Orthopedics Ready Reckoner RM Shenoy
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Trauma in General and Injuries of the Lower LimbSECTION 1

1.1. Examination of Bone and Joint Injuries
One of the most common causes of mortality and morbidity is trauma. Examination of an acutely injured person from an orthopedic preview helps in triage of the patient.
It should be brief and relevant. It should help to identify the mechanism of injury, the nature, severity of violence, extent of disabilities to the patient and the symptoms pertaining to associated neurovascular injuries.
Certain fractures are particularly seen in specific age, like epiphyseal separation is seen only in children and adolescents. Colles fracture occurs in elderly osteoporotic persons.
Mechanism of Injury
It can be interpreted by asking the mode of injury such as fall from height, RTA and position of the limb or body at the time of injury, rotational force acting on the body and the type of activity done by the patient at the time of injury.
By eliciting type of history we can divide the type of force as direct or indirect and muscular.
  • Direct injuries are due to a hit by an object.
    Tapping—There is transverse fracture with minimal skin damage
    Crushing—Multiple fragments with extensive soft tissue injury.
  • Indirect injuries are due to a force acting on a limb which is fixed to a point. This may be a bending force (leads to transverse or oblique fracture), twisting force (spiral fracture), bending with axial compression force (double oblique fracture with separation of butterfly fragment) or combination of all.
  • Muscular force—When a muscle is strongly contracted against resistance, it may lead to an avulsion of a bone fragment at its attachment and a fracture, e.g. patella, olecranon and lesser trochanter of femur.
A force of trivial nature causing a fracture in a bone which had a pre-existing pathology is called a pathological fracture. The pre-existing pathology had already weakened or softened the bone.
This softened bone breaks with a force of lesser magnitude.
Pain is felt during movements of the fractured site. It is least in impacted and greenstick fracture. In a dislocation, pain is constant and unbearable. This is because the soft tissues surrounding the joint are in a state of constant stretch.
Loss of Function
3 Patient will be unable to move the fractured limb due to pain. In case of dislocation patient is unable to move the involved joint. In either case there is loss of function of the limb.
Deformity and Swelling
A fracture or dislocation often presents with swelling or deformity. Classical deformity clinches the diagnosis, e.g. ‘Dinner fork’ deformity, ‘Garden spade’ deformity, etc.
General Examination
Look for evidence of shock. Vitals should be noted. Consciousness and orientation should be recorded at this stage.
Local Examination
Prerequisites: Patient should be made to sit or lie down in a comfortable position.
Part to be examined should be adequately exposed.
Injured side should always be compared to sound side.
Both limbs must be kept in identical position whenever possible.
Note:In a severly traumatized patient, clothes should be cut and removed and the patient should be covered with a clean bid sheet.
Attitude: Position of the limb after injury gives a clue to a diagnosis, e.g. in fracture neck femur, affected lower limb will be in external rotation.
In posterior dislocation of hip, thigh will be in flexion, adduction and internal rotation.
In anterior dislocation of shoulder, the contour will be lost with prominence of anterior axillary fold.
Swelling and deformity: The swelling is due to hematoma and edema and deformity is due to displaced segment following a fracture or a dislocation.
Shortening: Always expected in a displaced fracture due to overlapping of fractured segments, more obvious in fractures of the lower limb.
Overlying skin: To be examined for open wound, sinus and scar.
Compound/open fracture—Wound communicates with the fracture site.
Closed/simple fracture—Skin is intact.
Edema, blebs and bullae are quite common due to interference with venous return.
4 Confirmation of inspectory findings:
Temperature: A pulseless limb due to vascular injury will feel cold.
Loss of continuity and irregularity: Discontinuity and irregularity can be felt at the site of the fracture. This is a definitive sign of fracture.
Abnormal mobility: A fracture is a discontinuity occurring in a bone following injury. There will be abnormal mobility between two ends of fracture. This sign should never be elicited in a fresh fracture. It is a sure sign of a fracture and to be observed. When present the limb needs splinting immediately. It is usually elicited to assess union of a fracture in follow-up of patients.
Crepitus: It is a sensation of grating which may be felt or heard when bone ends are moved against each other. Commonly seen when there is comminution. Also appreciated in hematoma, osteoarthritis, Charcot’s joint.
Swelling: Whether swelling is arising out of a bone or a joint or soft tissue is to be ascertained.
Tenderness: Local bony tenderness is a sign of fracture. Site of tenderness in a joint will give a clue to the diagnosis of injured structure. In joint injuries the joint has to be stressed in various directions to make out the presence of subtle ligament injuries, e.g. Medial collateral ligament injury—Valgus stress test will be positive.
Wound: Note the size and extent of the wound and degree of contamination. Under aseptic precautions, the wound should be explored to note the position of the broken fragments, loss of and extent of injury to the tissue and the presence of a foreign body as well as contamination. Also observe the color of the muscles to exclude any possibility of gas gangrene.
May not be necessary in a fresh fracture. But certainly is necessary in a case of nonunion.
Longitudinal: To know if there is any shortening.
Circumferential: To know if there is any wasting due to injury.
Assessment may not be necessary in a fresh fracture. But certainly is necessary in a case of nonunion. Both active and passive movements should be tested very very gently. In a fresh fracture they are extremely painful. The active movements become limited or may not be possible at all but attempted passive movements, in the vicinity, may show abnormal mobility. In a dislocation both active and passive movements will be painfully and grossly restricted. In an old fracture or unreduced dislocation, joint will become stiff due to intra-articualr or extra-articular adhesions. A mechanical resistance to movements may be present in myositis ossificans or intra-articular loose fragments.
Neurovascular Examination
5 Adjacent neurovascular structures to an injured bone or joint should be examined to rule out any injury to them.
Shock, venous thrombosis, pulmonary embolism, fat embolism, compartmental syndrome are some of the early complications that can be associated with a major fracture.
Infection, delayed union, malunion, nonunion, avascular necrosis, VIC, myositis ossificans traumatica are the late complications.
1.2. Open Fractures
6I can assure you that even after most sophisticated operations succeed,
My delight is nothing in comparison with my feelings
I have after the successful management of an open fracture
—Billroth (1866)
The above statement remains true even today. An open fracture with extensive soft tissue defect still remains one of the most delicate and challenging problems in trauma surgery.
An open fracture is defined as one in which a break in the skin and underlying soft tissues, communicates with the fracture or its hematoma, or both and exposes it to the external environment.
Gustilo and Anderson in 1976 described a prognostic classification scheme for open fractures based on the size of the wound. However, Gustilo et al in 1984 reported a subclassification of type-III open fractures.
Based on Gustilo and Anderson Classification (Figure 1.2.1)
Type I: Open fracture as a result of low energy trauma. The features are—wound usually less than 1 cm, minimal soft tissue damage, and minimal contamination.
Type II: Open fracture due to a little severe trauma, high/low energy. Features are laceration of more than 1 cm moderate soft tissue damage, minimal to moderate contamination. The soft tissue stripping from the bone is none to minimal and primary wound closure is possible.
Type III: Open fractures are due to a high velocity trauma. Features are extensive soft tissue damage and crushing, and the injuries with extensive contamination.
Type IIIA: Despite skin loss, bone retains its soft tissue envelope irrespective of the size of the wound.
Type IIIB: Extensive soft tissue injury with extensive periosteal stripping and exposure of bone. Usually, flap coverage of the exposed bone is required.
Type IIIC: An open fracture with major vascular injury requiring repair. For example, distal humerus fractures with a brachial artery injury.
Management Of Open Fractures
Initial Management
All patients with open injuries must be assessed and resuscitated according to the established principles of Advanced Trauma Life Support (ATLS). Special emphasis must be placed on identification of associated life-threatening injuries.7
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Figure 1.2.1: Open fractures classification—based on Gustilo and Anderson.
