Tibial plateau fracture of the left knee (lateral plateau
Tutor 10 injury of leg
PATELLA DISLOCATIONWAN AWATIF WANMOHD ZOHDI
MECHANISM OF INJURY• Knee flexed, quadriceps relaxed >> patella forced laterally by direct force.:RARE• Common: due to indirect force Sudden, severe contraction of quadriceps muscle While the knees is stretch in VALGUS & EXTERNAL ROTATION
Lateral patellar dislocation. (a) Drawing shows theclassic mechanism of injury: fixed tibia, internal femoral rotation, and quadriceps contraction.
CLINICAL FEATURES• Tearing sensation• Knee has gone ; out of joint• When running : they may collapse and fall to the ground• Patella springs back into position spontaneously• remains unreduced >>deformity
• Downward dislocation Stuck btw condyles Marked prominence on front of the knee• If spontaneous reduction:-swollen knee-bruising tenderness on medial side• Joint aspiration-blood stained-fat droplets (concurrent osteochondral #)
CONSERVATIVE MXPush back w/o difficulty & anesthesiaCast splintage;• If no sign of soft tissue lesion• Retained for 2-3 weeks• Quadriceps strengthening exercise ; 2-3 months• Jt aspiration and immobilized it in full extension
SURGICAL MXIn intra articular (intercondylar) dislocation >> open reductionIf swelling, tenderness, bruising (medially)>> d/t patellofemoral ligaments torn, retinacular t/s torn
COMPLICATION• Recurrent dislocation• 1st time –treated as non-operatively• 15-20% recurrent dislocations.
DEFINITION• A tibial plateau fracture is a fracture involving the proximal (upper) portion of the tibia which extends through the articular surface .
MECHANISM OF INJURY• Caused by a varus/valgus force combined with axial loading• Eg: car striking a pedestrian (bumper #)• Often: fall from a height in which the knee is forced into valgus/varus• Tibial condyle is crushed/split by opposing femoral condyle.• Combination of both the above
PATHOLOGICAL ANATOMY TYPE 2: vertical split of TYPE 3 : depression of the lateral condyle + TYPE 1:vertical split of the articular surface depression of an the lateral condyle with an intact condylar adjacent loadbearing rim part of the condyle TYPE 6 : combined TYPE 4 : # of the medial TYPE 5 : # of both condylar & subcondylar tibial condyle condyles #Schatzker classification
• In younger people • Virtually undisplacedType 1 • Condylar fragment may be pushed inferiorly or tilted • Joint is widened • If # is not reduced : >> valgus deformityType 2 • Split to the edge of the plateau is absent • Stable jointType 3 • May tolerate early movement • 2 types # • Low energy lesion : depressed, crush # of osteoporotic bone in elderly ptType 4 • High energy l/s : condylar spilt that runs obliquely • Column of metaphysis wedged in btw that remains in continuity with the tibial shaftType 5 • High energy injury • >>severe comminutionType 6 • Tibial shaft disconnected from tibial condyles.
Imaging• X-ray View : AP, Lateral , oblique• CT : amount of comminuted and depression #• Give information on the location of the main # lines, site and size portion of condyle that is depressed• Crushed lateral condyle, >>medial ligament is intact• Crushed medial condyle >> lateral ligament may be torn
ManagementTYPE 1 # Undisplaced • Conservatively • Haemarthrosis is aspirated • Apply compression bandage • Limb is rest on CPM machine • Acute pain and swelling is subsided >> hinged cast-brace • Weight bearing –delayed ` 8 weeks Displaced • Open reduction • Internal fixation
TYPE 2 # Slight depression(<5mm), stable Depression >5mmknee, old patient, osteoporotic pt• # is treated closed to gain • Open reduction with elevation mobility and fx ( not anatomical of plateau restitution) • Internal fixation• Aspiration • Small 3.5 mm screws // beneath• Compression bandage the subchondral bone hold up• Skeletal traction via threaded elevated fragments : raft screws pin. • Buttress plate :-in type 2,,5 or 6• Active exercises every day• # -sticky in 3-4 weeks >> remove traction pin• Apply hinge cast brace• Full weight bearing deferred ; 6 weeks
TYPE 3 #• Similar to type 2• But lateral rim of the condyle is INTACT• Stable knee• Depressed fragments :elevated through a window in the metaphysis• Elevated fragements :supported by bone graft , raft screws.• Post op :exercises, cast –brace till # is united.
TYPE 4 #• Osteoporotic # crush –difficult to be reduced• >> varus deformity• Principles mx similar in type 2 #• Medial condylar split # : d/t high energy impact.• Underlying lateral ligament injury
Stable fixation on medial side Assess ligament injury If unstable joint after the fixation Repair the torn structure on the lateral side.
TYPE 5 and 6 #• Risk to compartment syndrome• In a simple condylar # and in an elderly pt:-reduced by traction-treated as type 2 injury• Usually internal fixation, early joint movement.• Danger of wide exposure to access both condyles:-increase wound breakdown-delayed or non-union
COMPLICATTIONS LATE EARLY COMPARTMENTJOINT STIFFNESS DEFORMITY OSTEOARTHRITIS SYNDROME
Mechanism of injury• Twisting force >> spiral # of both bones at different levels• Angulatory force >> transverse, short oblique #, at the same level• Indirect injury :-low energy-spiral or long oblique # , one of the bone fragments may pierce the skin• Direct injury:-crushes/splits skin over the #Common in motorcycle accident
Pathological anatomy• Behaviour of these injuries will depends on mode of treatment• It depends on following factors:
State of Severity of Stability ofsoft tissues bone injury # LOW ENERGY : Risk and CX depends on -closed # Consider displacement when amount and type of soft -Gustilo 1, 2 weight bearing is allowed tissue damage - spiral HIGH ENERGY: -direct traumaopen# : Gustilo classification -open # Sevely comminuted : least stable, need mechanical closed # : Tscherne’s -Gustilo 3 fixation -transverse -comminuted
TSCHERNE’s classification of skin lesions in CLOSED #IC1 •No skin lesionIC2 •No skin laceration but contusionIC3 •Circumscribed deglovingIC4 •Extensive, closed deglovingIC5 •Necrosis from contusion
Clinical features Examine limbs for signs of soft tissue damage• severe swelling,• bruising,• crushing or tenting of skin,• open wound,• circulatory changes,• weak or absent pulses,• loss of sensation, Alert for the• Inability to move toes compartment syndrome!!!!• Deformity
Imaging• X-ray of entire length of the tibia and fibula.(knee and ankle joints can be seen)• Notes the :-types of #-level-angulation and displacement
MANAGEMENT Limit soft t/s damage Prevent/recognize Start joint compartmentmovements ASAP syndrome Start early Obtain & hold the weightbearing # alignment
LOW ENERGY #• Gustilo type 1.• Conservative mx
LOW ENERGY # UNDISPLACED/ MINIMALLY DISPLACED DISPLACED Reduced under GA with X-ray control Full length cast fr upper thigh to metatarsal necks Alignment and rotation must be perfect Knee is slightly flexed, ankle at a right angle Full length cast. Position checked by x-ray Limb is elevated, observe for 48-72 hours. Discharged home on 2/3 rd day. With crutches
HIGH ENERGY #Transverse #• Usually stable after reduction• Treated as closed• Look for signs and symptoms of cx (excessive pain, swelling, tightness, sensory change)Comminuted and segmental #• If a/w bone loss, unstable >> treat with early surgical stabilization.