Practical clas №3

 

Practical clas №3

 

PELVIC FRACTURES

The incidence of pelvic fractures is on the rise following the increased number of vehicular accidents. It is commonly found as one of the fractures in a patient with multiple injuries. Often this fracture is not a serious management problem in itself, but may become so because of the visceral complications so often associated with it. These fractures occur in all age groups but are most common in young adults.

Relevant Anatomy

Pelvic ring: The pelvis is a ring shaped structure joined in the front by the pubic symphysis and behind by the sacro-iliac joints. There are projecting iliac wings on either side a frequent site of fractures. The pelvic ring is formed in continuity from the front, by pubic symphysis, pubic crest, and pectineal line of pubis, arcuate line of the ileum, and ala and promontory of the sacrum. Fractures in the anterior half of the ring may have an associated injury in the posterior half. This makes the pelvic ring unstable.

This ring can be divided functionally, into a posterior weight transmitting segment and an anterior segment serving only for muscular attachment. Inju­ries to the posterior segment are important from the locomotion point of view and are more disabling to the pelvic viscera like the bladder. Urethra, rectum and the veins.

А. В. The fractures of iliac bones.

С. D. The fractures of sacral bones.

Е. The fractures of sacro-iliac connection.

F. The fractures of pubis and ischiadic bones

          (the vertikal branches).

G. The fractures of pubis and ischiadic bones (the horisontal branches).

H.  The fractures of ischiadic bones .

І.  The rupture of the symphis  connection

 

Stability of the Pelvis: The stability of the pelvic ring depends, posteriorly on the sacro-iliac joints and anteriorly on the symphysis pubis. The sacro-iliac joints are bound in front and behind by the strong, band-like, sacro-iliac liga­ments. The pubic symphysis is reinforced by ligament fibers above and below it. Accessory ligaments of the pelvis, such as the ilio-lumbar ligament, sacro-tuberrous ligaments and sacro-spinous ligaments provide additional stability to the ring.

Nerves in relation to the Pelvis: The obturator nerve and the sacral plexus pass over the ala of the sacrum and cross the pelvic brim. These are likely to suffer injury in fracture in the region.

Classification: Marvin Tile (1988) classifies these fractures on the basis of stability of the pelvis into 3 types — type A, B and C.

Type A — The minimally displaced stable fracture, were previously known as "isolated fractures".

Type B and C — Unstable fractures, were previously known as "Pelvic Ring" disruption injuries.

Type A — Stable

Ai: Fractures of the pelvis not involving the ring; A2: Stable, minimally displaced fracture of the ring.

Type B — Rotationally unstable, vertically stable

B1: Open book-type

B₂: Lateral compression - upsilateral

B₃: Lateral compression - contralateral (Bucket - handle type)

Type C — Rotationally and vertically unstable

Ci: Unilateral

C₂: Bilateral

C3: Associated with acetabular fracture

Type A — Stable, minimally displaced fractures

In this type, the pelvic ring is stable and displacement is insignificant. This type is further subdivided into types A] & A₂.

In type Ai fractures (Previously known as Isolated Fractures) the pelvic -ring is not involved. Avulsion fractures of the pelvis and fractures of the iliac wing are included in this group. In type A₂ the pelvic ring is fractured but the fracture is undisplaced and remain stable. Isolated pubic rami fractures and un-displaced fractures of the acetabulum are included in this group.

Type B — Rotationally unstable vertically stable

In this type of injury the pelvis is unstable - rotational displacement can occur: although no vertical displacement can occur: This type is further subdi­vided into types B_b B₂ and B₃.

Type B₁ also known as "Open - Book Injury" is caused by a force tend­ing to open up the pelvis, i.e. an external rotation of force acting on the hemi-pelvis as occurs in an anterio-posterior compression. The result is disruption of symphysis pubis. This is no vertical displacement. Type B₂ results from lateral compression where there is upsilateral fracture of the pubic rami anteriorly and crushing of the posterior complex. Type B₃ results from lateral compression but the major anterior fracture is on the side opposite to that of the posterior fracture or dislocation. The affected hemi-pelvis rotates anteriorly fracture or dislocation. The affected hemi-pelvis rotates anteriorly and superiority like the handle of bucket (Bucket-handle injury).

Type C — Rotationally and Vertically Unstable

These are the most unstable injuries, the essential features being vertical instability. This type is further subdivided into type C|, C₂ and C3. In type Cj, the injury is limited to one side of the pelvis with vertical displacement if the hemi pelvis. In type C₂, the injury is on the both side of the pelvis anteriorly as well as posteriorly. In type C3 either of the above (Ci or C2) plus fracture of the acetabulum are present.

Type A Injury - Isolated Fractures

This is the commonest injury but the least serious of the three types. Any part of the pelvis may be affected; the essential feature being that the pelvis remains stable. Complications are uncommon in these relatively minor frac­tures of the pelvis. The following are some of the fractures included in this group.

The fractures of pelvis with injures of pelvis ring (Malgen’s)

1.                The fractures of sacro-iliac connection with displasement.

2. The fractures of pubis with displasement

3. The fractures of ischiadic bones with displacement

 

 

 

The fractures of half part of pelvis with displasement

 

The rupture of the symphis and sacro-iliac connection with displasement.

 

ISCHIO - PUBIC KAMI FRACTURES

These are the commonest of pelvic fractures. One or more rami may be fractured on one or both sides, the latter is called as Straddle fracture. Dis­placement is usually minimal. The fracture of rami may extend into the ace­tabulum. There may be and associated injury to the urethra or bladder.

Clinically the patient presents with pain and tenderness over the fracture site. Sometimes a patient with multiple injuries may not have any complaint referring to this fracture, and it is detected by the routine pelvic compression test.

Radiologically. Once an ischio-pubic rami fracture is detected one must carefully rule out an associated fracture in the posterior half of the pelvic ring (i.e. fracture through sacrum, sacro-iliac joint or ilium). It is only after this is done that diagnosis of'isolated pubic rami fracture can be made.

Treatment. These fractures pose no problems in successful union. Treat­ment is basically for relief of pain. Bed rest for one to three weeks is usually sufficient.

ILIAC WING FRACTURES

This is a relatively uncommon fracture resulting from direct injury to the wing of the ilium (e.g. in a road traffic accident) Sometimes, these patients may lose so much blood from "vascular " iliac wings that they develop hypo-volaemic shock. The fractures are otherwise without complications and unite in 4-6 weeks with rest and analgesic.

AVULSION FRACTURES OF ANTERIOR DUAC SPINE

The straight head of the rectus femoris muscle takes its origin from the an­terior inferior iliac spine.

ACETABVLAR FRACTURES

Some of the undisplaced or minimally displaced fractures of the acetabu­lum can be considered in this group of relatively 'beningn' fractures. Late, sec­ondary osteoarthritis develops in some cases because of the irregularity of the articular surface in the injury.

Type B and C Injuries (Ring Disruption Injuries)

These are uncommon but more important injuries because of the higher in­cidence of associated complications. Road traffic accidents are the commonest cause of such injuries.

Pathology. If a portion of the pelvic - ring is broken, and the fragments displaced, there must be a fracture or dislocation in another portion of the ring. The following combinations of fracture and dislocation in anterior and poste­rior halves of the pelvis may occur.

Displacements. It is generally slight. The type of displacement depends upon the force causing the fracture. The following displacements may occur:

a)    External Rotation of the hemi-pelvis (open-book type): The pelvic ring
is opened up from the front like a book. There may be a pubic sym­
physis disruption or rami fractures in front and damage to the sacro-
iliac joint behind.

b)    Internal rotation of hemi-pelvis: This may result from a lateral com­
pression force. There may be an overlap anteriorly with or without a
posterior lesion.

c)           Rotation superiorly (bucket handle type): The hemi-pelvis rotates su­
periorly along a horizontal antero-posterior axis.

d)         Vertical displacement: This results from a vertical force causing up­
ward displacement of half of the pelvis.

Diagnosis. Clinical examination of Pelvis fracture are major injuries, often with little or no clinically obvious deformity. It may be one of the fnctures in a seriously injured patient where the surgeons attention may be diverted to other injuries with more obvious manifestations. A pelvic fracture must be carefully looked for in all cases of road accident, especially in those with multiple inju­ries, these associate with hypovolaemic shock, and these with major lower limb fractures (fracture of the femur etc.) A pelvic compression test is a useful screening list in all such cases.

Pelvic Compression Test. The patient lies supine on the couch. The exam­iner compresses both iliac crests of the patient's pelvis towards each other. Any pain during this manoeure or a 'springly' feeling is an indicator of pelvic frac­ture. A pelvic fracture distraction test may reveal similar findings.

In displaced pelvic fracture there may be shortening of one of the lower limbs. The limb may lie in external rotation. There may be a haematoma in the

region of the pubic symphysis or at the back, in the region of sacro - iliac joints. Palpation may reveal a localised tenderness or crepitus.

Radiological examination. Pelvis with both hips — AP is the basic x-ray required for screening purposes. In case there is a pelvic injury, special views (inlet / outlet views) are sometimes necessary.

C.T. scan may be needed for better evaluation in cases where operative in­tervention is contemplated.

Treatment. First and foremost in the treatment of pelvic fractures is the correction of hypovolaemic shock. The patient should be moved as little as possible as movement at the fracture site may result in further bleeding or fat embolism.

Once the patient is stabilised, as assessment regarding the nature of the in­jury is made by suitable x-ray examination. Further treatment of the pelvic fracture depends on the type of fracture and presence of associated complica­tions. In case of complications like urethral injury etc. is present, emergency treatment for the same is executed. A pelvic fracture may fall into one of the following three categories from the treatment viewpoint.

a)       An injury with minimal or a no displacement:

The patient is advised absolute bed rest for 3-4 weeks. Once the fracture becomes 'sticky' and the pain subsides gradual mobilisation and weight bearing is permitted. It takes from 6-8 weeks for the patient to be up and about.

b)      An injury with anterior opening of the pelvis, (open book injury)

A minimal opening (less than 2.5cm) does not need any special treat­ment and is treated on the lines of a) Reduction is needed of the opening 2.5cm. This is done by manual pressure on the two iliac wings with the patient rolled onto his unaffected side as to close the pelvis. The reduc­tion thus achieved is maintained by one of the following methods, i) Plaster Spica. This may keep the reduction maintained but is not suitable in elderly patients for reasons of potential complications of immobilisation.

