a Quick reference for Lower Limb Fractures. Source: Toronto Notes 2014 edition.

1. Lower Limb Fractures
Dr.Ghassan Al Kefeiri

2. A-Pelvic Fractures:
Mechanism:
• In young Patients: High energy trauma either directly or
transmitted from Femur.
• In Elderly: low energy Trauma and fall from height.
• Lateral compression (Most Common) e.g: anteroposterior
compression fractures.
Clinical Features:
1- Local swelling, Tenderness.
2-Deformity of lower extremity.
3-pelvic instability.
Investigations:
1- X-Ray, inlet and outlet views.
2-CT is useful for evaluating posterior pelvic injury and acetabular
fracture.

3. Treatment:
1-ABCDE.
2- Assess genitourinary Injury ( Rectal exam, Vaginal exam, Hematuria,
Blood at the urethral meatus), If present the fracture is considered open.
3-Stable fractures are treated non-operatively with protected weight baring.
4-on ER:
I. I.V fluids/ Blood
II. Pelvic binder, sheeting.
III. Laparotomy id Fast is positive.
5-Indications for operative treatment:
I. Unstable pelvic injury.
II. Disruption of anterior and posterior SI ligament
III. Symphysis Diastasis > 2.5 cm
IV. Vertical instability of the posterior pelvis.
Specific Complications:
1. Life-Threatening Hemorrhage.
2. Injury to the rectum or urogenital tract.
3. Persistent SI joint pain.
4. High risk of DVT, PE.
5. Obstetrical difficulties
6. Post traumatic arthritis of the hip with acetabular fractures.

4. Stable
avulsion
Fracture
Open
Book
Unstable
Pelvic
Fracture

5. B- Hip:
Hip Dislocation:
1- Anterior Hip Dislocation:
I. Mechanism is by posteriorly directed blow to knee with hip widely
abducted.
II. Clinically: Shortened, abducted and externally rotated limp.
III. Treatment: Closed reduction under conscious sedation/GA, with post
reduction CT to assess joint congruity.
.

6. 2-Posterior Hip dislocation:
I. MOST FREQUENT type of hip dislocation.
II. Mechanism: Severe force to knee force to knee with hip flexed and
adducted e.g knee on dashboard in MVC.
III. Clinically : Shortened, adducted and internally rotated limb.
IV. Treatment:
I. Closed reduction under sedation/GA only if associated with
femoral neck fractures.
II. ORIF if unstable, Intra-articular fragments or posterior wall
fractures. If reduction is unstable put in traction 4-6 wks.
III. Post-reduction CT to assess joint congruity and fractures

7. Complications for all Hip Dislocations:
1- post traumatic osetoarthritis.
2-AVN of femoral head.
3-fracture of femoral head, neck or shaft.
4-Sciatic nerve Palsy in 25%, 10% permanent.
5-Thromboembolism.
6-Heterotopic ossification.
REMEMBER:
Up to 50% of patients with hip dislocation suffer fractures
elsewhere at the time of injury.

8. Hip Fracture:
General features: acute pain, painful ROM, unable to weight bear and shortened
and externally rotated Limp.
Remember that giving Low Molecular weight heparin is
recommended on admission. Unless surgery is to be done shortly.

11. AVN of femoral head:
Distal to proximal blood supply along femoral neck to head.
Suspect AVN if blood supply is disrupted.
Etiology:
1-Femur neck fractures.
2-Chronic systemic steroid use.
3- Slipped capital femoral epiphysis.
4-Legg-Calve-Perthes.
5-SLE.
6-RA.

12. Arthritis of the Hip:
Etiology: post traumatic, OA, inflammatory arthritis, late effect of
congenital hip disorders or septic arthritis.
Clinical Features:
1. Pain ( Groin, Medial thigh) and stiffness aggravated by activity.
2. Morning stiffness >1hr, multiple joint swelling, Hand nodule ( RA).
3. Decreased ROM ( Internal rotation is lost first).
4. Crepitus.
5. +/- fixed flexure contracture leading to apparent limb shortening (
thomas Test).
6. +/_ Trendelenberg sign

13. Investigations:
1. X-ray: shows joint space narrowing, subchondral sclerosis, subchondral cyst,
osteophytes.
2. RA: osteopenia, erosions, joint space narrowing, subchondral cyst, symmetric
joint space narrowing.
3. Blood work ANA, RF.
Treatment:
1. Non-operative: weight reduction, activity modification, physiotherapy,
analgesics, walking aids.
2. Operative Realign = osteotomy, Replace = Arthroplasty, Fuse= arthrodesis.
3. Arthroplasty is the standard of care in most patients with hip arthritis.

