Trauma IV

Tibia shaft

What is the most common long bone fracture that is commonly associated with open wounds?

often moderate to high energy mechanism (MVC, MV, fall from height (peds))

MOI for tibia shaft fractures

must evaluate for compartment syndrome, NV exam

What do we gotta do for tibial shaft fractures?

immediate fracture reduction, splint (lower extremity spint/AO), IMN maybe with external fixation first if open

Gameplan for tibia shaft fractures

open fractures, compartment syndrome, fat emboli, nonunion

Risk of tibia shaft fractures

Ankle fractures

A very common injury which occurs with twisting injuries (supination and pronation)

lateral malleolus (stable or unstable), bimalleolar ankle, pilon ankle, maisonneuve fracture

Types of ankle fractures

deltoid, syndesmosis (anterior inferior tibiofibular ligaments), lateral ligament complex (ATFL (lateral), PTFL, CFL (lateral))

Ankle stabilizing ligaments

Danis-Weber classification

What system is used to classify ONLY independent lateral malleolus ankle fractures?

Below the syndesmosis, stable, non-op

Describe a Weber A

At the level of the syndesmosis, variable stability, medial/lateral clear space widening

Describe a Weber B

Above the syndesmosis, operative due to instability and disruption of syndesmosis

Describe a Weber C

Supination, adduction

MOI for Weber A lateral malleolus fracture

Non-op - immobilization in a high fracture boot WBAT for 6-8 weeks (m/c); ORIF depending on displacement

55 y/o female presents to the ED for ankle pain after rolling her ankle going down the stairs. On physical exam you note swelling, ecchymosis, and pain to the lateral ankle over the distal fibula. See xray. What is your treatment plan?

supination and external rotation

MOI for Lateral Malleolus Weber B fracture

stability with gravity, manual (external rotation) stress exam (get xrays pre and post stress)

What do you need to evaluate for with Lateral Malleolus Weber B fractures?

no medial or lateral space widening with stress exam

Describe a stable Lateral Malleolus Weber B fracture

increased medial clear space (4+ mm - deltoid ligament injury), increased lateral clear space (6+mm - syndesmosis injury)

What makes a Lateral Malleolus Weber B fracture unstable?

reduction PRN, high fracture boot w/ WBAT for 6-8 weeks; follow up with WB xrays

gameplan for a stable Lateral Malleolus Weber B fracture

Splint NWB, ORIF (with tightrope and anchor to allow for motion)

gameplan for a unstable Lateral Malleolus Weber B fracture

Pronation and external rotation (commonly associated with disruption of syndesmosis)

MOI for Lateral Malleolus Weber C fracture

Splint NWB, ORIF

Gameplan for Lateral Malleolus Weber C fracture

Bimalleolar ankle fracture

A fracture of the medial malleolus and fibula

Closed reduction → Splint NWB → ORIF

Gameplan for Bimalleolar ankle fractures

trimalleolar fractures

A fracture of the medial malleolus and fibula AND the posterior malleoulus

Splint NWB → ORIF

Gameplan for trimalleolar fractures

Maisonneuve fracture

A fracture of the 1/3 proximal fibula with associated isolated medial malleolus fracture OR a deltoid (medial) ligament injury (syndesmosis is screwed up as well)

External rotation of the ankle (force is transmitted through syndesmosis up the interosseous membrane)

MOI for Maisonneuve fracture

isolated medial malleolus fracture

What is a red flag for a Maisonneuve fracture

medial ankle pain and proximal leg pain (get ankle and leg x-rays)

What might you see on exam for Maisonneuve fracture

ORIF

What is your treatment plan for Maisonneuve fractures?

Pilon (plafond) ankle fracture

A fracture involving the weight bearing articular surface of the distal tibia

High energy injuries with axial load to the joint (talus gets forced into distal tibia, fall from a roof)

MOI for Pilon ankle fractures

ORIF or external fixator with delayed ORIF → NWB for 12 weeks

Gameplan for Pilon ankle fractures to restore joint and length

Compartment syndrome, L1 fracture, post-traumatic arthritis (most patients will get this, surgery pushed that date back)

What do we need to watch for with Pilon ankle fractures

Lisfranc fractures

A midfoot injury with disruption of the lisfranc ligament leading to the disruption ot the TMT (tarsal-metatarsal) joint complex

Extends between the medial cuneiform and based of 2nd MT articulation

Where is the lisfranc fracture

forceful abduction of the forefoot on the tarsus OR crushing injury with force across the TMT

MOI of Lisfranc fractures

Plantar bruising (HIGHLY suggestive), swelling throughout, tenderness over TMT joint, inability to weight bear

What might you find on physical exam of a Lisfranc fractures

Splint NWB, operative treatment with ORIF (may need a CT to help for planning)

Gameplan for Lisfranc fractures

Widen space between base of 1st and 2nd MT, Flex’s sign (avulsion of ligament from 2nd MT)

How might a “subtle” lisfranc fracture look

3 view ankle xrays with axial harris views

If you suspect a calcaneus fracture → what are we ordering?

fall from height, high energy with axial load onto calcaneus (assess lumbar, femur, and pelvis)

MOI for calcaneus fracture

intra-articular

A calcaneal fracture in which a fragment displaces with variable comminution, resulting in heel shortening and valgus deformity

Well padded splint NWB (blisters are common); CT scan for surgical planning, ORIF

What is the gameplan for intra-articular calcaneus fractures

Extra-articular anterior process fractures

A calcaneal fracture that results from excessive inversion and plantarflexion (avulsion of the bifurcate ligament)

3 view xrays (oblique view is best)

What do you need to order if you suspect an anterior process calcaneal fracture

WBAT in fracture boot for 4 weeks

Gameplan for an anterior process calcaneal fracture

Tongue type (achilles/calcaneus avulsion)

A calcaneus fracture that results from a strong contraction of the gastroc-soleus

Call Ortho A$AP, assess posterior heel for skin breakdown/tenting

Workup for tongue type fractures

Splint in a resting plantar flexion position, NWB, ORIF (op)

Gameplan for tongue type fractures

5th! (then second, then third, then fourth)

What is the most common fractured metatarsals in adults?

Second (MRI)

Stress fractures are common in the metatarsals → which one is most common?

inversion injury from pull of the peroneus brevis tendon, stress fracture development

MOI for 5th metatarsal base fractures

Zone I

Which 5th metatarsal base fracture anatomical zone is the articular surface for metatarso-cuboid joint (pseudo-jones)

Zone II

Which 5th metatarsal base fracture anatomical zone is the articulation of the 4th and 5th MT (jones fracture)

Zone III

Which 5th metatarsal base fracture anatomical zone is a fracture 1.5 cm distal to the tuberosity

inversion and plantarflexion (tuberosity avulsion fractures)

MOI for Zone I 5th metatarsal base fracture

Fracture boot/hard soled shoe WBAT for 4-6 weeks (good healing, may need surge based on displacement)

Game plan for Zone I 5th metatarsal base fracture

adduction force of the foot

MOI for Zone II 5th metatarsal base fracture

risk of refracture, increased risk for delayed union/nonunion, poor healing potential (watershed blood supply)

Quirks of Zone II 5th metatarsal base fracture

NWB for 6-8 weeks → WBAT in a boot for 4 weeks; ORIF (potentially a faster recover) → 2 weeks NWB → Wb in boot 4-6 weeks

Treatment plan for Zone II 5th metatarsal base fracture

Dancer’s fracture

A spiral or oblique fracture of the 5th metatarsal SHAFT due to inversion and plantarflexion injury

Non-op with NWB in camboot 6-8 weeks

Treatment for dancer’s fractures