lecture all

1. Department of Traumatology and Orthopaedics
International High School of Medicine

2. Classification
1) Injuries around the hip
1) Pelvic injuries
2) Femoral neck fractures
3) Proximal femur fractures
4) Hip joint dislocation
2) Fractures shaft femur
3) Injuries around the knee
1) Fracture distal femur
2) Knee ligament injuries
3) Meniscal injuries
4) Dislocations in the knee joint
5) Injuries to the patella
6) Proximal tibial fractures
4) Fracture of shaft tibia and fibula

3. 5) Injuries around the ankle
1) Ankle sprains
2) Distal tibial and fibular fractures and fracture
dislocations
3) Tendo-achilles injury
4) intra-articular talus fractures
5) Injuries to the foot
1) Forefoot injuries
1) Phalangeal fractures and dislocations
2) Fracture of metatarsals
3) Fractures of sesamoid bones
2) Midfoot injuries
1) Lisfranc joint fractures and dislocations
2) Cuneiforms, navicular and cuboid bone fracts.
3) Hindfoot injuries
1) Fractures calcaneum
2) Fractures talus

4. Anatomical
Classificati
on

5. BRIEF ANATOMY OF THE HIP JOINT
• Ball and socket articulation between head femur
and acetabulum
• Lig. teres includes a small artery coming to the
head through fovea centralis
• Neck femur placed at 135 deg. angle to the shaft
• Inherent strength depends on the trabecular
pattern (primary and secondary compression
and tensile trabeculae)

6. VASCULARIZATION FEATURES
• 3 sources of blood supply to the head femur
▫ Intraosseus cervical vessels
▫ Artery of lig. teres
▫ Retinacular vessels
In case of a displaced fract. head 2 sources remain:
a.lig.teretis & revascularization from the
surrounding tissues

8. FEMORAL NECK FRACTURES,
AETIOLOGY
• Common in older patients (osteoporosis and
osteomalacia) – 12%
• More common in older women due to senile
osteoporosis
• Is regarded as a pathological fracture
• Comminution of posterior cortex is frequent,
which decreases quality of reduction

9. MECHANISM OF INJURY
• Fall on the greater
trochanter (direct
mechanism)
• Lateral rotation of
the extremity –
causes marked
posterior
comminution of
neck
• In young adults –
RTA, fall etc.

10. CLASSIFICATION
1. Anatomical
1. Subcapital
2. Transcervical
3. Basal
2. Fracture angle
1. Pawel’s: I, II, III
(30, 50, 70 deg.
respectively)
1. Garden’s:
1. Incomplete fracture
2. Complete fracture undisplaced
3. Complete with partial displacement
4. Complete with total displacement

11. Garden’s Classification

12. Diagnosis
Clinical features
External ratation of the leg. The patella
facing outwards
Shortening of the leg, usually slight
Attempted hip movements painful, and
associated with severe spasm
Active staight-leg-raising not possible.

13. Diagnosis
Radiological features (X-
ray of pelvis with both
hips)
Break the neck
External rotation of
femur (lesser trochanter
appearing more
prominent)
Overriding of greater
trochanter
Break in the trabecular
stream
Break in Shenton’s line

14. Treatment of neck fractures
• Conservative method
▫ Traction
▫ Immobolization (hip spica, Thomas splint et.c.

15. Operative treatment
• Multiple cancellous screws – most commonly
used
• Dynamic hip screw
• Multiple Knowle’spins/ Moore’s pins used in
children
• Smith – Peterson nail (S.P. nail) – not popular
now.
• Joint replacement surgery.

16. Multiple cancellous screws

17. DHS

18. Joint replacement surgery

19. Joint replacement surgery

20. Complications
• Non – union
• Avascular
necrosis
• Osteoarthritis

21. Subtrochanteric fractures
Fractrs in the area between the lesser
trochanter and the point 5cm distal to it
• Mechanism – primarily direct (RTA etc.)
• Clinical features – pain, swelling, external
rotation deformity etc.
• Radiology – pattern of fracture

22. Fielding’s classification
Fielding’s classification
Type I – fracture at
the level of the lesser
trochanter
Type II – 1” below
the lesser trochanter
Type III – 2” below
the lesser trochanter

23. X-ray showing
subtrochanteric
fracture of femur

24. Treatment
• Conservative – in the young – modified cast
brace with pelvic band
• Operative – ORIF
▫ Blade plate
▫ Proximal femoral nail
▫ Dynamic hip screws (not the treatment of choice)
▫ Dynamic condylar plate, condylar blade plate, dynamic
condylar screw
▫ Interlocking nail
▫ Sliding compression hip screw, gamma nail etc.