2) Hammock - Sling traction. It was a popular method in the past but poses nursing problems. The patient requires prolonged hospi­tal isati on.

3) External Fixato. This is a more reliable and comfortable method. Two or three pins threaded at the tip (Schanz pin) are inserted in the anterior part of the wing of the iliac bone on each side. After reduction of the displacement by manual pressure the pins are clamped to a metal rod or frame placed transversely over the front of the pelvis.

iv) Internal Fixation, The pubic symphysis disruption may be re­duced and internally fixed with a plate incase where as operation is to be performed for associated abdominal or urogenital compli­cations, c) Injuries with vertical displacement

These are the most difficult pelvic injuries to treat. These are treated by bi­lateral upper tibial skeletal traction. A heavy weight (up to 20 kg) may be required to achieve reduction. After 3 weeks, the weight is reduced to about 10 kg to maintain the position. The traction is removed after 6-8 weeks and the patient mobilised.

If the patient has no displasement – conservative treatment. The fractures without injures of pelvis ring are treatment with conservative methods  (bed regimen in position of the frog – in knee and hip joints flexing  30-40° and abduction 10°). This position create the maximal relaxation of the muscules.The period of treatment 6-7 weeks, after that – going with the scretches 3 month, the treatment massage and physical training and hydrokyneso- therapy.

The schem of sceletal traction during instabil fractures of the pelvis.

The treatment with gamac - loop.

 

 

 

 

The treatment of the symphisis rupture using pins aparats

Complications

1. RUPTURE OF URETHRA

This is commonly associated in cases where wide disruption of symphysis pubis and pubic rami fractures is present. The urethra in males is more com­monly injured -membranous urethra being the commonest site. The rupture may be complete or incomplete partial thickness or full thickness. Diagnosis may be made by three cardinal signs of urethral injury i.e. blood per urethra, perineal haematoma and distended bladder.

 

Treatment : It may be possible to pass a catheter gently in case with par­tial and incomplete urethral tear. In case this fails, the help ofuro surgeon should be sought.Principles of treatment are:

1)  Drainage of the bladder by suprapubic cystostomy

2)    Micfurating Cysto Urthrogram after 6 weeks to assess the severity of
urethral structure, and treatment accordingly.

2 RUPTURE OF BLADDER

The bladder is ruptured in pubic symphysis disruption or pubic rami frac­tures. In case the bladder is full at the time of injury. The rupture is usually ex­tra-peritoneal and urine extravasates into perevesical space. Diagnosis may be suspected if a patient has not passed urine for a long time after the fracture. Catherterisation may be successful but only a few drops of blood stain urine comes out. A cysto urethrogram will distinguish between a bladder and a ure­thral rupture.

Treatment: An urgent operation is required, preferably by a chologist. The principles of treatment are:

i)    to repair the rent in the bladder

ii)   drainage of the bladder by an indwelling catheter and

Hi) to drain the urine in the perevesical space.

3.       INJURY TO RECTUM OR VAGINA

There may be disruption of the perineum with damage to the rectum or va­gina. General surgeon and gynecologist can suitably manage these injuries.

4.       INJURY TO MAJOR VESSELS

This is a rare but serious complication of a pelvic fracture. The common il­iac artery or one of its branches may be damaged by a spike of bone. Aggres­sive management is crucial. If facilities are available, embolisation of the bleeding vessels under x-ray control is a good procedure. In other cases, the vessel is explored surgically and ligated or repaired.

5.       INJURY TO NERVES

In cases of major disruption of the pelvic ring with marked vertical dis­placement of half of the pelvis, it is common for the nerves of the lumbo-sacral plexus to be injured. The damage may be caused by a fragment pressing on the nerves or by stretching.

6.       RUPTURE OF THE DIAPHRAGM

A traumatic rupture of the diaphragm sometimes occurs in cases with se­verely displaced pelvic fractures. It is worthwhile getting an x-ray of the chest in case a patient with pelvic fracture complains of breathing trouble or pain in the upper abdomen.

Treatment is by surgical repair

FRACTURES OF ACETABULUM

Classification: The following is the recent classification:

Type I — Posterior Type: This includes fractures of the posterior wall or the whole column. These may be associated with posterior dislocation of the hip.

Type II — Anterior Type: This includes fractures of the anterior wall or column of the acetabulum. These may be associated with anterior dislocation of the hip joint.

Type HI — Transverse Type: This includes fractures of the floor of the acetabulum. This is associated with central dislocation of the hip.

Treatment. In recent years, the acetabulum fractures are actively treated, as Malunion leads to disabling Osteoarthritis of the hip joint. The assessment requires additional special oblique view radiographs of the pelvis. The treat­ment aims to produce congruent articular surface of unstable fractures require open reduction and internal fixation by special plates.

FRACTURE OF THE SACRUM AND COCCYX

Major fractures of the pelvis are often associated with fractures of the sa­crum. The fracture usually involves the ala of the sacrum through the sacral fo­ramen. There may be associated injuries to the sacral nerves. Direct trauma to the back of the pelvis produces fractures of the sacrum with or without dis­placement. The sacral fracture does not need any special treatment apart from the management of the major pelvic injury.

Injury to the coccyx is commonly due to the slipping and falling on the sit­ting posture while coming down the staircase. The patient complains of pain in the tail end of the spine and there is tenderness in the coccyx. The pain often becomes chronic and causes marked discomfort on sitting. This is called coc-cydynia. Treatment is symptomatic with analgesics and soft cushioned seats. Exercise to the gulteus maximas muscles help by toning up the muscles, which protect the coccyx from direct pressure on sitting. If required surgical treat­ment i.e. removal of coccyx.

With this information the following points should be noted:

·                     Internal haemorrhage is the most important immediate complication of pelvic fractures.

·                     Blood loss and the other complications of pelvic fracture are related to the pattern of injury.

·                     In assessing a pelvic fracture the most important consideration is to decide whether the injury is stable or unstable.

·                     Stable fractures either affect the pelvic ring at one point, or they do not involve it at all.

·                     Vertically unstable fractures are serious and potentially life threatening.

·                     Although injuries to the rami are generally stable, the possibility of urethral or bladder complications must always be kept in mind.

 

INJURIES OF THE HIP AND THIGH

Relevant anatomy

The hip joint is a ball and socket joint with inherent stability, formed by the nearly spherical head of the femur fitting into a deep acetabular cavity in the iliac bone. The socket is further deepened by the cartilaginous acetabular la-brum.

The acetabulum faces an angel 30deg outwards and anteriorly. The normal neck -shaft angle of the femur is 125 deg in adults with 15 deg of anteversion. The neck is made up of spongy bone with aggregation of bony trabeculae along the line of stress. The most important of these is the medial longitudinal trabecular stream.

The capsule of the joint is attached around the brim of the bony acetabu­lum. Distally it is attached anteriorly along the intertrochantric line and poste­riorly Vi" above the inetrochantric crest. The capsule is strengthened anteriorly by the strong illiofemoral ligament, which extends from the anterior iliac spine to the introchantric line. The puberfemoral ligament strengthens the capsule on the medial aspect and the ischiofemoral ligament strengthens if on the poste­rior aspect.

The inferior aspect of the capsule is the only weak and unsupported posi­tion of the capsule. The muscles surrounding the joint are all strong and help in maintaining the stability of the joint.

Blood supply of the femoral head: This comes from three main sources:

1) the medullary vessels from the neck

2) the retinacular vessels entering from the lateral side of the head

3) the foveal vessels from the ligamentum teres.

The most important of these (1) and (2) are generally cut off following a fracture of the neck of the femur and sometime result in a vascular necrosis of the head.

Dislocation of the Hip

It needs a very severe violence to cause a dislocation of a normal hip joint. The head of the femur can slip out only through the weak and unsupported in­ferior aspect of the joint capsule and thereafter it moves backwards or forwards depending on the directions of the violence. Traumatic dislocation occurs commonly in young adults but it does occur occasionally in children also.

Classification. There are 3 main types of dislocation of the hip:

1) Posterior dislocation (the commonest)

2) Anterior dislocation

3) Central fracture - dislocation

 

                         

                      1                                              2        3       4

X – ray schem of topical situation of the femoral head during different kindes of dislocation:

1. posterio – upper kinde (iliac);

2. posterio – lower  (ischiadicus kinde);

3. anterio – lower (obturatorius kinde);

4. anterio – upper kinde (suprapubis).

All of these may be associated with fracture of the hip of the acetabulum Posterior Dislocation of the Hip

The head of the femur is pushed out of the acetabulum posteriorly. In about 50% of cases this is associated with a chip fracture of the posterior lip of the acetabulum in which case it is called a fracture dislocation.

Mechanism of Injury. It is caused by violence applied along the femoral shaft when the hip joint is in a flexed and adducted position. It occurs in auto­mobile accident when the passenger sitting by the driver is thrown forward, his knees hitting against the dashboard also known as "dashboard injury"

Diagnosis

Clinical Features: A young adult is brought with a history of severe injury to the hip and inability to stand or walk. On examination, the limb is seen to lie in the characteristic position of adduction, flexion and internal rotation with marked shortening. The pulsation of the femoral artery at the mid-inguinal point is not palpable due to the absence of the femoral head in the normal posi­tion. The greater trochanter is raised and the head of femur could be felt poste­riorly under the gluteal muscle. All movements of the hip are extremely pain­ful. One must look for the presence of sciatic nerve paralysis causing food drop as a complication.

Radiological Features: The femoral head is out of acetabulum. The thigh is internally rotated so that the lesser trochanter becomes less prominent com­pare to that on the opposite side. "Shenton's Line" is broken. One must look for any bony chip from the lip of the acetabulum or from the head.

