L07_Patella-Fx-s_mechanism-injuries.ppt

8/19/2019 L07_Patella-Fx-s_mechanism-injuries.ppt

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Patella Fractures & Extensor

Mechanism Injuries

Lisa K. Cannada, MDRevised: October 2008; May 2011


2/67

Anatomy

• Largest sesamoid bone

• Thick artic!ar

carti!age "ro#ima!!y• Artic!ar sr$ace

divided into media!and !atera! $acets by

!ongitdina! ridge• %ista! "o!e

nonartic!ar


3/67

Anatomy

• &ate!!ar Retinac!m

' Longitdina! tendinos

$ibers ' &ate!!o$emora!

!igaments

• (!ood )""!y

' &rimari!y derived $romgenic!ate arteries


4/67

(iomechanics

• The "ate!!a ndergoes a""ro#imate!y * cm

o$ trans!ation $rom $!! $!e#ion to e#tension

• On!y 1+,+8- o$ the "ate!!ar sr$ace is in

contact .ith the $emr throghot its range

o$ motion


5/67

(iomechanics

• The "ate!!a increasesthe moment arm abot

the knee ' /ontribtes " to +0-im"rovement in !everarm

• &ate!!a .ithstandscom"ressive $orcesgreater than * body.eight .ith satting


6/67

(iomechanics

• 2 Tore:

' #tend $ina! 134

' Than to e#tend $rom a$!!y $!e#ed "osition to

13 degrees o$ $!e#ion


7/67

&hysica! #amination

• &ain5 s.e!!ing5 contsions5 !acerations

and6or abrasions at the site o$ in7ry

' /an determine timing o$ o"erative intervention

• &a!"ab!e de$ect

• Assessment o$ abi!ity to e#tend the knee

' /annot "er$orm a straight !eg raise .ith no

e#tensor !ag


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Radiogra"hic va!ation

• A& Latera! ' 9ote "ate!!a height ba7a or a!ta

' 9ote $ractre "attern

• Artic!ar ste",o$$5 diastasis

• Margina! im"action

• )"ecia! vie.s

' A#ia! or snrise

• /T )can

, Occ!t


9/67


• (i"artite &ate!!a:

• Don’t get fooled!

' Obtain bi!atera! vie.s ' O$ten s"ero!atera! corner

(Saupe Classification, 1923)

' Accessory ossi$ication center

' Occrs 1,2- o$ "atients


10/67

tio!ogy

• %irect trama ' %irect b!o. to $!e#ed knee dashboard

' =ncreasing cases .ith "enetrating trama

' /ommintion artic!ar margina! im"action

• =ndirect trama '

mechanism against a contracted adrice"s ' )im"!e5 transverse $ractre


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/!assi$ication

• A!!o.s gidance .ith

treatment

• Ty"es

' Transverse

' Margina!

' >ertica!

' /omminted ' Osteochondra!

' Av!sion not "ictred

Tip: Vertical fractures may not result in disruption of extensor mechanism


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OA6OTA/!assi$ication


13/67

9ono"erative Treatment

• =ndicated $or minima!!y or nondis"!aced $ractres

' ? 2mm o$ artic!ar ste",o$$ ? +mm o$ diastasis with an

intact extensor mechanism (extensor retinaculum) ' =$ di$$ic!ty assessing5 consider intra,artic!ar in7ection o$

!oca! anesthetic to better assess abi!ity to e#tend

• /onsider $or minima!!y dis"!aced $ractres in !o.

demand "atients eva!ate comorbidities $nction• &atients .ith a e#tensive medica! comorbidities


14/67

9ono"erative Treatment

• Long !eg cy!inder cast $or @, .eeks

' May consider a knee immobi!iBer or hinged knee

brace $or the e!der!y6!o. demand

• =mmediate .eight,bearing as to!erated

• Rehabi!itation inc!des range o$ motion

e#ercises .ith grada! adrice"sstrengthening

• &rotect eccentric contraction + months


15/67

O"erative Treatment

• Coa!s ' &reserve e#tensor $nction

' Restore artic!ar congrency

• &reo"erative )et" ' Torniet debatab!e

• &rior to in$!ation5 gent!y $!e# the knee

• A""roach ' Longitdina! mid!ine incision

recommended

' Transverse a""roach a!ternative dotted!ines ' "otentia!!y higher risk .ond

"rob!ems5 can !imit initiation o$ ROM

' /onsider $tre srgeriesD


16/67

&rocedre

Longitdina!=ncision

/!ean


17/67

&rocedre

Redce /om"ress


18/67

O"erative Technies

• E,.ires .6 tension band .iring T(F

• Lag,scre. $i#ation

• /ann!ated !ag,scre. .ith T(F tension

band scre. ' T()

