tutor 10 injury of leg

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PATELLA DISLOCATION WAN AWATIF WAN MOHD ZOHDI

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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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