51. •Longest and strongest bone
•3 parts:
• Proximal: head and neck, and
two bony processes – the
greater and lesser
trochanters
• The shaft
• Distal - medial and lateral
condyles
Anterior surface of proximal right
femur
Posterior surface proximal right
femur
52. Muscles of Thigh
• Largest and most powerful in the human
body.
• Three compartments, each associated
with nerves and vessels.
• Anterior compartment: Sartorius,
Quadriceps
• Posterior compartments: Biceps
femoris, Semitendinosus,
Semimembranosus
• Adductor compartment: Gracilis,
Adductor longus, Adductor brevis,
Adductor magnus
53. Blood Supply of Head and Neck of Femur
•Retinacular arteries
(branch of medial and
lateral circumflex
artery)
•Artery in ligamentum teres
(branch of obturator artery)
•Nutrient artery ( branch of
femoral artery)
55. •Incidence
• Increasingly common due to aging population
•Demographics
• Women > men
•Mechanism
• High energy in young patients
• Low energy falls in older patients
56. Symptoms
• Impacted and stress fractures
• Slight pain in the groin (lateral
and below femoral artery
pulsation)
• Pain referred along the medial
side of
the thigh and knee
• Displaced fractures:
• Pain in the entire hip region
Physical exam
• Impacted and stress fractures
• No obvious clinical deformity due
to intracapsular
• Minor discomfort with active or
passive hip range of motion,
muscle spasms at extremes of
motion
• Pain with percussion over
greater trochanter
• Displaced fractures:
• Leg in external rotation and
abduction, with shortening
57.
58. Imaging
Radiographs
• AP, Cross-table lateral, Full-length
femur
• Shenton line: imaginary curved line
drawn along the inferior border of
the
superior pubic ramus (superior
border of the obturator foramen)
and
along the inferomedial border of the
neck of femur
• Disruption:
• Developmental dysplasia of
the Hip (DDH)
• Neck of femur fracture
• Dislocation of hip joint
59. • CT scan
• Displacement and degree of comminution
• MRI
• To rule out occult fracture
• Not helpful in reliably assessing viability of femoral head after
fracture
60. Management
•Initial treatment
• Pain-relieving measures - analgesia and
a femoral nerve block
•Skin traction, or the application of a
Thomas splint - an adjunct to pain
relief and nursing care.
•Non-operative treatment of hip fractures
is limited to those patients who would
not survive the surgical
61. Young patient
•Preserve the femoral head
•Fix the fracture
Elderly
•Reduction and fixation of
fractures is not recommended
• Re-operation
• Nonunion
• Osteonecrosis of the femoral
head
•Consideration:Undisplaced and
stable fracture patterns
without comminution
62. • Young Patients (less than 60)
• Open-reduction internal fixation
• Elderly Patients
• Non-displaced (Garden Type 1 and 2)
• Percutaneous cannulated screws or sliding hip screw
• Displaced (Garden Type 3 and 4)
• Hemiarthroplasty-less active patients
• Total hip arthroplasty-active patients
• Fixation not indicated because of high risk of non-union (due to blood
supply) and AVN
63. Complications
•General complications in elderly:
• Thromboembolism, pneumonia, bed sores, UTI (associated with
prolonged bed rest)
•Non-Union
•AVN of femoral Head
•Secondary osteoarthritis: From subarticular bone necrosis or femoral
head collapse
66. •Elderly, osteoporotic women
•Unite quite easily
•Seldom cause avascular necrosis.
•Mechanism Of Injury:
• Fall directly onto the greater trochanter or by indirect twisting
injury.
• Younger individuals: high-energy injury (MVA, fall from a height)
• Elderly : simple fall
67. Clinical Features
•History of fall followed by
• Pain
• Swelling (more obvious compared
to neck of femur fracture; not
limited by capsule)
• Loss of function (unable to stand)
• Obvious deformity due to
extracapsular(shortening of limb,
external rotation)
Physical Examination
• Tenderness: Greater trochanter,
exacerbated by passive attempts
at hip flexion or rotation.
