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Orthopedics 5th year, 6th/part two & 7th/part one lectures (Dr. Ali A.Nabi)
 

Orthopedics 5th year, 6th/part two & 7th/part one lectures (Dr. Ali A.Nabi)

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The lecture has been given on Apr. 30th & May 7th, 2011 by Dr. Ali A.Nabi.

The lecture has been given on Apr. 30th & May 7th, 2011 by Dr. Ali A.Nabi.

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    Orthopedics 5th year, 6th/part two & 7th/part one lectures (Dr. Ali A.Nabi) Orthopedics 5th year, 6th/part two & 7th/part one lectures (Dr. Ali A.Nabi) Presentation Transcript

    • Supracondylar fractures of the femur
    • Supracondylar fractures of the femur
      • Supracondylar femur fractures usually occur as a result
      • of low-energy trauma in osteoporotic bone in elderly persons.
      • high-energy trauma in young patients.
      • Must also be aware of the potential for pathologic fractures through metastatic lesions or primary bone tumors in this area.
    • Supracondylar fractures of the femur
      • The fracture line usually above the condyles and may extend between them.
      • In sevsre trauma comminuted fracture could be seen.
    • Supracondylar fractures of the femur
      • The distal femur is funnel shaped, and the area where the stronger diaphyseal bone meets the thinner and weaker metaphyseal bone is prone to fracture with direct or indirect trauma.
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    • Supracondylar fractures of the femur
      • Presentation
        • Patients present with pain, deformity, weakness, and inability to use the leg.
        • The knee is swollen and deformed.
        • Elderly patients usually have a history of a fall.
    • Supracondylar fractures of the femur
        • Younger patients usually have had high-energy trauma. Especially for the younger patient, in whom significant soft-tissue injury may also be present, careful assessment of the whole limb is required.
        • Observe for compartment syndrome, vascular injury, and open wounds.
        • Fractures in other areas need to be identified.
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    • Supracondylar fractures of the femur
      • Imaging Studies
      • Patients with supracondylar femur fractures require anteroposterior (AP) and lateral radiographs of the entire femur to assess associated fractures and deformity; however, views centered at the knee are also important to assess the specific fracture pattern.
    • Supracondylar fractures of the femur
      • Treatment
      • No specific medical therapy for supracondylar femur fractures exists. If the patient is unable to tolerate surgery, temporary traction can be used to maintain length and alignment.
    • Supracondylar fractures of the femur
      • Supracondylar femur fracture treated in traction. Traction allows nonoperative restoration of length and alignment while the patient is stabilized for surgery, but it is associated with the major complications of prolonged bed rest when used as definitive treatment.
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    • Supracondylar fractures of the femur
      • 2. For nondisplaced and stable fractures, bracing can provide enough stability to control pain and allow healing; however, bracing cannot control alignment or length because immobilizing the joint above and below is impossible.
    • Supracondylar fractures of the femur
      • 3. Surgical therapy requires reduction followed by fixation to maintain alignment. Options include external fixation or internal fixation. Internal fixation is with intramedullary devices (e.g., flexible rods, more rigid retrograde or antegrade rods) or extramedullary plates and screws.
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    • Supracondylar fractures of the femur
      • Complications
      • Early includes arterial injury
      • Late
      • Complications include
      • Nonunion.
      • loss of alignment (malunion).
      • Infection.
      • joint stiffness.
      • medical complications (e.g. thromboembolic disease).
    • Knee injuries
      • Injuries involve the knee include
      • fractures around the knee.
      • dislocations (patella and knee).
      • soft tissue injuries (Ligaments, tendons and muscles).
      • meniscal injuries.
    • Knee injuries
        • Patellar and tibial plateau fractures each account for 1% of all skeletal fractures. Distal femoral condyle fractures account for 4% of all femur fractures.
    • Knee injuries
      • Fractures of the knee
      • This involve the followings
      • fractures of the patella.
      • femoral condyles.
      • tibial eminence (spine).
      • tibial tuberosity ( tubercle).
      • tibial plateau (condyles).
    • Fractures of the patella