After resuscitation secondary and tertiary surveys are mandatory to avoid “missed injuries” which can be present in up to 20% of these patients.
Antibiotics: What, When and for How Long?
Although use of antibiotics is now considered therapeutic and mandatory, abuse and misuse of antibiotics is perhaps most common in the management of open injuries. Antibiotics with broad spectrum coverage—usually a first generation cephalosporin derivative is given for all type I and type II fractures. The addition of aminoglycoside and penicillin is recommended for type III injuries. Penicillin is very effective against clostridia group of organisms causing gas gangrene and tetanus. One should never hesitate to test and use this wonder drug especially when encountered with deep punctured wounds, wounds with necrotic tissue and effused blood, wounds contaminated with silicic acid and ionized calcium, wound with foreign bodies and those with secondary infection 8with aerobic organisms (All these are predisposing factors for Gas Gangrene). Usually, antibiotics are given for five days followed by wound culture and further treatment is based on those cultures. When gas gangrene is suspected in those who are allergic to Penicillin other drugs such as Tetracyclines, Cephalosporins and Piperacillin may be used.
Infection Control
“The single factor which decides success or failure in open fractures is ‘infection’. At every stage of treatment, all members of the team must pay special attention to prevent contamination of the wound leading to infection.”
Debridement: When and By Whom?
“Debridement is fundamental to success. It is both an art and science and must be performed by a person well-experienced in this field preferably by the senior most member of the team.”
Fracture Stabilization
Although the external fixator is the work-horse of a trauma surgeon, there is enough material in literature to prove the safety and advantage of internal fixation in stabilization of open fractures. It has an added advantage of being very friendly to plastic surgical procedures without producing any hindrance for flap rotation. Solid nails are preferred to hollow nails as intramedullary implants.
It is a Teamwork
The team should comprise of a skilful anesthetist, an orthopedic surgeon and a plastic surgeon for resuscitation, stabilization and reconstruction.
1.3. Fractures of the Pelvis
9Disruption of the pelvic ring is a serious injury with significant mortality and morbidity. Despite early, more aggressive resuscitation including the early application of the external fixators, there is significant mortality in pelvic injuries.
Displacement of pelvic fracture is always associated with disruption of pelvic ligaments leading to instability of pelvic ring. Stabilizing an unstable injury in acute polytrauma is a conventional wisdom.
Mechanism of injury forms the key component in the classification, and management of pelvic injuries.
The ideal pelvic injury classification system would facilitate identification of injury. Predicts the morbidity and mortality in terms of associated injuries, and forms the basis for treatment decisions.
Many authors have classified pelvic disruptions. Much of these classifications are based on mechanism of injury and resultant instability of the pelvis. The management hence is directed to stabilize the pelvis, which, in fact, is guided by the mechanism of injury.
Pennal et al developed a mechanistic classification in which pelvic fractures are described as anteroposterior compression injuries, lateral compression injuries, or vertical shear injuries.
Tile modified the Pennal system to make it an alphanumeric system involving three groups based on the concept of pelvic stability with radiographic signs of stability and instability. He described pelvic ring disruption as stable (type A), rotationally unstable (type B), or both rotationally and vertically unstable (type C).
Based on Tile's Classification (Figure 1.3.1)
Type A: Stable (Posterior Arch Intact)
  • A1: Fractures of the pelvis not involving the rim; avulsion injuries.
  • A2: Iliac wing or anterior arch fracture caused by direct blow.
  • A3: Transverse sacrococcygeal fracture.
Type B: Rotationally Unstable, Vertically Stable (Incomplete Disruption of Posterior Arch)
  • B1: External rotation instability; open book injury.
  • B2: LC injury; internal rotation instability; ipsilateral only.
  • B3: LC injury; bilateral rotational instability (bucket handle).
    LC—Lateral compression 10
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Figure 1.3.1: Pelvic ring fractures—based on Tile’s classification.
Type C: Rotationally and Vertically Unstable (Complete Disruption of Posterior Arch)
  • C1: Unilateral injury.
  • C2: Bilateral injury, one side rotationally unstable, with the contralateral side vertically unstable.
  • C3: Bilateral injury, both sides rotationally and vertically unstable with an associated acetabular fracture.
Based on Tile’s Fracture Types following Stabilization Options can be Considered
Open—Book (Type B1)
  • If pubic symphysis opening <2 cm: No stabilization required.
  • If symphysis opening > 2 cm: Simple external fixator or symphyseal plate. If laparotomy is required for exploration/stabilization of injuries and there 11is no fecal or urinary soiling, plate fixation is preferred; otherwise external fixator preferred.
LC (Types B2, B3)
  • B2: No stabilization required as elastic recoil restores pelvic anatomy.
  • B3 (bucket-handle): Posterior complex (sacrum) commonly compressed. Hence options are: (a) No stabilization is necessary; (b) Reduction using external fixator or open reduction, if leg-length discrepancy is greater than 1.5 cm or gross pelvic deformity is present.
Rotationally and Vertically Unstable Injuries (Type C)
  • External fixation with or without skeletal traction/ORIF.
Based on Young and Burgess Classification (Figure 1.3.2)
Young and Burgess proposed a different modification of the original Pennal classification, adding a new category of a combined mechanism for these injuries. This system identifies four types of ring disruption based on the interpretation of the radiographic image:
  • Lateral compression (LC).
  • Anteroposterior compression (APC).
  • Vertical shear (VS).
  • Combined mechanism of injury (CM).
    zoom view
    Figure 1.3.2: Pelvic ring fractures—based on Young and Burgess classification.
12It is the result of collapse of pelvis due to laterally applied force that shortens the anterior sacroiliac (SI), sacrospinous (SS), and sacrotuberous (ST) ligaments. One may see oblique fractures of the pubic rami, ipsilateral or contralateral to the posterior injury. It is subdivided into three types based on degree of severity as shown on the radiographic appearance:
  • Type I: Sacral impaction on the side of impact.
  • Type II:Crescent (iliac wing) fracture on the side of impact.
  • Type III:LC-I or LC-II injury on the side of impact; force is continued to contralateral hemipelvis to produce an external rotation injury (“windswept pelvis”) owing to sacroiliac, sacrospinous, and sacrotuberous ligamentous disruption.
AP Compression (APC)
This is anteriorly applied force from direct impact or indirectly transferred force via the lower extremities or ischial tuberosities resulting in external rotation injuries, symphyseal diastasis, or longitudinal rami fractures. It is subdivided into three types based on degree of severity:
  • Type I: Slight (<2.5 cm) widening of pubic symphysis. Anterior SI, ST and SS ligaments are stretched but intact. Posterior SI ligaments intact.
  • Type II: More than 2.5 cm of symphyseal diastasis. Anterior SI, ST and SS ligaments are disrupted; posterior SI ligaments intact.
  • Type III: Complete SI joint disruption with lateral displacement. Anterior SI, ST and SS ligaments disrupted; posterior SI ligaments disrupted. Results in extreme rotational instability with the highest rate of associated vascular injuries and blood loss.
Either symphyseal diastasis or vertical displacement anteriorly and posteriorly occurs. Posterior displacement usually occurs through the SI joint, occasionally through the fractured iliac wing or sacrum.
Combination of injury patterns, LC/VS being the most common.
1.4. Hip Dislocations
13The hip joint is an inherently stable joint, and hip dislocations are produced by high energy trauma. Posterior dislocations occur much more frequently than the anterior dislocation.
