Knee dislocation

COLLES FRACTUREKNEE DISLOCATIONPRADHANEESH KUMARAN UTHAYAKUMARANANG SHU TINGNEHSAN Transverse fracture of the radius just above the wrist, with dorsal displacement of the distal fragment

Most common of all fractures in older people particularly in post-menopausal osteoporosis women

An older woman who gives a history of falling on her outstretched hand.COLLES FRACTUREForce is applied in the length of the forearm with the wrist in extension

Bone fractures at the cortico-cancellous junction

Distal fragment collapses into extension, dorsal displacement, radial tilt and shorteningMECHANISM-- FALL ON OUTSTRETCHED HAND

CLINICAL FEATURESDinner-fork deformity (prominence on the back of the wrist and a depression in front)Local tenderness and pain on wrist movements

DINNER FORK DEFORMITYOn X-ray:

Transverse fracture of the radius at the corticocancellous junctionUlnar styloid process is broken off (often)Radial fragment is impacted into radial and backward tiltSometimes there is an intraarticular fracture; sometimes it is severely comminuted

TREATMENTUndisplaced/slightly displaced:

Applied dorsal splint for a day or two until swelling has resolved, put cast thenTake X-ray at 10-14days to ensure the fracture is not slipped. If slipped, surgery is required.Cast can usually be removed after 4 weeks to allow mobilization

2) Displaced fracture:Reduced under anaesthesia (haematoma block, Biers block, or axillary block)Hand is grasped & traction is applied in the length of the bone- to disimpact the fragmentsThe distal fragment is then pushed into place by pressing on the dorsum while manipulating the wrist into flexion, ulnar deviation and pronationPosition is checked by X-ray before dorsal plaster slab is applied (extending from below the elbow to the metacarpal necks) and held in position by crepe bandage - maintaining the wrist in palmar flexion & ulnar deviation- Colles cast

TREATMENT

COLLES CASTExtreme position of flexion and ulnar deviation must be avoided; 20 degrees in each direction is adequate.The arm is kept elevated for the next day or two, shoulder and finger exercises are started asap.At 7-10 days fresh x-rays are taken to check for redisplacement (not uncommon) For patients with high functional demands : remanipulation and internal fixation.For older patients with low functional demands : modest degree of displacement is acceptable.The fracture unites in about 6 weeks,then slab can be safely discarded and exercises begun.3) Comminuted fractures:Sometimes fractures can be reduced and held with percutaneous wiresExternal fixator (if severe) with bone graft/substitute placed into the gap; fixator is attached to the distal radius and the second metacarpal shaftPlate fixation volar locking plate applied to the front of radius through the bed of flexor carpi radialisLocked intramedullary nailCrossed K-wireTREATMENTComminuted colles fracture reduced and held with percutaneous wires

Usually good.The amount of displacement depends on the patients factors such as age, commorbidity, functional demands, handedness, quality of bone, and treatment factors such as surgical skills and implants availableShortening of > 2mm at the distal radio-ulnar joint, dorsal tilt of >10degrees and dorsal translation of >30% leads to poor outcome and need early correction.Poor outcomes can be improved by osteotomyOutcome COMPLICATIONSEarly1) Circulatory problems- finger circulation must be checked, bandage is loosened2) Nerve injury- compression of the median nerve is common (CTS). May resolve with release of the dressings and elevation (mild). If severe, divide the transverse ligament

3) Reflex sympathetic dystrophy- quite common, seldom proceed to Sudecks atrophy. There may be swelling and tenderness of finger joint (so dont neglect the daily exercises). 5% of cases, hand is stiff and painful on removal of plaster. X-rays show osteoporosis and there is increased activity on the bone scan

4) TFCC injury as the distal radius displaces dorsally.

Late1) Joint stiffnessFinger is the commonest; also shoulder and elbow stiffness from neglect.Joints which are out of plaster should be moved several times/day2) Malunion - Due to not complete reduction or redisplacement of the fracture within the plaster so that a dinner-fork deformity results. There is weakness and loss of rotation. Excised the lower 1.5cm of ulna to restore rotation and osteotomy to correct the radial deformity

COMPLICATIONS3) Delayed union and Non-union : Non-union of the radius is rare.

4) Rupture of the extensor pollicis longus tendon - very rare, due to loss of blood supply to the tendon at the time of fracture/friction on the tendon in a malunited fracture

SMITHS FRACTUREReversal of Colles fractureUncommon, seen in adults and elderlyFalls on the back of the handDistal fragment displaces ventrally and tilts ventrallyGarden Spade deformityTreatment: closed reduction and plaster cast immobilisation for 6 weeksComplications are similar to Colles fracture19

SMITHS FRACTURE20In contrast to colles fracture, the displacement of lower radial fragment is forwards not backwards.

