Lower Extremity Injuries

by Ayse Ece Akceylan

Hip

Case Presentation

A 75-year-old male with a history of osteoporosis presented to the emergency department after falling on his right side. He complained of pain on the right hip.  His vital signs were normal. His right leg was in abduction and external rotation and shorter than the left leg. Distal pulses were palpable. An anteroposterior (AP) pelvis x-ray showed a femoral neck fracture. The patient was admitted to the orthopedics ward for surgical repair.

Critical Bedside Actions and General Approach

Preserving function, preventing infection and assuring perfusion of the limb should be the goals. Proper diagnosis and treatment are essential for establishing these goals.

  • Check vital signs
  • Learn mechanism of injury
  • Take medical history
  • Make an orderly and thorough examination
  • Order necessary imaging and labs
  • Noncritical orthopedic injuries should be treated only after more threatening injuries have been addressed.

Differential Diagnosis

The patient might have one or more of the following:

  • Hip fracture
  • Hip dislocation
  • Acetabular fracture
  • Neurovascular injury

History and Physical Examination Hints

  • Note systemic illnesses, known metabolic disorders and medications. These may provide clues that lead to uncovering the reason behind what may seem like a simple trauma. (I.e., a fall may be the result of a cardiovascular event.)
  • Visual inspection and palpation: look for tenderness, pallor, ecchymosis, deformity, abrasions, lacerations, and open wounds.An open fracture is a fracture associated with overlying soft tissue injury, creating communication between the fracture site and the skin. Even a puncture wound extending to the depth of an underlying fracture is considered an open fracture. Open fractures are usually classified by their severity, based on the size of the overlying laceration, the extent of tissue damage, lack of bone coverage, the kinetic energy of the injuring force, and evidence or likelihood of significant contamination.
  • In a femoral fracture, the limb is shortened and externally rotated.
  • Most hip dislocations are posterior. In posterior dislocations, the limb is adducted, internally rotated, and shortened. 
  • In anterior disloca­tions, the limb is abducted, externally rotated, and shortened. 
  • Check neurovascular status: Femoral nerve and artery may be injured with anterior hip dislocations. The sciatic nerve may be injured with a posterior hip dislocation or a hip fracture. Check pinprick sensation, light touch and motor function. Also, check femoral, popliteal, dorsalis pedis, and poste­rior tibial pulses.
  • Dislocations and fracture-dislocations of the hip are two true orthopedic emergencies. The hip joint possesses impressive inher­ent strength and stability; therefore, considerable force is required to produce these injuries. It is highly recommended that in the presence of this type of injury, patients be managed as major trauma victims.

Emergency Diagnostic Tests and Interpretation

  • Anteroposterior (AP) and lateral radiographs of the hip are usually sufficient to diagnose hip dislocations and fractures. (See Figure 1 and Figure 2) 

602 - Right hip dislocation

Figure 1. Right hip dislocation

https://flic.kr/p/26VuVMS
Figure 2. Fracture of the femoral neck and peritrochanteric fracture
  • Significant pain with weight bearing in the face of normal radiographs should raise suspicion for occult fracture, especially at the femoral neck or acetabulum. 
  • If there is a suspicion of fracture but plain radiographs appear negative, computed tomography (CT, See Figure 3) or magnetic resonance imaging (MRI) may be used for diagnosis.

780 - Left acetabular fracture

Figure 3. Left acetabular fracture

  • If there is suspicion of vascular injury, cardiovascular surgery consultation and Doppler flow ultrasound, plain angiography or CT Angiography are necessary. 

Emergency Treatment Options:

  • Most femoral and hip fractures need operative repair. Consult an orthopedic surgeon. Meanwhile, immobilize the extremity to prevent it from further damage.
  • If a fracture is suggested clinically but radiographic films appear negative, the patient should initially be treated with immobilization as though a fracture were present.
  • Patients with a traumatic fracture of the hip or femur may lose about 2 to 3 units of blood at the fracture site and require blood transfusions. Therefore, order blood type and crossmatch for at least 2 units of blood.
  • Dislocated hips need to be reduced as soon as possible, under procedural sedation and analgesia (see videos below).

