Download - Tutor 10 injury of leg
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PATELLA DISLOCATION
WAN AWATIF WAN MOHD ZOHDI
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• Knee flexed, quadriceps relaxed >> patella forced laterally by direct force.:RARE
• Common: due to indirect force
MECHANISM OF INJURY
Sudden, severe contraction of quadriceps muscleWhile the knees is stretch in VALGUS & EXTERNAL
ROTATION
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Lateral patellar dislocation. (a) Drawing shows the classic mechanism of injury: fixed tibia, internal femoral
rotation, and quadriceps contraction.
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• 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
CLINICAL FEATURES
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• Downward dislocation Stuck btw condylesMarked prominence on front of the knee• If spontaneous reduction:-swollen knee-bruising tenderness on medial side• Joint aspiration-blood stained-fat droplets (concurrent osteochondral #)
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IMAGING
MRI
X-RAY
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VIEW: AP, lateral
In unreduced dislocation: Patella is laterally displaced-tilted/rotated
X-RAY
Soft tissue lesion- disruption of medial patellofemoral ligament
MRI
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MANAGEMENT
CONSERVATIVE
SURGICAL
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CONSERVATIVE MX
Push 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
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SURGICAL MX
In intra articular (intercondylar) dislocation >> open reduction
If swelling, tenderness, bruising (medially)>> d/t patellofemoral ligaments torn, retinacular
t/s torn
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• Recurrent dislocation• 1st time –treated as non-operatively• 15-20% recurrent dislocations.
COMPLICATION
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TIBIAL PLATEAU FRACTURES
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DEFINITION
• A tibial plateau fracture is a fracture involving the proximal (upper) portion of the tibia which extends through the articular surface .
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• 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
MECHANISM OF INJURY
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• 60% lateral pleateau• 15% medial plateau• 25% bicondylar lesions.
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TYPE 1:vertical split of the
lateral condyle
TYPE 2: vertical split of the lateral condyle +
depression of an adjacent loadbearing part of the
condyle
TYPE 3 : depression of the articular
surface with an intact condylar rim
TYPE 4 : # of the medial
tibial condyle
TYPE 5 : # of both condyles
TYPE 6 : combined condylar &
subcondylar #
PATHOLOGICAL ANATOMY
Schatzker classification
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Type 1 •In younger people•Virtually undisplaced•Condylar fragment may be pushed inferiorly or tilted
Type 2 •Joint is widened•If # is not reduced : >> valgus deformity
Type 3 •Split to the edge of the plateau is absent•Stable joint•May tolerate early movement
Type 4 •2 types #•Low energy lesion : depressed, crush # of osteoporotic bone in elderly pt•High energy l/s : condylar spilt that runs obliquely
Type 5 •Column of metaphysis wedged in btw that remains in continuity with the tibial shaft
Type 6 •High energy injury•>>severe comminution•Tibial shaft disconnected from tibial condyles.
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Clinical features
• Swollen knee• Deformed• Extensive bruising• Doughy tissue (d/t haemarthrosis)• Medial/lateral instability• Examined leg/foot carefully TRO
neuro/vascular injury
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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
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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
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TYPE 2 #
Slight depression(<5mm), stable knee, old patient,
osteoporotic pt•# is treated closed to gain mobility and fx ( not anatomical restitution)•Aspiration•Compression bandage•Skeletal traction via threaded pin.•Active exercises every day•# -sticky in 3-4 weeks >> remove traction pin•Apply hinge cast brace•Full weight bearing deferred ; 6 weeks
Depression >5mm
•Open reduction with elevation of plateau•Internal fixation•Small 3.5 mm screws // beneath the subchondral bone hold up elevated fragments : raft screws•Buttress plate :-in type 2,,5 or 6
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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.
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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
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Assess ligament injury
If unstable joint after the fixation
Repair the torn structure on the lateral side.
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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
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COMPLICATTIONS
LATE
JOINT STIFFNESS
DEFORMITY
OSTEOARTHRITIS
EARLY
COMPARTMENT SYNDROME
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FRATURES OF TIBIA AND FIBULA
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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
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Pathological anatomy
• Behaviour of these injuries will depends on mode of treatment
• It depends on following factors:
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State of soft tissues
Risk and CX depends on amount and type of
soft tissue damage
open# : Gustilo classification
closed # : Tscherne’s
Severity of bone injury
LOW ENERGY :-closed #
-Gustilo 1, 2 - spiral
HIGH ENERGY:-direct trauma
-open #-Gustilo 3
-transverse-comminuted
Stability of #
Consider displacement when weight bearing
is allowed
Sevely comminuted : least stable, need
mechanical fixation
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IC1 •No skin lesion
IC2 •No skin laceration but contusion
IC3 •Circumscribed degloving
IC4 •Extensive, closed degloving
IC5 •Necrosis from contusion
TSCHERNE’s classification of skin lesions in CLOSED #
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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, • Inability to move toes• Deformity
Alert for the compartment syndrome!!!!
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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
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MANAGEMENT
Limit soft t/s damage
Prevent/recognize compartment
syndrome
Obtain & hold the #
alignment
Start early weightbearing
Start joint movements
ASAP
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LOW ENERGY #
• Gustilo type 1.• Conservative mx
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LOW ENERGY #
Full length cast fr upper thigh to metatarsal necks
Knee is slightly flexed, ankle at a right angle
UNDISPLACED/
MINIMALLY DISPLACED
Reduced under GA with X-ray control
Alignment and rotation must be perfect
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
DISPLACED
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EXERCISE
FUNCTIONAL
BRACING
SKELETAL FIXATION
CLOSED INTRAMEDULLARY NAILING
PLATE FIXATION
EXTERNAL FIXATION
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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.
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Closed #• External fixation• Closed nailing
Open #• Antibiotics• Debridement• Stabilization• rehabilitation
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COMPLICATIONS
EARLY
VASCULAR INJURY
COMPARTMENT
SYNDROME
INFECTION
LATE
MALUNION
DELAYED UNION
NON-UNION
JOINT STIFFNESS
OSTEOPOROSIS
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