25. Gamma nail

26. Interlockning nail

27. Trochanteric fractures
• Occur along the line between the greater and the
lesser trochanters
• Totally extracapsular
• The limb has to be kept in external rotation after
reduction
• Cancellous bone, heals well by 8-12 weeks
• 4 times more common than intracapsular #
• Age – elderly patients 65-72 yrs old
• Sex – females more frequent (3:1)

28. • Mechanism – direct/indirect
• Clinical pic. – pain, marked shortening of lower
limb, complete external rotation deformity,
swelling, tendernes
• X-ray – AP, lateral views
• Treatment
▫ Conservative – assoiated w’ 10% mortality,
performed in very old, terminally ill patients and
those having high medical and surgical risk –
simple support with pillows, skeletal/plaster
traction

29. Intertrocha
nteric
fracture

30. Traction

31. • Operative – should not be delayed for > than 48
hrs
▫ Closed/open reduction
▫ Internal fixation
 DHS
 PFN
 Gamma nail
• Complications: RARE – coxa vara, non union,
avascular necrosis; > FREQ. – exitus letalis,
malunion, traumatic osteoarthritis

32. Internal fixation methods – DHS, PFN

33. Hip joint dislocation
Classification
1) Posterior
 Superior - most frequent
 Inferior
1) Anterior
 Superior
 Inferior
1) Central – towards the abdominal cavity via
fractured acetabulum

34. Chip fracture (50 %)

35. Posterior Hip
dislocation

36. Anterior HJD

37. Posterior HJD
• Comprises about 70% of all HJD’s
• Mechanism –
indirect
(dashboard injury)

38. Diagnosis
• Clinical features
▫ Limb shortening
▫ Flexion/add/IR deformity
▫ Head felt in gluteal region
▫ Movements reduced
▫ Injury to sciatic nerve
• X-ray investigation

39. Examination

40. Treatment
▫ Closed reduction methods: gravity
method (Stimson’s), Cocher’s, Watson
Jones’, Bigelow’s, Allis’ (traction in the
line of deformity) – all applied under
general anaesthesia
▫ Open reduction – if indicated
(interposition of bony fragmts, soft
tissues; sciatic nerve injury)
▫ Immobilization – Thomas splint (3
weeks)

41. Watson Jones technique for
anterior HJD reduction

42. • Complications
▫ Myositis ossificans (2%) – seen in PDHJ + hip
head injury; avoided by early immobilization and
by immobilizing for 6 weeks in hip spica
▫ Sciatic nerve injury (10-13%) – x3 more common
in frctr dislocation. Due either to stretch of the
nerve or to its interposition between bone
fragments
▫ Traumatic osteoarthritis (35%) – is due to avascular
necrosis (damage to lig.teres and capsular vessels)
▫ Recurrent dislocation – due to fractr acetabulum,
rupture of the capsule, insufficient immobilization
▫ Unreduced dislocation

43. Mechanism of sciatic nerve injury

44. Anterior HJD
Mechanism – direct (blow to the back), fall
from the height

45. Diagnosis
• Clinical features – flexion
(superior)/extension (inferior) + abd + external
rotation, head palpable, injury to the femoral
nerve or vessels
• X-ray – confirms the dislocation, reveals
associated bone injury

46. • Treatment – Stimson’s gravity method, Allis’
method, reverse Bigelow’s methd, classical
Watson-Jones methd
• Complications
▫ Neurovascular injury (femoral artery, vein, nerve)
▫ Irreducibility (interposition of bone fragmts, soft
tissues)
▫ Post-traumatic osteoarthritis
▫ Aseptic necrosis
▫ Recurrent dislocation
NOTE: central hip dislocation will be discussed in the
pelvic injuries lecture

47. Reduction

48. Supracondylar fractures• 7% femoral #s
• Mechanism – severe valgus/varus forces + axial
loading and rotation (RTA, fall etc.)
• Neer’s classification:
▫ Undisplaced #
▫ Displaced #
 Medial displacement
 Lateral displacement
▫ Comminuted #

