Lower Limb

FRACTURE MANAGEMENT GUIDELINES

(adapted from Practical Fracture Treatment by Ronald McRae, 4th edition)

 

LOWER LIMB FRACTURES

Avulsion Fractures of the Pelvis

Mechanism

  • Sudden, violent muscle contraction of
    • ASIS – Sartorius
    • AIIS – Rectus Femoris
    • Posterior spine – erector spinae
    • Iliac Crest – abdominals
    • Ischial tuberosity – hamstrings

Management

  • ASIS, AIIS, Posterior spine of pelvis, Iliac Crest – Symptomatic management – Crutches, WBAT, strengthening and stretching (often caused by overuse and / or tight structures)
  • Ischial Tuberosity – may need internal fixation

Isolated Fractures of the Pubic Rami

Mechanism

  • Fall onto side

Management

  • Symptomatic – WBAT with gait aid

Fractures of the Acetabulum

Mechanism

  • MVA
  • Fall from height

Management

  • Variable depending on extent of damage – internal fixation, extensive bed rest / NWB

Fracture of the Neck of Femur

Mechanism

  • Fall +/- onto hip

Management

  • Internal fixation or hip replacement

Potential Complications

  • Avascular necrosis

Fractures of the Femoral Shaft

Mechanism

  • MVA
  • Fall from height
  • Crushing injuries

Management

  • Traction, internal fixation

Supracondylar Fractures of the Femur (distal 1/3rd of femur)

Mechanism

  • Motor Vehicle Accident
  • Falls from height

Management

  • Children – If minimally displaced, full leg POP, NWB
  • Adult, or Child if displaced – may need ORIF or reduction and then plastered into knee flexion

Condylar Fractures of the Femur

Mechanism

  • Motor Vehicle Accident
  • Falls from height

Management

  • ORIF

Patella Fractures

Mechanism

  • Direct violence
  • Sudden muscular contraction

Management

  • Undisplaced vertical or horizontal – plaster cylinder or ZKS for 6 weeks, WBAT
  • Otherwise – ORIF or patellar excision

Avulsion Fractures of the Tibial Tubercle

Mechanism

  • Sudden violent quadriceps contraction

Management

  • No or minimal displacement, or in skeletally immature – 6 weeks in plaster cylinder or ZKS
  • Marked displacement – fixed with a screw

Fractures of the Head of the Fibula

Mechanism

  • Varus force
  • Sudden muscular contraction (biceps femoris)

Management

  • Undisplaced / displaced
    • If knee is clinically stable – symptomatic treatment
    • If knee unstable – operative repair unless there is a definite, undisplaced fracture which seems likely to go on to union, in which case an plaster cylinder or Zimmer Splint is applied for 6-8 weeks

Potential complications

  • Common Peroneal Nerve palsy

Fractures of the Tibial Shaft

Mechanism

  • Direct violence
  • Torsional stress
  • Fall from height
  • Motor vehicle accidents

Management

  • Adults – usually internal fixation or manipulation
  • Children
    • Undisplaced– managed in long leg plaster over generous layer of wool; admission is desirable for observation of circulation; NWB with crutches commenced at about 2-3 days.
    • Angulated – need to be reduced under general anaesthesia

Complications

  • Often open injuries
  • Compartment syndrome

Tibial Plateau Fractures

Mechanism

  • Severe varus or valgus force
  • Fall from height

Management

  • No ligament damage, no tibial subluxation, tibial depression < 10mm – traction or internal fixation
  • >10mm tibial depression – internal fixation

Unicondylar and Bicondylar Tibial Fractures

Mechanism

  • As per tibial plateau fractures

Management

  • Internal fixation
  • Traction

Fractures of the Distal Fibula

Mechanism

  • Hyperinversion
  • Hypereversion

Management

  • Distal to syndesmosis (Weber A)
    • Undisplaced with normal talar alignment – below knee POP for 6 weeks,
    • Displaced or with talar tilting – manipulation or fixation
  • Distal fibular, at level of syndesmosis (Weber B)
    • Undisplaced (no talar tilting) – symptomatic as above, or internal fixation
    • Displaced or with talar tilting – manipulation or fixation
  • Distal fibular, above level of syndesmosis (Weber C)
    • undisplaced stable (where medial ligament and posterior tib/fib ligament are NOT involved – no talar tilting) – below knee POP or above knee POP
    • Unstable (posterior tib/fib ligament and/or medial ligament are involved – talar tilting) – internal fixation
  • Epiphyseal
    • Type 1 and 2
      • No or minimal displacement – below knee POP
      • Displacement appreciable – reduction, below knee POP
    • Type 3 and 4 – reduction, likely internal fixation
    • Type 5 – orthopaedic review and below knee POP