Treatment: Reduction of the dislocated hip is an emergency since, the longer the head remains out the more chance there is of its becoming avascu-lar. It is possible to reduce the hip by manipulation under general anesthesia in most cases. The chip fracture of the acetabulum usually falls in place as the head comes to its position. Open reduction may be required in cases where:

1)    Closed reduction fails, usually in those presenting late

2) If there is intrarticular loose fragment not allowing concentric reduc­tion

3) If the acetabular fragment is large and is from the weight bearing part of the acetabulum

Technique of close Reduction

The patient is anaesthetised and placed supine on the floor. An assessment grasps the pelvis firmly. The surgeon flexes the hip and the knee at a right an­gle and exert and axial pull. Usually one hears 'sound ' of reduction after which it becomes possible to move the hip in all direction freely the leg is kept in light traction which the hip abducted for 3 to 6 weeks. After this hip mobilisa­tion exercises are initiated.

Complications

1) Injury to the sciatic nerve: Sciatic nerve lies behind the posterior wall of the acetabulum. Therefore, it may be damaged in the posterior dislo­cation of the hip more so if the dislocation is associated with large bony fragment from the tip of the acetabulum displaced posteriorly.

Treatment: Injury in a neuropraxia is in most cases and recovers spon­taneously. In cases where the fragment of the posterior lip is not reduced by closed method, open reduction may be required at the same time the nerve is explored. In cases with severe damage to sciatic nerve at such high level prognosis is poor.

2)     Avascular Necrosis of femoral head: In some 15 to 20% of the cases
the femoral head undergoes avascular necrosis. Although the blood is
cut off at the time of dislocation. The change of avascular necrosis ap­
pears on x- rays generally 1 to 2 years after the injury. The avascular ne­
crosis of head appears dense and gradually collapse -wholly or in part.
The patient complains of pain in hip after a seemingly painless period
following the treatment of dislocated hip over a period of few years'
changes of Osteoarthritis becomes apparent clinically and radiologically.

3)     Osteoarthritis: This is the late complication of hip dislocation occur­
ring few to many years after the injury. The underlying cause may be an
avascular deformed head or an incongruous acetabulum and femoral
head. The treatment is initially conservative, and in some cases opera­
tion may be necessary. Commonly a total hip replacement is required.

4)     Myositis Ossificans: This occurs few weeks to months after the injury.
The patient complains persistent pain and stiffness of the hip. X-rays
shows the mass of fluffy new bone around the hip. Treatment is rest and
analgesic.

Anterior dislocation of the hip

This is much less common. It occurs in collision accidents when a motor cyclist is hit on the medial aspect of the thigh, which is in flexion and abduc­tion and external rotation.

In this type, the head of the femur slips forward and lies over the obturator foramen (Obturator type) or near the symphysis pubis (pubic type) the leg lies in marked abduction. Flexion and external rotation and will look longer. The head of the femur can be felt anteriorly in the medial aspect of the groin.

Reduction is done under general anesthesia. After good traction, the limb is circumducted through internal rotation and adduction and then extended.

Central dislocation

This is a rare type and is always a fracture dislocation. Due to violent in­jury on the lateral aspect of the hip, the floor of the acetabulum gives way with multiple fracture lines and the head of the femur is pushed into the pelvis.

The following are the two major types:

i) Fracture dislocation with an intact weight bearing articular surface

ii) Comminuted, displaced fractures of the floor of the acetabulum (bag of-bones)

Clinical Features: The patient complains of severe pain in the hip. The limb does not show marked deformities as in the other types of dislocation. The flexion extension movements of the hips are relatively free but there is marked limitation of abduction and rotations. When it is suspected, a rectal examination must be done. It reveals a smooth hemispherical bulge in the lateral wall of the rectum, which is diagnostic of the condition.

posterio – upper kinde (iliac) – adduction of the hip with inner rotation and flexion. The actives and passives moverment are absents and paintfules.

posterio – lower  (ischiadicus kinde). There are adduction and inner rotation of the hip with flection of the limb The actives and passives moverment are absents and paintfules.

Anterio – upper kinde (suprapubis). There is some abduction with external rotation and flexion of leg. The actives and passives moverment are absents and paintfules.

anterio – lower (obturatorius kinde) there is large adduction and external rotation with flection of leg. The actives and passives moverment are absents and paintfules.  

 

A radiograph will show the type of fracture in the floor of the acetabulum and the inward displacement of the head of femur.

Treatment: Continues, heavy skeletal traction is applied to the limb with the leg in about 30deg abduction. This will result in reduction of the disloca­tion. The fraction is maintained for 4 to 6 weeks. Subsequently, active non-weight bearing articular surface will require surgical fixation.

Old unreduced dislocation of the hip

The patient with the dislocation gets treated by the traditional bonesetter with massage for some months. He than presents with a painful stiff, and de­formed hip. This is a difficult problem for treatment. Radiograph will show an unreduced dislocation after complicated by myositis osscificans all round the joints. Closed as well as open surgical reductions are not possible in most cases if it is more than 3 months old. A subtrochantric osteotomy is done to correct the deformity and relieve pain.

Fracture of the neck of femur

Anatomical Factors: The structure of the head and neck of femur is de­veloped for the transmission of body weight efficiently with minimum bone mars, by appropriate distribution of the bony trabeculae in the neck. The ten­sion trabeculae and compression trabuculae along with the strong collar femo­ral on the medial cortex of the neck of the femur from an efficient system to withstand load bearing and tension under normal stresses of locomotion and weight bearing.

In old age, osteoporosis of the region occurs. The incidence of fracture neck of femur is higher in old age.

Most of these fractures are displaced with the distal fragment externally ro­tated, adducted and proximally migrated. These displacements also occur in inter-trochontric fracture in which these are more marked. This is because in an intra-capsular fracture, the capsule of the hip joint is attached to the distal fragment, and prevents extreme rotation and displacement of the distal frag­ment (and with it the limb) The fracture is an extra -capsular type (i.e. inter-trochontric fracture) is beyond the attachment of the capsule, hence wide dis­placement can occur in this fracture.

Classification:

a)      Two broad groups of fractures are recognised in the neck of femur:

1)     Intracapsular fractures 2) Extracapsular fractures

b)      Anatomical Classification

On the basis of anatomical location of the fracture it can be clas­sified as (under intravascular fracture 1) Subcapital i.e. a fracture just below the head 2)    Transcervical i.e. a fracture at the base of the neck 3) Basal i.e. a fracture at the base of the neck

 

 

 

 

 

 

c)       Pauwel's classification (Intra capsular)

This classification is based on the angle of inclination the fracture makes in relation to the horizontal plan.

Type I: Pauwel's angle is less than 30 deg the fracture line is nearer the horizontal.

Type II: The angle is between 30 deg and 70 deg.

Type III: The angle is more than 70 deg and the fracture line is nearer the horizontal.

           I                          II                       III

Pawles I – 30° (stabil)

Pawles II – 30°- 50°

Pawles III –70° > (nonstabil)

In more vertical fracture, the action of the gluteal and adductor mus­cles produces a shearing force on the fracture line and hence non­union is common. Thus, prognosis is worse in Type III and good in Type I.

d)      Garden's Classification: (Intracapsular)

This is based on the degree of displacement of the fracture. The de­gree of displacement is judged from change in the direction of the medial trabecular stream of the neck in relation to the bony trabecular in the weight bearing part of the head and in the corresponding part of the acetabulum.

Stage I: The fracture is in­complete with head tilted in postero lateral direction so that there is an obtuse angle laterally at the trabe­cular stream.

Stage II: The fracture is complete but undisplaeed so that there is a break in the trabecular stream with little angulation

Stage III: The fracture is complete and partially dis­placed.

 

Stage IV: The fracture is complete and fully dis­placed. As the distal frag­ment rotation further out­wards, it looses contact with the head. Which springs back to its original position

 

 

 

 

Intracapsular fracture

Mechanism: In elderly people, the fracture occurs with a seemingly trivial fall. Osteoporosis is considered an important contributory factor at this age. In young adults, this fracture is the result of a more severe injury. The fracture is uncommon in children in western countries, but is relatively common in devel­oping countries, probably because of dietary deficiency.

Diagnosis

Clinical Features: Occasionally, a patient with an impacted fracture may arrive walking the only complaint being a little pain in the groin. More often, the patient is an elderly brought to the casualty department with complains of pain in the groin and inability to move his limb or bear weight on the limb fol­lowing a trivial injury like slipping on the floor, missing a step etc. There is lit­tle pain or swelling and often the injury is not diagnosed for days or weeks. Examination reveals the following signs:

1)     External rotation of the leg, the patella facing outwards.

2)    Shortening of the leg, usually slight

3)   Tenderness in the groin

4)   Attempted hip movements painful and associated with severe spasm

5)    Active straight leg raising not possible

Radiological Features: It is useful to ask for x-rays of pelvis with both hips, rather than that of the affected hips alone, x-ray examination confirms the diagnosis. The following features should be noted.

■   Break in the medial cortex of the neck

■   External rotation of the femur is evident, the lessor trochantor appearing
more prominent

■   Overriding of greater trochantor, so that it lies at the level of the head of
the femur.

■   Break in the trabecular stream

■   Break in Shanton's line

Treatment: Fractures at this level have a poor capacity for union due to the following factors:

a)     Interference with the blood supplies to the proximal fragment.

b)     Difficulty in controlling the small proximal fragment.

c)     The lack of organisation of the fracture haematoma due to the synovial fluid present.

Impacted Fracture: An impacted fracture is treated in all age groups by conservative methods. In children a hip spica and in adults immobilisation in a Thomas splint are preferred methods. Some surgeons fix these fractures inter­nally with screws for fear of displacement.

Unimpacted or displaced fractures: The aim of treatment in-patients up to 60 years of age is to achieve union, for which internal fixation is usually re­quired. Since the incidence of failure of this type of treatment is high, elderly patients the head is excised and replaced by prosthesis as a primary procedure. In some younger patients these presenting late reduction of the fracture may be technically difficult. In such cases, an open reduction of the fracture is done. Internal fixation of these fractures, especially without open reduction under X-ray control is a technically demanding procedure. An accurate reduction and good fixation is important for a good result. In some centres an inter-trochantric osteotomy called McMurray's osteotomy is preferred. For this x-ray called is not required.