 

 

  • The sooner a joint is relocated, the better, to avoid neurovascular compromise. Also, delays cause swelling and muscle spasm, which hinder reduction. Use adequate analgesia or conscious sedation before attempting relocation. The emergency physician sometimes may be unable to reduce a dislocation. Orthopedic consultation is necessary in such cases.
  • For hip dislocations, after reduction, the legs are immobilized in slight abduction with a pillow between the knees, and the patient should be sent for radiographs. Check neurovascular status before and after all reductions and after administration of immobilization.
  • Withholding Oral Intake: Any patient who might go under general anesthesia or procedural sedation should not be allowed to eat or drink from the moment of arrival until the need for, and timing of, such a procedure has been ascertained.
  • In case of open dislocation/fracture, remove gross contaminants from the wound and irrigate the injury thoroughly. Apply saline-soaked sterile gauze, and splint the injured leg. If a significant deformity is present, immediate reduction before splinting is indicated. Administer tetanus immunoprophylaxis as appropriate (Tetanus booster: 0.5 ml (Tdap) IM, Tetanus immunoglobulin: 250 IU IM if not previously immunized against tetanus). Start the patient on intravenous antibiotics. For injuries with mild to moderate contamination, a first-generation cephalosporin such as cefazolin 1–2 g (pediatric dose: 20 mg/kg IM/IV)is usually sufficient.2Heavily contaminated wounds require the addition of gram-negative bacterial coverage, typically an aminoglycoside such as gentamicin 1.5–2 mg/kg IV(pediatric dose: 2–2.5 mg/kg IV). Adding either penicillin G 4–5 million U IV (pediatric dose: 50,000 U/kg IV)or, if penicillin allergic, clindamycin or metronidazole as a third antibiotic is necessary for farm-or soil-related crush injuries, in which contamination with Clostridium perfringens can be present.  Early surgical intervention for debridement and irrigation is crucial, so emergency orthopedic consultation is indicated. Administer analgesics as necessary (Morphine sulfate: 2–10 mg (pediatric dose: 0.05–0.1 mg/kg per dose IV or equivalent analgesic)).
  • In case of neurovascular injury, surgical consultation is necessary.

Special Populations

  • Treatment options are mostly the same for children, elderly and pregnant patients.
  • In a fall, elderly patients may have sustained additional injuries; most commonly, these injuries involve a fracture of a vertebral body or wrist. Cervical spine and intracranial injuries also are considered.2
  • The dislocation reduction methods for patients with hip arthroplasty are the same as with a native hip.6
  • Fractures involving the physis, the cartilaginous epiphyseal plate near the ends of the long bones of growing children, are called Salter fractures. Damage to the epiphyseal plate during a child’s growth may result in an aborted or deformed growth of the limb.1
  • Children who have sustained trauma at or near a joint may need comparison studies of the opposite extremity to differentiate fracture lines from normal epiphyseal plates or ossifying growth centers.1
  • The elderly are more prone to serious injury from low-energy mechanisms. The elderly are more susceptible to adverse outcomes following trauma because of comorbid diseases and physiologic changes that arise with aging.

Disposition Decisions (admission, discharge, referral)

  • Hip dislocations that cannot be reduced in the emergency department need to be reduced in the operation room under general anesthesia.
  • Hip fractures and hip dislocations (even if reduced in the ED) need to be admitted to the orthopedics ward.

Knee

Case Presentation

A 60-year-old female presented to the emergency department with pain and swelling on her right knee after a fall. Her vital signs were normal, and she did not hit any other part of her body. Upon physical examination, there was tenderness and deformity on the right knee. The neurovascular examination was normal. The x-ray revealed a comminuted patellar fracture. The patient was admitted to the orthopedics ward for surgical repair.

781 - Patella fracture

Critical Bedside Actions and General Approach

These steps are the same as those mentioned above in the topic “hip.”

Differential Diagnosis

The patient might have one or more of the following.