      • Patients with patella fractures may have a history of the following:
      • Direct or indirect trauma with resultant pain and edema
        • Caused by a direct blow, such as a dashboard injury in a motor vehicle accident or a fall on a flexed knee
        • Also caused by forceful quadriceps contraction while the knee is in the semiflexed position (e.g., in a stumble or fall).
    • Fractures of the patella
      • Clinically
      • When examining a patient for a knee fracture, one should first examine the patient for edema, ecchymosis, and point tenderness. Ask the patient to perform a straight-leg raise against gravity to check the integrity of the extensor mechanism, which commonly is disrupted with transverse patellar fractures caused by indirect forces. 
    • Fractures of the patella
        • The patient may have pain with leg extension or be unable to extend the knee with a severe fracture.
        • Patients present with pain directly over the patella.
    • Fractures of the patella
      • X – Ray
      • May show
      • One or more fracture lines without displacement.
      • Multiple fracture lines with irregular displacement.
      • Transverse fracture with a gap between the fragments.
    • Fractures of the patella
        • Other knee should be checked to exclude bipartite patella which usually bilateral.
        • An axial (or sunrise) view of the patella is useful for detecting vertical patellar fractures, which frequently are missed and nondisplaced. Transverse fractures are most common, followed by comminuted and avulsion fractures.
    • Fractures of the patella
      • Patellar fractures can be classified into
          • Transverse.
          • Longitudinal (vertical).
          • Polar.
          • Comminuted.
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    • Fractures of the patella
      • Treatment
        • Nondisplaced transverse fractures with an intact extensor mechanism are treated with a knee immobilizer, crutches, restriction to only partial weight bearing, and 6 weeks of immobilization.
    • Fractures of the patella
        • 2. Displaced fractures, or fractures associated with a disrupted extensor mechanism, are referred to orthopedics for possible open reduction and internal fixation usually by 2 K. wires and tension band wire or by screw. A partial or total patellectomy may be required for severe comminution.
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    • Fractures of the patella
        • 3. Patients with open fractures should receive antibiotics and orthopedics should be consulted for emergency irrigation and debridement.
    • Fractures of the patella
      • Complications
      • Soft-tissue infection
      • Osteomyelitis secondary to an open fracture
      • Delayed union or nonunion
      • Posttraumatic arthritis or knee stiffness
      • Chondromalacia patella
    • Femoral condyles fractures
        • Either medial condyle fracture or lateral condyle fracture or both condyles fractures.
        • Often associated with supracondylar fractures.
        • Femoral condyle fractures due to axial loading with valgus or varus stress like fall from hieght.
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    • Femoral condyles fractures
      • Clinically
        • When examining a patient for a knee fracture, one should first examine the patient for edema, ecchymosis, and point tenderness. A careful neurovascular examination should be performed.
        • Patient will present with pain over the distal femur and often will have a hemarthrosis.
        • Patients are often unable to bear weight.
    • Femoral condyles fractures
      • X –ray show T or Y- shaped fracture if the fracture involve both condyles.
    • Femoral condyles fractures
      • Treatment
        • These may be supracondylar, intercondylar, or condylar.
        • Nonoperative management may be used for nondisplaced or incomplete fractures.
        • Open fractures, displaced fractures, and those with neurovascular injury will need operative fixation.
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    • Femoral condyles fractures
      • Complications
      • Neurovascular injury.
      • Genu varum or valgum deformities.
      • Other bone and joint complications.
    • Tibial eminence (spine) fracture
      • Due to a direct blow to the proximal tibia with the knee flexed such as falling off a bicycle
      • Also due to hyperextension with varus or valgus stress, such as in motor vehicle collisions or athletic accidents
      • Tibial eminence avulsion fractures occur most often in children aged 8-14 years but can also occur in the skeletally mature patient.
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    • Tibial eminence (spine) fracture
      • Clinically
      • Patients may present with a knee effusion and pain.
