Fractures of the Lower Extremity

Fractures of the Lower Extremity

Pelvis

Pelvic fractures, although a rare circumstance in athletics, represent a serious emergency medical situation. The disruption of pelvic integrity necessitates a substantial degree of force. As such, pelvic fractures are most often the result of violent mechanisms of injury. These specific injuries typically result from a fall from a significant height in extreme sports or vehicular accidents in motor sports. Because of the considerable forces and mechanisms involved with pelvic fractures, associated injuries to internal organs and extensive vascular structure systems are common. Symptoms specific to pelvic fractures include extreme pain and tenderness throughout the injured area and hematuria indicating internal hemorrhage. Other clinical indications include Destot sign, indicated by formation of a hematoma above the inguinal region. Roux sign indicates bilateral distance discrepancies between the greater trochanter and anterior superior iliac spines, signifying an acetabular fracture. Extensive neurovascular deficiencies throughout the lower extremities may also be noted subsequent to pelvic pathology. The most important role of the on-site athletic trainer in managing pelvic fractures includes immediate activation of EMS for immediate transport to the nearest emergency medical facility. A thorough monitoring of the injured athlete’s vital signs must also be routinely conducted while awaiting definitive care. The athletic trainer should ensure that excessive pelvic girdle movement is avoided to limit pain and internal bleeding. Complications specific to inappropriate management of pelvic fractures and related injuries account for an elevated incidence of intrapelvic compartment syndrome, digestive and reproductive systems dysfunctions, and internal infections subsequent to disruption of urinary and bowel structures.

Femur

The femur is known to be the largest and strongest bone in the body. This bone also possesses a rich vascular supply and is surrounded by a dense cross-sectional area of musculature. As a result of the femur’s anatomical composition and orientation, an extremely significant force is required to disrupt its integrity. In the event of a fracture, the musculature surrounding

the femur will usually contract, causing additional displacement of the fractured ends. Of even greater concern is the extreme amount of blood loss, which is expected because of the bone’s extensive vascular supply. Three classes of femoral shaft fractures are typically described: Type I (spiral or transverse, which represents the most common); Type

II (comminuted); and Type III (open).47 Complications associated

with femoral fractures are common.

On examination of the injury site, athletic trainers will commonly note obvious deformity and significant pain. Considerable focal tenderness and crepitus typically accompany palpation of the injured bone. The quadriceps musculature may exhibit significant swelling as the result of a hematoma. A neurovascular examination of the lower leg should be performed and repeated frequently. Because of extreme forces required for fracturing the femur, accompanying injuries must be ruled out. Tachycardia and hypotension may result from extensive blood loss and are indicative of

hypovolemic shock. Although concern for lesions to nervous tissues is inherent, these injuries are rare because of the dense cross-sectional area of musculature shielding nerves.

Patella

Fractures to the patella may be the result of both indirect and direct mechanisms of injury. Indirect trauma is most prevalent with patellar fractures and occurs as the result of a violent quadriceps contraction. This abrupt contraction may cause a displaced transverse fracture to the patella and render the knee joint void of the quadriceps extensor mechanism.As

a result the athlete will be unable to actively extend the knee joint or perform a straight leg raise against gravity. Direct trauma is uncommon but results in a comminuted fracture and should raise suspicion for associated tibiofemoral injuries. Fractures of the patella usually elicit notable pain,

ecchymosis, and edema or effusion. Closed patellar fractures should be splinted with a knee joint immobilizer and the athlete should be referred to an orthopedic surgeon. Careful application of ice may be effective for pain relief. Open patellar fractures should be splinted with a knee joint immobilizer after the wound is appropriately cleaned and dressed for

transport to a hospital by EMS.

Tibia and Fibula

The tibia is the largest bone in the lower leg and accepts the majority of weight-bearing forces compared to the fibula during correct physiological gait. The fibula serves primarily as a point of attachment for tendons and ligaments. Because of the dense cortex of the tibia, a large force is typically necessary to yield a fracture. However, the tibia remains the most frequently fractured long bone in the human skeletal system and is often associated with open fractures.

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