Department of orthopaedics

Topic : Injuries of the lower limb including fracture

shaft of femur, supracondylar femur, fracture of
patella, dislocation knee and upper part tibia

Under the guidance of :

Respected Dr. P.K. Verma Sir ( Associate
professor)
PRESENTED BY:
BHARTI SINGH
AVINASH MISHRA
BINSU JOSEPH
FRACTURE SHAFT OF FEMUR
 FEMUR
• Largest and heaviest bone of body
• Shaft of femur is mostly smoothly rounded except
posteriorly, broad rough line, linea aspera exists
providing aponeurotic attachment to adductors of
thigh, Especially prominent at the middle third of
shaft where it has medial and lateral lips.
FRACTURE OF SHAFT OF FEMUR
• A fracture of the femur shaft typically results from
severe force, like in a road accident.
• The fracture can be caused by indirect forces (such as
twisting or bending) or direct impacts (like those in
traffic accidents).
FEMUR FRACTURE CLASSIFICATION
Winquist and Hansen Classification
• Type 0 – No comminution
• Type1 – Insignificant butterfly fragment with transverse
or short oblique fracture
• Type 2 – large butterfly of less than 50 percent of the
bony width, >50 percent of cortex intact
• Type 3 – larger butterfly leaving less than 50 percent of
the cortex intact
• Type 4 – Segmental comminution
 PATHOANATOMY
• A femur shaft fracture can occur anywhere along the bone and may be
transverse, oblique, spiral, or comminuted, depending on the force applied.
• In children, femur fractures generally show little displacement, while in
adults, significant displacement is more common.
• The upper (proximal) fragment is typically flexed, abducted, and externally
rotated due to muscle pull, while the lower (distal) fragment is often
adducted.
• The distal fragment may sag due to gravity, and there is often proximal
migration (overriding) caused by muscle pull across the fracture.
 DIAGNOSIS
➢CLINICAL FEATURES:
o The patient has a history of severe trauma to the thigh.
o Classic signs of a fracture are present, including pain, swelling, deformity,
and abnormal mobility.
o The diagnosis is typically straightforward based on these symptoms.
➢RADIOLOGICAL EXAMINATION:
• X-rays for a femoral shaft fracture should cover the entire femur and the
pelvis.
• This is important because femur fractures are often accompanied by pelvic
injuries.
 TREATMENT
❑ CONSERVATIVE METHODS:

a. TRACTION:
o A femur shaft fracture can be treated with traction, sometimes using a splint
like a Thomas splint.

o In children, skin traction is typically sufficient for treatment.

o In adults, skeletal traction is usually needed, using a Steinmann pin through

the upper tibia.
b. Hip spica:
o A plaster cast can cover both the trunk and the limb to
immobilize a femur fracture.

o It can be a single spica (for the fractured limb only)

or a one-and-a-half spica (covering more of the body).

o This cast is commonly used for children

and may also be used for young adults
once the fracture stabilizes.

Hip spica
❑OPERATIVE METHODS:
a. Closed interlocking nailing:
o The preferred treatment for most femoral shaft fractures is
closed nailing, where a nail is inserted into the bone's
medullary canal without opening the fracture, using X-ray
guidance.
o Closed nailing is less invasive than open nailing, which requires
opening the fracture site.
o Interlock nailing, a recent advancement, involves locking the
nail in place with screws at both ends, making it more stable
but technically demanding, requiring an image intensifier.
X- rays showing intra- medullary nailing done for fracture of
femoral shaft
b. Plating: fixing with a thick strip of metal-
•Plating is used for femoral fractures where the medullary canal
is too wide or the fracture is comminuted, requiring at least 8
screws (16 cortex hold) for stability.

•AO heavy-duty plates, with or without compression, or special

condylar blade plates, are used for fractures near the bone ends.

•Interlock nailing can now stabilize fractures that were

previously unsuitable for simple nailing.

•There is a trend towards using interlock nailing over plating for

femur shaft fractures.
X-rays showing plating done for fracture of distal third of the
shaft of femur
 COMPLICATIONS:
➢EARLY COMPLICATIONS:

1. Shock
2. Fat embolism
3. Injury to femoral nerve
4. Injury to sciatic nerve
5. Infection
➢LATE COMPLICATIONS:
1. Delayed union
2. Malunion
3. Non-union
4. Knee stiffness
SUPRACONDYLAR FRACTURE OF FEMUR
DEFINITION
• A supracondylar femur fracture involves the distal aspect
or metaphysis of the femur.
• The fracture frequently involves articular surfaces.