49. Neer’s classification: Undisplaced;
Displaced & medial; Displaced &
lateral; Comminuted

50. • Muller’s AO classification
▫ Type A – extra-articular #s
▫ Type B – unicondylar #s
▫ Type C – bicondylar #s
• Clinical picture – usual signs of #s + flexion
deformity (pull of gastrocnemius),
haemarthrosis (intra-articular #s)
• X-ray – AP, L views; arteriography – if vascular
damage suspected
• Treatment – conservative, traction, operative

51. Fractures distal femur –
supracondylar, unicondylar,
comminuted

52. • Conservative – in cases of impacted/
undisplaced #s – spica cast; long above knee
cast after traction
• Traction
▫ Upper tibial – applied thru the upper end o the
tibia – 8-12 weeks followed by cast braces
▫ Two pin traction – upper tibial + distal femur –
fractr reduced more accurately
• Operative – ORIF (preferred due to early
mobilization of knee joint, > accurate reduction,
rigid fixation)

54. Fixation methods
• Medullary fixation methods
▫ Rush pins
▫ Ender’s nail
▫ Medullary nails
▫ Split nails etc.
• Blade plate fixation methods
▫ AO plates
▫ Elliot plates
▫ 95 deg. condylar blade plate
▫ Dynamic condular screw
▫ Buttress plate (in highly comminuted #s)

55. Methods of IF of supracondylar
fractures femur

56. Complications (common)
• Delayed union
• Malunion
• Nonunion
• Popliteal vessels & peroneus communis nerve
injury
• Knee stiffness
• Deep vein thrombosis
• Infection
• Implant failure
• Residual deformities (varus, valgus, internal
rotation)

57. Injuries to the Knee

58. Knee ligament injuries
• Mechanism of injury:
▫ Direct valgus force
▫ Rotational (twisting) forces
 Abd + flex + intern.rotation (Ab FIR) => damage to
medial structrs (tibial collateral lig., medial capsule),
ACL, medial meniscus – O’Donoghue’s unhappy
triad
 Ad FER => lateral structures damage (fibular collateral
lig., lateral capsule, arcuate complex, common
peroneal nerve, biceps, anterior and/or posterior
cruciate ligg.)
 Hyperextension – ACL / PCL injury
 Anteroposterior displacement – – lI –

59. Common mechanism of knee
ilgament injuries

60. O’Donoghue’s unhappy triad

61. Collateral ligament injury (sprains)
• MCL more common (valgus stress more likely to
occur)
Classification (American Medical
Association):
• I Degree – minimal tear (<1/3), X-ray joint
separation < 5 mm
• II Deg. – more disruption (1/3 – 2/3), joint
separation 5-10 mm
• III Deg. – complete disruption => instability,
joint separation > 10 mm

62. Degrees of collateral lig. sprain

63. Clinical features
• Anamnestic data – sport injury, RTA etc.
• Examination – pain, swelling, local tenderness;
damage to the extensor mechanism of the knee
(20% patients)
• Clinical tests:
▫ Abduction (valgus) stress test
▫ Adduction (varus) stress test
▫ Tests to rule out injury to other structures (below)
• Stress radiographs (valgus or varus positioning)
• CT, MRI, US
• Arthroscopy – helps evaluate injury to the intra-
articular structures

64. A – valgus, B – varus stress tests

65. • Treatment of fresh injuries (nonoperative
preferred):
▫ I deg. – cold, NSAIDs etc.
▫ II deg. – long leg cast with knee in 30-40 deg.
flexion for 4-6 weeks
▫ III deg. – reconstructive operations, bracing 4-7
mnths.
• Old cases
▫ Distal transfer
▫ Reconstruction using tendons of adjacent muscles

66. Cruciate ligaments injury
• ACL the most common knee ligament to be
injured
• Clinical pic. – popping sensation felt or heard at
the time of injury, pain (at rest and when moving
in the joint), swelling
• Examination (examine the uninjured knee first)
– depends on damage to other structures around
the knee (ligs, menisci, bones, capsule)
▫ Anterior subluxation of >5 deg. => lax / disrupted
ACL

67. ACL tear tests
• Anterior drawer test - 3 positions:
▫ Foot in neutral position – detecting ACL tear
▫ Foot in 15 deg. internal rotation – detecting damage to
anterolateral structures
▫ Foot in 15 deg. external rotation – anteromedial structrs
• Lachman’s test – Ant.draw.test with the knee flexed at
20-30 deg., patient in supine position
• Jerk test of Hughston
• Pivot shift test
• X-ray – may be normal / avulsion # of tibial
spine

