Lower extremity injuries represent the primary cause of more than half of all hospitalizations for trauma. Their frequency, severity, and costs emphasize the impact of those injuries on society.1,2 Lower extremity fractures may be caused by either low- or high-energy forces and occur both in isolation and as multiple injuries. The mechanism of injury defines the specific individual fracture pattern. Typical trauma mechanisms include blunt versus penetrating trauma, low-energy versus high-energy forces, twisting, bending, or crushing forces. Significant lower extremity injuries compromise functional outcome and can lead to long-term pain, abnormal gait, degenerative joint disease, chronic infection, and limb loss.
Dislocations of the hip, knee, or more distal joints, as well as displaced fractures, may cause pressure on nerves, vessels, or skin, resulting in permanent deficits. Delay of more than a few hours in reducing a dislocated hip significantly increases the risk of avascular necrosis of the femoral head. Displaced intracapsular femoral neck fractures also have a high risk of avascular necrosis, which can be lowered by urgent reduction and fixation. In young patients, this injury may appropriately be considered as an “ischemic surgical emergency.” Failure to recognize an undisplaced fracture of the femoral neck may result in its displacement, with a much greater likelihood of poor outcome. Open fractures of the lower extremities are true emergencies, requiring a timely surgical treatment to minimize the risk of infection and limb loss.
The wide prevalence of safety belt usage and mandatory airbags in vehicles leads to an increased number of survivors of high-energy crashes, who consequently suffer from a higher severity of lower extremity injuries. Any trauma victim involved in a high-energy trauma mechanism may have associated potentially life-threatening injuries to the head and torso. Thus, the initial evaluation of lower extremity fractures must focus on the patient as a whole, and not focus exclusively on the injured limb.3–5 The concept of “damage control orthopedics” (DCO) was established based on the principle that prolonged early definitive treatment of long bone fractures can be detrimental for severely injured patients who are in unstable physiological conditions.6,7 In these patients, the early mitigation of the “lethal triad” of persistent metabolic acidosis, hypothermia, and coagulopathy represents the prime goal for survival.4 The controversial concept of “limb for life” entails the early amputation of a mangled lower extremity in critically injured patients with the aim of increasing the likelihood of survival. The ideal timing and modality of long bone fracture fixation in multiply injured patients, particularly in presence of severe head or chest trauma, represents another controversial topic of debate related to the care of lower extremity injuries.3,8
A relatively recent concept in lower extremity fracture care is that the majority of fractures can be treated entirely or in part with minimally invasive fixation. The evolution of techniques for percutaneous reduction and fixation of fractures, coupled with technological adaptation of fracture ...