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Lower grade fractures are by definition stable and almost always treated with casting or functional splinting. The best kind of fixation for the higher grade fractures, however, differs between adults and children. Appropriate treatments are discussed, and case-study illustrations are provided. Background on the anatomy of the tibia and femur is included.
150 sportsmen with lesions and diseases of the lower extremity served as basis for demonstrating the possibilities offered by diagnosis via sonography. Main indications were articular and paraarticular diseases of the large joints (hip and knee) to demonstrate effusions, ganglia, bursae and tendon ruptures, diseases and injuries of the musculature at the thigh and lower leg, as well as the Achilles tendon with its various changes such as rupture, achillodynia and peritendinitis. Muscular and tendon ruptures can be differentiated via sonography in respect of extension, type, age and localisation. This makes differentiated treatment possible. Intraarticular lesions of the knee joint remain the domain of arthroscopy. Sonographic findings should always be supplemented by anamnesis, clinical findings and x-ray film so as not to overlook any bony injuries and damage of the capsular ligaments.
The vena saphena magna is the most important arterial vascular substitute in today's vascular surgery. That is why modern varicose vein surgery is performed very carefully and cautiously with an aim to preserve the vessels as much as possible. This can be done only if the radiologist visualises both the healthy and the diseased superficial and deep venous systems as completely and a easily appreciable as possible when diagnosing varicosis. It is not enough to merely produce contrast images of the deep venous system when attempting to clarify varicosis via phlebography. The conditions obtaining at the points where the great saphenous vein and the small saphenous vein open into the femoral and popliteal veins, respectively, must be clearly visible. The maximum possible number of insufficient venae perforantes must be shown and the side branches of the great saphenous vein that have undergone varicose changes, must be visualised. It goes without saying that the deep venous system must be shown in a manner that it can be safely assessed. An extended thrombosis of the deep veins of the leg and pelvis does not present any diagnostic pitfalls when assessing the phlebogram. On the other hand, a beginning deep leg thrombosis is easily overlooked. Phlebographically it is quite difficult to clarify a relapsing thrombosis. This requires detailed knowledge of the patterns of signs in deep leg vein thrombosis.
Lower-extremity burns and skin grafts to these wounds have traditionally required extended hospitalization. We have used early tangential excision of the burn wounds and application of an Unna boot to fresh skin grafts in an attempt to shorten the hospitalization for such patients. Over a six-month period, 9 patients were treated with Unna boots to fresh skin grafts on the lower extremity. The average hospital stay was 0.9 days (range, 0 to 3 days). Graft take was 85% to 100%; no regrafting was required. Ambulation was begun 24 hours postoperatively. The technique described is a safe, effective, and inexpensive alternative to prolonged immobilization and hospitalization in patients with lower-extremity skin grafts.
Limb sparing procedures have become possible in many cases of tumor resections of the lower extremity by using the new free-tissue transplantation technique. In some cases the stump can be elongated. Forty-four patients were treated for soft tissue sarcoma of the lower extremity. In only one case conventional amputation was necessary. In all other cases the limb was saved by primary reconstruction. In four cases a distalisation of the stump was achieved.
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Lower extremity arterial insufficiency, a relatively common complication of ergotamine ingestion, is a rare complication of methysergide therapy for migraine headaches. Methysergide causes one of two typical angiographic patterns: intra-abdominal extrinsic compression of the aorto-iliac vessels in patients with retroperitoneal fibrosis, or marked diffuse bilateral spasm of the superficial femoral arteries in those without retroperitoneal fibrosis. We report a patient with methysergide-induced bilateral lower extremity arterial spasm and review the relevant literature. When one of the above arteriographic patterns is recognized, methysergide ingestion should be considered as a possible etiology.
We performed lower extremity arterial duplex mapping from the aortic bifurcation to the ankle in 150 consecutive patients evaluated for aortic and lower extremity arterial reconstruction and compared lower extremity arterial duplex mapping in a blinded fashion to angiography. On the basis of history, physical examination, and four-cuff segmental Doppler pressures individual lower extremities were classified as normal, isolated aortoiliac disease, infrainguinal disease, and multilevel inflow and outflow disease. For vessels proximal to the tibial arteries, lower extremity arterial duplex mapping was analyzed for its ability to insonate individual arterial segments, detect a 50% or greater stenosis, and distinguish stenosis from occlusion. In the tibial arteries lower extremity arterial duplex mapping was evaluated for its ability to visualize tibial vessels and to predict interruption of tibial artery patency from origin to ankle. Lower extremity arterial duplex mapping visualized 99% of arterial segments proximal to the tibial vessels, with overall sensitivities for detecting a 50% or greater lesion ranging from 89% in the iliac vessels to 67% at the popliteal artery. Stenosis was successfully distinguished from occlusion in 98% of cases. In the tibial vessels lower extremity arterial duplex mapping was better at visualizing anterior tibial and posterior tibial artery segments (94% and 96%) than peroneal artery segments (83%), (p less than 0.001). Overall sensitivities for predicting interruption of tibial artery patency were 90% for the anterior tibial, 90% for the posterior tibial, and 82% for the peroneal. Clinical disease category did not influence in a major way the accuracy of lower extremity arterial duplex mapping in either above-knee or below-knee vessels.