• Shortening of the extremity
and deformity of rotation in
resting position
70. Management
Nonoperative
•Non-weight bearing with early out of bed to chair
• Indications
• Non ambulatory patients
• High risk for perioperative mortality
• High rates of pneumonia, urinary tract infections,
decubiti, and DVT
71. Operative
•Sliding hip compression screw (Dynamic hip screw)
• Indications
• Stable intertrochanteric fractures
• Outcomes
• Equal outcomes when compared to intramedullary hip screws for
stable fracture patterns
• More cost-effective
72. Intramedullary hip screw
(cephalomedullary nail/ proximal
femoral nail)
•Indications
• Unstable fracture patterns
• Reverse obliquity fractures
• Subtrochanteric extension
• Lack of integrity of femoral wall
Arthroplasty
•Indications
• Severely comminuted fractures
• Preexisting symptomatic
degenerative arthritis
• Osteoporotic bone that is
unlikely to hold internal fixation
• Salvage for failed internal
fixation
76. ● Fractures between the inferior margin of
the lesser trochanter and 5 cm below this
point. (more distal are considered femoral
shaft fractures).
● Highly unstable.
● In elderly patients with osteoporosis,
osteomalacia, Paget’s Disease.
● Blood loss is greater than femoral next or
trochanteric fractures.
77. Mechanism of Injury
1. Young patients
• High-energy mechanism (MVA)
2. Elderly patients
• Low-energy mechanism (ground level falls)
3. Rule out pathologic or atypical femur fracture
• Denosumab or bisphosphonate use, particularly
alendronate, can be risk factor
78. Presentations
History
○ long history of bisphosphonate or denosumab
○ history of thigh pain before trauma occurred
Symptoms
○ hip and thigh pain
○ inability to bear weight
Physical exam
○ pain with motion
○ typically associated with obvious deformity (shortening and varus
alignment)
○ flexion of proximal fragment may threaten overlying skin
79. Imaging
● Fracture is thorough or below the lesser
trochanter
● Frequently comminuted
Warning sign on X-Ray:
● Communition, with extension into
piriform fossa.
● Displacement of medial fragment include
lesser
trochanter
● Lytic lesions in the femur
80. Classifications
Based on integrity of the piriformis fossa.
Designed to guide treatment of intramedullary nails using a piriformis
fossa starting
point.
● Type I- intact piriformis fossa
○ A- lesser trochanter attached to proximal fragment
○ B- lesser trochanter detached from proximal fragment
● Type II- fracture extends into piriformis fossa
○ A- stable posterior-medial buttress
○ B-comminution of lesser trochanter
81. Treatment
● Manipulation and reduction under X-Ray.
● Internal fixation with PFNA(Proximal femoral nail antirotation;
form of intramedullary
nailing) or fixation with locking plate.
● Postoperative partial weight-bearing with crutches until union is
secure.
82. Complications
● Malunion - Varus and rotational malunions are fairly common. This can be
prevented by careful attention to accurate reduction before internal fixation
is applied
● Non-union - This occurs in about 5 per cent of cases; it will require
operative correction of any deformity, renewed fixation and bone
grafting.
84. ● Fracture of femoral diaphysis occur between 5cm distal
to lesser trochanter and 5cm proximal to adductor
tubercle.
● Mechanism of injury
○ Most commonly due to high energy trauma in young
adults.
○ Spiral fracture: usually caused by a fall in which the
foot is anchored
○ Twisting fracture: the force is transmitted to the
femur
○ Transverse and oblique fractures: more often due to
angulation or direct violence.
○ Comminuted or segmental fractures:severe violence
85. 1. Pain
2. Swelling and deformity of the limb
3. Shortening of the lower limb
4. Complete external rotation deformity
5. Severe blood loss up to 1500 mL
6. Shock features - unconscious , pallor, tachycardia, cold
and clammy
skin, hypotension
Clinical features
86. Radiographic evaluation
● AP and lateral views of the whole femur
● The knee and hip joint must be included in the
x-rays film.
