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Patella, tibia, foot and ankle injuries
This document provides an overview of common orthopedic injuries of the lower extremity, including the patella, tibia, foot, and ankle. It describes the anatomy, mechanisms of injury, clinical presentation, imaging, and treatment options for fractures of the patella, tibial plateau, tibial shaft, talus, calcaneus, and fifth metatarsal. Treatment may involve non-operative management with casting or early range of motion, or surgical options like open reduction internal fixation or external fixation depending on the fracture pattern and stability. Complications of these injuries include nonunion, malunion, infection, arthritis, and impaired function.
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Patella, tibia, foot and ankle injuries
- 1. Patella, tibia, footand ankle injuries Dr. Yasser Alwabli Orthopedics
- 2. Contents • Patella fracture •Knee dislocation • Tibia fractures • Tibial plateau • Shaft • Ankle fractures • Talus fracture • Calcaneus fracture • Metatarsal fractures
- 3.
- 4. Anatomy • Patella • Largestsesamoid bone • Triangular shape (apex distal) • Distal pole - patellar tendon origin • Proximal pole – quadriceps insertion • Proximal ¾ covered with articular cartilage • Medial/lateral facets: Lateral is typically larger
- 5. Patella fractures • Mechanism •Direct blow • Indirect trauma
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- 11. Imaging – bipartitepatella
- 12. Treatment • Non-operative • Non-displacedfrx (˂ 2 mm) with intact extensor mechanism • Long leg / cylinder cast in extension • Typically 4-6 weeks • Operative • ORIF for displaced, comminuted or disrupted extensor mechanism • Partial patellectomy • Total patellectomy
- 13. ORIF by tensionband wiring
- 14. Tension Band Biomechanical Principle •Distractive forces of quadriceps contracture produces compression along articular surface
- 15. Complications • Anterior kneepain • Symptomatic hardware • Non-union • Stiffness • Infection
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- 17. Knee dislocation • Mechanism •High-energy trauma • 3 out of 4 ligaments should be torn to dislocate the knee • Imaging • X-Ray: AP, Lateral • MRI for surgical planning (later)
- 18. Initial management • X-rays •NV exam • Vascular is priority • Initial stability exam • Reduce knee • Maintain reduction • Secondary studies • MRI • MRA • CTA • Angio
- 22. Other investigations • Ankle-BrachialIndex • Less than 0.9 is abnormal • CT angiography for suspected vascular injury
- 23. Treatment • Urgent closedreduction • Assessment of neurovascular status • Immobilize for 6-8 weeks • Surgery (indications) • Vascular injury • Irreducible dislocation • Open fracture/dislocation
- 24. Initial management • Reduceknee • Usually need relaxation and sedation • If knee remains reduced, brace or splint can be adequate temporarily • If knee re-dislocates, ex-fix • If unable to close reduce, then open reduction needed with placement of ex-fix
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- 27. Anatomy • Consist ofmedial and lateral plateau • Medial larger • Medial lower (concave) • Medial bone harder (thus less likely to fracture) • Lateral higher (convex) • Lateral cartilage thicker (3 vs.. 4 mm) MedialLateral
- 28.