14. C- Femur:
Femoral Diaphysis Fractures:
Mechanism: High energy e.g MVC. Low Energy in children ( spiral fractures).
Clinical Features:
• Shortened, externally rotated leg (if fracture is displaced).
• Inability to weight-bear.
• Often open injury always a gustillo 3.
Investigations:
AP pelvis, AP/lateral Hip, Femur, Knee.
Complications:
• Hemorrhage requiring transfusion.
• Fat embolism leading to ARDS.
• Extensive soft tissue injury.
• Ipsilateral hip dislocation/Fracture.
• Nerve injury.
Treatment:
• ABCDE
• ORIF I.M nail or external for unstable patients.
• Early mobilization and strengthening.

15. Distal femoral Fracture:
Mechanism: Direct High energy force or axial loading.
Clinical Features:
• Extreme pain.
• Knee effusion. (hemarthrosis).
• Shortened, externally rotated leg if displaced.
Treatment:
• ORIF if displaced.
• Early mobilization and strengthening.
Complications:
• Femoral artery Tear.
• Nerve Injury.
• Extensive soft tissue injury.
• Angulation deformities.

18. Evaluation of Knee:
1- Common Knee Symptoms:
• Locking: Mechanical Block to extension e.g Torn
meniscus, Loose Body in Joint.
• Pseudo-Locking: Limited ROM without mechanical
Block e.g effusion, muscle spasm after injury,
arthritis.
• Painful clicking (audible) e.g torn meniscus.
• Giving way: instability e.g cruciate ligament or
meniscal tear, patellar dislocation.
6 Degrees of freedom of Knee:
• Flex and extend.
• Extension and internal rotation.
• Varus and Valgus angulation.
• Ant. And Post. Glide.
• Med. and lat. Shift.
• Compression and distraction.
REMEMBER:
On examining the Knee,
Always evaluate Hip.

19. Special Tests of the Knee:
Anterior and Posterior Drawer Test:

20. Lachman Test:

21. Thessaly Test:

22. Posterior Sag Sign:

23. Pivot shift sign:

24. Collateral Ligament stress test:

25. Tests For meniscal Tear:
1- joint line Tenderness:

26. 2- Crouch compression test:

27. 3-McMurray’s Test

28. Cruciate Ligament Tears:

29. Collateral Ligament Tears:
Mechanism:
• Valgus force to the Knee: MCL tear.
• Varus force to the Knee: LCL tear.
Clinical Features:
• Swelling, Effusion.
• Tenderness above and below Joint line medially or laterally.
• Joint laxity with valgus or varus force to knee. Presence of end point
differentiate complete from partial tears.
• Test for other injuries like O’Donoghue’s unhappy Triad ( ACL
rupture, MCL rupture, Meniscal Damage) or common peroneal
nerve injury.
Treatment:
• Partial Tear: immobilization 2-4wk and early ROM and strength.
• Complete Tear: Immobilization at 30 degree felxion.
• Multiple ligament injuries : surgical repair of ligaments.

30. Meniscal Tear:
Medial is much MORE COMMON than Lateral.
Mechanism:
• Twisting force on knee when it is partially flexed ( e.g stepping down and
turning).
• Requires moderate trauma in young person but only mild trauma in
elderly due to degeneration.
Clinical Features:
• Immediate pain, difficulty weight-bearing, instability and clicking.
• Increased pain with squatting &/or twisting.
• Effusion ( hemarthrosis) with insidious onset ( 24-48 hr after injury).
• Joint line tenderness medially or laterally.
• Locking of knee.
Investigations: MRI, arthroscopy.
Treatment:
• If not Locked : ROM, strengthening and NSAIDs
• If Locked or failed above: arthroscopic repair/ partial menisectomy.

32. Dislocated knee:
Caused by a high energy trauma.
Clinical Features:
• Classified by relation of Tibia with respect to Femur to : Anterior,
Posterior, Lateral, Medial, Rotary.
• Knee Instability.
• Effusion.
• Pain.
• Ischemic Limb.
Investigations:
• X-ray : AP. Lateral ( look for other fractures
on Tibia and Fibula
• Ankle Brachial Index ( abnormal if <0.9).
• Arteriogram if abnormal vascular exam.