● Fracture pattern should be evaluated
87. Treatment
Emergency treatment
a. Set up an IV line
b. Cross-match blood and check Haemoglobin
c. If there is other injuries: give 2 units of blood
d. Wound debridement (pack the wound and treat by
delayed primary
suture)
e. Antibiotic and anti tetanus for open fracture
88. Femoral shaft fracture treatment
1. Traction, bracing, spica cast
a. Main indication for traction:
i. Femoral shaft fracture in children
ii. Contraindication to anaesthesia/surgery
iii. Lack of facilities for internal fixation
89. 2. Plate and screw fixation
a. Main indication:
i. Fractures of either end of the femoral shaft
ii. Shaft fracture in growing child
iii. Fracture with a vascular injury which requires open repair
3. Intramedullary nailing
a. Method of choice as the complication rate is low
b. Cannot be applied to growing child, only indicated for adults. This is
because the intramedullary nail will pass through the growth plate
90. 4. External fixation
a. Main indications:
i. Treatment of severe openinjuries
ii. Management of patient with multiple injuries
iii. The need to deal with severe bone loss by the
technique of bone
transport
92. Supracondylar
and
Intercondylar
fracture of Femur
Seen in:
● Young adults – high-energy trauma
● Elderly – low energy, often fall from
standing, in osteoporotic bone
Mechanism of Injury:
● Caused by direct trauma
● The fracture line is just above the condyles
but may extend between them.
● In the worst cases the fracture is severely
comminuted.
93. Supracondylar and Intercondylar fracture of Femur
Clinical features
● Knee – Swollen due to hemarthrosis
● Restriction of movement due to severe pain
● Distal pulses should always be checked to
ensure popliteal artery was not injured in
the fracture
Deforming forces
● Due to muscle pull, it can
result in deformity
● Quadriceps = Shortening
● Adductors muscle = Varus
● Gastrocnemius = recurvatum
(hyperextension of knee)
Gastrocnemius, arising from the posterior
surface of the distal femur, will tend to pull
the distal segment into extension, thus
risking injury to the popliteal artery
94. Muller AO Classifications
Type A
have no articular splits and
are truly ‘supracondylar’
Type B
are simply shear fractures of
one of the condyles
Type C
have supracondylar and
intercondylar fissures
95. Muller AO Classifications
● The fracture types are further subdivided describing
the degree of comminution and other characteristics.
● Further subdivision of type B fractures includes
○ Bl (sagittal, lateral condyle)
○ B2 (sagittal, medial condyle)
○ B3 (frontal, Hoffa type)
● Fracture type C is divided
○ C1 (articular simple, metaphyseal simple)
○ C2 (articular simple, metaphyseal
multifragmentary)
○ C3 (multifragmentary)
96. Imaging
● The entire femur should be X-rayed so as not
to miss a proximal fracture or dislocated hip.
● Of importance are:
○ whether there is a fracture into the
joint and if it is comminuted
○ the size of the distal segment
○ whether the bone is osteo-porotic.
● These factors influence the type of internal
fixation required.
● CT is often used as an adjunct to fully describe
the pattern of the fracture and aid surgical
decision making (any intra-articular extension).
97. Management
● Conservative treatment (slightly displaced & extra-articular fracture)
○ Skeletal traction through proximal tibia with cradled on
Thomas’ splint with a knee flexion piece - to encourage
movement
○ If distal fragment is displaced by gastrocnemius pull, put a
second pin above the knee and do vertical traction
○ At 4-6 weeks,replace traction with cast brace and allow patient up
and partially weight bearing with crutches.