Posterior dislocation is also called as “dashboard dislocation”. It results from a posteriorly directed force to the flexed knee with the hip also in a flexed position. Lesser degrees of hip flexion and increasing amounts of hip abduction at the time of impact results in an acetabular fracture. Anterior dislocation is caused by a reverse mechanism to that of a posterior dislocation. The mechanism is abduction and external rotation force to the affected limb.
Radiographic Evaluation
For the radiographic evaluation of a patient with hip dislocation anteroposterior view of the pelvis should be taken before reduction and is repeated after reduction. A 45-degree oblique Judet view of the pelvis is also necessary.
Hip dislocations are classified according to the position of the femoral head in relation to the acetabulum.
The three basic types are as follows:
  • Posterior dislocation.
  • Anterior dislocation.
  • Central dislocation.
The associated acetabular or femoral fracture indicates the greater magnitude of the force and severity of the injury.
Posterior Dislocation
Patients with an isolated posterior hip dislocation present with a classical flexion, adduction, internal rotation, deformity of the lower limb and with shortening of the limb extremity. No movement is possible at the hip and an attempted movement is associated with very severe pain.
Based on Thompson and Epstein
Posterior dislocations are classified into five types (Figure 1.4.1):
  • Type I:Posterior dislocation with or without a minor fracture.
  • Type II: Posterior dislocation with a large single fracture of the posterior acetabular rim.
  • Type III:Posterior dislocation with a comminuted fracture of the rim of the acetabulum; with or without a major fragment.
  • Type IV:Posterior dislocation with fracture of the acetabular rim and floor.
  • Type V:Posterior dislocation with fracture of the femoral head.
    zoom view
    Figure 1.4.1: Posterior hip dislocation—based on Thompson and Epstein classification.
Anterior Dislocation (Figure 1.4.2A)
The classical attitude of an anterior dislocation is flexion, abduction and external rotation of the lower limb. Anterior dislocation also has been classified by Epstein.
  • Superior—Pubic
    • With no fracture (simple).
    • With fracture of the head of the femur.
    • With fracture of the acetabulum.
  • Inferior—Obturator and Perineal
    • With no fracture (simple).
    • With fracture of the head of the femur.
    • With fracture of the acetabulum.
Central Dislocation (Figure 1.4.2B)
Central dislocation is referred to as medial position of the femoral head after a fracture involving the medial wall of the acetabulum.
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Figure 1.4.2A and B: (A) Anterior dislocation—pubic (Simple); (B) Central dislocation(Fracture dislocation).
15Hip dislocation is an orthopedic emergency and should be reduced on an emergency basis, as delaying the reduction significantly increases the risk of osteonecrosis of the femoral head. Closed reduction of the hip initially should be attempted in the emergency department under general anesthesia with adequate muscle relaxation.
Guidelines for the treatment of hip dislocations without significant associated femoral head or acetabular fractures:
Thompson and Epstein Type I
  • Reduction should be attempted taking into consideration direction of the deforming force. For posterior dislocation—flexion, adduction, and internal rotation; for anterior dislocation—abduction and external rotation in extension. Traction in line with the affected femur along with good counter traction at the pelvis and small amounts of rotation and adduction/abduction completes the reduction.
  • Popular methods of reduction
    • Allis’ maneuver.
    • Stimson maneuver.
    • Bigelow maneuver.
Indications for Open Reduction of the Dislocated Hip
  • Dislocation irreducible by closed methods.
  • Nonconcentric reduction.
  • Fracture of the acetabulum or femoral head requiring open reduction and internal fixation.
  • Ipsilateral femoral neck fracture.
1.5. Fractures of the Femoral Neck
16We come to the world under the brim of pelvis and go out of the world through the fracture neck of femur!!!
Fractures of the femoral neck have always presented several challenges to orthopedic surgeons and remain in many ways even as the unsolved fracture as far as treatment and results are concerned.
Various classifications have been described for these fractures. Structurally, these are:
  • Impacted fractures.
  • Nondisplaced fractures.
  • Displaced fractures.
The most common classification of femoral neck fractures is that of Garden (1961), as it is fairly simple and easily applied. It is based on degrees of displacement. Garden believed that the various types of femoral neck fractures represent different stages of displacement from the same mechanism.
In his classification, he described the trabecular angle or “alignment index” serving as guide for accurate reduction before internal fixation is carried out. On AP radiograph the angle between the primary compressive or medial trabeculae (coming from the calcar and rising superiorly into the weight bearing dome of the femoral head) and the medial cortex of the femoral shaft is around 160 degrees; these trabeculae also align with similarly oriented trabeculae in the acetabulum.
On the lateral projection, the trabecular alignment from the head fragment to the neck fragment normally is 180 degrees.
Based on Garden’s Classification (Figure 1.5.1)
Garden stage I: The fracture is incomplete, with the head tilted in a posterolateral direction. So this is a valgus impacted fracture with retroversion with increased alignment index as well as angle of the trabeculae.
Garden stage II: Fracture is complete but undisplaced with no evidence of impaction or change in trabecular angle but a break in compression trabeculae is observed.
Garden stage III: Fracture is complete and partially displaced as judged by the direction of the trabecular stream in the head fragment. The trabecular pattern of the femoral head does not line up with that of the acetabulum as well as the neck.
Garden stage IV: The fragments are completely displaced, and the trabeculae of the femoral head realign themselves and assume a linear orientation with the trabeculae within the acetabulum. Complete dissociation of the head from the neck is the hallmark of the stage IV.
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Figure 1.5.1: Fracture neck of femur—based on Garden’s classification.
However, broadly Garden stages I and II can be grouped together as “nondisplaced” and stages III and IV can be grouped together as “displaced”.
  • It is imperative to distinguish impacted fractures from nondisplaced fractures.
  • In impacted fractures the name itself suggests that there is impaction. The fracture surfaces are crushed together or invaginated and trabeculae of the neck are pushed into the soft trabecular bone of the head.
  • Impaction causes significant stability at the fracture site. Hence, conservative or nonoperative approach is indicated. However, when these fractures are operated and fixed not only the possibility of displacement is taken care of but also they will certainly unite (rate of displacement with nonoperative approach is around 15%). Hence can be treated surgically too.
  • All other stages from Garden stages II - IV are inherently unstable and are unsuitable for nonoperative treatment. Surgery in the form of accurate reduction and internal fixation is a must.
  • In elderly patients replacement arthroplasty is the preferred treatment.
    zoom view
    Figure 1.5.2: Fracture neck of femur—based on Garden’s classification.
Based on Anatomical Classification (Figure 1.5.2)
Based on this classification fracture neck of femur can be classified as:
  • Subcapital.
  • Transcervical.
  • Basal.
1.6. Intertrochanteric Femoral Fractures
19 These fractures occur through the intertrochanteric line in the region between the greater and lesser trochanter, occasionally extending into the subtrochanteric region.
Boyd and Griffin in 1949 classified Peritrochanteric femoral fractures into four types as follows:
Based on Boyd and Griffin Classification (Figure 1.6.1)
Type I: Fractures that extend along the intertrochanteric line from the greater to the lesser trochanter.
Type II:Comminuted fractures, the main fracture is along the intertrochanteric line, with multiple fractures in the cortex. Look for the comminution in both AP and lateral views to know the exact nature and behavior of the fracture.
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Figure 1.6.1: Intertrochanteric fractures—based on Boyd and Griffin classification.
20Type III: Fractures that are basically subtrochanteric with at least one fracture passing across the proximal end of the shaft, just distal to or at the level of lesser trochanter along with intertrochanteric extension.
Type IV: Fractures of the trochanteric region and the proximal shaft, with fracture in at least two planes, one of which usually is the sagittal plane and may be difficult to see on routine anteroposterior radiographs.