➢Mechanism of injury:
• In younger patients, this fracture is usually secondary to
high energy trauma, such as being struck by an
automobile.
• In elderly patients, this fracture is usually secondary to
low energy trauma, such as a simple fall.
Supracondylar femoral fracture
DIAGNOSIS
• Pain, swelling, and bruising around the knee suggest the
presence of these fractures.
• These fractures can be missed when they occur with more
severe injuries, like a femur shaft fracture.
• Diagnosis is confirmed using X-rays.
• It's important to assess if the fracture extends into the
joint and if there is any misalignment.
TREATMENT
• Displaced supracondylar fractures are best
treated with internal fixation.
• This can be done using either closed or open
techniques.
• A nail or plate can be used for fixation.
COMPLICATIONS
• Knee stiffness
• Osteoarthritis
• Malunion
PATELLA FRACTURE
A patella fracture is a
break in the kneecap ,
the small bone that sits
at the front of the knee

It is a serious injury that

can make it difficult or
even impossible to
straighten the knee
 Cause of the injury

PATELLA may be fractured due to

● Direct injury
● Indirect injury
● Combined injury
Direct injury results
from

● A blow on anterior aspect

of flexed knee. E.g. road
traffic accident

● It leads to stellate
fracture or comminuted
fracture of patella
 Indirect injury results
from

● Forced passive flexion of

knee when the quadriceps
muscle is in the state of
contraction
● Example- fall on feet
 TYPES
1. Based on type of fracture
displacement

●Undisplaced fracture
●Displaced fracture
2. Based on type of fracture pattern
 Clinical features
• Pain , swelling, tenderness over the knee
• There may be bruises over the front of the knee
– a tell tale sign of direct trauma.
• In comminuted fracture, crepitus is felt
• In displaced fractures, one may feel a gap
between the fracture fragments. The patient will
not be able to lift his leg with the knee in full
extension; it remains in a position short of full
extension (extensor lag) because of disruption of
the extensor apparatus
RADIOLOGICAL
EXAMINATION

Antero-posteriorand
lateral X-rays of the knee
are sufficient in most
cases.

In some undisplaced
fractures, a skyline view’
of the patella may be
required.
X-rays of the knees lateral view
Treatment: It depends upon the type of fracture

● Undisplaced fracture: Treatment is aimed

primarily at relief of pain. A plaster cast
extending from the groin to just above the
malleoli, with the knee in full extension
(cylinder cast) should be given for 3 weeks,
followed by physiotherapy.
 b) Clean break with separation of fragments :
The pull of the quadriceps muscle on the proximal
fragment keeps the fragments 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 mobilised early following this
operation.
In cases where it is not possible to achieve accurate
reduction of the fragments, as in comminuted fracture,it
is better to excise the fragments (patellectomy) and
repair the extensor retinaculae.

In cases where one of the fragments constitutes only

one of the poles of the patella, it is excised. The major
fragment is preserved and the extensor retinaculae
repaired (partial patellectomy).
Such operations on the patella are followed by support
in a cylinder cast for 4-6 weeks.
Complications
• Knee stiffness
• Extensor weakness
• Osteoarthritis
DISLOCATION KNEE
 Injuries to ligaments of knee
• With increasing sporting activities, injuries to the
knee ligaments are on the rise.

• The type of injury depends upon the direction of

force and its severity.
Ligaments of knee joint
Mechanism :
• Knee ligaments are injured most often from indirect, twisting or bending forces on the
knee.
• The various mechanisms 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 (valvus force).

• :• Lateral collateral ligament: This ligament is damaged by a mechanism of

adduction of the tibia on the femur (varus force). Lateral collateral ligament injuries
are uncommon.

• :• Anterior cruciate ligament: This ligament is most commonly ruptured..

Commonly, it occurs as a result of twisting force on a semi-flexed knee.

• :• 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 backwards on to the
femur.
Essential features of knee ligament injury
Pathoanatomy :
• The ligament may tear at either of 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 fibres
to a complete tear.