Internal Fixation: Any of the following implants may be used for internal fixation :

■   Multiple cancellous screws - most commonly used

■   Smith Peterson nail (sp. nail) - not popular now

■   Dynamic hip screw (DHS) - used sometimes

■   Multiple knowle's pins/Moore's pins used in children

■   Deyerele apparatus used at some centres
Complications:

1. Non-Union

          2. Avascular Necrosis

          3. Osteoarthritis

Inter trochanteric fractures

Fractures in the inter-trochanteric region of the proximal femur, involving either the greater or the lessor trochanter or both are grouped in this category. In the elderly, a sideways fall or a blow normally sustains the fracture over the greater trochanter. In the young it occurs following violent trauma as in a road traffic accident.

Patho-Anatomy. The distal fragment rides up so that the femoral neck shaft angle is reduced (COXA VERA). The fracture is generally comminuted and displaced. Very rarely it can be an undisplaced fracture.

Diagnosis

Clinical Features: As for fractures of the neck of the femur the patient is brought in with a history of a fall or road accident, followed by pain in the re­gion of the groin and an inability to move the leg. There will be swelling in the region of hip, and the leg will be short and externally rotated. There is tender­ness over the greater trochanter. The physical findings in such a case are more marked compared to those in a fracture of the neck of the femur.

Radiological Features: Diagnosis is easy on x-ray. Presence of commin­uted of the medial cortex of the neck avulsion of the lower trochanter and ex­tension of the fracture to the subtrochantric region indicates an unstable frac­ture and a poor prognosis.

Treatment: Contrary to fracture of the neck of the femur, trochantric frac­tures unite radically. The main objective of treatment is to maintain a femoral neck shaft angle during the process of union. This can be done by conservative means (traction) or by internal fixation. In elderly patients, internal fixation is preferred because in them prolonged bed rest (as much as 3-4 months) in trac­tion may cause complications related to recumbency i.e. bed sores, pneumonia etc.

  

Open reposition and fixing with L- like plate (130°).

  

Open reposition and fixing with L- like plate and screw.

 

Conservative methods: There are a number of traction's described for an inter-trochanteric fracture. Those used most frequently are Russell's traction and skeletal traction in a Thomas Splint.

Operative Methods: The fracture is reduced under x-ray control and fixed with internal fixation devices. The most commonly used ones are:

1)    Smith Peterson nail with McLaughlin's plate (sp. nail plate)

2)   Dynamic Hip Screw (DHS)

3) Ender's nails

External fixation is sometimes useful for patients with bedsores, and for those who are unfit for a major operation.

Complications:

1)          Mat Union

2)    Osteoarthritis

Fracture shaft of femur

The femur has the following powerful groups of muscles inserted into it:

 1)    Iliopsoas which is a powerful flexor is inserted into the lesser trochan-tor

2) Gluteus medius and minimus, which powerfully abduct the hip, are inserted into the greater trochanter.

3) The adductor longus, Brevis and Magnus are inserted along the medial aspect of the shaft.

4) The gastrocnemicus muscle origins are attached to the posterior aspect of the lower end of the shaft.

These muscle attachments cause the typical displacements of the fragments in the fractures at the proximal, middle and distal thirds of the shaft of the fe­mur.

Fracture of the femur from the subtrochantric level at the Supracondylar level will be included in this group. The femur being the strongest weight bear­ing bone in the body, a fracture is usually due to a very severe violence. The powerful muscles surrounding the bone create problems in maintaining the fragments in position after reduction.

In fractures of the proximal third, the proximal fragment is small and is drawn into a flexed position by the illiopsoas muscle and into the abducted po­sition by the gluteus medius and minmus muscles. In the fracture of the middle third, the distal fragment is displaced medially and pulled upwards by the ad­ductor causing overriding and outward angulation. In fractures at the Supra­condylar level of the shaft the distal fragment is flexed by the origin of the gas­trocnemicus muscle. In this position, the popliteal vessels are in great danger of injury by the sharp and irregular edges of the flexed distal fragment.

Classification. The fractures of the femoral shaft can be classified as:

a)     Subtrochantric fracture (Proximal)

b)    Midshaft - Middle third

c)            Distal third including Supracondylar fracture

Clinical Features: The patient with a fracture of the femur is likely to show symptoms of shock due to the loss of blood into the muscles of the thigh. Locally, there will be swelling of the thigh, deformity and tenderness. The presence of abnormal mobility and shortening of the limb will complete the clinical picture. One must always examines the distal pulsation in the dorsalis pedis and posterior tibial arteries. In fracture caused by run over injuries, the femoral vessels are often traumatised, leading to ischaemic and even gangrene of the leg.

Radiological Features: Radiographs of the femur will show the level and type of fracture: transverse, oblique, spiral or comminuted. Radiograph includ­ing the hip joint is mandatory as an associated dislocated hip could be missed in the clinical examination.

Management

First Aid Treatment: The best first aid splint for fracture of the femur is the "Thomas Splint". Slings support the leg across the two bars and the foot is steadied by a clove hitch bandage at the ankle tied to the end of the splint. The thigh and leg are then bandaged firmly to the splint. With this, the patient can be transported safely to the hospital.

Definitive Treatment: The patient is examined for evidence of shock and necessary treatment given. The aim of the treatment is to reduce the fracture and maintain reduction till union is complete. Any overriding or angulation must be corrected and the length of the limb maintained. Stiffening of the knee joint must be prevented.

Fracture femur  upper third

Conservative Treatment: Fracture of the femur is good example for illus­trating the need for the use of continuous or sustained traction in the treatment of fracture. Oblique fractures are easily maintained in good position by con­tinuous traction. Transverse fractures must be reduced under general anesthe­sia. The fragment must be hitched and the limb immobilised in a Thomas Splin with skin or skeletal traction. As the upper fragment tends to go into abduction and flexion the leg is kept in the position of abduction and flexion to maintain the distal fragment in alignment.

Operative Treatment: In cases, where reduction and maintenance by con­servative methods fail surgical reduction and internal fixation is indicated. As the subtrochanteric level the internal fixation is done with Nail plates similar to the ones used in trochanteric fractures. A fracture at a little lower level in the shaft is fixed using a knutsher intramedullary nail.

Fracture femur  upper third

Conservative Treatment: Fracture of the femur is good example for illus­trating the need for the use of continuous or sustained traction in the treatment of the fractures- Oblique fractures are easily maintained in good position by continues traction. Transverse fractures must be reduced under general anes­thesia. The fragment must be hitched and the limb immobilised in a Thomas Splint with the skin or skeletal traction. As the upper fragment tends to go into abduction and flexion the leg is kept in the position of abduction and flexion to maintain the distal fragment in alignment.

Operative Treatment: In cases where reduction and maintenance by con­servative methods fail surgical reduction and internal fixation is indicated. At the subtrochantric level the internal fixation is best done with nail plates simi­lar to the ones used in trochantric fractures. A fracture at a lower level in the shaft is fixed using a Kuntscher intramedullary nail.

Fracture femur middle third

Conservative Treatment: At this level there is usually overriding of the fragments due to the pull of powerful muscles. The distal fragment is displaced inwards. In the case of transverse fractures, the fracture is reduced under gen­eral anesthesia by traction and counter traction is used only to maintain the re­duction. In muscular individuals, skeletal traction is more effective in main­taining reduction. Conservative management as above can successfully treat the vast majority of fractures of the shaft of the femurs. Check radiographs are taken. If the check radiographs reveal any angulation, it is corrected by apply­ing a local board splint at the site and firm bandaging.

Excessive skeletal traction may cause distraction between the fragments leading to slow union. This must be corrected by reducing the weight used for traction and allowing the fragments to come together. Radiograph is repeated every 3 weeks to watch the progress of the union and the callus formation-Physiotherapy: It is very important to institute physiotherapy as soon as the acute pain of reduction is over. Active exercise of the quadriceps is started a few days after reduction of the fracture. General lateral movement of the pa­tella is done to prevent adhesion of the patella to the femur. The knee joint is allowed to move in about 6 weeks after the reduction. This is done by using a Pearson's knee flexion piece with the suspended Thomas Splint.

After Treatment: It takes about 12 weeks for the clinical union to be sound. When local tenderness has disappeared and there is no yielding at the fracture site, the bone is assumed to be clinically united, but it will not be fit to bear the whole weight of the body. The quadriceps must be well developed and knee joint mobilised before ambulation. The patient is allowed only partial weight bearing by the use of crutches or a weight relieving walking caliper.

Operative Treatment: In cases where reduction and maintenance by con­servative methods fail surgical reduction and internal fixation is indicated. Fixation by Kuntscher intra-medullary nailing is ideal in transverse fractures. Oblique unstable fractures are better treated by special plate and screws.

Fracture femur lower third

Conservative Treatment: These fractures are not only difficult to reduce but also difficult to maintain in the reduced position. As the origin of the gas-trocnemius muscle pulls the distal fragments posteriorly. A dangerous compli­cation of the Supracondylar fracture is the injury to the popliteal artery by the sharp edge of the flexed distal fragment.

This fracture is treated by continuous skeletal traction through the tibia and using a Bohlor Braun Splint.

The forward angulation can be corrected by an upward pull by another Steinman's pin passed through the distal fragment.

Operative Treatment: If conservative treatment fails to correct the angu­lation, open reduction and fixation by angled blade plate is indicated.

Compound Fracture: Compound fractures of femur are usually due to blast or gunshot injuries. In addition to the management of the shock and open wounds use of external fixation maintain the stability of the reduction.

Complication:

1)          Mai union and shortening of the leg

2)    Stiffness of the knee joint

3)    Non union

With this information the following points should be noted:

·                   Complete muscle relaxation is essential when an attempt is being to reduce a dislocated hip.

·                   The two most serious complications of dislocation of the hip are avascular necrosis of the femoral head and sciatic nerve palsy.

·                   The more distal a femoral neck fracture is situated, the better the prognosis.

·                   Reduction and internal fixation is the most common method of treating intracapsular fractures.

·                   The two main complications of intracapsular fractures are non-union and avascular necrosis.

·                   Total hip replacement is the usual treatment for either of these complications.

·                   Union in extracapsular fractures of the femoral neck is usually rapid and avascular necrosis is not a problem.

·                   In the fractures of the femoral shaft, be alert to the dangers of oligaemic shock.

