patella and tibial plateau fractures
TRANSCRIPT
Patella and tibial plateau fractures
presented by
Aisha Motaher Abutaleb
Patella f ractures
Anatomy
Mechanism
Fractures of the patella are caused by
A. Direct violence (injury)Due to trauma to anterior aspect of the flexed knee leading to comminuted fractures.
B. Indirect violence (injury)Due to forced flexion of the knee when the sudden quadriceps muscle is contracting In these case the fracture is transfers
Types of fractures
1. Undisplaced transverse fractureDue to direct injury , the two fragment of the patella are undisplaced as they are held in position by the pre patellar expansion of the quadriceps tendon and patellar tendon
2. Displaced transverse fracture
Due to more sever trauma with gap between the fragment
(this is indirect injury due to forced , passive flexion of the knee while the quadriceps muscle is contracted
Active knee extension is impossible
3.Comminuted (stellate) fractureDue to fall or direct injury on the front of the knee
4.Vertical fractureOne or two small fragments are separated from the medial or
lateral border of the patella
Clinical features
1. Local pain and tenderness3. Swelling 1. Palpable gap between the fragment2. presence of crepitus is felt 3. An x- ray examination Fissure or crack fracture Transverse fracture with dislocation Comminuted fracture
Treatment1. Undisplaced transvers fractures
Immobilization of knee by long leg plaster splintage for 4-6 weeks combined with quadriceps exercise
If there is a heamarthrosis , it is aspirated under aseptic condition
2. Displaced transverse fractures Open reduction and internal fixation with screw
especially if pt is young
Small pollar fragment may be excised
Reduction and maintenance of the reduced position may also be gained by strong wire passed around periphery of the patella
In all these cases , the leg is splinted in long leg plaster for 8 weeks
3. Comminuted fractures Undisplacemen-A fracture with little or no displacement
can be treated conservatively by a posterior slab of plaster that is removed several times a day for gentle active exercises.
Displacement Reduction is impossible and so the best treatment are
1. partial patelloectomy with the segment held by circlage wire and the leg is splinted in the extended position for 2
weeks
2. Total patelloectomy is excision of all the segment and the quadriceps aponeurosis is reconstructed by absorbable suture
early physiotherapy after the operation prevent knee
stiffness
Patella-hinged brace
Complications Knee Stiffness Most common complication
OsteoarthritisMay result from articular damage
ChondromalagiaUnunion loss of fixation
Dislocation of the patellais almost always over the lateral
femoral condyle
Mechanism
1. Direct trauma
2. sudden muscular contraction
In the presence of
Flattening of the lateral femoral condyle
Genu valgus and external rotation
Ligamentous laxity
Anatomical bony abnormalities :-
Small or high patella
clinical feature Locking of the knee in the flexed position
Swelling of the knee due to haemarthrosis
Tenderness over the anteromedial aspect of the knee joint
Positive patellar apprehension test
An x-ray examination would reveal the dislocation
1. Traumatic acute dislocation this result from an injury on the medial side of the knee while the knee in flexed position
TreatmentReduced under sedation the knee is immobilized in the extended position in a plaster of Paris cylinder for 3 weeks
Complication
Osteoarthritis
Recurrent dislocation
2. Recurrent dislocation predisposing factors
Post traumatic as rupture or weakness of medial patellar retinaculum
Anatomical bony abnormalities Small and high patella Unequal pull of the quadriceps muscle
component • Weakened vastus medialis • Shorter vastus lateralis• Genu valgus
surgical reconstruction
1. Direct medial patello-femoral ligament repair
2. Suprapatellar realignment (Insall)
3. Infrapatellar soft-tissue realignment (Goldthwaite)
3 4. Infrapatellar bony realignment (Elmslie–Trillat)
Treatment
TIBIAL PLATEAU FRACTURES
Anatomy
Mechanism of injury -:Fractures of the tibial plateau are caused
by varus or valgus force
force is more likely to rupture the ligaments
a car striking
fall from a height
Classification of Schatzker -:Type 1 – simple split of the lateral condyle
Type 2 – a split of the lateralcondyle with a more central area of depression.
Type 3the articular surface with an intact condylar rim
Type 4 – a fracture of the medial condyle.
Type 5
–fractures of both condyles, but with the central
portion of the metaphysis still connected to the tibial
shaft.
Type 6– combined condylar and subcondylar fractures
effectively a disconnection of the shaft from the
metaphysis.
Clinical feature1. Sever pain
2. Swelling
3. Valgus deformity
4. Local tenderness
on examination:-The knee may suggest medial or lateral instability
the leg and foot should be carefully examined
for signs of vascular or neurological
X-ray:-X-rays provide information about the position
of the main fracture lines
and areas of articular surface depression
CT :-for reveal direction and extent of displacement
Treatment
Type1 Undisplaced type 1 fractures can be treated
conservatively
Displaced fractures should be treated by open reduction and internal fixation
Type2 1. If the depression is slight (less than 5 mm)or
patient is old , the fracture is treated closed with the aim of
regaining mobility and function rather than anatomical
restitution. skeletal traction is applied with 5kg for 4 – 6 w
2. In younger patients, and in those with a central
depression of more than 5 mm, open reduction with
elevation of the plateau and internal fixation is often
preferred
Type3 Depression of more than 5 mm in a type 3 fracture
can be treated by elevation from below and supported by bone
grafts and fixation
Type 4
Treated by open reduction and internal fixation .
Type 5,6 Open reduction and internal fixation with plate
and screw.
A combination of screw fixation and circular external fixation is lower risk complication .
Complication EARLY:-
Compartment syndrome
Late :-
Joint stiffness.
Deformity.
Osteoarthritis
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