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Alignment of the lower extremities in secondary coxarthrosis (273 lower extremities) and controls (240 normal lower extremities) were studied using roentogenograms of whole lower extremities including the pelvis taken in the standing position with both legs. Secondary coxarthrosis, which is caused by congenital dislocation of the hip joint, was classified into four groups: unreduced dislocation, high dislocation, incomplete dislocation, and dysplasia of the acetabulum. Comparative studies were conducted using statistical data on measured items, obtained from secondary coxarthrosis cases and controls. In controls, the femoro-tibial angle (FTA) was 175.5 +/- 2.08 degrees and the mechanical axis passed through the medial side to the middle of the knee. It has been noted that a tendency for bow-legs was seen after the age of 50. In coxarthrosis with high dislocation, the most marked knock-knees were observed (FTA of 172.5 +/- 3.88 degrees), while in coxarthrosis with incomplete dislocation and dysplasia of the acetabulum, there was a tendency to coxa valga but no tendency toward knock-knees was evident. Cases of total hip replacement revealed that it is possible to improve knock-knees by installing a socket in the primary acetabulum as much as possible, correcting the difference between the length of the legs and elimating adduction contracture. It was also possible to study factors contributing to bow-legs and knock-knees by means of multivariate analysis.
Severe lower extremity trauma frequently results in a soft-tissue deficit that mandates wound coverage using some form of vascularized flap. The recent rediscovery of inclusion of the deep fascia during elevation of random skin flaps has enhanced the viability of large local flaps as a reconstructive option in the lower leg. In selected cases of relatively uncontaminated, moderate-sized defects, the choice of this maneuver has permitted closure of many defects which previously might have required a complex microsurgical tissue transfer. This series of 41 random-based local fasciocutaneous flaps in the lower leg in 38 patients has in all cases except two been successful in achieving preferred wound healing. Flap necrosis occurred only in these two cases presumably due to peripheral vascular insufficiency necessitating limb amputation in one patient. Eight (19%) had some form of complication, most occurring in the subset of flaps used for distal third lower leg wounds. The fasciocutaneous flap is conceptually simple, rapidly elevated and inset, and minimizes the region of surgical insult for many multitrauma patients who otherwise might have to forego any attempt for limb salvage.
Improved lower extremity venography has been achieved by a distally directed superficial foot venipuncture. Supine position and short procedure time afford excellent patient acceptance. Dilute contrast is believed responsible for eliminating venospasm and postvenography phlebitis; the low sodium concentration permits safe evaluation of cardiac patients. Sequential imaging (and the use of anteroposterior and lateral projections) eliminates false positive and negative interpretations. Skip areas are avoided by the use of 90-cm (36-inch) cassettes.
Lower extremity venous thrombosis is a major clinical problem because of its potential for pulmonary embolism and local vascular compromise. We present an anatomical and physiological overview followed by a review of current diagnostic methods and their underlying rationale.
Severe lower extremity injuries are devastating in their impact on the patient, his or her family, and the future. A critical evaluation of the results of previous salvage efforts provides the basis for the formulation of a treatment strategy. Success can be measured only in terms of functional outcome. The type of therapy is perhaps less important than the effectiveness of establishing a coordinated multidisciplinary approach to these injuries.
Massive lower extremity trauma, in particular open tibial fractures with associated vascular injuries, presents an immediate and complex decision-making challenge between a limb salvage attempt and primary amputation. Unfortunately, the literature to date is deficient in providing sound and defensible guidelines for primary amputation. Individual patient variables, specific extremity injury characteristics, and associated injuries must all be weighed before a decision can be reached. Further prospective studies are necessary before a well-defined protocol for primary amputation can be properly developed.
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Edema of the lower extremities is a difficult clinical problem. It can be due to stasis, obstruction of the lymphatic channels, increased production of lymph beyond the drainage capacity of the lymphatic vessels. It is often difficult to differentiate between these varieties. Lymphoscintigraphy was performed on 164 patients complaining of swelling of the lower extremities and on 5 volunteers. All patients were injected with 1 mCi of Tc-99m human serum albumin (HSA) intradermally in the medial web of the dorsum of each foot. Data were acquired dynamically for both inguinal regions for 45 minutes, and static images of the legs, thighs, and pelvis were taken at 90 minutes. Time activity curves were generated for the equal regions of inguinal nodes on both inguinal sides. The following patterns were recognized: normal (5 volunteers and 57 patients), enhanced (17 patients), stasis with mild obstruction (70 patients), and marked stasis with obstruction (20 patients).