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KEY POINTS

KEY POINTS

  • Compartment syndrome, mangled extremities, high-grade open fractures, irreducible dislocations, and fractures with vascular compromise require emergent treatment.

  • Low-grade open fractures, femur fractures, and hip fractures are ideally treated within 24 hours.

  • Evidence shows decreased infection rate for open fractures when antibiotics are administered within 1 hour of admission.

  • Extreme diligence is required in the care of knee dislocations due to a 7% to 15% incidence of injury to the popliteal artery.

  • Unnecessary testing delays surgery, increases costs, and does not provide clinical benefit in geriatric patients with hip fractures.

  • Geriatric hip fractures are often life-changing events, with only 60% of patients returning to preinjury activity level and a 30% 1-year mortality.

  • External fixation is an excellent option for rapid initial stabilization of many fractures in the lower extremities.

  • Non–life-threatening injuries such as pilon, calcaneus, and Lisfranc fractures can have a dramatic long-term negative impact on a patient’s functional status.

  • Advances in prosthetics currently make below-knee amputation a better functional option than limb salvage in many patients.

INTRODUCTION

Lower extremity injuries are a common cause of hospital emergency department visits. These injuries and their effect on patient function have a great impact on society.1 Lower extremity fractures can occur as simple injuries or as complex, high-energy injuries in a polytraumatized patient. Patients with significant injury to their lower limbs are at risk for a wide variety of complications including ischemia, infection, nonunion, chronic pain, and long-term functional deficits. Complex extremity trauma requires prompt assessment of the injury including bone, neurologic, vascular, integument, and muscular evaluations. Technical advances in both osseous and soft tissue reconstruction have led to improvements in treatment, mobilization, and postinjury rehabilitation of severely injured patients. Rehabilitation concepts have changed from prolonged rest to the present emphasis on rapid restoration of skeletal stability allowing prompt mobilization. Appropriately timed management and well-executed surgical interventions are critical to prevent infection, achieve wound healing, promote osseous union, avoid systemic complications, and maximize functional outcome. Many victims of extremity trauma also have associated life-threatening injuries to the head and torso. Therefore, the initial evaluation of lower extremity fractures must focus on the patient as a whole and not exclusively on the injured limb.2-4

The wide prevalence of safety belt usage and changes in vehicular design, such as crumple zones and mandatory air bags, has improved the survival rates in high-energy crashes. This has led to an increasing number of severe lower extremity injuries previously “unseen” because the patient did not survive. Additionally, with an aging population, there has been an increase in the rate of fractures in elderly patients, often accompanied by multiple medical comorbidities that can compromise their response to traumatic insults.5 Many of these patients are on anticoagulants or other medications that can dramatically amplify the effects of even low-energy trauma. These patients require a high level of diligence, from both the trauma and orthopedic surgeons, because ...

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