·                   Treat fractures of the femoral shaft in children and adolescents by conservative methods.

·                   In adults, consider using internal fixation so that mobilisation may be started early and the risk of knee stiffness reduced.

 

INJURIES AROUND THE KNEE

The knee joint is the most frequently injured joint. The following injuries will be discussed in this chapter.

1) Condylar fracture of the femur

2) Fracture of the patella

3) Injuries to the ligaments of the knee

4) Injuries to the menisci of the knee

5) Miscellaneous knee joint

6) Dislocation

Relevant Anatomy: The knee is a hinge joint formed between the tibia and femur (tibia - femoral). The patella also glides over the front of femoral condyle to form a patella femoral joint. The stability of the knee depends pri­marily upon its ligaments. The functions of different ligaments of the knee are given:

Extensor apparatus of the knee:

It constitutes from proximal to distal by quadriceps muscle, quadriceps tendon, and patella with patellar rctinaculae on the sides, and the patellar ten­don. Failure of any of these results in an inability to actively extend the knee.

Mechanism of knee injuries:

The knee joint is subjected to a variety of forces during day to day activi­ties and sport. The nature of the forces may be direct or indirect. An indirect An indirect force on the knee may be:

1) Valgus

2) Varsus

3) Hyperextension

4) Twisting most often it is a combination of the above forces.

CONDYLAR FRACTURE OF THE FEMUR

These are the three types:

1)  Supra Condylar fracture

2)  Intercondylar fractures T or Y types

3) Unicondylar fractures medial or lateral

These fractures commonly result from a direct trauma to the lower end of the femur. These fractures commonly result from a direct trauma to the lower end of the femur. An indirect force more often results in unicondylar (by a va-rus/valgus bending force) or Supracondylar fracture (by a hyperextension force)

Diagnosis:

Diagnosis of this fracture is suggested by pain, swelling and bruising around the knee. These fractures are often missed when associated with more major injuries such as a fracture of the shaft of the femur; Diagnosis is made on x-rays. A careful assessment of the intra-articular extension of the fracture and joint incongruity must be made.

Treatment:

Unicondylar Fracture: Ifundisplaced, a long leg cast is given for 3-6 weeks, followed by protected weight bearing. If displaced, open reduction and internal fixation with cancellous screws is performed.

Intercondylar Fractures: The aim of treatment is to restore congruity of the articular surface as far as possible. In displaced T or Y fracture with mini­mal comminution, the joint is reconstructed by open reduction and internal fixation. Comminuted fractures are treated conservatively by upper-tibial skeletal for 6-10 weeks.

Supracondylar Fractures: It is possible to achieve good reduction with traction using a Thomas Splint. Once the fracture is sticky (in about 6-8 weeks) the knee is mobilised using a cast - brace. In elderly people, open reduction and internal fixation is preferred to permit early mobilisation.

Complication:

1)   Knee Stiffness: Residual knee stiffness sometimes remains because
of dense intra end pin-articular adhesions. A long course of physio­
therapy is usually rewarding.

2)          Osteoarthrosis: Fracture with intra-articular extension gives rise to
Osteoarthrosis a few years later.

3)                      Mai-Union: A mat union may result in varus or valgus deformities,
sometimes requiring corrective osteotomy.

FRACTURE OF THE PATELLA

The patella is the biggest seamoid bone in the body. Being incorporated in the quadriceps muscle, it improves the leverage for the action of its tendon by altering favourably the line of insertion of the tendon.

Mechanism: This can be injured by one of the following two mechanisms: a) Muscular violence: A sudden contraction of the muscle to prevent a fall causes a transverse fracture of the patella along with a tear of me­dial and lateral retinaculae of the quadriceps expansion. The fracture may be across the middle of the patella or near the lower pole. This fracture is really a part of the rupture of extensor mechanism of the knee.

b) Direct Violence: A direct injury on the patella due to a fall on the knee produces usually a stellate fracture of the patella with a comminution of the bone. In this type the quadriceps expansion is intact.

Clinical Features: The patient complains of pain and swelling over the knee. In an Undisplaccd fracture the swelling and tenderness may be localised over the patella. A crcptus is felt in a comminuted fracture. In displace frac­tures, one may feel a gap between the fracture fragments. The patient will not be able to lift his leg with the knee in fall extension; it remains in a position short of foil extension (exterior - leg) because of disruption of the exterior ap­paratus. There may be bruises over the front of the knee a tell tale signs of di­rect trauma. The knee may be swollen because ofhaemarthrosis.

Radiological Examination: An antero-posterior and lateral x-rays of the knee are sufficient in most cases. In some undisplaced fracture "Skyline View" of the patella may be required. A fracture with wide separation of the frag­ments is easy to diagnose on a lateral x-rays. Often it is not possible to visual­ise comminution on the x-ray. It becomes obvious only during surgery.

Treatment: It depends upon the type of fracture and in some cases on the age of the patient. The following groups may be considered.

a)                   Undisplaced I'vacturc: Treatment is aimed primarily at relief of pain.
A plaster cart extending from the groin to join above the malleoli with
the knee in full extension (cylinder cart) should be given for 3 weeks,
followed by physiotherapy.

b)        Clean break with separation of fragments (two-part fracture): The pull
of the quadriceps muscle on the proximal fragment keeps the frag­
ments apart, hence an operation is always necessary. The operation
consists of reduction of the fragments, fixing them with tension band
wiring (TBW) and repair of extensor retinaculae- The knee can be mo­
bilised early following this operation. In cases in which it is not possi­
ble to active accurate reduction of the fragments it is better to excise
the fragment (Patellectomy) and repair the extensor retinaculae. In
cases, where one of the fragments constituted only one of the poles of
the patella, it is excised. The major fragment is preserved and the ex­
tensor retinaculae repaired (Partial Patellectomy) Such operation on
the patella are followed by support in a cylinder cart for 4-6 weeks.

c)                    Comminuted Fracture : In comminuted fracture with displacements, it
is impossible to restore a perfectly smooth articular surface, so it best
to excise the patella (Patellectomy) irrespective of the age of the pa­
tient. This takes care of any future risk of osteoarthritis at the patella -
femoral joint.

Complications:

1.  Knee Stifjhess: 11 is common complication after a fracture of the patella,
mostly due to intra and pin articular adhesions. Treatment is by physio­
therapy. Sometime an operative release of adhesive may be required.

2.     Exterior Weakness; This results from an inadequate repair of the exten­
sor apparatus due to quadriceps weakness.

3.      Osteoarthritis: Patella-femoral osteoarthritis occurs a few years after the injury.

INJURIES TO THE LIGAMENTS OF THE KNEE

With increasing sporting activities, injuries to the knee ligaments are on the increase.

Mechanism: Knee ligaments are injured most often indirect, twisting or bending forces on the knee. The various mechanism by which knee ligaments are injured are given below:

■     Medial collateral Ligament: This ligament is damaged if the injuring
force has the effect of abducting the leg on the femur (valgus force). It ruptures most commonly from its femoral attachment.

■     Lateral Collateral Ligament: This ligament is damaged by a mechanism
just the reverse of above i.e. adduction of the tibia on the femur (varus force) commonly, the ligament is avulsed from head of the fibula with a piece of bone. Lateral collateral ligament are uncommon because the knee is not often subjected to rams force (the knee is not likely to be hit from the inside)

■     Anterior cruciate Ligament: This ligament most commonly damaged.
Often is association with the tears of medial or lateral collateral liga­ments. Commonly, it occurs as a result of twisting force on a semi-flexed knee. Often the injury to medial collateral ligament, medial me­ niscus and anterior cruciate ligament occur together. This is called O'Donoghue triad.

■ Posterior Cruciate Ligament: This ligament is damaged if the anterior
aspect of the tibia is struck with the knee semi flexed so as to force the
tibia backward on the femur.

Patho Anatomy: The ligament may tear at either of its attachment. Some* times, it takes a chip of bone from its attachment. The ligament may be torn in its substance (mid-substance tear) the severity of the tear varies from a rupture of just a few fibers to a complete tear.

Diagnosis

Clinical Examination: Pain and swelling of the knee are the usual com­plaints. Often the patient is able to give a history of having sustained a particu­lar type of deforming force at the knee (Valgus, Varus etc), followed by a sound of something tearing. The pain may be localised over the ligament (in cases injury to injury to collateral ligaments), but there is vague in cruciate ligament injuries. The swelling (haemarthrosis) is variable but appears early after the injury-Damage to the medial and lateral collateral ligaments can be assessed clinically by stress tests. Pain at the site of the torn ligament and / or an abnormal opening up of the joint indicate a tear. Cruciate ligaments prevent anterior-posterior gliding of the tibia. The anterior cruciate prevents glide. This property is made use in detecting injury to these ligaments.

Radiological Examination: A plain x-ray may be normal or a chip of bone avulsed from the ligament attachment may be visible. It may be possible to demonstrate on abnormal opening up of the joint on stress x-rays. MRI is anon-invasive method of diagnosing ligament injuries but is rarely needed.

Other Investigation: Arthrography or arthroscopic examination may be needed in cases where doubt persists.

Treatment: Treatment of ligament injuries is a controversial subject. Con­ventionally these injuries have been treated by non-operative methods. With increased demands particularly in young athletic individuals and with avail­ability of newer techniques. Better results have been achieved by operative re­construction of ligaments, particularly for anterior cruciate ligament tear.

Conservative Method: The knee is immobilised in a cylinder cart for a pe­riod of 3-6 weeks. Most cases of grade I and 11 injuries can be successfully treated by this method. After a few weeks, the swelling subsides and adequate strength can be regained by physiotherapy.

Operative Methods: These are indicated in grade ITT injuries especially in young athletics. This consists of the following.

a)                   Repair of the ligament : It is performed for fresh. Grade ffl collateral
ligament injuries. In cases presenting after 2-3 weeks an additional reinforcement is provided by a fascial or tendon graft.

b)        Reconstruction : This is used in cases of ligament injuries presenting
late with features of knee instability. A ligament is 'constructed¹ using
patient's tendon or fascia late. A tendon or fascia taken from another
person (allograft) or 9 synthetic ligament has also be used.

