd arnnu true () ayi → 3rd full stress () arnnu

• Description:
• Fracture of the base of the 5th metatarsal.

• Zones of Jones Fracture:
• Zone 1 (Pseudo Jones fracture = Dancers #):
• Due to avulsion of peroneus brevis tendon.
• Zone 2 (True Jones fracture):
• In the watershed area (decreased vascularity) leading to non-union.
• Zone 3 (Stress fracture):
• Often from repetitive stress.

• Treatment (Rx):
• Non-weight bearing short leg cast for 6-8 weeks.
• Intramedullary screw fixation if displacement is present (Ideal Rx).

NOTE

Nerve Injuries

Summary of Femur Fractures

• Intracapsular Neck of Femur Fracture:
• ≥ 65 years:
• Hemiarthroplasty/Total hip replacement.
• < 65 years:
• MRI → Osteotomy (if viable, if fails then replacement).

• Intertrochanteric Fracture:
• DHS/PFN (for all age groups).

• Femur Shaft Fracture:
• Nailing (for all age groups).