• &artia! "ate!!ectomy

• Tota! &ate!!ectomy


19/67

Tension (and Firing

• Transverse5 non,comminted

$ractres

• Redce and c!am"5 then "!ace

t.o "ara!!e! 1Gmm E, .ires "!aced "er"endic!ar to the

$ractre

• 18 gage .ire "assed behind

"ro#ima!!y and dista!!y• %ob!e


20/67

Tension (and Firing

• Fire converts anterior distractive

$orces to com"ressive $orces at the

artic!ar sr$ace

• T.o t.ists are "!aced on o""osite

sides o$ the .ire

' Tighten sim!taneos!y to achieve

symmetric tension

• Retinac!ar =n7ry ' Eee" o"en nti! the end

' Findo. to assess artic!ar redction

' Re"air the retinac!ar in7ry !ast


21/67

Lag,)cre.


22/67

#am"!e


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#am"!e


24/67

Lag,)cre.


25/67

/ann!ated Lag,)cre. Fith

Tension (and T()• &artia!!y threaded

cann!ated scre.s@G0mm

• Fire throgh scre.s andacross anterior "ate!!a in$igre o$ eight tension

band

• Make sure tip of screwremains uried in oneso it will not compromisewire


26/67

/ann!ated Lag,)cre. Fith

Tension (and• More stab!e constrct

' )cre.s and tension band .ire combination

e!iminates both "ossib!e se"aration seen at the$ractre site .ith E .ire6T(F and scre.

$ai!re de to e#cessive three "oint bending


27/67

)tre vsG Fire Tension (and

osal et al "n#ury $%%&

• Fire vG H3 thibond

• +* "atients• Reo"eration +8- .ire

gro" vsG -

• =n$ection + "ts .iregro" vsG 0

'atel et al "n#ury $%%%

Mcreal et al Med

*ng Tech &+++• /adaveric mode!s

• Ia!ity and stabi!ityo$ $i#ation com"arab!e

to .ire• /onc!de stre an

acce"tab!e a!ternative


28/67

&artia! &ate!!ectomy

• =ndicated $or $ractres invo!ving

e#tensive commintion not amenab!e

to $i#ation

• Larger $ragments re"aired .ith scre.s

to "reserve ma#imm carti!age

• )ma!!er $ragments e#cised

' Jsa!!y invo!ving the dista! "o!e


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&artia! &ate!!ectomy

• Tendon is attached to $ragment .ithnonabsorbab!e stre "assed throgh dri!!

ho!es in the $ragment ' %ri!! ho!es sho!d be near the artic!ar sr$ace to

"revent ti!ting o$ the "ate!!a

• Load sharing .ire "assed throgh dri!! ho!es

in the tibia! tberc!e and "ate!!a may be sedto "rotect the re"air and $aci!itate ear!y rangeo$ motion


30/67

Tota! &ate!!ectomy

• =ndicated $or dis"!aced5 comminted

$ractres not amenab!e to reconstrction

• (one $ragments shar"!y dissected

• %e$ect may be re"aired throgh a variety o$

technies

• Jsa!!y res!ts in e#tensor !ag +04 and

!oss o$ strength +0- ' H Kaufer, JBJS


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&osto"erative Management

• =mmobi!iBation .ith knee brace5 F(AT in e#tension

• ar!y range o$ motion ' (ased on intrao"erative assessment o$ re"air bone a!ity

' Active $!e#ion .ith "assive e#tension

• Iadrice"s strengthening ' (egin .hen there is radiogra"hic evidence o$ hea!ing5

sa!!y arond .eeks

• Modi$y de"ending "on $ractre5 osteo"orosis5comorbidities5 tenos $i#ation and6or .onds at risk


32/67

/om"!ications

• Enee )ti$$ness

' Most common

com"!ication

• =n$ection

' Rare5 de"ends on so$t

tisse com"romise

• Loss o$


33/67

9onnion


34/67

Loss o$


35/67

Ma!nion


36/67

Extensor Tendon Rutures

• &atients are ty"ica!!y ma!es in

their +0s or @0s

' &ate!!ar ? @0 yo ' Iadrice"s @0 yo

• Mechanism

' A

' Tendono"athies5 )teroids5 Rena!