Complications: If left untreated, ligament injury gives rise to symptoms of instability i.e. the joint tends to give way on bearing weight. The nature of this instability depends on the ligament injured. In the long run this leads to os-teoarthrosis. In some young, athletic individuals therefore ligament reconstruc­tion may be required. Ligament reconstruction is commonly done for and ACL deficient knee. Arthroscopic ACL reconstruction is state of the art technique in this field.

 

MENISCAL INJURIES OF THE KNEE

These constitute a common group of injuries peculiar to the knee, fre­quently being reported with increasing sporting activity.

Mechanism: The injury is sustained when a player standing on a semi-flexed knee, twists his body to one side. The twisting movement an important component of the mechanism of injury, is possible only with a flexed knee. During this movement the meniscus is sucked in and nipped as rotation occurs between the condyles of femur and tibia. This results in a longitudnal tear of the mensicus. Sometimes the meniscus may be torn with a minor twisting, as may occur while walking on an uneven surface. There may be no history of in­jury, and the meniscus, a degenerated one, tears spontaneously. The medial meniscus is torn move frequently because it is less mobile (being fixed to the medial collateral ligament).

Patho Anatomy: The meniscus in torn most often in its posterior horn, with every subsequent injury. The tear extends anteriorly. The meniscus, being an avascular structure once torn does not heal (The peripheral meniscal tears undergoes many more subtears, and damages the articular cartilage thus initiat­ing the process ofostcoarthritis.

Type of meniscal tear

The bucket - handle tear are the commonest type, other are radial anterior horn, posterior horn and complex tears. Some underlying pathological changes in the meniscus -(the meniscus while the normal semilunar shape is shaped like a disc) degenerated meniscus (in osteoarthritis) and a meniscal cyst.

 

Clinical Features

Presenting complaints: The patient is generally a young male actively en­gaged in sports like football, volleyball etc. The presenting complaint is recur­rent episodes of pain, and locking of the knee. At times the patient complains of a sudden jerk while walking or something flicking over inside the joint. This may followed by a swelling, appearing after a few hours and lasting for a few days. After some time the pain becomes persistent but with little or no swell­ing.

On tracing back the symptoms to their origin, one often finds a history of a classic twisting injury to the knee, followed by a swelling appearing overnight as the effusion collects. After the effusion collects. After the effusion subsides the knee may remain in about 10 degree of flexion, beyond which the patient is unable to extend his knee (locking). This is because the torn portion of the me­niscus gets interposed between the femoral and the tibial condyles. Locking may missed because the attention is drawn to move obvious signs of pain and swelling. The displaced fragment sometimes returns to its original position spontaneously and thus the original episode of locking may never be noticed. Every successive episode of locking may be either spontaneously corrected. The history of sudden locking in one or other joint compartment is diagnostic of a meniscus tear.

On examination: la a typical episode presenting after, the knee may be swollen. There may be tenderness in the region of the joint line, either anteri­orly or posteriorly. The knee may be locked. Gentle attempts to force fall ex­tension produces a sensation of elastic resistance and pain localised to the ap­propriate joint compartment. In between the attacks, the knee may not have any finding except wasting of the quadriceps. The maneuvers carried out to de­tect a hidden meniscus tear arc McMurray's and Apley's lost.

Often it is difficult to diagnose the cause of knee symptoms. On history and clinical examination. Such non-specific symptom complex is termed as In­ternal Derangement of the Knee (IDK)

Radiological Examination: With meniscal tears there are no abnormal x-ray findings. X- rays are taken to rule out any associated bony pathology. MRI is a non invasine method of detecting mensicus tears, but is a rather sensitive investigation and picks up tears which are of no clinical relevance.

Arthrography: It is a technique where x-rays are taken after injecting ra-diopaque dye into the knee. The dye outline the meniscus. So that a tear, if pre­sent can be visualised. Being an mvasine technique it is no longer used.

Arthroseopy: This is a technique where a thin endoscope, about 4-5 mm in diameter. The arthroscope is introduced into the joint through a small stab wound and inside of the joint examined.

Treatment: Treatment of acute meniscal tear : If the knee is locked, it is manipulated under general anesthesia. No special maneuver is needed. As the knee relaxes, the lorn meniscus falls into place and the knee is unlocked. The knee is immobilised in a Robert Jones Compression bandage for 2-3 weeks, followed by physiotherapy. In a case where locking is not present, immobilisa­tion with the Robert - Jones bandage is sufficient. With this, small number of peripheral tears will heal. Rest of the tears may produces recurrent symptoms.

Treatment of chronic meniscal tear: Once the diagnosis is established clinically, the treatment is to excise the displaced fragment of the meniscus by opening up the joint (arthrotomy). Now-a-days it is possible to excise a torn meniscus arthroscopically (arthroscopic surgeory). By this technique, once the fault is detailed e.g. a loose meniscal flap the same is excised using fine cutting instruments introduced from another puncture wounds. This technique is a sig­nificant advance as it can be done as a day care procedure. Sometimes even under local anesthesia since it is a minimally invasine technique early return to work is possible. Recent research has shown that meniscus are not "useless" structure as was though earlier. Hence, wherever possible the trend is to pre­serve the meniscus by suturing (Meniscography)

 

RARE INJURIES AROUND THE KNEE

Dislocation of the knee: This rare injury results from severe violence to the knee so that all of its supporting ligaments are torn. It is major damage to the joint, and is often associated with injury to the popliteal artery and the nerve. Treatment is by reduction followed by immobilisation in a cylinder cart for 2 months. Complete recovery of knee function does not occur. The knee function does not occur. The knee commonly gets stiff or unstable.

Disruption of Exterior Apparatus: Injury from sudden quadriceps con­traction most often results in fracture of the patella. Sometimes, it may results in tearing of the quadriceps tendon from its attachment on the patella, or tear­ing of the attachment of the patellar tendon from the tibial tuberculae. In either case, operative repair of the tendon is required-Dislocation of the Patella; The patella usually dislocates laterally. It can be one of three types:

1)    acute dislocation

2) recurrent dislocation and

3) habitual dislocation

Acute dislocation of the patella results from a sudden contraction of the quadriceps while the knee is flexed or semi-flexed. The patella dislocates later­ally and lies on the other : ide of the knee. The patient is unable to strengthen the knee. The patient is unable to straighten the knee. The medial condyle of femur appears more prominent. Sometimes, the dislocation reduces spontane­ously but one can elicit marked tenderness antero-medially as a result of the rupture of the capsule at that site.

Treatment: Consists of reduction and immobilisation in a cylinder cart for 3 weeks. A piece of bone covered with articular cartilage (Osteochondral fragment) may be shaved off from the patella or the femoral condyle at the time of dislocation. This results in repeated episodes of pain swelling and sen­sation of a loose body.

Recurrent dislocation of the patella after the first episode of dislocation, generally during adolescence, the dislocations tends to recur with more ease. The reason for recurrence may be laxity of the medial capsule or some under­lying defect in the anatomy of the knee.

These could be

1 excessive joint laxity

2 a small patella

3 a patella alta ( the patella is high lying in the shallower part of intercondylar grove)

4 genu valgum

Treatment: Consists of operative reconstruction where the insertion of the patellar tendon on the tibi it tuberosity. is shifted medially and downwards so that the line of pull of the quadriceps shifts medially (Hausor's operation)

Habitual dislocation means that the patella dislocates laterally every time the knee is flexed. The patient presents early in childhood. Underlying defects are very similar to those in recurrent dislocation. In addition; a shortened quad­riceps (vastus lateral is component) may result in an abnormal lateral pull on the patella when the knee is flexed.

Treatment: Is release of the tight structure on the lateral side and repair of the lax structure on the medial side.

CONDYLAR FRACTURE OF THE TIBIA

The mechanism of injury is more or less the same as that for condylar frac­ture of the femur. One special variety of comminuted fractures of the lateral condyle of the tibia is sustained when the bumper of a motorcycle strikes the lateral side of the knee (bumper fracture). The clinical diagnosis is suspected from pain, swelling and bruising near the knee joint. X-ray helps in total evaluation of the fracture. Often the fracture is badly comminuted.

Treatment: Most cases do well with reduction under anesthesia, followed by calcaneous bone traction for 3 weeks. As the fracture becomes sticky, the knee is mobilised. A few cases need open reduction and joint reconstruction. Knee stiffness and late Osteoarthrosis are common complication.

 

INJURIES TO THE LEG. ANKLE AND FOOT

FRACTURE OF SHAFTS OF TIBIA AND FIBULA

Relevant Anatomy: The tibia is the major weight bearing bone of the leg. It is connected to the less important bone the fibula, through the proximal and distal tibiofibular joints. Like fractures of forearm bones, these bones fre­quently fracture together, and are referred to as "fracture both bones of leg". The following are some of the characteristics of these bones fractured so com­monly.

a)           A Subcutaneous bone: This is responsible for the large number of
open tibia fractures also often there is loss of bone through the
wound.

b)           Fractures in this region are often associated with massive loss of skin, a common mode of injury being a run over by a vehicle.

c)            Precarious blood supply: The distal third of tibia is particularly prone to delay and non-union because of its precarious blood supply to the bone is the medullary vessels. The periostea! blood supply be­ing poor because of the few muscular attachments on the distal third of the bone. The fibula on the other hand is a bone with many muscu­ lar attachments and thus has a rich blood supply.

d)           Hinge joints proximally and distally: Both the proximal and distal joint (the knee and ankle) is hinge joint. So, even a small degree of rotational mat-alignment of the leg fracture becomes noticeable. This is unlike a fracture of the femur or humerus, where some degree of rotational mat-alignment of the leg fracture becomes noticeable.

Mechanism: The tibia and fibula may be fracture by a direct or indirect in­jury.

Direct Injury: Road traffic accidents are the commonest cause of these fractures mostly due to direct violence. The fracture occurs at about the same level in both bones. Frequently the object causing the fracture laureates the skin over it, resulting in an open fracture.

Indirect Injury: A bending or tensional force on the tibia may result in an oblique or spiral fracture respectively. The sharp edge of the fracture may pierce the skin from within resulting in an open fracture.