• It may be an 'isolated' ligament injury, or more than one

ligaments may be injured.

• Rarely, in a very severe injury, the knee may get dislocated and a
number of ligaments injured.
Diagnosis :
• Clinical examination:
• 1. Pain : localised in case collateral ligament injuries and vague pain
in cruciate ligament injuries.

• 2. Swelling of the knee : variable, but appears early after the

injury.

• 3. Often, the patient is able to give a history of having sustained a

particular type of deforming force at the knee, followed by a sound of
something tearing.

• 4. Damage to the medial and lateral collateral ligaments can be

assessed clinically by stress tests.
Stress tests
• This is a very useful test in diagnosing a sprain and judging its
severity.

• The ligament in question is put to stress by a manoeuvre.

• When a ligament is stressed, in first and second- degree sprains,

there will be pain at the site of the tear.

• In third-degree sprain, the joint will ‘open up’ as well.

• Cruciate ligaments prevent anterior–posterior gliding of the tibia.

The anterior cruciate prevents anterior glide, and the posterior

cruciate prevents posterior glide.

This property is made use in detecting injury to these ligaments.

Anterior drawer test: This is a test to detect injury to the anterior cruciate
ligament.
A similar test in which anterior glide of the tibia is judged with the knee in 10-15
degrees of flexion is called Lachmann test.

Posterior drawer test: This is a test to detect injury to the posterior cruciate
ligament. A posterior sagging of the upper tibia may be obvious, and
indicates a posterior cruciate tear.
Radiological examination:
• A plain X-ray may be normal, or a chip of bone
avulsed from the ligament attachment may be
visible.

• MRI is a non-invasive method of diagnosing

ligament injuries.

• Other investigation: Arthroscopic

examination
 Treatment:
Conservative method: The haematoma is aspirated and the knee is
immobilised in a cylinder cast.
Most cases of grade I and II injuries can be successfully treated by this
method.

Operative methods: These are indicated in multiple ligament injured knee.

It consists of the following:
a) Repair of the ligament: It is performed for fresh, grade III collateral
ligament injuries.

b) Reconstruction: This is done in cases of ligament injuries presenting late with

features of knee instability. A ligament is ‘constructed’ using patient's
tendon or fascia lata.
The ACL is the commonest to be ruptured.

The treatment of choice is arthroscopic ACL reconstruction.

The torn ligament is replaced with a tendon graft. This is done endoscopically,
without opening the joint.

The joint is first examined by a 4 mm telescope (arthroscope). A tendon graft

taken from patellar tendon or hamstring tendons is introduced into the knee
through bone tunnels. The graft is fixed at both ends with screws or other devices.

Bio-absorbable screws are now being used.

Arthroscopic surgery has advantages of being minimally invasive, and results in

quick return to function with minimal risks.
Complications :
1. Knee instability: An unhealed ligament leads to
instability.
• Surgery is usually required.

2. Osteoarthritis: A neglected ligament injury may result in

further damage to the knee in the form of meniscus tear,
chondral damage etc.
• This eventually leads to knee osteoarthritis.
IBIAL PLATEU FRACTURE
• TIBIAL PLATEU is the proximal
end of TIBIA including
metaphyseal, epiphyseal region as
well as articular surfaces
• These are common fractures
sustained in two wheeler accidents
when one lands on the knee.
• Either one or both condyles of
tibia are fractured
Mechanism of injury
•an indirect force causing
varus or valgus force on
knee

•a direct hit on the knee.

•These fractures commonly occur
in six patterns which are defied by
Schatzker classification
•Type I-IV involve only one
condyle, lateralor medial.
•Type V and VI are more complex
intercondylar fractures
 Symptoms and signs:

•The patient complains of pain

and swelling, and inability to
bear weight.
•Often crepitus is heard or felt
Diagnosis

X Ray:
• AP view
• Lateral view
• 40 degree internal rotation view (lateral
PLATEU)
• 40 degree external rotation view
(medial PLATEU)
Treatment
• Like most fractures, both conservative
and operative methods can be used.
• Conservative methods are used for
minimally displaced fractures, and those
in elderly people.
• Immobilisation with cast or brace for a
week followed by early range of knee
motion along with skeletal traction