The knee is a very stable joint generally requiring high-energy trauma to produce dislocation.The cruciate ligaments and one or both lateral ligaments are torn.Motor vehicle collisionsAuto-pedestrian impactIndustrial injuriesFallsAthletic injuries

Knee dislocationKnee dislocations are described using either positional or anatomical classification systems.The positional classification system was developed by Kennedy and describes 5 major types of positional dislocation. It describe the position of the tibia relative to the femur.Knee dislocation

1. Anterior dislocation :most common typeof dislocation (30-50%)due to hyperextension injuryusually involves tear of PCLarterial injury is generally anintimal teardue to traction2. Posterior dislocation: 2nd most common type (25%)due to axial load to flexed knee (dashboard injury) or a high-energy fall on a flexed knee.highest rate ofcomplete tear ofpopliteal artery

Knee dislocation3. Lateraldislocation :13% of knee dislocationsdue to varus or valgus forceusually involves tears of both ACL and PCLhighest rate of peroneal nerve injury4. Medial dislocation : varus or valgus forceusually disrupted PLC and PCL5. Rotational dislocation :posterolateral is most common rotational dislocationusuallyirreducible

Knee dislocationThe anatomical classification system :Schenck Classificationbased on pattern of multiligamentous injury of knee dislocation (KD)

- C (added to above) - Arterial injury included - N (added to above) - Nerve injury included

Knee dislocationSchenck ClassificationKD IMultiligamentous injury with involvement of ACLorPCLKD IIInjury to ACL and PCL only (2 ligaments)KD IIIInjury to ACL, PCL, and medial collateral ligament (MCL) or lateral collateral ligament (LCL) (3 ligaments)KD IVInjury to ACL, PCL, PMC, and PLC (4 ligaments)KD VMultiligamentous injury with periarticular fractureClinical Features :Severe bruising and swellingGross deformity of the kneeCirculation maybe impaired as the popliteal artery maybe torn or obstructedMay have compartment syndromeCommon peroneal nerve injury (20%) decreased sensation at the first webspace with impaired dorsiflexion of the foot.

Knee dislocationX- Ray: AP and Lateral

Abnormal joint spaceSubluxationAssociated Fractures (proximal tibia, distal femur)

Knee dislocation

Avulsionstibial spine posterior part of the plateau (PCL avulsion), fibular styloid (LCL)lateral tibial condyle (Segond fracture).Also, medial epicondyle (MCL)Lateral epicondyle (LCL)

Knee dislocation

ArteriographOnly when clinical assessment of circulation is abnormal.Ankle/brachial arterial pressure index(ratio of systolic pressure at the ankle relative to systolic pressure at the elbow) should not be less than 0.9.Knee dislocation

CT ScanAvulsions ( better detail)Associated fractures (distal femur, proximal tibia)CT Angio

MRI Gives detail of all non-bony structures :MenisciArticular cartilageLigamentsTendons (biceps, Popliteus, ITB)MR Angiogram (MRA)

Knee dislocation

Treatment:REDUCTION under ANESTHESIA (Closed Reduction)- Should be done IMMEDIATELY with sufficient muscle relaxation (Dont apply aggressive force!)- By pulling directly in the line of the leg (hyperextension should be avoided because of the danger to the popliteal vessels).After reduction, resting the limb on a back-splint and the circulation is checked repeatedly during 48 hours.Vascular injury required immediate repair and the limb is splinted with an anterior external fixator.

Knee dislocation

POSITION of DISLOCATION (Tibia relative to Femur)

AnteriorTraction & elevation of distal femurPosteriorTraction & extension of proximal tibiaLateral / MedialTraction & correctional translationRotationalTraction & correctional derotation

Closed Reduction ManeuverIrreducible by Closed methodsRareTypically POSTEROLATERALDimple sign Puckering of anteromedial skinButtonhole of medial femoral condyle through soft tissues (capsule, MCL, retinaculum, vastus medialis)Watch for skin necrosis

Open Reduction

Repair or reconstruction of the capsule and collateral ligaments enable early movement of the knee with the support of a hinged knee brace.Early reconstruction of the torn ligaments followed by protected movement of the joint reduces the severity of the joint stiffness.Prolonged cast immobilization is no longer recommended(less good at preseving function of the knee)Knee dislocationComplications :Early : - arterial damage : popliteal artery damage (20%)Needs immediate repair; if delay, can leads to ischemia and result in amputation. - nerve injury : lateral popliteal nerve injuryspontaneous recovery is possible if nerve is not completely disrupted. If no sign of recovery, a transfer of tendon of tibialis posterior through the interosseous membrane to the lateral cuneiform restore the ankle dorsiflexion. Knee dislocationLate : - joint instability - stiffness : loss of movement due to prolonged immobilization

Knee dislocationTHANK YOU38