%ia!ysis


37/67

Iadrice"s Tendon R"tre

• Ty"ica!!y occrs in "atients @0 years o!d

• Jsa!!y 0,2 cm above the s"erior "o!e

• Leve! o$ten associated .ith age

' R"tre occrs at the bone,tendon 7nction in

ma7ority o$ "atients @0 years o!d

' R"tre occrs at midsbstance in ma7ority o$ "atients ? @0 years o!d


38/67

Iadrice"s Tendon R"tres

• Risk


39/67

Kistory

• )ensation o$ a sdden "o" .hi!e stressing

the e#tensor mechanism eccentric !oad

• &ain at the site o$ in7ry

• =nabi!ity to e#tend the knee

• %i$$ic!ty .eight,bearing


40/67

&hysica! #am

• $$sion

• Tenderness at the

""er "o!e• &a!"ab!e de$ect aboves"erior "o!e

• Loss o$ e#tension

• Fith "artia! tears5e#tension .i!! beintact


41/67

Iadrice"s Tendon R"tre

,adiographic *-aluation

• ,ray, A&5 Latera!5 and

Tangentia! )nrise5Merchant ' %ista! dis"!acement o$

the "ate!!a "ate!!a ba7a

•MR= ' Jse$! .hen diagnosis

is nc!ear

Treatment

• 9ono"erative

' &artia! tears and strains• O"erative

'


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O"erative Treatment

• Rea""ro#imation o$ tendon to bone sing

nonabsorbab!e stres .ith tears at the

msc!e,tendon 7nction ' Locking stitch (nne!5 Erako. .ith 9oG 3

ethibond "assed throgh vertica! bone tnne!s

' Re"air tendon c!ose to artic!ar sr$ace to avoidabnorma! "ate!!ar ti!ting


43/67

O"erative Treatment

• Midsbstance tears may

ndergo end,to,end re"air

a$ter edges are $reshened

and s!ight!y over!a""ed ' May bene$it $rom

rein$orcement $rom dista!!y

based "artia! thickness

adrice"s tendon trned

do.n across the re"air site)cderi Technie


44/67

Treatment

• /hronic tears may

reire a >,P

advancement o$ aretracted adrice"s

tendon /odivi!!a >,P,

"!asty Technie


45/67


• Enee immobi!iBer5 Kinged Enee (race5 or

cy!inder cast $or 3, .eeks

• =mmediate .eight,bearing as to!erated

• At 2,+ .eeks5 hinged knee brace starting

.ith @3 degrees active range o$ motion .ith

10,13 degrees o$ "rogression each .eek


46/67

/om"!ications

• Rer"tre

• &ersistent adrice"s

atro"hy6.eakness

• Loss o$ motion

• =n$ection


47/67

&ate!!ar Tendon R"tre

• Less common than

adrice"s tendon

r"tre• Associated .ith

degenerative changes

o$ the tendon

• R"tre o$ten occrsat in$erior "o!e

insertion site


48/67

&ate!!ar Tendon R"tre

• Risk


49/67

Anatomy

• &ate!!ar tendon

' Averages @ mm thick bt .idens to 3, mm at

the tibia! tberc!e insertion ' Merges .ith the media! and !atera! retinac!m

' Q0- ty"e = co!!agen


50/67

(!ood )""!y

•


51/67

(iomechanics

• Createst $orces are at 0 degrees

o$ $!e#ion

• +,@ times greater strain are at the

insertions com"ared to the

midsbstance "rior to $ai!re

•


52/67

Kistory

• O$ten a re"ort o$

$orce$! adrice"s

contraction against a$!e#ed knee

• May e#"erience and

adib!e N"o"

• =nabi!ity to .eightbearor e#tend the knee


53/67

&hysica! #amination

• &a!"ab!e de$ect

• Kemarthrosis

• &ain$! "assive knee$!e#ion

• &artia! or com"!ete !osso$ active e#tension

• Kigh riding "ate!!a onradiogra"hs "ate!!aa!ta


54/67


• A& and Latera! ,ray ' &ate!!a a!ta seen on !atera! vie.

