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Patella and tibial plateau fractures


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Patella and tibial plateau fractures
Taiz University,faculty of medicine and health sciences
By Dr : Aisha Motahr

Published in: Health & Medicine
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Patella and tibial plateau fractures

  1. 1. Patella and tibial plateau fractures presented by Aisha Motaher Abutaleb
  2. 2. Patella fractures
  3. 3. Anatomy
  4. 4. Mechanism Fractures of the patella are caused by A. Direct violence (injury) Due to trauma to anterior aspect of the flexed knee leading to comminuted fractures. B. Indirect violence (injury) Due to forced flexion of the knee when the sudden quadriceps muscle is contracting In these case the fracture is transfers
  5. 5. Types of fractures
  6. 6. 1. Undisplaced transverse fracture Due to direct injury , the two fragment of the patella are undisplaced as they are held in position by the pre patellar expansion of the quadriceps tendon and patellar tendon
  7. 7. 2. Displaced transverse fracture Due to more sever trauma with gap between the fragment (this is indirect injury due to forced , passive flexion of the knee while the quadriceps muscle is contracted Active knee extension is impossible
  8. 8. 3.Comminuted (stellate) fracture Due to fall or direct injury on the front of the knee 4.Vertical fracture One or two small fragments are separated from the medial or lateral border of the patella
  9. 9. Clinical features 1. Local pain and tenderness 3. Swelling 1. Palpable gap between the fragment 2. presence of crepitus is felt 3. An x- ray examination  Fissure or crack fracture  Transverse fracture with dislocation  Comminuted fracture
  10. 10. Treatment 1. Undisplaced transvers fractures Immobilization of knee by long leg plaster splintage for 4-6 weeks combined with quadriceps exercise If there is a heamarthrosis , it is aspirated under aseptic condition
  11. 11. 2. Displaced transverse fractures  Open reduction and internal fixation with screw especially if pt is young  Small pollar fragment may be excised  Reduction and maintenance of the reduced position may also be gained by strong wire passed around periphery of the patella  In all these cases , the leg is splinted in long leg plaster for 8 weeks
  12. 12. 3. Comminuted fractures  Undisplacemen-A fracture with little or no displacement can be treated conservatively by a posterior slab of plaster that is removed several times a day for gentle active exercises.  Displacement Reduction is impossible and so the best treatment are 1. partial patelloectomy with the segment held by circlage wire and the leg is splinted in the extended position for 2 weeks 2. Total patelloectomy is excision of all the segment and the quadriceps aponeurosis is reconstructed by absorbable suture
  13. 13. early physiotherapy after the operation prevent knee stiffness
  14. 14. Patella-hinged brace
  15. 15. Complications Knee Stiffness  Most common complication Osteoarthritis  May result from articular damage Chondromalagia Ununion loss of fixation
  16. 16. Dislocation of the patella is almost always over the lateral femoral condyle
  17. 17. Mechanism 1. Direct trauma 2. sudden muscular contraction In the presence of Flattening of the lateral femoral condyle Genu valgus and external rotation Ligamentous laxity Anatomical bony abnormalities :- Small or high patella
  18. 18.  clinical feature  Locking of the knee in the flexed position  Swelling of the knee due to haemarthrosis  Tenderness over the anteromedial aspect of the knee joint  Positive patellar apprehension test  An x-ray examination would reveal the dislocation 1. Traumatic acute dislocation this result from an injury on the medial side of the knee while the knee in flexed position
  19. 19. Treatment Reduced under sedation the knee is immobilized in the extended position in a plaster of Paris cylinder for 3 weeks
  20. 20. Complication Osteoarthritis Recurrent dislocation
  21. 21. 2. Recurrent dislocation predisposing factors Post traumatic as rupture or weakness of medial patellar retinaculum Anatomical bony abnormalities  Small and high patella  Unequal pull of the quadriceps muscle component • Weakened vastus medialis • Shorter vastus lateralis • Genu valgus
  22. 22. surgical reconstruction 1. Direct medial patello-femoral ligament repair 2. Suprapatellar realignment (Insall) 3. Infrapatellar soft-tissue realignment (Goldthwaite) 3 4. Infrapatellar bony realignment (Elmslie–Trillat) Treatment
  24. 24. Anatomy
  25. 25.  Mechanism of injury -: Fractures of the tibial plateau are caused by varus or valgus force force is more likely to rupture the ligaments a car striking fall from a height
  26. 26. Classification of Schatzker -: Type 1 – simple split of the lateral condyle Type 2 – a split of the lateral condyle with a more central area of depression.
  27. 27. Type 3 the articular surface with an intact condylar rim Type 4 – a fracture of the medial condyle.
  28. 28. Type 5 –fractures of both condyles, but with the central portion of the metaphysis still connected to the tibial shaft.
  29. 29. Type 6 – combined condylar and subcondylar fractures effectively a disconnection of the shaft from the metaphysis.
  30. 30. Clinical feature 1. Sever pain 2. Swelling 3. Valgus deformity 4. Local tenderness on examination:-The knee may suggest medial or lateral instability  the leg and foot should be carefully examined for signs of vascular or neurological
  31. 31. X-ray:- X-rays provide information about the position of the main fracture lines and areas of articular surface depression
  32. 32. CT :- for reveal direction and extent of displacement
  33. 33. Treatment
  34. 34. Type1  Undisplaced type 1 fractures can be treated conservatively  Displaced fractures should be treated by open reduction and internal fixation
  35. 35. Type2 1. If the depression is slight (less than 5 mm)or patient is old , the fracture is treated closed with the aim of regaining mobility and function rather than anatomical restitution. skeletal traction is applied with 5kg for 4 – 6 w
  36. 36. 2. In younger patients, and in those with a central depression of more than 5 mm, open reduction with elevation of the plateau and internal fixation is often preferred
  37. 37. Type3 Depression of more than 5 mm in a type 3 fracture can be treated by elevation from below and supported by bone grafts and fixation
  38. 38. Type 4 Treated by open reduction and internal fixation .
  39. 39. Type 5,6  Open reduction and internal fixation with plate and screw.  A combination of screw fixation and circular external fixation is lower risk complication .
  40. 40. Complication EARLY:- Compartment syndrome Late :- Joint stiffness. Deformity. Osteoarthritis
  41. 41. Thanks