While operating an intertrochanteric fracture, the goal is to achieve a stable fixation as well as a strong fracture fragment-implant assembly. It can be influenced by following variables:
  • Bone quality.
  • Fracture geometry.
  • Type of reduction, i.e. anatomical or nonanatomical.
  • Type of implant.
  • Placement of implant.
Considering these factors various intertrochanteric fractures can be managed by following methods:
  • Type I:Reduction usually is simple and is maintained with little difficulty. These fractures which were being treated nonoperatively, later were treated by Jewett nailing. These days Dynamic hip screw fixation is a preferred method of fixation.
  • Type II:Reduction of these fractures is more difficult because the degree of comminution varies. Dynamic hip screw fixation is usually the preferred method for fixation of these fractures.
  • Type III:These fractures are more difficult to reduce as abductors tend to displace the greater trochanter laterally and proximally, iliopsoas displaces the lesser trochanter medially and proximally and adductors pull the distal fragment medially and proximally. Intramedullary device seems to have some advantage with respect to stability in these fractures. When feasible, it is preferred to dynamic hip screw.
  • Type IV:Intramedullary nail fixation is preferred for these fractures. Dynamic hip screw fixation can be used with modified techniques, e.g. Dimon-Hughston technique.
Based on Evans Classification (Figure 1.6.2)
Evans devised a widely used classification system based on the division of fractures into:
  • Stable.
  • Unstable groups.
He divided unstable fractures further:
  • Unstable fractures in which stability can be restored by anatomical or near anatomical reduction.
  • Unstable fractures in which stability cannot be restored by anatomical or near anatomical reduction.21
    zoom view
    Figure 1.6.2: Intertrochanteric fractures—based on Evans classification.
Evans type I: Fracture line extends upwards and outwards from the lesser trochanter.
Evans type II: Reverse oblique fracture, with a major fracture line extending downwards and outwards from the lesser trochanter. These fractures have a tendency for medial displacement of the femoral shaft because of the adductor muscle pull.
1.7. Subtrochanteric Fmoral Fractures
22Subtrochanteric fracture is a fracture between the lesser trochanter and a point approximately 7.5 cm distal to the lesser trochanter. Subtrochanteric region is a site of very high biomechanical stresses. High compressive forces are experienced by medial and posteromedial cortices whereas lateral cortex experiences a high tensile stress.
There are various deforming forces in this region; proximal fragment is pulled into abduction by gluteus medius, into external rotation by short external rotators, and into flexion by the psoas. The distal fragment is pulled proximally and into varus by the adductors.
Young individuals with normal bone sustain these fractures usually due to high energy trauma whereas older individuals with osteoporotic bones can sustain these fractures even with a minor fall.
Boyd and Griffin (1949) included subtrochanteric fractures as a variant of peritrochanteric fractures in their classification as types 3 and 4. There are various classification systems for subtrochanteric fracture indicating the uncertainty regarding the treatment and prognosis of this complex fracture.
Based on Fielding’s Classification
Based on Fielding’s classification these fractures are classified based on the level of fracture:
  • Type 1: At the level of lesser trochanter.
  • Type 2: 2.5 to 5 cm below the lesser trochanter.
  • Type 3: 5 to 7.5 cm below the lesser trochanter.
Transverse fracture may fit into this classification, but oblique and comminuted fractures may involve a larger area and more than one level.
Seinsheimer developed a classification system based on the number of fragments and the location and configuration of the fracture lines.
Based on Seinsheimer Classification (Figure 1.7.1)
Type I: Nondisplaced fracture or one with less than 2 mm of displacement.
Type II: Two-part fracture.
Type IIa: Transverse fracture.
Type IIb: Spiral fracture configuration with the lesser trochanter attached to the proximal fragment.
Type IIc: Spiral fracture configuration with the lesser trochanter attached to the distal fragment.
Type III: Three-part fracture.
Type IIIa: Three part spiral fracture configuration with the lesser trochanter a part of the third fragment.23
zoom view
Figure 1.7.1: Subtrochanteric fractures—based on Seinsheimer classification.
24Type IIIb: Three-part spiral fracture configuration with the third part a butterfly fragment.
Type IV: Comminuted fracture with four or more fragments.
Type V: Subtrochanteric-intertrochanteric configuration. It includes any subtro­chanteric fracture with extension through the greater trochanter.
The problem with the Fielding and Seinsheimer classification is that they do not separate fractures according to the different treatment methods. So with the development of modern reconstruction nails, also called as second generation intramedullary nails, these classification systems become less useful for deciding the implant required for fixation of these fractures.
As far as the decision of the implant required for the fixation of subtrochanteric fractures is concerned, the two major variables should be considered:
  • Whether the fracture is extending into the greater trochanter posteriorly and involving the piriformis fossa because piriformis fossa is the most commonly used nail entry portal.
  • Whether there is continuity of the lesser trochanter.
Based on these two variables which influence the treatment, Russell and Taylor devised a classification system for the subtrochanteric fractures.
Based on Russell and Taylor Classification (Figure 1.7.2)
There are broadly two types:
Type I: Fractures that do not extend into the piriformis fossa.
Type II: Fractures that involve the piriformis fossa.
Each type is further subclassified based on the lesser trochanter continuity.
Type IA: Fractures not extending into the piriformis fossa and the lesser trochanter is intact. Comminution and fracture lines extend from below the lesser trochanter to the femoral isthmus; any degree of comminution may be present in this area.
Type IB: Fractures not extending into the piriformis fossa and the lesser trochanter is fractured. Comminution and fracture lines involving the area of the lesser trochanter and the medial femoral cortex.
Type IIA: Fractures that involve the piriformis fossa as the fracture extends from the lesser trochanter to the isthmus. But there is no significant comminution of the lesser trochanter.
Type IIB: Type IIA + significant comminution and loss of continuity of the lesser trochanter and medial femoral cortex.
Russell and Taylor recommended the following treatment options based on their classification:
IA: As the piriformis fossa is intact with intact lesser trochanter so standard IM interlocking nailing can be done.
IB: Piriformis fossa is intact but there is comminution of lesser trochanter and medial femoral cortex so reconstruction IM nailing should be done.25
zoom view
Figure 1.7.2: Subtrochanteric fractures—based on Russell-Taylor classification.
IIA: There is involvement of the piriformis fossa however, the lesser trochanter is intact; therefore, a dynamic hip screw fixation or reconstruction IM nailing should be done.
IIB: There is involvement of the piriformis fossa with comminution of the lesser trochanter and medial femoral cortex, therefore a dynamic hip screw with bone grafting or a reconstruction IM nailing should be done.
In brief, in type I fractures closed IM nailing should be attempted so as to minimize the vascular compromise of the fracture fragments. In type II fractures, the extension into the piriformis fossa complicates closed nailing techniques. In fractures with intact lesser trochanter, medial stability is present. So plate fixation can be done.
Newer nails have been developed with a trochanteric entry portal, so one should be very careful while doing nailing in type II fractures as there are even more chances of comminution of the trochanter. Therefore, a careful attentionto the surgical technique is required so as to avoid further comminution of the fracture or displacement of the fracture during nailing.
1.8. Fractures of Patella
26Patella is predisposed to direct trauma because of its subcutaneous location. However, patellar fractures can also occur by indirect trauma like violent contraction of quadriceps with the knee in flexion. Usually, most patellar fractures are caused by combination of both direct and indirect trauma. The most significant effects of patellar fractures are loss of continuity of the extensor mechanism of the knee and the potential incongruity of the patellofemoral articulation hence, they should be properly addressed and managed well.
Classification (Figure 1.8.1)
They can be classified broadly as:
  1. Undisplaced.
  2. Displaced.
zoom view
Figure 1.8.1: Classification of patella fractures.