68. Scheme of ACL tear

69. Grading of the Lachman’s test
• Grade I – end feel appreciation (0-5 mm
displacement)
• Grade II – visible anterior movement of the tibia
(5-10 mm)
• Grade III – gross anterior tibial translation (>10
mm)

70. Lachman’s test

71. • PCL tear – occurs rarely and is frequently
accompanied by injury to other knee structures
• Signs & symptoms – same as ACL tear
• Clinical tests:
▫ Posterior drawer test
▫ Posterior sag sign
Combined knee instabilities
• Anteromedial and anterolateral – if anterior,
medial and lateral structures are torn
• Anterolateral & posterolateral – ACL + PCL +
lateral structures torn
• Anteromedial & posteromedial – ACL, PCL,
medial structures torn

72. Posterior ‘sag sign’ for PCL tear

73. Treatment
• Conservative – for grade I-II ACL and PCL tears
– rest, long leg casts (4-6 weeks), NSAIDs etc.
• Operative
▫ Arthroscopy assisted ACL repair
▫ Primary repair (fresh tears)
▫ Reinforcement
▫ Reconstructive operations

74. Methods of ACL repair

75. Fractures of the patella
• Constitute almost 1% of all skeletal injuries
• Resulting from
▫ direct trauma (the knee striking the dashboard of an
automobile or from a fall on the anterior knee)
▫ indirect trauma (a violent contraction of the
quadriceps with the knee flexed)
• May be associated with tears of the medial and
lateral retinacular expansions
• Significant effects
▫ Loss of continuity of the extensor mechanism of the
knee
▫ Potential incongruity of the patellofemoral articulation

76. Classification

77. • Clinical picture – swelling (hemarthrosis),
localized tenderness, inability of the patient to
extend the affected knee.
• In displaced fractures a palpable defect may be
present.
• Aspiration of blood from joint indicates
haemarthrosis
• An open wound in the vicinity of a patellar
fracture (possible sign of an open fracture) –
confirmed by the saline test

78. • X-ray – anteroposterior, lateral, and axial
(Merchant) views.
▫ Transverse fractures usually best seen on a lateral
view,
▫ vertical fractures, osteochondral fractures, and
articular incongruity best evaluated on axial views.
▫ A comparison view of the opposite knee
sometimes is necessary to differentiate an acute
fracture from a bipartite patella, (a failure of
fusion of the superolateral portion of the patella,
usually bilateral)

79. Treatment
• Nonoperative – closed fractures with minimal
displacement, minimal articular incongruity,
and an intact extensor retinaculum
▫ immobilizing the knee in extension in a cylinder
cast from ankle to groin for 4 - 6 weeks, with
weight bearing allowed as tolerated
• Operative – fractures associated with retinacular
tears, open fractures, fractures with more than 2
to 3 mm of displacement or incongruity

80. • When the skin is normal, the operation should
be performed as soon as is practical.
• Delay retards convalescence and unfavorably
affects the result.
• If contusion or laceration of the skin is
present, it is best to perform the operation
immediately on admission to the hospital or
very soon thereafter.
• When lacerations or abrasions become
superficially infected, surgery must be delayed
7 to 10 days until the danger of contaminating
the operative wound is minimal.

81. Methods
• Wiring techniques
▫ Modified tension band (most rigid fixation)
▫ Lotke longitudinal anterior band (LAB)
▫ Circumferential wiring
▫ Magnusson wiring etc.
• Screw fixation
▫ Figure-of-eight wiring through parallel cannulated
compression screws
▫ Arthroscopically assisted percutaneous screw fixation
(full knee range of motion regained in > cases)
• Patellectomy – indicated in severe comminution
(impairs the efficiency of the quadriceps
mechanism)
▫ Partial patellectomy (preferarble)
▫ Total patellectomy

82. Types of patellar fixation. A, Modified tension
band. B, Lotke longitudinal anterior band
(LAB) wiring. C, Magnusson wiring

83. Schauwecker technique of tension
band wiring of patella

84. Displaced transverse fracture of patella fixed with
tension band wires using two anterior wire loops
and two longitudinally directed screws.