• &ate!!a s"erior to (!mensaats !ine

• J!trasonagra"hy ' $$ective means to con$irm diagnosis by determining

continity o$ tendon

' O"erator and reader de"endant

• MR= ' $$ective means to assess "ate!!ar tendon5 es"ecia!!y i$other intraartic!ar or so$t tisse in7ries are ss"ected

' Re!ative!y high cost


55/67

/!assi$ication

• 9o .ide!y acce"ted means o$ c!assi$ication

• /an be categoriBed by:

' Location o$ tear

• &ro#ima! insertion most common

' Timing bet.een in7ry and srgery

• Most im"ortant $actor $or "rognosis• Acte: ? 2 .eeks

• /hronic: 2 .eeks


56/67

Treatment

• )rgica! treatment is

reired $or restoration

o$ the e#tensor

mechanism

• Re"airs categoriBed as

ear!y or de!ayed


57/67

ar!y Re"air

• (etter overa!! otcome

• &rimary re"air o$ the tendon

• )rgica! a""roach is throgh a mid!ine incision ' =ncise 7st !atera! to tibia! tberc!e as skin thicker .ith

better b!ood s""!y to decrease .ond com"!ications

• &ate!!ar tendon r"tre retinac!ar tears are e#"osed

•


58/67

ar!y Re"air

• Fith a (nne!! or Erako.

stitch5 t.o ethibond stres or

their eiva!ent are sed to

re"air the tendon to the "ate!!a• %ri!! ho!es in "ate!!a in mid,

sagitta! "!ane to "revent ct ot

o$ stre

• )tres "assed throgh three "ara!!e!5 !ongitdina! bone

tnne!s and tied "ro#ima!!y


59/67

ar!y Re"air

• Re"air retinac!ar tears

• May rein$orce .ith .ire5

cab!e or mbi!ica! ta"e• Assess re"air

intrao"erative!y .ith knee

$!e#ion


60/67


• Maintain hinged knee brace .hich is grada!!y increasedas motion increases tai!or to the "atient

• =mmediate vsG de!ayed + .eeks .eightbearing as

to!erated• At 2,+ .eeks5 hinged knee brace starting .ith @3 degrees

active range o$ motion .ith 10,13 degrees o$ "rogressioneach .eek

•=mmediate isometric adrice"s e#ercises• A!! restrictions are !i$ted a$ter $!! range o$ motion andQ0- o$ the contra!atera! adrice"s strength are obtained;sa!!y at @, months


61/67

%e!ayed Re"air

• .eeks $rom initia! in7ry

• O$ten res!ts in "oorer otcome

• Iadrice"s contraction and "ate!!ar migration areencontered

• Adhesions bet.een the "ate!!a and $emr may be "resent

• O"tions inc!de hamstring and $ascia !ataatogra$t agmentation o$ "rimary re"air orAchi!!es tendon a!!ogra$t


62/67


• More conservative .hen com"ared to ear!y

re"air

• (iva!ved cy!inder cast $or .eeks; maystart "assive range o$ motion

• Active range o$ motion is started at .eeks


63/67

/om"!ications

• Enee sti$$ness

• &ersistent e#tensor .eakness

• Rer"tre

• =n$ection

• &ate!!a ba7a =nsa!!,)a!vati ratio o$ ? 0G8


64/67

Re$erences &ate!!a


65/67

Re$erences &ate!!a


66/67

Re$erences:

#tensor Mechanism =n7ries• )i.ek /F5 Rao &G R"tres o$ the e#tensor

mechanism o$ the knee 7ointG J Bone Joint Sur& $"

1Q81; +:Q+2,Q+*G

• (hargava )&5 Kynes M/5 %o.e!! EG Tramatic

"ate!!a tendon r"tre: ear!y mobi!iBation

$o!!o.ing srgica! re"airG Injury 200@;+3:*,*QG

• Eonrath CA5 /hen %5 Lock T et a!G Otcomes$o!!o.ing re"air o$ adrice"s tendon r"tresG J

Ortop !rau"a 1QQ8;12:2*+,2*QG


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Thank You!Thank You!

lcannada.slu/edu

R=$ yo .o!d !ike to vo!nteer as an athor $or the
http://../index_lower%20extremity.htmlhttp://www.ota.org/res_slide/index.htmlmailto:[email protected]?subject=Resident%20Slide%20Presentation%20L07http://../index_lower%20extremity.html

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