Lower Limb Fractures

Fracture Principles - Bone Break Basics

• Definition: Break in cortical continuity of bone.
• Description:
  • Skin: Open (communicates with exterior) vs. Closed.
    • Open #: Gustilo-Anderson classification (I, II, IIIA/B/C). Requires antibiotics, debridement.
  • Displacement: Angulation, Rotation, Translation, Shortening.
  • Pattern: Transverse, Oblique, Spiral, Comminuted (>2 fragments), Segmental, Greenstick (pediatric), Avulsion.
• Healing (Secondary - most common):
  1. Inflammation (Haematoma)
  2. Soft Callus (Fibrocartilaginous)
  3. Hard Callus (Woven Bone)
  4. Remodelling (Lamellar Bone) 📌 Wolff's Law: Bone remodels in response to mechanical stress.
• Initial Care: ATLS survey. RICE (Rest, Ice, Compression, Elevation). Splinting. Analgesia. Neurovascular assessment.

⭐ Compartment Syndrome: Intracompartmental pressure > 30 mmHg (or diastolic minus compartment pressure < 30 mmHg). Leads to ischemia. 6 Ps: Pain (key!), Paresthesia, Pallor, Pulselessness, Paralysis, Poikilothermia.

Hip & Femur Fractures - Thighbone Traumas

• Neck of Femur (NOF): Intracapsular. Main blood supply: Medial Circumflex Femoral Artery (MCFA). 📌 MCFA: Main Circulation For Adult NOF.
  • Classifications:
    • Garden: I (incomplete/impacted), II (complete, undisplaced), III (complete, partial displacement), IV (complete, full displacement).
    • Pauwels Angle: I (<30° stable), II (30-50° shear), III (>50° high shear).
  • Mgmt: Young (<65 yrs) or Garden I/II: Internal Fixation. Elderly (>65 yrs) & Garden III/IV: Arthroplasty (Hemi/Total).
  • Complications: Avascular Necrosis (AVN), non-union.

  ⭐ Garden stages III & IV and Pauwels III have the highest risk of AVN.

• Intertrochanteric: Extracapsular, good blood supply. Mgmt: Dynamic Hip Screw (DHS) or Proximal Femoral Nail (PFN).
• Subtrochanteric: Below lesser trochanter. Mgmt: Cephalomedullary IM Nail.
• Femoral Shaft: High-energy. Mgmt: IM Nailing. Complications: Fat embolism, ARDS.

Knee & Tibial Fractures - Shinbone Shockers

• Tibial Plateau Fractures (Intra-articular)

  • Schatzker Classification (Types I-VI):
    • I: Pure cleavage, lateral.
    • II: Cleavage + depression, lateral.
    • III: Pure depression, lateral.
    • IV: Medial plateau; worst prognosis due to varus collapse.
    • V: Bicondylar.
    • VI: Metaphyseal-diaphyseal dissociation.
  • Management: ORIF for articular depression >2-3 mm or condylar widening >5 mm.
  • Complications: Peroneal nerve injury (anterolateral approach), popliteal artery injury (posterior fractures), post-traumatic OA.

• Tibial Shaft Fractures

  • Most common long bone fracture.
  • Management:
    • Closed, stable: Cast/functional brace.
    • Unstable/displaced/open: Intramedullary (IM) nailing.
  • ⚠️ Complications:
    • Compartment syndrome (📌 6 P's: Pain out of proportion, Paresthesia, Pallor, Paralysis, Pulselessness, Poikilothermia). Fasciotomy if intracompartmental pressure >30 mmHg or ΔP <30 mmHg (Diastolic BP - Compartment Pressure).
    • Non-union, malunion, infection (especially open fractures - Gustilo-Anderson classification).

⭐ Schatzker Type II (lateral split with depression) is the most common type of tibial plateau fracture.

Ankle & Foot Fractures - Distal Damage Details

• Ankle Fractures:
  • Lauge-Hansen: Foot position & force (SER commonest).
  • Weber (Fibular #):
    • A: Below syndesmosis (intact).
    • B: At syndesmosis (variable injury).
    • C: Above syndesmosis (injured).
  • Pilon: Distal tibia comminuted intra-articular #; axial load.
• Foot Fractures:
  • Talus: Neck # (Hawkins class.); ↑AVN risk. 📌 Hawkins sign (subchondral lucency) = viable.
  • Calcaneus: ↓Böhler's angle (normal 25-40°). Assoc. lumbar spine #.
  • Navicular: Often stress #; AVN risk.
  • Lisfranc Injury: Tarsometatarsal disruption. Fleck sign pathognomonic.
  • Jones #: 5th MT base (meta-diaphyseal); high non-union.
  • March #: Metatarsal stress # (2nd/3rd).

⭐ Weber Type C fractures, being above the syndesmosis, always involve syndesmotic injury and typically require surgical fixation with syndesmotic screws for ankle stability.

High‑Yield Points - ⚡ Biggest Takeaways

• Femoral Neck Fx: Garden's classification; high AVN risk with displacement.
• Intertrochanteric Fx: Extracapsular; better prognosis than femoral neck.
• Femoral Shaft Fx: High-energy; risk of fat embolism, compartment syndrome. IM nailing standard.
• Tibial Plateau Fx: Schatzker types; associated meniscal/ligamentous injuries (ACL, MCL).
• Tibial Shaft Fx: Most common long bone fracture; risk of non-union, compartment syndrome.
• Ankle Fx: Danis-Weber (fibula & syndesmosis); Lauge-Hansen (mechanism).
• Calcaneal Fx: Fall from height; associated lumbar spine fractures; check Bohler's angle.