Date post: | 05-Jul-2015 |
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Health & Medicine |
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Muscle Attachments
› TFL – Gerdy’s tubercle
› Patellar tendon – Tibial tuberosity
› Sartorius + Gracillis + Semitendinosus – Pes
Anserinus.
› Semimembranosus(Horizontal head) –
Medial Condyle.
› Biceps femoris – small slip to lateral condyle
Articular surface
› Medial condyle bigger than Lateral condyle
› Medial condyle concave in both coronal
and saggital axes.
› Lateral condyle convex in both coronal and
saggital axes.
1 % of all fractures
8 % of all fractures in elderly
Lateral condyle # - 55 – 70%
Medial condyle # - 10 – 25%
Bicondylar # - 10 – 30%
Open # - 1-3%
Varus or valgusforce with axial loading in fully extended or partially flexed knee.
A result of high energy trauma in adults.
A result of tivialfall in osteopenicelderly.
Pain
Swelling & Haemarthroses knee
Inability to bear weight
Restricted mobility
Instability
Deformity Around the Knee
Pale, Cool Foot
Neurovascular injury
Compartment syndrome
DVT
Contussion & crush injury with open
wounds.
Ligamentous injury – more with #
dislocation pattern (60%) as compared
to pure # pattern (4-33%)
Given by Tscherne & Lobenhoffer in
association with # dislocation patterns.
› Meniscal injuries – 67%
› MCL injury – 85%
› Cruciate ligaments injury – 96%
Palpation
1.Elicit tenderness.
2.Any Ligamentous disruption.
Careful neurovascular examination is
done
Skin condition
Pulses
Compartment syndrome
X-rays
› Antero posterior
› Lateral
› Oblique
› Beam at a 10 degree angle caudally
Computed tomography.
Magnetic Resonance Imaging.
•Moore and Hohl classification of
primary # pattern
AO classification
Schatzker’s classification
Type -1› 4-6%› Valgus force + Axial loading
Type – 2› 60-75%› Valgus force
Type – 3› Very rare› Pure compression
Type – 4› 7-10%› High energy varus force +/- Axial loading
Type – 5› 2-3%› High energy complex varus and valgus force
Type – 6› 16-20%› High energy complex varus and valgus force
Goals
›Restore articular congruity.
›Axial alignment.
›Joint stability.
›Functional motion at knee.
Indications
› Unstable # + ligament injury + articular
displacement
Instability - > 10 degrees of varus or valgus
Depression or displacement > 10 mm
› Open #
› # with compartment syndrome
› # with vascular injury
Tscherne and lobenhoffer recommended surgical reduction of fractures with more than 2mm of articular incongruity
Bennet and Browner >5 mm of joint displacement or >5 mm degree of axial malalignment indication of operative treatment
If depression or displacement › <5 mm in stable fracture non operative treatment is
considered
› If 5to 8 mm –
Age
Motion demands
› >10 mm - surgical fixation.
1. Percutaneous screw fixation
› Indications - Nondisplaced type I fractures
› Advantages - Simple technique with minimal
soft-tissue injury.
› Disadvantages - Not applicable for other
patterns of fracture.
1. Percutaneous screw fixation
› Advantages - Simple technique with minimal
soft-tissue injury.
1. Percutaneous screw fixation
› Disadvantages - Not applicable for other
patterns of fractures.
2. Percutaneous elevation and screw
fixation
› Indications - Type II and III fractures in
osteoporotic bone.
2. Percutaneous elevation and screw
fixation
› Advantages - Simple technique with minimal
soft-tissue injury.
2. Percutaneous elevation and screw
fixation
› Disadvantages - Not useful for high-energy
fractures with ligamentous and meniscal
injuries.
3. Arthroscopic-assisted elevation and
screw fixation
› Indications - Types I, II, III, and IV fractures
with ligamentous and meniscal injuries.
3. Arthroscopic-assisted elevation and
screw fixation
› Advantages –
Minimal soft-tissue injury.
Helps to diagnose and treat intra-articular
injuries.
Aids in reduction of depressed articular
fractures.
Allows for joint lavage.
3. Arthroscopic-assisted elevation and
screw fixation.
› Disadvantages - Not useful in high-energy
fractures
4. Open reduction and internal fixation with
or without bone grafting.
› Indications - Types II,III, IV, V, and VI fractures
without soft-tissue injury.
4. Open reduction and internal fixation
with or without bone grafting.
› Advantages –
Allows anatomic reduction.
rigid internal fixation and bone grafting.
facilitates joint exploration and treatment of
intra-articular injuries.
4. Open reduction and internal fixation
with or without bone grafting.
› Disadvantages –
Should not be performed in the acute setting
in the presence of soft-tissue injury.
unnecessary for type I fractures
5. External fixators - Half-pin fixator, ring
fixator, hybrid fixator
› Indications –
Open injuries and high-energy (types IV, V,
and VI) fractures with soft-tissue injury.
fractures with vascular injury with or without
compartment syndrome.
polytrauma patients
5. External fixators - Half-pin fixator, ring
fixator, hybrid fixator
› Advantages –
Minimal soft-tissue injury.
5. External fixators - Half-pin fixator, ring
fixator, hybrid fixator
› Disadvantages –
Nonrigid fixation.
difficult to achieve anatomic fracture
reduction.
joint stiffness.
pin-tract infections.
septic arthritis.
Recovering range of motion is a challenge for patients who› cannot actively participate in rehabilitation,
› may have soft-tissue injuries that preclude immediate range of motion, and
› have had external-fixation pins inserted near their quadriceps. .
Motion is restricted until surgical and traumatic wounds are dry.
Continuous passive motion begins when wounds are dry; the goal is full extension and 90° of flexion within 5-7 days.
If other injuries allow, the patient is mobilized with a hinged brace locked in extension for 6 weeks.
Non – weight-bearing precautions
generally continue for 12 weeks.
Active flexion and passive extension are
encouraged for 6 weeks, after
which active knee extension is started.
Early complications
Compartment syndrome
Vascular injuries
Swelling and wound-healing problems
Infections
Deep vein thrombosis
Late complications
Knee stiffness
Knee instability
Angular deformities
Late collapse
Malunion
Post traumatic arthritis