27 Displaced fractures are further subclassified based on the fracture configuration as:
  1. Transverse.
  2. Lower or upper pole.
  3. Comminuted.
  4. Vertical.
  5. Osteochondral.
Patellar fractures are usually associated with hemarthrosis and retinacular tears. Surgical treatment is advocated as the patient is not able to extend the knee indicating the disruption of extensor mechanism and torn retina­culum. Suspected patellar fractures should be evaluated with antero­posterior, lateral, and axial (Merchant) views. Transverse fractures are usually appreciated better on a lateral view. Vertical and osteochondral fractures on axial view.
As a first aid measure all the acute patellar fractures should be splinted with extremity in extension so as to avoid the further displacement and locally ice packs should be applied. Closed patellar fractures with minimal dis­placement (2–3 mm), minimal articular incongruity (2–3 mm), and an intact extensor retinaculum can be managed conservatively with cylindrical/AK cast for 6 weeks.
Indications for Surgery
Usually all patellar fractures with disrupted extensor retinaculum should be operated as early as possible and the knee is mobilized. Delay increases the morbidity. These include:
  • Open patellar fractures.
  • Patellar fractures with retinacular tears.
  • Displacement more than 2 to 3 mm.
  • Articular incongruity more than 2 to 3 mm.
Open fracture of patella is a surgical emergency. The goal of surgery in patellar fractures is to restore articular congruity along with repair of extensor retinaculum (quadriceps plasty) and early mobilization. Various methods of fixation described are, wiring techniques like circlage wiring or tension band wiring, screw fixation, etc. Partial patellectomy may have to be done in comminuted fractures of the distal or proximal pole of the patella; the small fragments are removed with preservation of the large fragment. However, when there is extensive comminution and significant loss of fragments and reconstruction of the articular surface is impossible, complete patellectomy may have to be performed, especially if the patient is elderly. It is rarely done in young individuals.
1.9. Tibial Plateau Fractures
28Tibial plateau fractures also known as Bumper or Fender injury are intra-articular fractures caused by usually high energy trauma like motor vehicle accidents and are common in younger age group; whereas in elderly patients with osteoporotic bones these fractures occur even with a less violent trauma.
A varus or valgus force along with axial loading is the usual mechanism for these fractures. These fractures are commonly associated with ligamentous injuries. Minimally displaced fractures, fractures with local compression and split compression are to be carefully assessed for the presence of ligament injuries.
Schatzker, McBroom, and Bruce classified these fractures into six types.Schatzker classification (Figure 1.9.1).
Type I—Pure split of the lateral plateau: A typical wedge shaped uncomminuted fragment is split off and displaced laterally and downwards. This fracture is common in younger age group. If displaced, it can be fixed with transverse cannulated cancellous screws.
Type II—Lateral plateau split combined with depression: A lateral split is seen, and in addition to the split there is a depression in the articular surface. It is common in older age with osteoporotic bones. If the depression is more than 5 to 8 mm, or instability is present, it should be treated with open reduction with elevation of the depression and bone grafting. The fracture should be fixed with cancellous screws along with buttress plating for the lateral cortex.
zoom view
Figure 1.9.1: Tibial plateau fractures—based on Schatzker classification.
29Type III—Pure central depression: The articular surface is depressed with intact lateral cortex. It is usually seen in osteoporotic bones. If the depression is more than 5 to 8 mm or if the instability is present, it should be treated with open reduction with elevation of the depression and bone grafting along with buttress plating for the lateral cortex.
Type IV—Medial plateau fracture: There may be a pure split or split with comminution/depression. In this fracture, tibial spine may also be involved. These fractures have a tendency to angulate into varus. Therefore, they should be treated with open reduction and fixation with cancellous screws and buttress plating for the medial cortex.
Type V—Bicondylar fractures: In these fractures there is a split of both the plateaus. But there is a continuity of metaphysis and diaphysis. This helps to differentiate these fractures from type VI. Bicondylar fixation should be done with cancellous screws and buttress plating.
Type VI: Plateau fracture with separation of the metaphysis from the diaphysis. There is uni- or bicondylar fracture along with fracture of the proximal tibia. It is a highly unstable fracture because of dissociation of diaphysis and metaphysis and should be treated with buttress plating and cancellous screws. Usually types I–III are low energy injuries and types IV–VI are high energy injuries.
To summarize these fractures should be managed according to the AO principles for the management of intra-articular fractures:
  • Atraumatic anatomical reduction of the articular surfaces.
  • Stable fixation of the intra-articular fragments.
  • Reconstruction of the metaphysis with bone grafting and buttressing by buttress plate.
  • Functional postoperative treatment without immobilization.
Intra-articular reconstruction must be undertaken as early as possible and with least trauma to the tissues. It has been recognized that preserving the viability and integrity of the soft tissue envelope of the metaphysis is the key to success. MIPPO technique should also be kept in mind while treating these injuries.
1.10. Ankle Injuries
30 Ankle fractures cause disruption of not only the bony component but also the ligament and soft tissue anatomy of ankle joint. The severity of trauma may range from ankle sprains to fracture dislocations. The outcome depends on the identification of the mechanism of injury and subsequent restoration of anatomy of the ankle.
Sir Percival Pott was the first to describe an ankle fracture in 1768, i.e. a fibular fracture with deltoid ligament disruption. The bimalleolar fracture was described by Dupuytren in 1819, which was actually the supination-eversion (external rotation) type of the ankle fracture. Maisonneuve in 1840 described a spiral fracture in the proximal part of fibula, caused by external rotation. Tillaux, in 1872 described the avulsion fracture from the tibial insertion of the anterior tibiofibular ligament. In the year 1915, FJ Cotton described a trimalleolar fracture. All of these have become eponymous names for certain types of ankle fractures (Figure 1.10.1).
Radiographic Assessment
For radiographic assessment of ankle injuries AP, lateral, and mortise views are taken and following parameters are evaluated:
zoom view
Figure 1.10.1: Eponymous names for ankle fractures.
On AP View
  • 31Tibiofibular overlap that is overlap between anterior tibial tubercle and fibula if <10 mm implies syndesmotic injury.
  • Interosseous clear space (Chaput clear space) > 5 mm signifies syndesmotic injury.
  • A difference in width of the medial and lateral aspects of the superior joint space if > 2 mm indicates medial or lateral ligament disruption.
On Lateral View
  • The dome of the talus should be centered under the tibia and congruous with the tibial plafond.
  • Look for the posterior tibial tuberosity fractures, as well as direction of the fibular injury.
  • Tibiotalar line both on AP and lateral radiographs must pass through the center of the tibia and the center of the talus.
On Mortise View (Foot in 15–20° of Internal Rotation)
  • Medial joint space is less than 4 mm, with talar tilt less than 2 mm.
  • Talocrural angle, i.e. angle between the intermalleolar line and a line parallel to the distal tibial articular surface. It should be between 83° +/- 4 degrees.
  • Talar tilt (0°, with a tolerance of 5° difference between two ankle joints).
After reduction the results are evaluated on a control X-ray and acceptable results are up to 2 mm of residual displacement, especially for the fibular length and up to 0.5 mm of talar displacement.
There are many classifications for ankle fractures involving the mechanism of injury as well as correlation with fracture patterns. The most common classifications are those of Danis-Weber and Lauge-Hansen. Danis-Weber is much easier for the clinical use but is too simple to cover the complex mechanism of ankle injuries.
Based on Danis-Weber Classification (Figure 1.10.2)
The Danis-Weber classification is based on the level of the fibular fracture, the level of the tibiofibular syndesmotic disruption and potential ankle instability. Three types of ankle fractures are described:
Type A: There is a transverse fibular fracture below the joint line, with the intact syndesmosis and these fracture types correspond to the supination-adduction fracture type of Lauge-Hansen.