      • Patients may represent with an avulsion of the tibial attachment of the anterior cruciate ligament.
    • Tibial eminence (spine) fracture
      • X – Ray fracture may easily miss unless the x-ray is carefully examined.
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    • Tibial eminence (spine) fracture
      • Treatment
        • For a nondisplaced fracture (and stable knee joint), immobilize the knee.
        • A complete avulsion of the tibial spine, or a displaced fracture for possible surgical fixation.
    • Tibial eminence (spine) fracture
      • Complications
      • Stiff knee.
      • Locked knee due to non-union and entrapment of the piece.
      • Osteoarthritis.
    • Tibial tubercle (tuberosity) fracture
        • Usually occur with jumping activities such as basketball, diving, gymnastics, and football. 
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    • Tibial tubercle (tuberosity) fracture
      • Clinically
        • More common in males than in females.
        • Patients present with pain over the anterior tibia about 3 cm distal to the articular surface.
        • In severe fractures, the patient may be unable to extend the knee.
        • More common in adolescents; infrequent in adults.
    • Tibial tubercle (tuberosity) fracture
      • X – Ray is obvious
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    • Tibial tubercle (tuberosity) fracture
      • Treatment
        • For nondisplaced fractures, immobilize the knee.
        • Displaced fracture treated with open reduction and internal fixation.
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    • Tibial plateau (condyles) fractures
      • Caused by axial loading with valgus or varus forces, such as in a fall from a height or collision with the bumper of a car
        • Due to the impaction of the femoral condyle into the tibial plateau
        • In elderly persons and those with osteoporosis, tibial plateau fracture can occur with minor trauma.
    • Tibial plateau (condyles) fractures
      • Clinically
        • Patient is generally unable to bear weight.
        • The lateral tibial plateau is fractured more frequently than the medial plateau.
        • Often, patients present with a knee effusion, and tenderness will be present over the medial or lateral plateau.
    • Tibial plateau (condyles) fractures
        • Up to 30% of tibial plateau fractures are associated with knee ligamentous injuries (medial collateral or anterior cruciate ligaments with lateral plateau fractures, lateral collateral or posterior cruciate ligaments with medial plateau fractures).
    • Tibial plateau (condyles) fractures
      • X –Ray
      • Obtain anteroposterior, lateral, and oblique radiographs of the knee. Four views have been shown to be superior to two views in detecting fractures.
      • Oblique views are particularly useful in detecting subtle tibial plateau fractures (internal oblique profiles lateral plateau, external oblique profiles medial plateau).
    • Tibial plateau (condyles) fractures
      • C-T scan
        • CT scans may be necessary to fully delineate the extent of tibial plateau fractures and other complex knee fractures.
        • Compared to CT scans, plain radiography underestimates the amount of articular depression of tibial plateau fractures in most tibial regions. This is significant as the amount of tibial plateau depression is an indicator for operative repair.
    • Tibial plateau (condyles) fractures
      • Classification
      • Schatzker in 1987 classify the tibial plateau fractures into
      • Type I – Vertical split of the lateral condyle,
      • Type II - Vertical split of the lateral condyle combined with depression of the adjacent load-bearing part of the condyle.
    • Tibial plateau (condyles) fractures
      • Type III – central depression of the articular surface with an intact condylar rim.
      • Type IV – fracture of the medial tibial condyle.
      • Type V – fracture of both condyles.
      • Type VI – combined condylar and subcondylar fractures.
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    • Tibial plateau (condyles) fractures
      • Treatment
        • Immobilize nondisplaced fractures and have patient remain non weight bearing.
    • Tibial plateau (condyles) fractures
        • displaced (depressed) fractures require open reduction and internal fixation. Articular depression of greater than 3 mm may be considered for surgery.
    • Tibial plateau (condyles) fractures
        • The goal of treatment is a stable, aligned, mobile, and painless knee joint to minimize risk of posttraumatic osteoarthritis.
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    • Tibial plateau (condyles) fractures
      • Complications
      • Vascular injury and compartmental syndrome.
      • Knee stiffness.
      • Non-union.
      • Malunion and deformity.
      • Osteoarthritis