  • Distal femoral, proximal tibial, proximal fibular fracture
  • Knee dislocation
  • Ligamentous injury
  • Meniscal injury
  • Popliteal artery injury
  • Peroneal, tibial (less common) nerve injury

History and Physical Examination Hints

  • Note systemic illnesses, known metabolic disorders and medications, as mentioned above in the topic “hip.”
  • Visual inspection and palpation – mentioned above in the topic “hip.”
  • See Figure 4 for open knee dislocation.

782 - Figure 4 knee open dislocation

  • Check peripheral nerves: knee trauma, especially knee dislocations may cause peroneal nerve injury. Examine the peroneal nerve by testing the sensation of the dorsum of the foot and by dorsiflexion of the ankle. The posterior tibial nerve may also be injured. This manifests with diminished plantar sensation and plantar flexion of the foot.
  • Check vascular status: knee trauma may cause vascular injury. Check the popliteal, dorsal pedal and posterior tibial arteries.
  • Palpate the extensor mechanism for tenderness and crepitation: quadriceps tendon, patella, patellar tendon, and tibial tubercle.
  • Palpate the joint line (for meniscal or collateral ligament injuries)
  • Check the range of motion of the knee
  • Perform knee stability testing and meniscal testing (see videos)

  • Comparison with the uninjured knee is helpful, especially for assessment of ligamentous laxity.
  • A grossly unstable knee after a traumatic injury should be assumed to be a reduced dislocation until proven otherwise (See Figure 4)
  • For more information, these videos will be helpful:

Emergency Diagnostic Tests and Interpretation

  • The Ottawa Knee Rule and the Pittsburgh Knee Rule are useful for deciding when to order plain radiographs. Both criteria are sensitive for fractures, but the Pittsburgh criteria are more specific and can be applied to both children and adults. This approach is associated with an approximately 1% chance of a missed fracture. Therefore patients should be reevaluated in the event of persistent or progressive symptoms.
  • Ottawa Knee Rule video

  • If plain radiographs are indicated, obtain a minimum of an antero¬posterior (AP) and a lateral view. See Figure 5 for comminuted tibia fracture around the knee joint. Remember to examine the joint above and the joint below the injury, not to miss associated injuries.

783 - Tibia plateau fracture

 

  • The joints above and below a fracture should generally be imaged for coexisting fractures.
  • Pre-and-post-reduction radiographs are advisable both before and after reduction of dislocations and fractures.
  • See Figure 5 for comminuted tibial plate fracture involving the knee joint.
  • In acute knee trauma, the goal of radiography is to rule out frac¬ture. Because radiographs are not 100% sensitive, knee immobi¬lization and orthopedic referral for reevaluation are options. When suspicion for a fracture is extremely high, CT or MRI can be used.
  • If there is suspicion of vascular injury, the same rules apply as mentioned above in the topic “hip.”

Emergency Treatment Options

  • Most fractures concerning the knee joint need operative repair. Consult an orthopedic surgeon. Meanwhile, immobilize the extremity to prevent further damage.
  • If a fracture is suggested clinically, but radiographic films appear negative, immobilize the limb as though a fracture is present and consult an orthopedic surgeon.
  • Patellar Fractures: Nondisplaced fractures usually heal with a long leg cast for 4 to 6 weeks.7 Displaced fractures are treated surgically.
  • Patellar Dislocation: After reduction, immobilize the knee in full extension for 3 to 6 weeks. Ice, elevation, non–weight bearing, and analgesia are beneficial in the acute setting. The patient can be discharged with a referral for a follow-up within 2 weeks.

  • Knee Dislocation: To avoid tissue damage, the reduction should be attempted as soon as possible.. After reduction, immobilize the knee and call for an orthopedic consultation.

  • For open fractures/dislocations, the same rules apply as mentioned above in the topic “hip.”
  • Meniscal Injuries: Unless the knee is locked and cannot be extended or flexed (which requires orthopedic consultation), a patient with a meniscal tear should be managed with analgesics, immobilization, ice, non–weight-bearing status, and referral for an orthopedic follow-up.
  • In case of neurovascular injury, urgent surgical consultation is necessary.
  • Controlling Pain and Swelling: The early application of cold and elevation are effective in minimizing swelling or at least deterring its progression. Administer analgesics as necessary.
  • Withholding Oral Intake: same as mentioned above in the topic “hip.”