Type B: It involves a fracture at the level of the ankle joint line, with a partial syndesmotic injury as the anterior syndesmotic ligament is injured whereas the posterior syndesmotic ligament remains intact.
zoom view
Figure 1.10.2: Ankle fractures—based on Danis-Weber classification.
It corresponds with the supination-eversion (external rotation) injury of the Lauge-Hansen classification.
Type C: There is a fibular fracture proximal to the tibiofibular joint with associated disruption of the syndesmosis. Here two subtypes of fractures are recognized: A diaphyseal one called as Dupuytren fracture and a proximal one called as Maisonneuve. This type of fracture corresponds with the pronation-eversion (external rotation) type of injury of Lauge-Hansen. These have the greatest susceptibility to instability.
The major drawback of the Danis-Weber classification is that it ignored the medial side of the ankle joint and emphasized on the fibula and tibiofibular syndesmosis.
Ankle Mortise Ring Concept of Stability (Figure 1.10.3)
To know the stability of the ankle injuries, the ankle can be considered as a ring in which bones as well as ligaments play an equally important role in the maintenance of the stability of the joint. If the ring is broken at one place the ring remains stable. The single break with distortion of the ring should be fixed. However, when it is broken in two places the ring is unstable because a portion of it can be or is dislocated. Ligament disruption is seen as widening of the ankle mortise and along with fracture can lead to instability of the ankle joint because the ring is broken at two places. Therefore, it needs open reduction and stable internal fixation.
Based on Lauge-Hansen Classification
The most accepted classification of ankle injuries was given by Lauge-Hansen in 1948 based on the cadaveric studies. It demonstrated that the fracture pattern depends upon the:
  • Position of the foot at the time of the injury.
  • Direction of the deforming force at the moment of the injury.33
    zoom view
    Figure 1.10.3: Ring concept of stability.
There are six main groups based on Lauge-Hansen classification:
  1. Supination-external rotation (eversion).
  2. Supination-adduction.
  3. Pronation-external rotation (eversion).
  4. Pronation-abduction.
  5. Vertical compression.
  6. Unclassifiable.
Supination-External Rotation (Figure 1.10.4)
This is the most common mechanism of injury accounting for 40 to 75% of the ankle injuries.
Stage I: Produces the disruption of the anterior tibiofibular ligament with or without an associated avulsion fracture at its tibial or fibular attachment.
Stage II: Results in the typical oblique or spiral fracture of the distal fibula.
Stage III: Produces either a disruption of the posterior tibiofibular ligament or a fracture of the posterior malleolus.
Stage IV: Produces either a transverse avulsion-type fracture of the medial malleolus or a rupture of the deltoid ligament.
Complete bony failure pattern produces a trimalleolar fracture otherwise known as Cotton’s fracture.
Supination-Adduction (Figure 1.10.5)
It is the only type of ankle injury associated with the medial displacement of the talus.34
zoom view
Figure 1.10.4: Ankle fractures—based on Lauge-Hansen classification—supinationexternal rotation.
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Figure 1.10.5: Based on Lauge-Hansen classification—supination-adduction.
Stage I: It produces either a transverse avulsion type fracture of the fibula distal to the level of the joint or a tear of the lateral collateral ligaments.
Stage II: Results in a vertical fracture of the medial malleolus.
The supination-adduction type of injury is characterized by a transverse fracture of the distal fibula and a relatively vertical fracture of the medial malleolus.
Pronation-External Rotation (Figure 1.10.6)
Stage I: Produces either a transverse fracture of the medial malleolus or a rupture of the deltoid ligament.35
zoom view
Figure 1.10.6: Based on Lauge-Hansen classification—pronation-external rotation.
Stage II: Results in the disruption of the anterior tibiofibular ligament with or without avulsion fracture at its insertion site (Anterior Tillaux fracture).
Stage III: Results in an oblique or spiral fracture of the distal fibula at or above the level of the syndesmosis up to the neck (Maisonneuve fracture).
Stage IV: Produces either a rupture of the posterior tibiofibular ligament or an avulsion fracture of the posterolateral tibia (Posterior Tillaux fracture).
Stage V: Oblique or comminuted fracture of the lower 1/3rd of the fibula. (Dupuytren’s fracture).
So the pronation-external rotation mechanism is characterized by a deltoid ligament tear or a fracture of the medial malleolus and a spiral oblique fracture of the fibula relatively high above the level of the ankle joint or a fracture of the lower 1/3rd of the fibula. The inferior tibiofibular syndesmotic disruption is always seen, either incomplete or complete (partial or total).
Stage I: Results in either a transverse avulsion fracture of the medial malleolus or a rupture of the deltoid ligament.
Stage II: Produces a high transverse bending or a short oblique/comminuted fracture of the distal fibula at or above the level of the syndesmosis.
Vertical compression—Subclassified by Reudi-Allgower classification (next chapter).
36There are few important rules in the treatment of the ankle fractures:
  • Anatomical restoration of ankle mortise as soon as possible is a must.
  • Maintaining the fibular length is the key to success, hence to be fixed first.
  • Fractures and fracture-dislocations should be reduced as soon as possible, as gross displacement can lead to impairment of the peripheral circulation, and skin sloughing.
  • Early mobilization gives excellent results.
1.11. Tibial Pilon Fractures
37Intra-articular fractures of the distal tibia are known as tibial pilon fractures, also called as tibial plafond and distal tibia explosion fractures. Most of these fractures are caused by high energy trauma.
Mechanism of Injury
  • Axial/vertical compression due to fall from height.
  • Shear.
  • Combined compression and shear.
Radiographic Evaluation
Usually AP, lateral, and mortise radiograph of ankle are sufficient for evaluation.
Classification of these fractures is important in determining their prognosis and chosing the optimal treatment. Reudi-Allgower classification is the commonly used classification for these fractures (Figure 1.11.1).
zoom view
Figure 1.11.1: Tibial Pilon fractures—based on Reudi and Allgower classification.
Based on Reudi and Allgower Classification
38It is based on the severity of comminution and the displacement of the articular surface. Prognosis correlates with the increasing grade. It divides the tibial plafond fractures into three categories:
  • Type I:Nondisplaced cleavage fractures that involve the joint surface.
  • Type II: Fractures have cleavage-type fracture lines with displacement of the articular surface, but minimal comminution.
  • Type III: Displaced fractures with significant articular comminution and metaphyseal impaction.
  • Nonoperative—For type I by immobilization in a long leg cast for 6 weeks.
  • Operative—For displaced fractures.
    Goals of operative fixation:
    • Maintenance of fibular length and stability.
    • Restoration of tibial articular surface.
    • Bone grafting of metaphyseal defects.
    • Buttressing of the distal tibia.
1.12. Talar Neck Fractures
39Anderson coined the term aviator’s astragalus in 1919 for talar neck fractures based on his observation of occurrence of these fractures in Royal Flying Corps. There are various problems associated with talar neck fractures. They are difficulty in assessment, surgical approaches, timing of surgery, method of fixation, frequency of postoperative complications.
Hawkins in 1970 classified talar neck fractures into three types—type I, II and III. This is the most widely used classification, as it is simple, provides guidelines for treatment, and enables to predict the outcome. Canale and Kelly added another type to Hawkins classification and labeled it as type IV (Figure 1.12.1).
zoom view
Figure 1.12.1: Talar neck fractures—based on Hawkins classification and type IV of Canale and Kelly.
Based on Hawkins Classification
40Type I: Nondisplaced talar neck fractures. (However, it should be thoroughly evaluated before labeling it as a type I). It can be managed conservatively with below knee cast for 8 to 12 weeks.