FRACTURES  OF  THE TIBIA

Fractures of the tibia are considered in 3 groups:

І)        Fracture of the proximal tibia

ІІ)       Fracture of the shaft

ІІІ)     Fracture of the distal tibia (ankle fracture)

Patho Anatomy: The fracture may be closed or open and may have vari­ous patterns. It may occur at different levels (M, U or LI 3). Occasionally, it may be single bones fracture i.e. only the tibia or fibula is fractured. Displacements may be sideways, angulatory or rotational. Occasionally, the fracture may remain Undis-placcd.

Diagnosis

Clinical Features: The patient is brought to the hospital with a history of injury to the leg followed by the classic features of a fracture viz, paia, swelling, deformity etc. There may be a wound communicating with the underlying bone.

Radiological Features: The diagnosis is usually confirmed by x-ray examination. Evaluation of the anatomical configuration of the fracture on x-ray helps in reduction.

FRACTURES OF THE PROXIMAL TIBIA

Fractures of the proximal tibia are classified as articular or non-articular. The commonest type of articular fractures of the lateral tibial plateau usually results from a direct blow to the lateral aspect of the knee, e.g. when a car bumper strikes the knee which causes the tibia to be abducted on the femur and the lateral femoral condyle is driven downward into the tibial plateau thus frac­turing it. There may also be damage to the medial collateral ligament. Fall from a height may result in a fracture of one or both tibial condyle in these cases, the fracture line passes outwards from the Intercondylar eminence, thus sparing the actual articular surface of the plateau. Sometimes the two types of fractures are combined.

Fracture of the shaft of the tibia and fibula:

a)                                  Fracture of the shaft of the tibia alone: This fracture is usually due to torsion causing a spiral fracture, which may appear to be oblique x-ray. Diagnosis is easy, as the bone is subcutaneous so that deform­ity and localised tenderness arc readily detected.

b)                                  Fracture of the shaft of the Fibula alone: This fracture results from direct violence to the fibula or occurs in association with exter­ nal rotation and abduction injuries of the ankle joint. It is, therefore important to exclude an associated ankle fracture or ligament injury when a diagnosis of a fibular fracture has been made.

c)                                    Fractures of the Tibia and Fibula: These fractures occur as a result of either direct or indirect violence. Road traffic accidents are the commonest cause of fracture due to direct violence. The fracture oc­curs at about the same level in the two bones, are transverse or oblique, and are frequently associated with a butterfly fragment or more extensive comminution. These fractures are frequently com­ pound as a result of the impact tearing the skin and there is usually significant displacement.

Treatment: Fractures of the bones of the leg can be treated in 3 ways: 1. By plaster after manipulative reduction this form of treatment is used for fractures in patients under the age of 16, and is used for fractures in older patients, in whom a stable reduction can be obtained e.g. after obtaining end to end opposition of the fragments of a transverse fractures. It is the most widely used and the safest form of treatment. If a stable reduction cannot be obtained, an alternative method is to insert a transverse skeletal pin above and below the fracture, and then incorporate these two pins in a fall leg plaster cart in order to hold bones out to length and prevent short­ening. One disadvantage of this technique is the possibility of distracting the fragments during the formal manipulation, following which the frag­ments will be held apart by this method, leading to delayed union.

2.                       By skeletal traction through the lower end of the tibia or the os calcis with the leg in a special frame or a plaster cart. Traction may render formal manipulation unnecessary. This form of treatment is used if a stable re­ duction cannot be maintained by plaster alone. A variant of this method in which pins are passed into the tibia both and below the fracture and are then fixed to an external metal frame can be used to immobilise the frac­ ture rather than to apply traction. This latter method is particularly useful in the treatment of compound fractures because the fragments can be ac­ curately reduced during wound debridement and exploration and follow­ing this held reduced by the external fixator. Because no plaster cart is then necessary. Excellent access to the wound is allowed for the purpose of dressings, skin grafts or flaps etc.

3.                       By internal fixation with a compression plate or an intramedullary nail. It is particularly indicated in multiple fractures and in closed fractures in non-elderly patients where an acceptable reduction cannot be obtained by closed means.

Where possible in an intramedullary nail should be used for fixation because it is a much stronger method of fixation than a plate, and allows the patient to folly weight bear soon after operation. However it can be used in noncomminuted transverse fractures of the middle third of the diaphysis.

The tibia usually takes about 12 weeks to unite. It is rarely fit to take weight without support under 16 weeks, but if the fracture is stable, weight bearing may be allowed shortly after injury in a plaster cart, with the aid of internal fixation, or in an appliance 'cart - brace' composed of a cart around the skin to which is attached a brace that transmit some weight from the shoe directly to the proximal fragment.

Should the fracture be ununited at 3 months, farther immobilisation in an above knee plaster cart preferably with weight bearing is required. If union ha& still not occurred after a farther 6 weeks, immobilisation can be continued, but many surgeons prefer the duration of treatment by bone grafting the tibia, with or without the addition of internal fixation.

Complications:

Delayed and Non-Union. The fractures of the tibia sometimes take usually long to unite; more so the ones in the lower half. In some cases, clear signs of non-union become apparent on x-rays. The most important factor responsible for delayed and non-union is the precarious blood supply of the tibia others be­ing frequent compounding with loss of fracture haematoma wound infection etc.

Failure of union results in pain and inability to bear weight on the leg.

Treatment. Treatment of delayed and non-union is by bone grafting with or without internal fixation. The following treatment options are available:

a) Nailing with bone grafting

b)      Phernister Grafting - This is a type of bone grafting where the grafting is performed'without disturbing the sound fibrous union at the fracture side.

This results in bony union in about 3-4 months. It is a good operation provided the case satisfies the following criteria:

1)  There is minimal or no mobility at the fracture site (fibrous Union)

2) The fracture has an acceptable alignment.

3)The knee joint has a good range of movement.

c)            ILIZAROV'S Method

d)    Other Methods — 1. Electromagnetic stimulation 2. Mai Union 3. In­
fection 4. Compartment Syndrome — due to the crushing of the soft tis­
sue, leading to compartment syndrome. 5. Injury to the major vessels
and nerves. U/3 associated to the injury of popliteal artery or common
peroneal and tibial nerves, vascular gangrene etc.

ANKLE INJURIES

The bones forming the ankle joints are a frequent site of injuries. A large variety of bending and twisting forces result in a number of fractures and frac­ture dislocation at this joint. All these injuries are sometimes grouped under a general title 'Pott's fracture¹.

Relevant Anatomy: The ankle joint is a modified hinge joint. The 'socket' is formed by the distal articular surface of the tibia and fibula, the intervening tibiofibular ligament and the articular surfaces of the malleoli. These together constitute the "ankle-mortice" the superior articular surface of the talus (the dome) articulates with this socket.

The strong tibia-fibular syndesmosis, along with the medial and lateral malleoli makes the ankle a strong and stable articulation. Therefore, pure dis­location occurs only with fractures of the malleoli. The elongated posterior part of the distal articular surface of the tibia often gets clipped off in ankle injuries, and is termed as 'Posterior Malleolus".

Ligaments of the ankle: The ankle joint has two main ligaments the me­dial and lateral and collateral ligaments.

a)          Medial Collateral Ligament (Deltoid Ligament): This is a strong
ligament on the medial side. It has a superficial (tibio-Calcaneal) and a
deep (tibio-talar) part.

b)         Lateral Collateral Ligament: This is a weak ligament and is often in­
jured. It has three parts

I               Anterior tabia-fibular

II                         Calcaneo - fibular in the middle and

III         Posterior talo – fibular

SOME TERMS USED IN RELATION TO ANKLE INJURIES

The following are some of the terms used to describe different forces the ankle may be subjected to:

a)                         Inversion (adduction}: Inward twisting of the ankle

b)                       Eversion (abduction) : Outward twisting of the ankle

c)                          Supination : Inversion pulls adduction of the foot so that the sole
faces medially

d)                       Pronation: Eversion and abduction of the foot so that the sole faces
laterally.

e)            Rotation: (External or Internal). A rotatory movement of the foot so
that the talus is subjected to a rotatory force along its vertical axis.

f)  Vertical Compression: A force along the long axis of the tibia.
Classification: The lauge - Hansen classification of ankle joint is most widely used. It is based on the mechanism of injury. It is believed that a spe­cific pattern of bending and twisting forces results in specific fracture pattern. Different types of ankle injuries have been classified on the basis of five basic mechanisms. These are as follows:

a)            Adduction injuries

b)                        Abduction injuries

c)                          Pronation external rotation injuries

d)           Supination external rotation injuries

e)                          Vertical Compression injuries

ADDUCTION FRACTURE

This is caused by forcible adduction at the ankle level.

1^st degreei This is and isolated fracture of the medial malleolus. The char­acteristic feature is that the fracture line is vertical at the base of the medial melleolus. This occurs due to the wedging action of the superomedial margin of the body of the talus, which splits off the media malleolus.

2^nd degree: In addition to the vertical fracture in the medial malleolus there is a transverse fracture of the lateral malleolus with inward displacement of the foot.

3^rd degree: In this type, there is in addition, a posterior marginal fracture of the tibia with posterior dislocation of the foot.

Special Type

1.  Pott's Fracture: It was described by Percival Pott in 1765. This is
caused by combined abduction external rotation violence. It includes 1)
Rupture of medial ligament / Fracture medial malleolus 2) Fracture of
the lateral malleolus 3) Lateral displacement of the ankle

2.          Duputtran's Fracture: This again is due to abduction external rotation
violence. In a typical case, there is a) Fracture of the medial malleolus
b) Diastases of the inferior tibio tabular syndesmosis and c) A fracture
of distal tibula.

3.    Maisonneure: Described an injury where there are partial diastases of
the inferior tibio fibular syndesmosis with a fracture at the proximal fibula. Hence, it is imperative that in ankle fractures one must look for tenderness at the upper end of fibula and a fracture there is the radio­graph.

       ABDUCTION FRACTURE

Abduction fracture at the ankle occurs when the foot is forcibly abducted on the ankle or with the foot fixed on the ground there is a blow or a weight falling on the outer side of the leg. The violence causes traction in the medial side and compression on the lateral side. The injury on the traction side may be rupture of the medial ligament or a fracture of the medial malleolus. The three degrees of the fracture are as follows;

1^st degree: There is an isolated avulsion fracture of the medial malleolus. The fracture line is transverse at the level of the articular surface of the tibia.