- 29. Anatomy • Bony prominences •Intercondylar eminence (menisci & cruciate ligaments attachment) • Tibial tubercle (patellar tendon) • Gerdy’s tubercle (Iliotibial band)
- 30. Anatomy • Lateral Meniscus •Larger (cover more articular surface) • Commonly torn with lateral plateau fracture • Medial Meniscus • “C” shaped MedialLateral
- 31. Tibial Plateau Fracture •Mechanism • Varus/valgus load with or without axial load • Like fall from height
- 32. Mechanism of Injury •Valgus producing force • Lateral plateau • Varus producing force • Medial plateau • Axial compressive force • Bicondylar plateau • Combination • High energy • Bicondylar plateau • Soft tissue injury
- 33. Mechanism of Injury •Valgus producing force • Lateral plateau • Varus producing force • Medial plateau • Axial compressive force • Bicondylar plateau • Combination • High energy • Bicondylar plateau • Soft tissue injury
- 34. Mechanism of Injury •Valgus producing force • Lateral plateau • Varus producing force • Medial plateau • Axial compressive force • Bicondylar plateau • Combination • High energy • Bicondylar plateau
- 35. Associated Injuries • Ligaments •MCL, LCL • ACL, PCL • Menisci • Popliteal artery • Peroneal nerve • Compartment syndrome MCL tear
- 36. Associated Injuries • Lateralplateau • Tear of meniscus • MCL / ACL tear • Medial Plateau • Fracture / dislocation variant • Popliteal artery injury • Peroneal nerve injury • Bicondylar • Open injury • Compartment syndrome
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- 39. Tibial Plateau Fracture •Presentation • Swelling • Effusion • Inability to bear weight • Always rule out open fractures • Always check for compartment syndrome • Always check NV status
- 40. Evaluation - History •Mechanism of injury • Injury factors • Patient factors • Age • Bone quality • Comorbidities • Previous level of activity • Function demands
- 41. Evaluation – PhysicalExam • Initial Inspection • Skin integrity • Soft tissue swelling • Open fracture • Gross deformity • Shortened limb • Neurovascular status • Document the Exam
- 42. Evaluation – PhysicalExam • Low energy mechanism • Knee swelling • Limited knee ROM • Tender to palpation • Able to assess knee stability • Varus/valgus stress • 0 and 30 degrees • Lachman’s exam for ACL deficiency • High energy mechanism • ATLS • Resuscitation • Limb threatened • Soft tissue integrity • Open fracture • Abrasions • Blisters • Compartment syndrome
- 43. Evaluation – PhysicalExam • Soft tissue assessment • Know • Gustilo open fractures classification • Avoid missing compartment syndrome • Determine timing of surgery
- 44. Evaluation – PhysicalExam • Document NV status • Neurologic • Peroneal nerve • Vascular • Ankle-Brachial Index • ABI > 0.9
- 45. Evaluation – PhysicalExam • ABI < 0.90 • Predictable of arterial injury • Vascular consult • Proceed with arteriogram • ABI > 0.90 • Admit for observation • Followed with serial reassessments
- 46. Tibial Plateau Fracture •Imaging: • X-Ray: AP, Lateral • CT for preop planning, assessing articular depression • MRI • ABI if any differences in pulses between limbs
- 48. Evaluation - Radiographic •CT scan • Surgical consideration exists • Complex fractures to assist in surgical planning • Obtain CT after applying traction (ex fix)
- 49. Evaluation - Radiographic •MRI scan? • Subtle nondisplaced fracture line
- 50. Treatment • Non-operative • Minimallydisplaced frx (˂ 3 mm) • Hinged knee brace + immediate passive ROM • Operative • Delayed ORIF and temporary external fixator • Significant soft tissue injury • ORIF • Displaced ˃ 3 mm • All bicondylar fracture • All medial plateau fractures
- 51. Treatment Principles • Softtissue management • Surgical timing is important • Wrinkles in the skin • Temporary Stabilization • Staged protocol
- 52. Treatment Principles • Anatomicreduction of articular surface • Reduce condylar width • Restore mechanical axis • Stable fixation • Early ROM
- 53. Treatment Options: Nonsurgical •Patient factors • Elderly • Nonambulatory • Injury factors • Articular congruity • Stable Varus / Valgus stress
- 54. Nonsurgical • Immobilize 1-2weeks • Knee immobilizer or hinge knee brace • Start ROM • NWB 6-8 weeks
- 55. Indications for Surgery •Relative indications • Malalignment • Articular incongruity • >3mm in young, active • Condyle widening • Absolute indications • Open tibial plateau • Associated compartment syndrome • Associated vascular injury
- 56. Timing of Surgery LowEnergy: Fixed electively and early High Energy: Be patient
- 57. Temporary External Fixation •Knee external fixation • Improve fracture fragment gross alignment • Length and alignment • Minimize further damage to articular surface
- 58. Complications • Infection • Nonunion •Stiffness • Posttraumatic arthritis
- 59.