Special Populations

Treatment options are mostly the same for children, elderly and pregnant patients.

Disposition Decisions

  • All dislocations (even if reduced in the ED) and most fractures need to be admitted to the orthopedics ward.
  • Ligamentous and meniscal injuries can be sent home, with the advice of immobilization, elevation, ice application and analgesic use and an orthopedics outpatient follow-up.
  • Give the patient instructions about splint care, crutch use, range-of-motion exercises, weight-bearing status, warning signs for neurovascular impairment and compartment syndrome and follow-up.
  • The patient can begin exercises when the pain subsides and can return to full activity when full pain-free motion and equal strength are attained in both limbs.

Ankle

Case Presentation

A 25-year-old male presented to the emergency department with right ankle pain after a fall during a soccer game. His medial right ankle was swollen, and palpation revealed tenderness on the medial ligaments and the medial malleolus. He could not bear weight on his right foot. Anteroposterior and lateral ankle x-ray revealed a lateral and medial malleolar fracture (see Figure 6) involving the joint. The patient was admitted to the orthopedics ward for elective surgical repair.

99 - Figure 18 - Fracture of fibulaand Fracture of medial malleolus

Figure 6. Fracture of fibula and fracture of medial malleolus

Critical Bedside Actions and General Approach

These steps are the same as those mentioned above in the topic “hip.”

Differential Diagnosis

The patient may have one or more of the following.

  • Fracture (distal tibia, distal fibula, talus, calcaneus)
  • Ankle dislocation
  • Neurovascular injury
  • Soft tissue injury

History and Physical Examination Hints

  • Note systemic illnesses, known metabolic disorders and medications, as mentioned above in the topic “hip.”
  • Visual inspection and palpation: mentioned above in the topic “hip.”
  • Check neurovascular status
  • Evalua¬te weight-bearing ability only if clinical suspicion of a fracture is low.
  • The patient with a sprain may complain of hearing a “snap” or a “pop” at the moment of injury. Examine the joint for abnormal motion.
  • Examine the proxi¬mal fibula in all medial ankle injuries. A medial ankle disruption (deltoid ligament tear or medial malleolar fracture) can cause complete tearing of the tibiofibular syndesmotic ligament and fracture of the proximal fibula (Maison¬neuve fracture).
  • See Figure 8 and 9 for ankle open fracture plus dislocation.

784 - Fig 9 ankle open dislocation+fracture

 

785 - Fig 8 x-ray ankle dislocation+fracture

  • See video for ankle examination

  • Achilles tendon may be ruptured in patients exhibiting posterior ankle pain after a shortfall or jump onto a slightly plantar-flexed foot. The Thompson test is used to assess the integrity of this tendon. (see video)

Emergency Diagnostic Tests and Interpretation

  • The blunt ankle trauma evaluated within 48 hours of injury, the Ottawa Ankle Rules (OAR) can be used to determine necessity of x-rays. The OAR does not apply to the hindfoot or forefoot. Finally, the OAR is not applicable to intoxicated patients, patients with head injuries, multiple injuries, or diminished sensation related to neurologic deficits.
  • Views of the ankle should include AP, lateral, and mortise views. See Figures 6 and 7 for an ankle fracture. The mortise view allows a reasonably good image of both the mortise and the talar dome.
  • OAR video

  • Plain radiography may miss subtle ankle fractures. If plain radiography is negative, but there is suspicion of a fracture, other imaging modalities or orthopedic consultation is advisable.

Emergency Treatment Options

  • Ankle Dislocations: See video for reduction maneuvers. Reassessment of the neuro¬vascular status, splint immobilization, ankle elevation, and post-reduction radiography should follow.