2^nd degree: When the abduction force continues, there occurs in addition to the medial malleolar fracture, a comminuted fracture of the lower end of the fibula. There is a lateral displacement of the whole foot with the talus. This will nearly correspond to the original description by Pott.

3^rd degree: In this type, in addition to the above, there is a posterior mar­ginal fracture of the tibia resulting in a posterior dislocation of the foot.

EXTERNAL ROTATION FRACTURES

This is the commonest type of fracture. The foot with the talus externally rotates in the ankle mortise. External rotation is often combined with abduction violence also. Depending on the severity of the force, the following three de­grees of external rotation fracture are recognised.

l^s( degree: This is an isolated spiral fracture of the lateral melleolus.

2" degree: The above fracture is associated with a transverse avulsion fracture of the medial melleolus, or rupture of the medial ligament. This results in a lateral displacement of the foot.

3^r degree: In addition to the above, there is posterior marginal (Posterior Malleolus) fracture of the tibia with posterior dislocation of the ankle.

The 1^st degree injury is an isolated fracture of the lateral malleolus whereas the second and third degree injuries are really fracture dislocation of the ankle.

VERTICAL COMPRESSION FRACTURES

These are caused by a fall from a height on the heels:

Type I — This may result in an anterior marginal fracture of the articular end of tibia with anterior displacement of the talus.

Type II — This is a comminuted fracture of the tibial articular surface with upward displacement of the talus.

Treatment. For purpose of treatment, the various ankle fractures are grouped as follows according to the degree of injury.

1)  Single malleolus fractures: This consists of all l^sl degree fractures
due to any type of violence.

2)    Fracture Dislocations: a) with lateral and posterior dislocations (2ⁿ
and 3 ^rd degree of external rotation or abduction fractures), b) with medial and posterior dislocation (2^nd and 3^rd degree of adduction fracture), c) with anterior dislocation (vertical compression fracture)

Conservative Treatment. In isolated undisplaced fracture of the lateral or medial malleolus the foot is immobilised first in a below padded posterior plaster slab. When the edema subsides a complete plaster cart is applied and the patient allowed walking. The cart is kept for 4-6 weeks.

In displaced fracture, manipulative reduction under anesthesia is done and plaster applied. If manipulation fails, surgical reduction and screw fixation is done.

FRACTURE DISLOCAITONII & III DEGREES

It is important to obtain accurate anatomical reduction of all displaced frac­tures and those involving the articular surface of the ankle joint. All these need manipulative reduction under general anesthesia and immobilisation in plaster.

   Dupuitren’s              Malgen’s fracture

   fracture

 

Surgical Treatment:

a)                   Bimalleolar fracture with dislocation, which are unstable after manipu­
lative reduction need open reduction and screw fixation.

b)        Fracture with tibio fibular diastases is often unstable after reduction.
An additional transverse screw fixing the lower ends of the tibia and
fibula best fixes them.

Complication:

1)  Mai Union

2)          Non Union

3)          Joint Stijfness

Non Union is commoner in medial malleolus when it has to be treated by surgery. Malunion will later result in Osteoarthrosis.

THE FOOT

Fracture of the Talus

These are uncommon injuries. This is cause by falls on the foot with the foot forced into dorsiflexion. The following are the types.

1)        Crack fracture neck of talus

2)       Fracture neck with displacement

3)     Fracture with dislocation of the body of talus.

There will be marked swelling around the ankle. In fractures with displacement, the body of the talus may be felt subcutaneously in the posteriomedial aspect of the ankle. Undisplaced fractures of the neck of the talus are treated by immobilisation, in a below knee plaster with the foot in plantar flexion position. When the body is displaced, manipulation under anesthesia is done and the fragment pushed manually into position. Reduction will be stable when the foot is placed in an equinus position and a below knee plaster cart applied. Many of these fracture dislocations will need open surgical reduc­tion.

In cases, where the body is badly displaced pestero medially, and the superficial skin may necrose making it compound. The other late complication will be avascular necrosis (body of the talus) causing later degenerative arthrosis of the ankle.

FRACTURE OF THE CALCANEUM

Incidence and Mechanism:

Calcaneum is the commonest tarsal bone to be fracture. Injuries to the cal-caneum are caused by falling from a height and landing on the foot It is com­mon in young adults engaged in building construction work.

Classification:

1)  Fracture of the tubrosity, sustantacaulum talus and the body, which do
not involve the articular surface of the subtaloid joints.

2)        Compression fractures of the body, which involve the subtaloid, joint
with varying degrees of comminution.

The compression fractures involving the joint surface are far more important and serious than the other fractures and will be described in detail.

Clinical Features:

There is a history of a fall from a height and the patient complains of pain in the heel. The normal signs of a fracture in a long bone such as deformity, abnormal movements etc. will be absent in the case of a fracture in the cal­caneum.

On inspection, there is swelling in the region of the heel. Seen from behind, the heel is broader when compared with the normal side. There is tenderness on holding the heel below the melloli between the thumb and fingers. This also confirms the broadening of the injured heel. The movements of innersion and exersion are markedly limited and painful. The vertical distance between the tip of the malleoli and the ground is diminished as the calcaneus is vertically compressed in the fracture.

In examining a patient with injury to the calcaneum one should always ex­amine the other foot to detect any fracture in the other calcaneum, as the fall from a height often produces bilateral fracture of calcaneum. It is also very im­portant to examine the spine for the presence of any associated fracture of the spine, which is also caused by fall from a height.

Radiological Features: The compression fracture in a solid irregular bone like the calcaneum may not be obvious as a fracture line in the radiograph. Due to the vertical compression, the trabecular pattern in the bone will be distorted and a area of increased density may appear due to interlocking of trabeculae. Minimal compression will be detected by the diminution of the lubber joint angle (Bohler's) in the lateral radiograph. Axial view radiographs should be taken to show involvement of the subtaloid joint and comminution.

Treatment: Simple fracture, which involves the peripheral process of the bone, are treated by rest in a below knee plaster slab for about 2-3 weeks and strapping thereafter for 2-3 weeks. In case of compression involving the joint surfaces the conservative line of management gives good functional results. In cases, where there is minimal involvement of joint surface the patient is kept non-weight bearing with plaster slab for 2-3 weeks. When the edema and pain have subsided a full below knee walking plaster is applied and the patient is allowed to walk. The plaster is removed after 4-6 weeks and the joints are mo­bilised. In case with severe comminution and distortion, the shape of the bone is molded by manual compression under anesthesia and the leg put in plaster slab. Gradual weight bearing is allowed only after 6-8 weeks.

Complications: In cases with the fracture involving the articular surfaces the patient will develop subtaloid Osteoarthrosis causing pain. If this pain is not relieved by conservative treatment and there is disabling pain, subtaloid ar-throdesis will have to be done.

FRACTURE OF METATARSALS AND PHALANGES

Fractures of the metatarsals are due to direct violence, the foot being crushed by weights falling on it. Crack fractures without displacement are best treated by strapping the foot and weight bearing after a few days. These should not be immobilised in plaster carls, as prolonged immobilisation results in a stiff painful foot with loss of tone in the intrinsic muscles. This leads to post traumatic valgus or flat foot, which is painful and disabling. Such feet need in­trinsic foot muscle exercises and contrast bath to relive pain and restore func­tion. In cases where two or more metatarsal bones are fractured, the foot is put in plaster slab till the edema subsides and thereafter strapping is done and weight bearing allowed.

STRESS FRACTURE METATARSAL BONE

This is one of the common forms of stress fracture. The fracture occurs in new recruits to the Army and Police due to the unaccustomed strain on the foot during training. It is also called March fracture or Fatigue fracture. Treatment is mainly symptomatic by strapping.

FRACTURE BASE OF THE VMETATARSAL BONE (Jone 's fracture)

The fracture is caused by severe inversion of the fore foot, when the foot gets doubled up with the body weight falling on it. This is often associated with sprain of the lateral ligament of the ankle. The base of the bone can be avulsed by the pemeus brevis insertion. Treatment is by strapping the foot and early weight bearing if the edema is minimal. If the edema is severe the foot is immobilised in a below knee slab for a week or 10 days and later on strapped.

FRACTURES OF THE PHALAGES OF TOES

These fractures are treated by strapping the injured toe to the adjacent toe or toes for a period of 2-3 weeks. Displaced fractures need manipulative reduc­tion and strapping.

With this information the following points should be noted:

·                   The majority of tibial fractures in children, and many tibial fractures in adults, may be treated successfully by closed method.

·                   Unstable tibial fractures in the adult are usually best treated by plating or intramedullary nailing. Method of perosseous osteosynthesis may be widely used in these cases.

·                   An external fixator is often the best method of holding a severely contaminated open fracture.

·                   Be on the look out for non-union and do not delay in carrying out appropriate treatment.

·                   Be aware that ankle injuries may be associated with proximal fractures of the tibia and that these will only show on appropriate films.

·                   The most common ankle fractures is an external rotation fractures of the lateral malleolus. It is relatively stable injury and may be treated conservatively.

·                   Vertical compression fractures are more likely than any other ankle fractures to be complicated by secondary osteoarthritis.

·                   Sudeck’s atrophy is a common complication of ankle injuries, even when these are confined to the soft tissues.

·          The most serious complication of talar neck fractures is an avascular necrosis. If it occurs, weight bearing should be deferred until the bone revascularises.

·          In assessing any calcaneal fracture, it is important to note whether the subtalar joint is involved, as in such fractures there is risk of loss of inversion and eversion movements and secondary osteoarthritis.

·          Persistent pain from subtalar joint involvement may merit surgical fusion.

·          Dislocation of the talus is a serious injury, which is always followed by avascular necrosis.

·          Peritalar dislocation may lead to subtalar osteoarthritis.

·          Tarso-metatarsal dislocations may affected the blood supply to the distal part of the foot and the toes.

·          Fracture of the fifth metatarsal base is the common injury in the lower limb and is often missed as it may be mistaken for an ankle sprain.