Type II: Displaced talar neck fractures with subluxation or dislocation of the subtalar joint. These fractures should be managed with prompt open reduction and internal fixation. Achieving closed reduction may not be possible.
Type III: Talar neck fractures with dislocation of the subtalar and ankle joints.
Type IV (Canale and Kelly): An additional type was described by Canale and Kelly in which not only the body of the talus is extruded from the ankle mortise, but also the head of the talus is subluxated or dislocated from the navicular articulation.
Type III and type IV fractures should be managed on emergency basis for two reasons:
  1. Pressure from the dislocated talar body on the skin and neurovascular structures leads to sloughing of skin, neurovascular insult, or both.
  2. The blood supply to the talus, if occluded, and not severed can be restored only through emergency reduction of the displaced body.
Incidence of osteonecrosis increases significantly from Type I to Type IV.
Hawkins Sign
A thin line of subchondral atrophy along the dome of the talus. It indicates the presence of vascularity and excludes osteonecrosis. It is usually seen at 6 to 8 weeks after trauma, on a good anteroposterior radiograph of ankle.
1.13.Calcaneal Fractures
41The calcaneum is the most frequently fractured tarsal bone. While extra-articular calcaneal fractures managed simply with casts give good results, surgical management of intra-articular calcaneal fractures still remains controversial.
Calcaneal fractures can be extra-articular or intra-articular dependingupon:
  • Position of foot relative to ankle at the time of trauma.
  • Direction and magnitude of deforming force.
  • Bone quality of the patient.
Extra-articular Calcaneal Fractures
The extra-articular calcaneal fractures can involve the body, anterior process, or tuberosity.
Intra-articular Calcaneal Fractures
These fractures are usually caused by an axial loading such as fall from a height.
Radiographic Evaluation
The initial radiographic evaluation should include:
  • AP and oblique view of the foot to assess the anterior process and calcaneocuboid involvement.
  • Lateral view of the ankle and calcaneum to assess the height loss (loss of Bohler angle) and rotation of the posterior facet (Figure 1.13.1).
  • An axial view to assess the varus position of the tuberosity and width of the heel.
  • Borden view which is taken to evaluate congruency of the posterior facet.
On the lateral radiograph Bohler tuber joint angle and Gissane (crucial) angle give useful information with respect to subtalar joint and should be assessed both preoperatively and postoperatively.
Bohler tuber joint angle: It is the angle between a line drawn from the highest point of the anterior process of the calcaneum to the highest point of the posterior facet and a line drawn tangential from the posterior facet to the superior edge of the tuberosity. Normally the angle is between 20° to 40°; a decrease in this angle indicates that the weight-bearing posterior facet of the calcaneum has collapsed.
Gissane (crucial) angle: It is an angle formed by two strong cortical struts extending laterally, one along the lateral margin of the posterior facet and the other extending anterior to the beak of the calcaneum. This angle can be visualized directly beneath the lateral process of the talus. Normally the angle is between 100º to 130º. Increase in the angle indicates collapse of the posterior facet (Figure 1.13.1).42
zoom view
Figure 1.13.1: Bohler and Gissane angle.
Based on Essex-Lopresti Classification (Figure 1.13.2)
Intra-articular calcaneal fractures are of two types:
  • Joint depression type: If the fracture line producing the posterior facet fragment exits behind the posterior facet and anterior to the attachment of the Achilles tendon.
  • Tongue type: If the fracture line producing the posterior facet fragment exits straight backwards distal to the Achilles tendon insertion.
There are more descriptive and more complex classification systems for the calcaneal fractures like Crosby and Fitzgibbons and Sanders classification. They are all CT based.
zoom view
Figure 1.13.2: Intra-articular calcaneal fractures—based on Essex-Lopresti classification.Also showing loss and restoration of Bohler angle following injury and after surgery.
43 The advantage of the Sanders classification is its precision regarding the location and number of fracture lines through the posterior facet, however both the systems lack the description of the other important aspects of the calcaneal fractures, like heel height and width, varus-valgus alignment and calcaneocuboid involvement.
Extra-articular Calcaneal Fractures
  • These fractures can be treated effectively with cast immobilization and non-weight bearing for 6 weeks.
  • Only exception is the displaced tuberosity avulsion fracture which should be managed by open reduction and internal fixation, as it serves as the attachment of the Achilles tendon. A good fixation restores the power of Achilles tendon.
Intra-articular Calcaneal Fractures
The challenges with the management of intra-articular calcaneal fractures are:
  • Adequate pain relief both immediately as well as in the long-term.
  • Adequate restoration of subtalar joint function.
  • Reduction of the risk of subtalar osteoarthritis.
Goals of Treating an Intra-articular Calcaneal Fracture
  • Restoration of congruency of the posterior facet of the subtalar joint (Gissane angle).
  • Restoration of the height of the calcaneum (Bohler’s angle).
  • Restoration of calcaneal width.
  • To decompress the subfibular space for the peroneal tendons.
  • To realign the tuberosity into the valgus position.
  • To reduce the calcaneocuboid joint.
1.14. Tarsometatarsal (Lisfranc) Fracture Dislocation
44 Tarsometatarsal (TMT) injuries are rare, however if overlooked, can lead to long-term pain and disability. Therefore precise anatomical reduction and stabilization should be achieved as soon as possible. Jacques Lisfranc de St. Martin (1790–1847) was a French gynecologist and surgeon in the Napoleonic army. He described the amputation through the tarsometatarsal joint called as Lisfranc amputation, but he did not describe the fracture dislocation himself.
Radiological Evaluation
To evaluate the suspected Lisfranc injury radiograph should be taken with weight bearing if possible.
Following X-ray parameters are used for identifying Lisfranc injury(Figs 1.14.1 to 1.14.3):
  • On AP view the first metatarsal lines up medially and laterally with the medial cuneiform.
  • The first metatarsal-cuneiform articulation should have no incongruency.
  • Medial border of the 2nd metatarsal aligns itself with the medial border of middle cuneiform.
  • Lateral border of 3rd metatarsal aligns itself with the lateral border of lateral cuneiform.
  • On oblique view the medial border of 4th metatarsal aligns itself with the medial border of cuboid.
Disturbance in these normal relations is seen in Lisfranc's injury.
zoom view
Figure 1.14.1: AP-view (foot): Lateral border of the 1st metatarsal aligned with lateral border of 1st (medial) cuneiform. Medial border of 2nd metatarsal is aligned with medial border of 2nd (intermediate or middle) cuneiform.
zoom view
Figure 1.14.2: Oblique view (foot): Medial and lateral borders of the 3rd (lateral) cuneiform should align with medial and lateral borders of 3rd metatarsal. Medial border of 4th metatarsal is aligned with medial border of cuboid. Lateral margin of the 5th metatarsal may project lateral to cuboid by as much as 3 mm.
zoom view
Figure 1.14.3: Lateral view (foot): A line drawn along long axis of talus should intersect long axis of the 1st metatarsal.
Further following specific features should be looked into:
  • A “fleck sign” should be sought in the medial cuneiform—second metatarsal space representing an avulsion of the Lisfranc ligament.
  • The compression fracture of the cuboid should be sought.
  • The naviculocuneiform articulation should be evaluated for subluxation on both AP and lateral views.
  • Dorsal or plantar displacement should be evaluated on lateral view.
Clinical Evaluation and Classification
For clinical evaluation Trevino and Kodros described a “rotation test” in which stressing the second tarsometatarsal joint by elevating and depressing the second metatarsal head relative to the first metatarsal head elicits pain at the Lisfranc joint. Look for any ecchymosis at the plantar aspect of foot indicating the significant injury.