34. Treatment:
• Urgent closed reduction
• Assessment of peroneal nerve, tibial artery, and ligamentous
injury.
• Repair of associated injuries and consider fasciotomy in case of
vascular repair.
• Knee immobilization 6-8 weeks.
Specific Complications:
• High incidence of associated injuries:
• Popliteal artery tear.
• Peroneal nerve injury.
• Capsular tear.
• Chronic: Instability, Stiffness, Post-Traumatic arthritis.

36. Patellar Fracture:
Mechanism:
• Direct blow to the Patella e.g MVC.
• Indirect Trauma by sudden flexion of the knee against contracted
quadriceps.
Clinical features:
• Marked tenderness
• Inability to extend knee or straight leg raise.
• Proximal displacement of patella.
• Patellar deformity.
• +/- effusion/hemarthrosis.
Investigations:
• X-ray AP, Lateral, Skyline.
Treatment:
• Goal: to restore extensor mechanism with maximal articular
congruency.
• Non-displaced: straight leg immobilization and physiotherapy.
• Displaced, Comminuted or disrupted extensor mech.: ORIF

37. Patellofemoral Syndrome:
Mechanism:
1. Softening, erosion and fragmentation of articular cartilage,
predominantly medial aspect of patella.
2. Commonly seen in active young females.
Predisposing factors:
1. Post Trauma
2. Malalignment e.g valgus.
3. Deformity of patella or femoral groove.
4. Recurrent patellar dislocation.
5. Excessive knee strain.
Clinical Features:
1. Deep, aching anterior knee pain. Exacerbated by prolonged sitting.
Stairs climbing, squatting or strenuous athletic activities.
2. sensation of instability, pseudolocking.
3. Pain with extension against resistance through terminal 30-40 degrees.
4. Rarely, minimal swelling.

38. Investigations:
1. X-ray AP/ Lat. Skyline.
Treatment:
1. Non-operative:
I. Continue non-impact activities.
II. NSAIDs.
III. Physiotherapy.
2. Surgical with refractory patients:

40. Tibial Plateau Fracture:
Mechanism:
• Axial loading e.g fall from a height.
• Femoral condyles driven into proximal tibia.
• Can result from minor trauma in osteoporotic.
Clinical Features:
• Lateral fractures MORE COMMON than medial.
• Medial fractures requires more energy –often have concomitant
vascular injury.
• Knee effusion.
• Inability to bear weight.
• Swelling.
Investigations:
• X-ray: AP. Lateral.
• CT preoperative planning.

41. Specific Complications:
• Ligamentous injuries.
• Meniscal legions.
• AVN.
• Infection.
• Osteoarthritis.

43. Tibial Shaft fracture:
Mechanism:
1. Numerous icluding MVC, Falls, sports.
Clinical features:
1. Open vs. closed
2. Amount of displacement.
3. Neurovascular status.
4. MOST COMMONLY fractured bone.
5. MOST COMMON open fracture.
Investigations: X-ray: AP, Lat, Skyline.
Treatment:
1. Closed: minimally displaced ( Straight leg cast). Displaced: ORIF
2. Open: external fixation or IM nail, vascularized coverage of soft tissue to
promote healing.
Complications:
1. Compartment Syndrome.

45. Ottawa Ankle Rules:

46. Special Tests:
1- Anterior Drawer:

47. 2- Talar Tilt:

48. Ankle Fracture:
Mechanism:
• Pattern depends on postion of Ankle when trauma occurs.
• Generally involves:
• Ipsilateral ligamentous tear to transverse bony avulsion.
• Contralateral shear fracture.
• Classification system:
• Danis-Weber:

49. • Lauge-hansen: Based on Foot’s and motion relative to leg.
Treatment:
• Undisplaced: non-weight bearing below knee cast.
• Indicationd for ORIF:
• Any Fracture-dislocation: restore vvascularity, minimize
articular injury, reduce pain and skin pressure.
• Most of type B and all type C.
• Trimalleolar ( medial, posterior, lateral)
• Talar tilt >10 degrees.
• Medical clear space on x-ray greater than superior clear space.
• Open fracture/open joint injury.
• High incidence of post traumatic arthiritis.
• Wrinkle test: wrinkles on skin to show that edema has resolved.