98. Management
Operative treatment - ORIF
1. Locked intramedullary nails
a. Introduced retrograde through
intercondylar notch
2. Plates
a. Applied to lateral surface of femur:
95° condylar screw plate
b. In severely comminuted type C: newer
plate design with locking screw
3. Simple lag screw
a. Type B
b. Inserted in parallel( screw heads buried
within articular cartilage to avoid abrading
the opposing joint surface)
100. ANATOMY OF KNEE
•The knee joint is the largest joint in the body
•Type: Complex Hinge
•Movement: Flexion, Extension, Medial rotation,
Lateral rotation
•Consists of 3 joints:
-Medial condylar joint – between the femoral medial
condyle and tibial medial condyle
-Lateral condylar joint – between the femoral lateral
condyle and tibial lateral condyle
-Patellofemoral joint: between patella and patellar
surface of the femur
102. Knee Surface Anatomy
2: Patella: triangular sesamoid bone on the anterior aspect
of knee
3: Ligamentum patellae tendon: extend from apex of patella
to the tibial tuberosity - Edges of tendon palpable on knee
flexion
4: Tibial tuberosity: bony prominence on proximal end of
anterior tibial border & the insertion of ligamentum patellae
5: Tibial plateau: medial and lateral to it is knee joint line
6: Head of fibula: round bony prominence on lateral aspect
of the leg, on a level with tibial tuberosity
8: lateral epicondyle of femur
103. Bursae of the Knee
Found wherever skin, muscle or tendon rubs against bone.The
main function: to reduce friction between adjacent moving
structures.
Anterior Bursae
➢ Suprapatellar bursa
➢ Prepatellar bursa
➢ Superficial infrapatellar bursa
➢ Deep infrapatellar bursa
Posterior Bursae
➢ Popliteal bursa
➢ Semimembranosus bursa
➢ Remaining bursae are related to the tendon of the biceps
femoris; sartorius,gracilis & semitendinosus muscles
105. ANATOMY OF KNEE
INNERVATION OF THE
KNEE
Knee joint is innervated by
branches from :
1. Obturator nerve
2. Femoral Nerve
3. Tibial Nerves
4. Common Peroneal
Nerve
106. ANATOMY OF KNEE
BLOOD SUPPLY OF THE KNEE
❖ 5 genicular branches of the popliteal
artery (main supply):
● Medial and lateral Superior Genicular
Arteries encircle the femoral condyle
● Medial and lateral Inferior Genicular
Arteries encircle tibial condyle
● Middle Genicular Artery supplies ACL and
PCL
❖ Descending branch of the lateral circumflex
femoral artery
❖ Descending genicular branch of the femoral
artery
❖ Circumflex fibular branches of the posterior
tibial artery
❖ Anterior and posterior recurrent branches of the
anterior tibial artery
107. ANATOMY OF KNEE
MOVEMENTS OF THE KNEE
Normal active knee range of motion is:
➔ Knee Flexion: 135° i.e. fully bent
➔ Knee Extension: 0° i.e. fully straight
➔ Internal Knee Rotation: 10°
➔ External Knee Rotation: 30-40°
Normal passive knee ROM is:
➔ Passive Knee Flexion: up to 150°, depending on the size of the leg – the
limit is the calf pushing onto the back of the thigh
➔ Passive Knee Extension: up to 10° hyperextension is considered normal
110. •Complete disruption of the integrity of
tibiofemoral articulation
•Resulting in multi-ligament knee injury,
commonly rupture to at least 2 major knee
ligament structures
➢ Half of them are secondary to motor
vehicle accidents
(high-velocity dislocations)
➢ One-third are sport injuries
(low-velocity dislocations)
➢ 10% are from simple falls
(ultra-low-velocity dislocations)
112. CLINICAL FEATURES
Severe bruising and swelling :
● due to rupture of the joint capsule and leads to leak of hemarthrosis
Test of distal sensation and movement:
● popliteal artery may be torn or obstructed
Acute ischemia
● Surgical emergency
● Ankle brachial pressure index (ABPI): suspect