  • Ankle fractures: Displaced intraarticular fractures require surgery.
  • Achilles Tendon Rupture: Splint the leg in plantar flexion; arrange orthopedic follow up as an outpatient.
  • Sprains: Application of ice, elevation, and analgesia are recommended. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in many patients.3 Immobilization of the limb for the first 48 to 72 hours provides protection and comfort. For complete or nearly complete ligamentous disruption, orthopedic consultation is mandatory.
  • A neurovascular injury requires urgent surgical evaluation.

Special Populations

Treatment options are mostly the same for children, elderly and pregnant patients.

Disposition Decisions

  • Ankle dislocations and most ankle fractures should be admitted to the orthopedic ward. Consult an orthopedic surgeon.
  • Soft tissue injuries can be discharged with the recommendation of ice application, elevation, immobilization, and analgesic use.

References and Further Reading

  • Menkes JS. Initial Evaluation and Management of Orthopedic Injuries. In: Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, David M. Cline, Rita K. Cydulka, Garth D. Meckler, The American College of Emergency Physicians. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 7th Edition. New York, NY: McGraw-Hill; 2011.
  • Murray BL. Femur and Hip. In: Marx J, Hockberger R, Walls R, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th Edition. Philadelphia, PA: Elsevier. 2013: 672-697.
  • Geiderman JM, Katz D. General Principles of Orthopedic Injuries. In: Marx J, Hockberger R, Walls R, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th Edition. Philadelphia, PA: Elsevier. 2013: 511-533.
  • www.youtube.com/watch?v=VYl6M87Uh68
  • www.youtube.com/watch?v=mAL-Szu7qAc
  • Bossart P. Hip and Femur Injuries. In: Adams JG, Barton ED, Collings JL, DeBlieux PMC, Gisondi MA, Nadel ES, editors. Emergency Medicine: Clinical Essentials, 2nd Edition. Philadelphia, PA. Elsevier. 2013:726-730.
  • Pallin DJ. Knee and Lower Leg. In: Marx J, Hockberger R, Walls R, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th Edition. Philadelphia, PA: Elsevier. 2013: 698-722.
  • www.youtube.com/watch?v=S8_hz_pQ1Yo
  • www.youtube.com/watch?v=3mKZ8iwF1WI
  • Hopkins C. Knee and Lower Leg Injuries. In: Adams JG, Barton ED, Collings JL, DeBlieux PMC, Gisondi MA, Nadel ES, editors. Emergency Medicine: Clinical Essentials, 2nd Edition. Philadelphia, PA. Elsevier. 2013:731-744.
  • www.youtube.com/watch?v=M5fUm5a5ls4
  • https://www.youtube.com/watch?v=zipNJOQU7lM
  • https://www.google.com.tr/search?q=pittsburgh+knee+rules&espv=2&biw=1600&bih=799&source=lnms&tbm=isch&sa=X&ved=0CAYQ_AUoAWoVChMIvMGp_5LbyAIVhF4sCh3OGgE6#imgdii=V44epBtL4pqx-M%3A%3BV44epBtL4pqx-M%3A%3BGKd4DNUXlZAhLM%3A&imgrc=V44epBtL4pqx-M%3A
  • https://www.youtube.com/watch?v=rSNLi0XrYHM
  • https://www.youtube.com/watch?v=_J01mLsi53I
  • https://www.youtube.com/watch?v=aN7zDxtyHy8
  • Del Castillo J. Foot and Ankle Injuries. In: Adams JG, Barton ED, Collings JL, DeBlieux PMC, Gisondi MA, Nadel ES, editors. Emergency Medicine: Clinical Essentials, 2nd Edition. Philadelphia, PA. Elsevier. 2013:745-755.
  • https://www.youtube.com/watch?v=QiSm8rz2cmo
  • https://www.youtube.com/watch?v=t5dbvfv-_hQ
  • Rose NGW, Abu-Laban RB. Ankle and Foot. In: Marx J, Hockberger R, Walls R, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th Edition. Philadelphia, PA: Elsevier. 2013:723-750
  • https://www.youtube.com/watch?v=zLrPsNCC18I
  • https://www.youtube.com/watch?v=peSuuAOXVaQ