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Lower Limb Trauma

Overview. Femoral shaft fracturesIntra-articular fractures of the kneeAnkle fractures. Femoral shaft fractures. EpidemiologyManagement. Femoral shaft fractures Epidemiology. Boys 72%Age ? bimodal distribution. Hinton et al JBJS 1999; 81A: 500. Femoral shaft fractures Epidemiology. Mechanism of

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Lower Limb Trauma

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    1. Lower Limb Trauma Mr Matthew Barry MS FRCS(Orth) Consultant Orthopaedic Surgeon

    2. Overview Femoral shaft fractures Intra-articular fractures of the knee Ankle fractures

    3. Femoral shaft fractures Epidemiology Management

    4. Femoral shaft fractures Epidemiology Boys 72% Age – bimodal distribution

    5. Femoral shaft fractures Epidemiology Mechanism of injury

    6. Femoral shaft fractures - Management Traction Traction & hip spica Immediate hip spica ORIF Ex-fix Elastic nail

    7. Femur - Traction Common method of treatment ? in hospital ? until # united ? convert to POP cast

    8. Femur - immediate hip spica Advantages Short hospital stay Cost Disadvantages GA required ? malunions

    9. Femur - ORIF Advantages Anatomical reduction Early mobilisation Short hospital stay Disadvantages Scars Neuro-vascular injury 2nd GA to remove plate Re-fracture

    10. Femur – im nail Why not treat the fracture like an adult and use a standard intramedullary nail?

    11. im nail Entry point: piriformis fossa = damage to piriformis anastomosis = AVN femoral head in ~5% = unsalvagable ? use trochanteric entry point

    12. Femur – Ex-Fix Advantages Early mobilisation Good for open or infected cases Disadvantages Scars Large device Pin site problems Re-fracture – 10%

    13. Femur – Elastic Nail Advantages Excellent stability Early mobilisation Early weight bearing Short hospital stay Small scars V.low re-fracture rate Disadvantages Wound problems 2nd GA to remove nails Cost

    14. Intra-articular fractures of the knee ACL avulsion fractures

    15. ACL avulsion fracture Mechanism of injury ACL rupture vs avulsion fracture Classification Management Prognosis

    16. ACL avulsion fractures Mechanism of injury Hyperextension injury Fall of bicycle Sport

    17. Fracture vs ACL rupture ACL rupture is uncommon in children < 14 years “bone is weaker than the ligament”

    18. Classification of ACL fracture

    19. ACL avulsion fracture Management Type I: long leg cast with knee in extension ? aspirate haemarthrosis

    20. ACL avulsion fracture Management Type II and III

    21. ACL avulsion fractures Prognosis Good. Bone unites Malunion of Type III fracture may result in impingement

    22. Ankle Fractures Ottawa ankle rules Classification Management

    23. Ottawa Ankle Rules Initially applied to ADULT ankle injuries Determines the need for an X-ray Xray if bone tenderness at: A: post edge lat mall B: post edge med mall C: base of 5th MT D: navicular + unable to wt bear Reduces number of x-rays by ~35%

    24. Ottawa Ankle Rules Subsequently validated in children 25% reduction in number of x-rays obtained No fractures missed

    25. Classification of Ankle Fractures Modification of Lauge-Hansen classification of adult fractures Dias & Tachdjian CORR 1978; 136: 230

    26. Management Undisplaced: conservative Rx Displaced: Reduce and hold the physeal fracture Non physeal fracture will probably “follow” and may not need any Rx Consider the periosteum as a block to reduction

    27. “Special” ankle fractures Tillaux Triplane

    28. Tillaux Older child nearing skeletal maturity External rotation injury

    29. Tillaux Why does it occur ? Related to physeal closure Last part to close is antero-medial part

    30. Tillaux Management ORIF for displaced fracture ? percutaneous k wire

    31. Triplane 1 - 2 years younger than Tillaux fracture Usually 2 part fracture Occasionally 3 or 4 part ORIF for displaced fracture

    32. Conclusions Femur fracture Immediate hip spica for younger child Elastic nails in older children ACL avulsion fracture ORIF for displaced fractures Ankle fracture Get the physis right Remember “special” fractures n older children

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