vascular injury
● If ABPI < 0.9, vascular imaging should be done (CT angiography)
113. •Patients who sustain
vascular injuries associated
with a knee dislocation need
immediate transport to a
trauma hospital, rapid
assessment and diagnosis at
presentation, and
revascularization
•Ischemia time >8 hours has
amputation rates as high as
86%
114. TREATMENT
➔ Must be reduced as soon as possible and held with brace, plaster or
external fixator
➔ Hyperextension must be avoided because of danger to popliteal
vessels
➔ Surgical intervention should be performed early (within 2 to 3 weeks)
for better outcomes
➔ Surgical techniques such as:
- Primary repair
- Repair and augmentation
- Reconstruction
➔ Above knee cast applied after swelling subsides (for 4-12 weeks)
➔ Quadriceps muscle exercises
115. COMPLICATION
S
➔ Early
★ Arterial damage : popliteal artery damage
★ Common peroneal nerve injury: weak or absent ankle
dorsiflexion
➔ Late
★ Joint instability
★ Stiffness : loss of movement, due to prolonged immobilization
117. MECHANISM OF
INJURY
Direct Injury
-Usually a fall onto the knee or
a blow against the car’s
dashboard
-Either an undisplaced crack
or a comminuted (stellate)
fracture
Indirect Injury
-Occurs when someone
catches the foot against a
solid obstacle and to avoid
falling, the quadriceps muscle
contract forcefully
-Transverse fracture with a
gap between fragments
118. CLINICAL FEATURES
•Swollen and painful knee
•Haemarthrosis
•Patella is tender and sometimes gap can be felt
•Active knee extension should be tested. IF patient CAN LIFT the
straight leg, quadriceps mechanism still intact
119. IMAGING
The x-ray may show:
➢ One or more fine fracture lines
without displacement
➢ Multiple fracture lines with
irregular displacement
➢ A transverse fracture with gap
between the fragments
120. CLASSIFICATIO
N
➢ Patella fractures are classified as:
- Transverse
- Longitudinal
- Polar
- Comminuted (stellate)
➢ May be undisplaced or displaced
121. TREATMENT
➢ UNDISPLACED OR MINIMAL DISPLACED FRACTURES
★ The extensor mechanism is generally intact and treatment is mainly
to protect
★ A plaster cylinder or an extension brace holding the knee
straight should be worn for 3 to 4 weeks
★ Quadriceps exercise should be practised every day
➢ COMMINUTED (STELLATE) FRACTURE
★ Patient may be able to lift the leg but the undersurface of the
patella is irregular and has a serious, risk of damage to the
patellofemoral joint
★ Open reduction and internal fixation should be done
122. TREATMENT
➢ DISPLACED TRANSVERSE FRACTURES
★ The lateral expansion are torn and entire
extensor mechanism is disrupted
★ The fragments are reduced and transfixed
with two stiff K-wires (flexible wire is then
looped tightly around the protruding
K-wires and over the patella)
124. MECHANISM OF
INJURY
INDIRECT FORCE
(more common)
-sudden, severe contraction of the
quadriceps muscle while the knee
is stretched in valgus and external
rotation
-occurs in field sports when a
runner dodges to one side
DIRECT FORCE
-direct force while knee is flexed and the
quadriceps muscle relaxed
-patella dislocates laterally
-medial patellofemoral ligament and
retinacular fibres may be torn
125. CLINICAL FEATURES
‘FIRST-TIME’ DISLOCATIONS
➢ Tearing sensation
➢ Feeling that the knee has gone ‘out of joint’
➢ Remains unreduced:
○ Obvious deformity; the displaced patella seated on the lateral side of knee
○ Active or passive movement is not possible
❖ Reduced spontaneously:
➢ Knee may be swollen
➢ Bruising and tenderness on the medial side
RECURRENT DISLOCATIONS
● Episode characterized by acute pain with knee stuck in flexion and patella displaced
laterally
● Patellar apprehension test positive
126.
