tutor 10 injury of leg
DESCRIPTION
my presentation during ortho posting,.TRANSCRIPT
PATELLA DISLOCATION
WAN AWATIF WAN MOHD ZOHDI
• 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
Lateral patellar dislocation. (a) Drawing shows the classic mechanism of injury: fixed tibia, internal femoral
rotation, and quadriceps contraction.
• 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
• 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 #)
IMAGING
MRI
X-RAY
VIEW: AP, lateral
In unreduced dislocation: Patella is laterally displaced-tilted/rotated
X-RAY
Soft tissue lesion- disruption of medial patellofemoral ligament
MRI
MANAGEMENT
CONSERVATIVE
SURGICAL
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
SURGICAL MX
In intra articular (intercondylar) dislocation >> open reduction
If swelling, tenderness, bruising (medially)>> d/t patellofemoral ligaments torn, retinacular
t/s torn
• Recurrent dislocation• 1st time –treated as non-operatively• 15-20% recurrent dislocations.
COMPLICATION
TIBIAL PLATEAU FRACTURES
DEFINITION
• A tibial plateau fracture is a fracture involving the proximal (upper) portion of the tibia which extends through the articular surface .
• 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
• 60% lateral pleateau• 15% medial plateau• 25% bicondylar lesions.
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
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.
Clinical features
• Swollen knee• Deformed• Extensive bruising• Doughy tissue (d/t haemarthrosis)• Medial/lateral instability• Examined leg/foot carefully TRO
neuro/vascular injury
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
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
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
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.
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
Assess ligament injury
If unstable joint after the fixation
Repair the torn structure on the lateral side.
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
COMPLICATTIONS
LATE
JOINT STIFFNESS
DEFORMITY
OSTEOARTHRITIS
EARLY
COMPARTMENT SYNDROME
FRATURES OF TIBIA AND FIBULA
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
Pathological anatomy
• Behaviour of these injuries will depends on mode of treatment
• It depends on following factors:
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
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 #
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!!!!
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
MANAGEMENT
Limit soft t/s damage
Prevent/recognize compartment
syndrome
Obtain & hold the #
alignment
Start early weightbearing
Start joint movements
ASAP
LOW ENERGY #
• Gustilo type 1.• Conservative mx
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
EXERCISE
FUNCTIONAL
BRACING
SKELETAL FIXATION
CLOSED INTRAMEDULLARY NAILING
PLATE FIXATION
EXTERNAL FIXATION
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.
Closed #• External fixation• Closed nailing
Open #• Antibiotics• Debridement• Stabilization• rehabilitation
COMPLICATIONS
EARLY
VASCULAR INJURY
COMPARTMENT
SYNDROME
INFECTION
LATE
MALUNION
DELAYED UNION
NON-UNION
JOINT STIFFNESS
OSTEOPOROSIS