85. After treatment
• Posterior plaster splint or removable knee brace in
extension
• Bearing weight as tolerated on the first postoperative
day is allowed. Isometric and stiff-leg exercises are
encouraged
• In patients with stable fixation and limited retinacular
tears, continuous passive motion can be initiated
immediately after surgery if desired.
• Active range-of-motion exercises can be performed
when the wound has healed, (2 to 3 weeks)
• Progressive resistance exercises begun and the brace
discontinued at 6 to 8 weeks if healing is evident on
radiograph. Unrestricted activity can be resumed
when full quadriceps strength has returned, (18 to 24
weeks)
• In patients with less stable fixation or extensive
retinacular tears, active motion should be delayed
until fracture healing has occurred.

86. Comminuted Patellar Fractures
• Often, only one pole of the patella is fragmented
• The substantial (larger) fragment is an
important part of the extensor mechanism and
should be preserved
• Partial patellectomy is the preferred treatment

87. Schauwecker method of compression wiring of patella
using supplemental screws for comminuted fracture
(C). Comminuted fragments (A) are transformed with
screws into bifragmental fracture (B).

88. Complications
• Delayed union
• Malunion
• Non union
• Joint surface incongruity => decreased range of
motion
• Infection
• Post-immobilizational contractures
• Post-traumatic osteoarthritis

89. TIBIAL PLATEAU FRACTURES
• Caused by high-energy mechanisms
• May be associated with
▫ Injury to other articular structures
▫ neurological and vascular injury,
▫ compartment syndrome,
▫ deep vein thrombosis,
▫ contusion or crush injury to the soft tissues,
▫ open wounds
• Major causes:
▫ motor vehicle accidents or bumper strike injuries;
▫ sports injuries, falls, and other less violent trauma
(especially in elderly patients with osteopenia)

91. Classification
Hohl, Moore:
• Type 1, minimally displaced;
• Type 2, local compression;
• Type 3, split compression;
• Type 4, total condyle;
• Type 5, bicondylar.

92. Hohl and Moore classification of tibial
plateau fractures

93. Schatzker:
• Type I — pure cleavage – wedge-shaped
uncomminuted fragment is split off and
displaced laterally and downward
• Type II — cleavage combined with depression
• Type III — pure central depression
• Type IV — fractures of medial condyle - may be
split off as a single wedge or may be comminuted
and depressed
• Type V — bicondylar fractures
• Type VI — plateau fracture with dissociation of
metaphysis and diaphysis

94. Schatzker classification of tibial
plateau fractures

95. Clinical features
• History: determination of the mechanism of injury
and the patient's overall medical status, age, and
functional and economic demands
• Physical examination – detection of concomitant
ligamentous injuries, neurovascular injuries,
compartment syndrome, additional fractures, and
other injuries; common signs and symptoms of
fractures.
• AP, lateral, and oblique radiographs, CT (assessment
of the degree and the size of depressed articular
fragments)
• Compartmental pressure measurement, arteriography
– if indicated

96. Treatment goals
•Restoration of articular congruity,
•Axial alignment,
•Joint stability,
•Functional motion

97. Methods – according to the type of
fracture
• Type I - transverse cancellous screws
• Type II - open reduction, elevation of the
depressed plateau “en mass,” bone grafting of the
metaphysis, fixation of the fracture with
cancellous screws, and buttress plating of the
lateral cortex.
• Type III - bone-grafting, the lateral cortex support
with a buttress plate.
• Type IV - open reduction and fixation with a
medial buttress plate and cancellous screws.
• Type V - buttress plates and cancellous screws
• Type VI - buttress plates and cancellous screws,
pin and wire fixators
Ilizarov’s technique – appropriate in any of the
above cases

98. A, Type II fracture-dislocation of tibial plateau
fixed with plate and screws (B)

99. A and B, Fracture of tibial plateau. C, Stabilization
with Ilizarov circular external fixator. D, After
fixator removal

100. Newer methods
• Arthroscopy
• Limited arthrotomy and percutaneous screw
fixation or external fixation with pin or wire
fixators
• Closed manipulation and casting, especially
with a cast brace
• Traction with early motion.
Newer plating techniques are done with less soft
tissue stripping and employ smaller incisions.