127. TREATMENT
CONSERVATIVE TREATMENT
★ If unreduced, dislocations can be pushed back into place without much difficulty
★ No need for immobilization or bracing
★ Non-operative therapy
★ To reduce swelling and increase the range of movement of knee
★ Include muscle-strengthening exercise, physiotherapy such as closed chain exercises
and vastus medialis oblique (VMO) strengthening
OPERATIVE TREATMENT
★ Should be considered when the conservative treatment have failed and recurrent
nature of disease has resulted in functional impairment
129. ● The second-largest bone in the body
● The tibia's main function in the leg is to
bear weight.
● Important proximal tibia landmark.
○ Lateral and medial condyles
(articulation with femur–knee joint)
○ Tibial plateau
○ Anterior and posterior
intercondylar areas
○ Tibial tuberosity
PROXIMAL TIBIA
130. Avulsion fracture of ACL
● Anterior cruciate ligament (ACL) avulsion
fractures contribute most of the injuries around
the knee joint and commonly occurred in
children.
● They are caused by forceful hyperextension of
the knee or by a direct blow over distal end of
femur with the knee flexed.
131. Avulsion fracture of
ACL
● Standard imaging for ACL avulsion
fractures include anteroposterior and
lateral radiographs.
● The fracture is best seen on the lateral
radiograph.
● An MRI is useful to determine the site of
origin of the bone fragment and to
assess the associated soft tissue
injuries.
132. Management
● Type I can be managed
conservatively
● Types II–IV needs open
reduction and internal fixation
The Meyers and
McKeever classification
of ACL avulsion
133. Avulsion fracture of PCL
● The posterior cruciate ligament
(PCL) is an important structure for
stabilizing the knee joint.
● Avulsion fracture of the PCL will
directly lead to backward
instability of the knee joint, which
will lead to an increase in
articular cartilage pressure and
eventual degenerative changes in
the joint
● These injuries are commonly seen
in motorcycle or car accidents
(dashboard injuries) in which
posteriorization forces occur
against the tibia in a exed knee.
135. Tibial plateau fracture
● The knee is swollen and may be
deformed
○ The tissue feels ‘doughy’ due
to hemarthrosis
● On examination:
○ Usually tender and may have
medial or lateral instability
○ Identify any signs of vascular
or neurological injury
■ Popliteal artery injury
■ Common peroneal nerve
injury (foot drop)
Mechanism of injury
1. Low energy - commonly seen in older
female due to osteoporotic bone changes
2. High energy - commonly due to motor
vehicle accident, falls or sport related
injury
3. Caused by a varus or valgus force
combined with axial loading or weight
bearing knee
a. A car striking a pedestrian‘s fixed
knee (bumper fracture)
b. Fall from a height in which the knee is
forced into varus or valgus
Clinical features
136. Imaging
AP, lateral, oblique X-rays
● Location of main fracture lines
● The areas of the portion of condyle that is
depressed
● The position of major parts of articular
surface that have been displaced
CT scan
● Amount of comminution
● Degree of plateau depression
● Extent and degree of
displacement
137. Schatzker Classification
● A vertical split of the lateral
condyle
● May be undisplaced, or the
condylar fragment may be
pushed inferiorly and tilted
● Undisplaced:
○ A hinged cast-brace or ROM
brace is used to allow early
immobilization (after pain
and swelling have
subsided)
● Displaced:
○ Should be treated with open
reduction internal fixation
(ORIF)
○ Lag screws alone or in
combination with plate are
used for fixation
Type 1 Management
A simple split of lateral
condyle
138. Schatzker Classification
● A vertical split of the
lateral condyle combined
with depression of an
adjacent load-bearing part
of the condyle
● Condylar fragment is
displaced laterally and the
joint is widened
● If depression is less than 5 mm or
the patient is old with
osteoporotic bone:
○ treat conservatively aim to
regain mobility and function
● In younger patient with
depression more than 5 mm
○ open reduction internal
fixation is required and bone
graft may be needed
Type 2 Management
Type 1 + a more central
area of depression
139. Schatzker
Classification
● Depression of the
articular surface with an
intact condylar rim
● No vertical split of lateral
condyle and the joint is
usually stable
● The depressed fragments may
need to be elevated
● The elevated fragments can be
supported with bone graft and the
whole segment is held with ‘raft’
screws
Type 3 Management
Depression of the lateral
condyle + intact rim
140. Schatzker Classification
● Fracture of the medial
tibial condyle
● Can cause rupture of the
lateral collateral ligament
and a traction injury of the
peroneal nerve
● Stable fixation of medial side is
needed
● Assess for any ligament injury
Type 4 Management
A fracture of the medial
condyle
141. Schatzker Classification
● Both condyles are split but
there is a column of the
metaphysis wedged in
between that remains in
continuity with the tibial
shaft.