Quenu and Kuss were the first to classify these fractures into a simple system based on the direction of the metatarsal displacement as three groups, homolateral, isolated and divergent.
Hardcastle (1979) modified this classification into current accepted classification and Myerson (1986) relabeled the same (Figure 1.14.4):
Type A—Total incongruity: There is incongruity of the entire TMT joint. Also called as homolateral injury. Displacement may be sagittal, coronal or both.
Type B—Partial incongruity: There is a partial incongruity. The displaced segment is in one plane. These injuries are further subdivided as:
Medial B1: Displacement affects the first metatarsal either in isolation or combined with displacement of 2nd, 3rd or 4th metatarsal.
  • Lateral B2: Displacement affects the 2nd–5th metatarsal, not the first.46
    zoom view
    Figure 1.14.4: Tarsometatarsal (Lisfranc) fracture dislocation—based on Myerson classification.
TypeC—Divergent: There can be partial or total displacement. The first metatarsal displaces medially and lateral metatarsals, 2nd–5th, single or in combination, displace laterally. These injuries are usually high energy injuries, associated with significant swelling, and prone to complications, especially compartment syndrome.
Subtle Lisfranc injuries: Faciszewski et al (1990) described these injuries where displacement is revealed only by weight bearing X-rays.
  • There is no role of closed treatment (as once the soft tissue swelling subsides there are high chances of redisplacement).
  • Reduction achieved by closed or open methods and secured with K-wire or screws is the accepted method of treatment.
  • Type A injury can be treated by passing a K-wire across the first TMT joint and a second laterally into the 5th TMT joint.
  • For type B injuries a single lateral K-wire for the lateral segment for lateral injuries and two K-wires into the first TMT joint for medial injuries should be used.
  • However for type C injuries, two medial and one lateral K-wire can be used.
  • Inadequate anatomical reduction and stabilization yields poor results.
Complications include osteoarthritis of the TMT joint, deformities like pes planus, cavus or planovalgus, chronic pain, prominent exostosis and painful gait.
1.15. Jones Fracture
47 There is still a lot of confusion in the classification of Jones fracture even after more than a century of its original description by Sir Robert Jones in 1902, when he himself sustained this fracture while dancing. We prefer the three zone concept by Lawrence et al when classifying these fractures.
Based on Lawrence et al Classification (Figure 1.15.1)
Zone I is the most proximal tuberosity avulsion fracture, also called as pseudo-Jones or Dancer’s fracture. They are most common (93%).
Zone II is the metaphyseal-diaphyseal region, also the level of the fourth and fifth metatarsal articulation. This is the true Jones fracture location.
Zone III is the proximal diaphyseal stress fracture. The fracture is distal to the 4th–5th metatarsal articulation.
Mechanism of Injury
  • Zone I and Zone II fractures are due to acute injury whereas the Zone III fractures are usually pathological stress fractures.
  • Zone I avulsion fracture of the base of the fifth metatarsal is caused by the inversion and overpull of the peroneus brevis muscle. The peroneus brevis is inserted into the tubercle at the base of the fifth metatarsal bone and severe inversion stresses applied to the foot may give rise to a crack fracture or to complete avulsion of the fragment of bone to which the tendon is inserted.
Radiological Evaluation
  • Usually AP and lateral and oblique view of the foot are sufficient for radiological evaluation.
  • Epiphyseal line at the base of the tubercle in children, and the sesamoid bones should not be confused with the avulsion fracture.
    zoom view
    Figure 1.15.1: Lawrence et al classification: (A) Zone I; (B) Zone II; (C) Zone III fracture.
Zone I: Avulsion Fractures
  • 48Avulsion fracture can be managed nonoperatively with a walking cast.
Zone II: Jones Fracture
  • Jones fracture is slow to unite due to vascular watershed. If they are undisplaced, they can be managed nonoperatively with cast immobilization for 6 weeks.
  • Indications for operative intervention for Jones fracture:
    • High performance athletes.
    • Recreational athletes.
    • Nonathletes with delayed union.
Zone III: Stress Fractures
  • Operative intervention is required.
1.16. Nonunion
49There is no clear criterion for defining a fracture as nonunion, however in 1986 a US FDA Panel defined nonunion as “when a minimum 9 months have elapsed since injury and the fracture shows no visible progressive signs of healing for 3 months”. It implies that there is no union and the process of healing has stopped. However, this criterion cannot be universally applied, to all fractures. Nine months are too long a period to wait for the union. So it is fair to conclude that three consecutive reviews during the stipulated period for union shows no progressive signs of healing and changes of nonunion develop at the site of fracture both clinically as well as radiologically, one can perhaps call it as nonunion.
Radiological Evaluation
Following features can be seen on radiograph of an established nonunion:
  • There is no callus formation in atrophic nonunion, however, if there is callus formation, there would not be a bridging callus across the fracture site.
  • Fracture ends appear smooth and regular.
  • There will be obliteration of the medullary canal.
  • Fracture ends are sclerotic.
Weber BG and Cech O from Switzerland in 1976 assessed the vascularity of fracture ends by Strontium 85 uptake and classified nonunions as:
  • Hypervascular (Hypertrophic) nonunion
  • Avascular(Atrophic) nonunion
However, they are further subclassified as follows:
Hypervascular Nonunions (True Delayed Unions) (Figure 1.16.1)
‘Elephant Foot’ Type
Presents with exuberant expansile callus and the picture resembles the foot of an elephant. It is the result of movement occurring at the fracture site before union has occurred, e.g. premature weight bearing.
‘Horse Hoof’ Type
Presents with little callus and picture resembles a horse hoof. Perhaps, this is the result of instability at the fracture site following inadequate reduction or fixation.
‘Oligotrophic’ Type
These are hypervascular but are not hypertrophic and do not show callus. They are considered to be the result of major displacement/distraction persisting after treatment.50
zoom view
Figure 1.16.1: Hypervascular nonunion—based on Weber BG and Cech O classification.
Avascular Nonunions (True Nonunions) (Figure 1.16.2)
  1. Torsion wedge type:Seen when there is an intermediate fragment with poor blood supply. It unites on one side but does not unite on the other.
  2. Comminuted type: Is the result of many intermediate fragments with poor blood supply.
  3. Defect type:Seen when there is bone loss.
  4. Atrophic type:Seen when intermediate fragments are small and are missing. The defect is replaced by scar tissue.
Causes of Nonunion
Inherently the nature of injury eg high velocity and low velocity and the nature of the fracture open / closed determines the chances of a fracture non union.I addition certain factors listed below contribute to non union.
Vascular insufficiency
Loss of soft tissue coverage
Periosteal stripping (iatrogenic)
Damage to nutrient vessel
Segmental fracture
Mechanical instability
Inadequate reduction
Inadequate fixation
Excessive traction/distraction
Bone loss
Pathological destruction
Metabolic diseases
Miscellaneous comorbid factors
Old age
Nutritional deficiency
Drugs, e.g. steroids, etc.
zoom view
Figure 1.16.2: Avascular nonunion—based on Weber BG and Cech O classification.
Basic Factors Influencing Healing of Nonunion and Treatment
  • Mechanical instability leading to hypervascular nonunion—stable fixation/immobilization.
  • Biologically inert (atrophic) but mechanically stable—biological stimulation by bone grafting or physiological stimulation by functional loading —cast brace or Ilizarov/Orthofix.
  • Biologically inert (atrophic) and mechanically unstable—stabilization and biological stimulation by fixation and grafting or physiological loading with stabilization like Ilizarov/Orthofix.
  • Gap nonunion, shortening, avascular nonunion—Bone transportation and lengthening using Ilizarov technique or Orthofix or Allograft and internal fixation.52