101. Post-operative treatment
• Splinting – a few days followed by early active
knee motion
• Weight bearing should be delayed until fracture
healing is evident (8 to 10 weeks)

102. Complications
• Joint incongruity => post-traumatic
osteoarthritis
• Infection
• Valgus/varus deformity
• Delayed union, malunion, nonunion – resulting
from defects in operative technique

103. Meniscal injury
• The structure of the knee joint most commonly
injured
• Medial meniscus is injured in 80-90% cases,
lateral – 10-20%
• Mechanism
▫ indirect (rotation, twisting of the trunk with leg
fixed, severe extension in the knee) – sports
activities, dancing etc.
▫ direct (squashing mechanism – jumping from
high alt., sudden rise from squatting position;
RTA)

104. Classification (O'Connor)
• (1) longitudinal tears;
• (2) horizontal tears;
• (3) oblique tears;
• (4) radial tears;
• (5) mixed tears (flap tears, complex tears,
degenerative meniscal tears)

105. Basic patterns of meniscal tears: I, longitudinal; II,
horizontal; III, oblique; IV, radial.

106. Longitudinal tears• Most commonly occur as a result of trauma to a
reasonably normal meniscus.
• Usually vertically oriented, may extend completely
through the thickness of the meniscus or partially
through it.
• Is oriented parallel to the edge of the meniscus,
• If complete, a displaceable inner fragment frequently is
produced.
• Bucket-handle tear – when the inner fragment
displaces over into the intercondylar notch
• Peripheral tear - if the tear is near the
meniscocapsular attachment of the meniscus
• A peripheral vertical tear in zone I (red-red tear), and
a tear between zone I and II (red-white tear) are in the
vascularized portion of the meniscus - should be
repaired when feasible.

107. Bucket-handle tear, displaced
centrally

108. • Horizontal tears – more common in older
patients,
▫ The horizontal cleavage plane occurs from
shear, which divides the superior and inferior
surfaces of the meniscus
▫ More commonly seen in the posterior half of
the medial meniscus or the midsegment of the
lateral meniscus.
▫ Many flap tears and complex tears begin with
a horizontal cleavage component.
• Oblique tears - full-thickness tears running
obliquely from the inner edge of the meniscus
out into the body of the meniscus.
▫ posterior oblique tear – the base of the
tear is posterior
▫ the base of an anterior oblique tear is in
the anterior horn of the meniscus

109. • Radial tears – vertically oriented, extending from the
inner edge of the meniscus toward its periphery.
▫ Can be complete or incomplete
▫ Similar in pathogenesis to oblique tears
• Flap tears - have a horizontal cleavage
▫ Can be superior or inferior, depending on where the
flap is based on the surface of the meniscus.
• Complex tears may contain elements of all of the
above types and are more common in chronic
meniscal lesions or in older degenerative menisci.
▫ Are caused by chronic, long-standing, altered
mechanics of the meniscus,
▫ The initial tear occurring in the meniscus may not
be identifiable after several different planes of
tearing have resulted.
▫ Degenerative tears refer to complex tears.
 Present with marked irregularity and complex
tearing within the meniscus
 Are most often seen in older patients.

110. Clinical picture
• Pain, swelling, limitation of active and
passive movements right after trauma
(acute phase)
• On examination – joint defiguration; pain,
tenderness, limited volume of active and
passive movements in the joint;
haemarthrosis on joint puncture
• Ultrasonography, arthroscopy, MRI –
confirm the diagnosis
• X-ray – not informative, however necessary
to be made to exclude bone injury

111. Old (“chronic”) cases
• Considerable cartilage destruction due to
constant functional load on discongruent
articular surfaces
• ‘Blockade symptom – sudden resilient resistance
in attempt of movements in the joint (inability of
full extension most common) due to
interposition of the torn meniscal shred between
articular surfaces of the tibia & femur – may
appear periodically, or may be absent in some
patients
• Periodically developing pain in the joint,
especially after physical stress;
• Local tenderness along the joint surface on the
side of injury

112. • ‘cracking’ sound when moving the limb in knee
joint
• Steinman-Buckhard’s symptom – pain on the
side of injury when rotating the shin to the
opposite side
• ‘Turkish seat’ symptom
• ‘Palm’ symptom
• Femoral muscles atrophy (the patient constantly
spares the injured limb when walking)
• Chucklin’s symptom – contouring of sartorius
muscle when raising the straight leg due to the
quadriceps muscle atrophy
• Turner’s symptom – skin hypesthesia on the
medial surface of the knee joint