● Fixation is most commonly done
using combination of screws
with locking plates with bone
graft as required.
● Use circular external fixator to
stabilize and hold the
metaphysis to shaft.
Type 5 Management
Fracture of both condyles but
with the central portion of the
metaphysis still connected to
the tibial shaft.
142. Schatzker Classification
● This is a high-energy
injury that may result in
severe comminution.
● The tibial shaft is
effectively disconnected
from the tibial condyles.
● Fixation is most commonly done
using combination of screws
with locking plates with bone
graft as required
● Use circular external fixator to
stabilize and hold the
metaphysis to shaft
Type 6 Management
Combined condylar and
subcondylar fractures
143. Neurovascular injury:
a. Popliteal artery injury
b. Common peroneal nerve injury (foot drop)
1. Malunion
2. Joint stiffness
3. Deformity
Late
Complications of Tibial Plateau Fracture
Early
1. Compartment syndrome
-Bleeding and swelling in type 4 or 5
fractures
-Any sign of disproportionate pain on
passive stretching of muscle
145. Fracture shaft of tibia and fibula
● Tibia is more commonly fractured
because of its subcutaneous
position.
● Fractures of the tibia generally are
associated with fibula, because the
force is transmitted along the
interosseous membrane to the fibula.
● The skin and subcutaneous tissue are
very thin over the anterior and medial
tibia → usually open fracture
● In closed fractures, the thin soft tissue
can become compromised.
Mechanism of Injury
● Twisting force causes spiral fracture of
both leg bones at different levels
● An angulatory force produces transverse
or short oblique fractures, usually at the
same level
● Indirect injury is usually low-energy; with a
spiral or long oblique fracture one of the
bone fragments may pierce the skin from
within.
● Direct injury crushes or splits the skin over
the fracture; this is usually a high-energy
injury and the most common cause is a
motorcycle accident.
146. Fracture of both tibia and fibula
● The behaviour of these injuries, and therefore the choice of treatment
will depend on the following factors :
a. The state of the soft tissue
■ The risk of complications and the progress to fracture
healing are directly related to the amount and type of
soft-tissue damage.
■ Closed fractures are best described using Tscherne’s method
■ Open injuries, Gustilo’s grading is more useful
b. The severity of the bone injury
c. The stability of the fracture
d. The degree of contamination
e. Patient factors
147. Clinical features
1. Pain/ swelling in lower leg area
2. Obvious deformity or uneven leg lengths
3. Inability to stand/ walk (More likely
happen with tibia, less likely if only the
bula is broken)
4. Limited range of motion in the knee or
ankle area
5. Bruising/ discoloration (May indicate
damage to blood vessels)
148. Radiological findings (X-ray)
● The entire length of the tibia and
fibula, as well as the knee and ankle
joints, must be seen.
● The type of fracture, its level and the
degree of angulation and displacement
are recorded
● Rotational deformity can be gauged by
comparing the width of the tibiofibular
interspace above and below the
fracture.
151. Managemen
t
For close fracture
● If undisplaced / minimally displaced
○ Immobilise with full length cast from upper
thigh to metatarsal neck apply with the knee
slightly flexed and ankle at right angle
● If fracture is displaced
○ ORIF with intramedullary nails
152. For open fracture
1. Antibiotics
2. Debridement
3. Stabilization
4. Prompt soft tissue cover
5. Rehabilitation
