JUNIORBONES
Orthopaedics and trauma for junior orthopaedic trainees and medical students
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Assessment and management of lower limb long bone fractures
by James Donaldson

Femur shaft fracture

History:
Age – young, high energy energy, often associated with life-threatening trauma. In elderly due to osteoporosis and low energy fall
Occupation.
Mechanism of injury - often road traffic collision
Time/date of injury

Past medical/surgical history

Medication/drugs and allergies

Last ate/drank (for timing of emergency surgery if needed)

Radiographs / Imaging:
  • AP and lateral of whole femur
  • AP and lateral of ipsilateral hip and knee
  • CT can be considered to exclude ipsilateral femoral neck # if indicated
femur fracture
AP x-ray demonstrating displaced, angulated fracture of femoral shaft
Symptoms and signs:
  • Pain, swelling and deformity in the thigh
  • Unable to weight bear
  • Ipsilateral femoral neck # seen in 2-6% but missed in up to 30% of cases
  • Document neurovascular status
Initial management:
  • ATLS principles. This is a significant injury
  • Analgesia, IV fluids, skin traction for comfort
  • Assess for other injuries
  • Admit for surgical fixation. In elderly liaise with care of the elderly team if appropriate
  • Call senior if patient is unstable, polytrauma, open fracture or neurovascular compromise
Definitive treatment:
  • Nearly all need operative fixation
            - Unless medically moribund or paediatric patient
  • Intramedullary femoral nail            - Antegrade is gold standard
            - Retrograde if ipsilateral femoral neck #, floating knee, acetabular #, bilateral femoral #s
  • Consider damage control if polytrauma patient, neurovascular injury or significant soft tissue compromise
Complications:
  • Malunion: sagittal, coronal, rotational, length
  • Delayed union
  • Nonunion
  • Heterotopic ossification
  • Infection
  • Iatrogenic #
  • Neurovascular injury

Tibial shaft fracture

History:
Age –    High energy fractures in young as a result of direct trauma.
Low energy fractures due to torsional forces

Radiographs:
  • AP and lateral of tibia and fibula
  • Ipsilateral knee and ankle recommended
tibia fracture
AP x-ray showing segmental tibial shaft fracture
Symptoms and signs:
  • Commonest long bone #
  • Pain, swelling, deformity, inability to weight bear
  • Crucial to assess:
            - Soft tissues – often an open #
            - Compartments – commonest location of compartment syndrome
            - Neurovascular status
            - Associated injuries
Open fracture classification (Gustillo and Anderson) of open fractures:
Grade -      1. Wound <1cm. Often inside out injury
                 2. Wound 1-10cm. Mild – moderate periosteal stripping
                 3.    a) significant soft tissue injury but adequate periosteal coverage
                        b) as above but inadequate periosteal and soft tissue coverage. Will require a flap
                        c) associated vascular injury requiring repair

Initial management:
  • ATLS principles. This is a significant injury
  • Analgesia, IV fluids, skin traction for comfort
  • Admit for surgery. Call senior if open, neurovascular compromise or polytrauma
  • Open fracture management (see BAPRAS guidelines):
            - Remove gross wound contaminants
            - Photograph and dress the wound
            - Antibiotics (1.2g co-amoxiclav or 600mg clindamycin if allergic) and anti-tetanus
            - Limb splintage eg. above knee backslab
  • Immediate debridement if:
            - Gross contamination
            - Compartment syndrome
            - Devascularised limb
            - Multiply injured patient
  • Otherwise debridement <24hrs of injury
Definitive treatment:
  • Early debridement with further co-amoxiclav and 1.5mg/kg gentamicin
  • Continue co-amoxiclav for until soft tissue closure or maximum of 72hrs
  • At the time of stabilization vancomycin 1g or teicoplanin 800mg should be given
  • Spanning ex-fix if the fracture is not definitively stabilized or the skin not closed at primary debridement
  • Convert to definitive internal stabilization as early as possible if soft tissues allow – usually intramedullary nail
Complications:
  • Malunion: sagittal, coronal, rotational, length
  • Delayed union
  • Nonunion
  • Knee pain (if IM nail in >50%)
  • Infection
  • Compartment syndrome (1-9%)
  • Neurovascular injury
Consider primary amputation if:
  • Uncontrollable haemorrhage
  • Incomplete traumatic amputation
  • Segmental muscle loss > 2compartments
  • Bone loss > 1/3 of tibia
  • Avascular >6hrs
  • 2 consultant decision

Fibula shaft fractures

Isolated shaft fracture:
  • Often from a direct blow
  • Check common peroneal nerve
  • Analgesia and mobilise as tolerated
  • POP or immobilisation is not needed
  • # clinic follow-up 1-2 weeks

Associated with tibial shaft fracture:

  • Fix tibia and follow above suggestions
  • The fibula can be left untreated

Maisonneuve fracture:
  • Is a proximal fibula fracture associated with an external rotation injury of the leg
  • Ankle syndesmosis is disrupted and needs stabilization
  • Obtain ankle radiographs if suspected
  • The fibula fracture itself does not need fixing

isolated fibula fracture
AP x-ray demonstrating minimally displaced isolated fibula shaft fracture
Maisonneuve fracture
AP x-ray demonstrating undisplaced fracture of proximal fibula
Maisonneuve fracture
AP x-ray of ankle of same patient demonstrating ankle joint disruption due to Maisonneuve injury
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