113. Treatment
• Conservative – elastic bands, NSAIDs, local cold
application (after trauma)
• Operative – in cases of repeated blockage,
decreasing life quality etc.
▫ Arthrotomy – open meniscectomy – traditional
method
▫ Arthroscopy with partial or complete
meniscectomy – a newer, less traumatic method
that much less interferes with the joint integrity
• After treatment – immobilization – 2-6 weeks

114. Anterior view of knee showing standard and
optional portal sites and landmarks

116. Types of meniscal excision. A, Partial meniscectomy. B,
Subtotal meniscectomy. C, Total meniscectomy

117. Balancing meniscal resection. A, With radial tear.
B, With longitudinal tear. C, With flap tear

118. Basic technique of meniscal suture

119. Complications
• Post-traumatic joint instability
• Post-traumatic osteoarthritis
• Muscle atrophy
• Contractures

120. Ankle joint anatomy

124. Soft tissue structures of the dorsal
surface of the ankle and foot

125. Arteries of the foot and technique of
palpating the dorsal artery of the foot

129. Acute ankle ligament injury• May be the result of:
▫ (1) acute severe ligamentous injuries with joint disruptions,
▫ (2) ligamentous injuries of lesser magnitude from a single
episode or from repetitive “overuse” producing nondisruptive
and microscopic abnormalities of the joint, and
▫ (3) aggravation of preexisting joint abnormalities.
• Sprains constitute 85% all ankle injuries,
▫ and 85% of those involve a lateral inversion
mechanism.
• Ankle injuries account for 14% to 21% of all sports-
related injuries
▫ approximately 40% of basketball injuries
▫ 25% of soccer injuries involve the ankle.
• Compared with men, women have a slightly higher
incidence of ankle injuries in similar sports activities

130. O’Donoghue classification of sprains
• I deg - minor ligamentous “stretch” injuries
• II deg - incomplete ligamentous tears
• III deg - complete disruption of the ligament
or ligaments

131. Classification of Ankle Ligament Injury and
Treatment Recommendations (Clanton)
• Type I, stable ankle to clinical testing (with
anesthesia, if necessary)
• Type II, unstable ankle with positive anterior
drawer test or positive talar tilt test or both
▫ Grade 1, nonathlete or older patient—functional
treatment
▫ Grade 2, athlete or high-demand patient
 Type A, negative radiograph stress test—functional
treatment
 Type B, positive tibiotalar stress test—surgical
repair
 Type C, subtalar instability—functional treatment

132. Signs and symptoms
• Local symptoms
• Clinical signs:
▫ Stress tests (clinical + X-ray)
 Inversion and Eversion Stress Tests – for deltoid
and talofibular ligg.
 Anteroposterior test (anterior drawer sest) – for
anterior talofibular lig.
▫ Squeeze and external rotation tests – for distal
syndesmosis
• Ultrasound, CT, MRI

133. TREATMENT
• Conservative (most cases of acute sprains)
▫ Sturrup brace
▫ Boot immobilization
• Operative – ligament repair
• Distal syndesmosis – operative treatment
required if widening of the joint space
persists after conservative treatment

134. Ankle joint fractures and fracture-
dislocations
• Only slight variation from normal is compatible with good
joint function.
• Radiographs after reduction should be studied with these
requirements in mind:
▫ (1) the normal relationships of the ankle mortise must be
restored,
▫ (2) the weight bearing alignment of the ankle must be at a right
angle to the longitudinal axis of the leg, and
▫ (3) the contours of the articular surface must be as smooth as
possible.
• Best results are obtained by anatomical joint restoration;
methods used:
▫ closed manipulation
▫ open reduction and internal fixation. For most fractures, the
latter method most often ensures anatomical joint restoration
and union.

135. Elements of ankle (Dupuitren’s)
fracture-dislocation
• Fracture medial malleolus or deltoid lig.
rupture
• Fracture lateral malleolus or distal third
fibula or rupture of calcaneofibular lig.
• Subluxation/dislocation talus
• Distal tibiofibular syndesmosis rupture
• Fracture of anterior/posterior part tibia
(trimalleolar fractures)
1 to all of these elements may be present