Fractures of the Distal Tibia

Mechanism

  • As above, usually with greater force

Management

  • Medial malleolus (Undisplaced or displaced) – internal fixation
  • Medial malleolus (elderly) – may wish to try conservative management – manipulation if necessary and below knee POP, NWB for 6 weeks
  • Isolated Posterior Malleolus, Bimalleolar and Trimalleolar – manipulation and/or internal fixation

Isolated Fractures of Navicular

Mechanism

  • Inversion
  • Avulsion of tibialis posterior

Management

  • Tuberosity
    • Undisplaced – below knee POP for 6 weeks
    • Displaced – internal fixation
  • Other
    • Undisplaced – below knee POP for 6 weeks
    • Otherwise – internal fixation

Fractures of the Talus

Mechanism

  • Forced dorsiflexion

Management

  • Avulsion fracture of ligamentous or capsular attachments – symptomatic treatment, eg 2-4 weeks in a below knee walking plaster
  • Talar Dome
    • Undisplaced – padded below knee POP
    • Displaced – internal fixation or excision if small
  • Talar Body
    • Undisplaced – padded below knee POP, NWB for 3 months
    • Displaced – internal fixation
    • Comminuted – bandaging, NWB for 8-10 weeks, AROM, isometrics ASAP
  • Talar Neck
    • Undisplaced – padded below knee POP, NWB for 3 months
    • Displaced – manipulation or internal fixation
  • Talar Head
    • Undisplaced – uncommon – opinion necessary
    • Comminuted – bandaging, NWB for 8-10 weeks, AROM, isometrics ASAP

Potential complications

  • Often open injuries
  • Avascular necrosis

Calcaneal Fractures

Mechanism

  • Fall from height onto the heels
  • Eversion (sustentaculum tali)

Management

  • Vertical fracture of the tuberosity – Compression, WBAT (initially sore++), heel cushion
  • Avulsion of Sustentaculum tali (by deltoid ligament) – NWB 6 weeks or BK POP for 4 weeks, then WBAT
  • Horizontal fractures
    • Avulsion type (including achilles tendon attachment) –  internal fixation
    • Posterior superior angle of the calcaneus (not involving achilles attachment) – manipulation if severely displaced and managed in below knee, padded plaster NWB for 1 week, then 5 weeks in a below knee walking plaster OR crepe bandage over wool, NWB for 6 weeks.
  • Anterior fractures
    • No significant compression or shortening – as per sustentaculum tali
    • If calcaneal shortening – internal fixation and/or bone graft
  • Body
    • Not involving subtalar joint
      • Minimally displaced – pressure bandage, rest, elevation, NWB for 6 weeks, calf exercises (stretch and strength) ASAP. May use Cam walker for position
      • Significantly displaced – internal fixation
    • Involving subtalar joint
      • Undisplaced – as per sustentaculum tali
      • Displaced – internal fixation

Fractures of the First Metatarsal

Mechanism

  • Crushing accidents

Management

  • Undisplaced – below knee walking plaster for 5-6 weeks
  • Displaced – reduction, then as above or internal fixation

Fractures of the 5th metatarsal base

Mechanism

  • Inversion mechanism (pull of peroneus brevis)

Management

  • All fractures – Symptomatic – crepe bandage for 2-3 weeks; if marked pain – walking below knee plaster for 5-7 weeks

Jones Fracture (proximal 5th metatarsal shaft)

Mechanism

  • Not usually associated with inversion; some features of a stress fracture

Management

  • Usually undisplaced – 7 weeks in below knee POP, NWB OR Internal fixation

Potential Complications

  • Non union

Metatarsal Shaft and Neck fractures (except the first metatarsal)

Mechanism

  • Crushing accidents

Management

  • Undisplaced, without soft tissue damage – symptomatic treatment – bandage or walking plaster if pain severe
  • Multiple fractures without much displacement – treat conservatively with below knee walking plaster for 6 weeks
  • Multiple fractures with displacement – internal fixation

Fractures of the Lower Limb Phalanges

Mechanism

  • Crushing

Management

  • Middle / Proximal Phalanges
    • Minimally displaced – Buddy strapping
    • Severely displaced – reduction and then buddy strapping
  • Distal Phalanx – Buddy strapping, cut out for shoe or walking plaster for 2-4 weeks
  • For first ray, may wish to consider walking plaster with toe platform