- 60. Tibia shaft fractures •Mechanism • Low energy usually torsional injury • High energy, e.g. road-traffic accident
- 61. Tibia shaft fractures •Presentation • Swelling • Pain • Inability to bear weight • Always rule out open fractures • Always check for compartment syndrome • Always check neurovascular status
- 62. Tibial Plateau Fracture •Imaging: • X-Ray: AP, Lateral • Full length • Knee and ankle also
- 68. Treatment • Non-operative • Closedand minimally displaced • or adequate closed reduction • Long leg cast for 8-12 wks • Operative • Displaced or open • If displaced and closed • Standard treatment is reamed IM nail • If open frx – treat as per open fracture guidelines
- 69. Closed Tibial ShaftFracture • Broad Spectrum of Injures w/ many treatments • Closed Management • Intramedullary Nails • Plates • External Fixation
- 70. Non-Operative Treatment Indications •Stablefracture pattern • < 5° varus/valgus • < 10° pro/recurvatum • < 1 cm shortening
- 71. Surgical Indications • InjuryCharacteristics • Open Fracture • Compartment Syndrome • Ipsilateral Femur Fx • Vascular Injury • Fracture Characteristics • Oblique fracture pattern • Coronal Angulation > 5° • Sagittal Angulation > 10° • Rotation > 5° • Shortening > 1cm • Intact fibula
- 72. Surgical Options • IntramedullaryNail • ORIF with Plate • External Fixation • Combination of fixation
- 73. Advantage of IMNail • Less malunion • Early weight-bearing • Early motion • Early WB
- 74. Too Low! TooMedial! Procurvatum Valgus
- 75. Plating of TibialFractures • A plate can be used for shaft fractures • Newer periarticular plates available for metaphyseal fractures
- 76. Advantages of Plating •Anatomic reduction usually obtained
- 77. Disadvantages of Plating •Increased risk of infection and soft tissue problems, especially in high energy fractures • Higher rate hardware failure than IM nail • Delayed WB
- 78. External Fixator • Generally reservedfor open tibia fractures
- 79.
- 88. Imaging • AP, Lateral •Mortise view • CT scan • Especially posterior malleolus
- 89. Initial treatment- reducedislocations
- 90. Treatment • Isolated lateralmalleolus fractures • Isolated medial malleolus fractures • Bimalleolar fractures • Posterior malleolus fractures
- 95.
- 97. Special consideration • Diabetics •Enhance fixation • Delay weight-bearing for 8-12 wks
- 98. Complications • Wound complications •Deep infections • Posttraumatic arthritis
- 99.
- 100. Talus Fractures • Mostcommon at talar neck • Axial load with forced dorsiflexion
- 102. Imaging • AP, Lateral •Canale view • CT scan • Best for delineating fractures
- 103. Treatment • Non-displaced • Short-legcast for 8-12 wks • Displaced • ORIF
- 104. Complications • Osteonecrosis • Varusmalunion • Posttraumatic arthritis
- 105.
- 106. Calcaneal Fractures • Mostfrequent tarsal fracture • High energy, axial loading • fall from height onto heels • 10% of fractures associated with compression fractures of thoracic or lumbar spine (rule out spine injury) • 75% intra-articular and 10% are bilateral
- 107. Imaging • AP, Lateral •Harris view • CT scan • Gold standard • MRI • For calcaneal stress fractures
- 108.
- 111. Treatment • Controversial • Mostlyconservative • Immobilization and NWB for 10-12 weeks • Indications for surgery • Tongue type • Displaced articular • Other general indications for surgery in fractures
- 113. Complications • Wound complications •Posttraumatic arthritis • Compartment syndrome • Malunion
- 114.
- 115. Fifth metatarsal fractures •Common injury • Divided into 3 zones • Zone 2 is Jones fracture • Zone 1 is Pseudojones fracture
- 121.
Editor's Notes
- #6 Direct anterior blow Typically with knee flexed Failure in compression Often comminuted Extensor mechanism may be intact Indirect mechanism Forceful extensor mechanism contraction that exceeds patellar tensile strength 2 part transverse fracture
- #8 Lateral is most helpful.
- #13 Goals Maintain biomechanical/functional integrity Restoration of articular congruity
- #18 Classification based on position of tibia in relation to femur.