136. Lauge-Hansen Classification
• Pronation-Eversion (External Rotation) (PER)
▫ Transverse fracture of the medial malleolus or disruption of the deltoid ligament
▫ Disruption of the anterior tibiofibular ligament
▫ Short oblique fracture of the fibula above the level of the joint
▫ Rupture of posterior tibiofibular ligament or avulsion fracture of the posterolateral tibia
• Pronation-Dorsiflexion (PD)
▫ Fracture of the medial malleolus
▫ Fracture of the anterior margin of the tibia
▫ Supramalleolar fracture of the fibula
▫ Transverse fracture of the posterior tibial surface
• Pronation-Abduction (PA)
▫ Transverse fracture of the medial malleolus or rupture of the deltoid ligament
▫ Rupture of the syndesmotic ligaments or avulsion fracture of their insertions
▫ Short, horizontal, oblique fracture of the fibula above the level of the joint
• Supination-Adduction (SA)
▫ Transverse avulsion-type fracture of the fibula below the level of the joint or tear of the
lateral collateral ligaments
▫ Vertical fracture of the medial malleolus
• Supination-Eversion (External Rotation) (SER)
▫ Disruption of the anterior tibiofibular ligament
▫ Spiral oblique fracture of the distal fibula
▫ Disruption of the posterior tibiofibular ligament or fracture of the posterior malleolus
▫ Fracture of the medial malleolus or rupture of the deltoid ligament

137. Clinical picture
• Local signs and symptoms – common to all
fractures
• X-ray – confirms the diagnosis

138. Treatment
• Conservative –
▫ Close reduction + casting – in non-displaced,
stable fractures of a single malleolus
• Operative (preferred) – ORIF
▫ Lag screws
▫ Tension band wires
▫ Kirschner wires
▫ Plate and screws

139. Complications
• Joint instability
• Osteoarthritis
• Irreducible fracture or fracture-dislocation
(operative treatment required)

140. Trimalleolar (Cotton’s) fracture• require open reduction more often than any
other type of ankle fracture.
• The results of treatment usually are not as
good as the results for bimalleolar fractures.
• Usually are caused by an abduction or
external rotation injury.
• In addition to fractures of the medial
malleolus and fibula, the posterior lip of the
articular surface of the tibia is fractured and
displaced, allowing posterior and lateral
displacement and external rotation with
supination of the foot.
• The medial malleolus may remain intact,
with a tear of the deltoid ligament occurring
instead of a malleolar fracture

142. Hindfoot, midfoot, forefoot
fractures, Sheopeur and Lisfranc
joint dislocations – self-preparation !
! !

143. Pes planus (flatfoot)
• loss of the normal medial longitudinal arch.
• Other anatomical abnormalities
▫ valgus posture of the heel;
▫ mild subluxation of the subtalar joint, in which the head
of the talus tilts medially and plantarward, appearing
foreshortened on the standing dorsoplantar radiograph;
▫ eversion of the calcaneus at the subtalar joint;
▫ lateral angulation (abduction) at the midtarsal joint
(talonavicular and calcaneocuboid joints);
▫ supination of the forefoot relative to the hindfoot, which
places the first ray plantigrade.
• Achilles tendon frequently shortened, accentuating
the valgus of the hindfoot.
• Standing radiographs in the anteroposterior and the
lateral planes and nonstanding lateral oblique views
are necessary to evaluate the severity
▫ talocalcaneal divergence on the dorsoplantar view
▫ plantar flexion of the talus on the lateral view.

144. Classification
• Flexible pes planus
• Rigid PP
• PP due to accessory navicular bone

145. Treatment
• Not required unless the child is symptomatic
• PP does not predispose athletes to
subsequent lower extremity injury
• Up to 3 years – not required
• 3 to 14 years - arch support placed in a leather
shoe with a firm heel counter; extended medial
counter; steel shank; Thomas heel; medial heel
wedge can be used if a child is symptomatic
• Specially designed heels may also be used

146. Operative treatment
1. Durham pes planus plasty
2. Plantar flexion osteotomy of medial
cuneiform (Hirose and Johnson)
3. Triple arthrodesis (triplane)
4. Posterior calcaneal displacement osteotomy
(Koutsogiannis)
5. Anterior calcaneal lengthening-distraction
wedge osteotomy (Mosca)

147. Durham plasty for pes
planus.
• A, Incision.
• B, Elevation of posterior tibial
tendon.
• C, Elevation of osteoperiosteal
flap from proximal to distal.
• D, Arthrodesis of navicular–first
cuneiform joint.
• E, Extent of arthrodesis
resection through midfoot.
• F, Internal fixation of
navicular–first cuneiform joint.
• G-I – soft tissue suturing