50. Ligamentous Injuries:
Medial ligament complex:
• Eversion inusry.
• Usually avulses medial or posterior malleoulus and strains syndesmosis.
Lateral Ligament Comples:
• Inversion injury.
• Anterior talofibular ligament most commonly and severly injured if
ankle is plantar flexed.
• Swelling and tenderness anterior to lateral malleolus.
• ++ ecchymosis.
• Positie ankle anterior drawer. May have significant medial talar tilt on
inversionstress x-ray.
Treatment:
• Microscopic tear: rest, ice, compression, elevation.
• Macroscopic tear: Strap ankle in dorsiflexion and eversion,
physiotherapy.
• Complete: below knee walking cast, physiotherapy or surgery if chronic
symptomatic instability occurs.

52. Talar Fracture:
Mechanism:
• Axial loading of hyperdorsifelxion
• 60% of talus covered by articular
cartilage.
• Tennous blood supple runs distal to
proximal along talar neck, resulting
in high risk of ANV with displaced
fractures.
Investigations:
• X-rays: AP, Lateral.
• Ct to better characterize fracture.
• MRI can clearly define extent of AVN.
Treatment:
• Undisplaced: non-weight bearing
below knee cast for 20-24 wk.
• Displaced: ORIF ( High rate of
nonunion, AVN)

53. Calcaneal Fracture:
Mechanism:
1. Axial loading, fall from height.
2. 10% of fractures associated with compression fractures of
thoracic or lumbar spine.
3. 5% bilateral.
Physical examination:
1. Swelling, bruising on heel/sole.
2. Wider, shortened, flatter heel when viewed from behind.
3. Varus heel.
Investigation:
1. X-ray: AP, Lateral, Oblique (Broden’s view).
2. Loss of Bohler’s angle.
3. CT: assess intra-articular extensions.
Treatment:
1. Closed vs open reduction is controversial.
2. Non-weight bearing cast 3wk, early ROM and strengthening.

55. Achilles Tendonitis:
Mechanism:
• Chronic inflammation from activity or poor-fitting footwear.
• May also develop heel bumps.
Physical examinations:
• Pain, stiffness and crepitus with ROM.
• Thickened tendon, palpable pump.
Treatment:
• Rest, NSAIDs.
• Gentle stretching, deep tissue calf massage.
• Orthotics, open back shoes.
• Shockwave therapy in chronic tendonitis.
• DO NOT inject steroids.

56. Achilles Tendon Rupture:
Mechanism:
1. Loading activity, stop-and-go sports.
2. Secondary to chronic tendinitis, steroid injection.
Clinical features:
1. Audible pop, sudden pain with push off movement.
2. Sensation of being kicked in the heel when trying to planterflex.
3. Palpable gap.
4. Apprehensive toe off when walking.
5. Weak plantar flexion strength.
6. Thompson test.
Treatment:
1. Low demand or elderly: cast foot in plantar flexion.
2. High demand: surgical repair, then cast 6-8 wks.

57. Thompson Test:

58. Plantar Fasciitis ( Heel Spur Syndrome):
Mechanism:
• Repetitive strain injury causing micro tears and inflammation of
plantar fascia.
• Female:male 2:1.
• Common in athletes especially runners.
• Also associated with obesity, D>M, seronegative and seropositive
arthritis.
Clinical Features:
• Morning pain and stiffness.
• Intense pain when walking from rest that subsudes as patient continues
to walk.
• Swelling, tenderness over sole.
• Greatest at medial calcaneal tubercle and 1-2 cm distal along plantar
fascia.
• Pain with toe dorsiflexion.

59. Investigations:
• Plain radiographs to rule out fractures.
• Often see bony exostoses at insertion
of fascia into medial calcaneal tubercle.
• Spur is secondary to inflammation, not
the cause of pain.
Treatment:
• Rest, ice, NSAIDs, steroid injection.
• Physiotherapy
• Orthotics with heel cup.
• Endoscopic surgical release of fascia in
refractory cases.

60. Bunions ( Hallux Valgus):
Mechanism:
1. Valgus alignment on fist MTP causes eccentric pull of extensor and
intrinsic muscles.
2. Reactive exostosis froms with thickening of the skin creating a bunion.
3. Most often associated with poor-fitting footwear but can be heriditary.
4. 10x more frequent in women.
Clinical Features:
1. Painful bursa over eminence of first metatarsal head.
2. Pronation of great toe.
3. Numbness over medial aspect of great toe.
Investigations:
1. X-ray AP/lateral/sesamoid.
Treatment:
1. Indications: painful bunion, overriding second toe.
2. Non-operative: properly fitted shoes and toe spacer.
3. Surgery: osteotomy with realignment.

62. Metatarsal fractures: