Patella, tibia, foot and ankle injuries
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Patella, tibia, foot and ankle injuries
- 1. Patella, tibia, foot and ankle injuries Dr. Yasser Alwabli Orthopedics
- 2. Contents • Patella fracture • Knee dislocation • Tibia fractures • Tibial plateau • Shaft • Ankle fractures • Talus fracture • Calcaneus fracture • Metatarsal fractures
- 4. Anatomy • Patella • Largest sesamoid bone • Triangular shape (apex distal) • Distal pole - patellar tendon origin • Proximal pole – quadriceps insertion • Proximal ¾ covered with articular cartilage • Medial/lateral facets: Lateral is typically larger
- 5. Patella fractures • Mechanism • Direct blow • Indirect trauma
- 6. Clinically
- 7. Imaging
- 8. Imaging
- 11. Imaging – bipartite patella
- 12. Treatment • Non-operative • Non-displaced frx (˂ 2 mm) with intact extensor mechanism • Long leg / cylinder cast in extension • Typically 4-6 weeks • Operative • ORIF for displaced, comminuted or disrupted extensor mechanism • Partial patellectomy • Total patellectomy
- 13. ORIF by tension band wiring
- 14. Tension Band Biomechanical Principle • Distractive forces of quadriceps contracture produces compression along articular surface
- 15. Complications • Anterior knee pain • Symptomatic hardware • Non-union • Stiffness • Infection
- 16. Knee Dislocation
- 17. Knee dislocation • Mechanism • High-energy trauma • 3 out of 4 ligaments should be torn to dislocate the knee • Imaging • X-Ray: AP, Lateral • MRI for surgical planning (later)
- 18. Initial management • X-rays • NV exam • Vascular is priority • Initial stability exam • Reduce knee • Maintain reduction • Secondary studies • MRI • MRA • CTA • Angio
- 22. Other investigations • Ankle-Brachial Index • Less than 0.9 is abnormal • CT angiography for suspected vascular injury
- 23. Treatment • Urgent closed reduction • Assessment of neurovascular status • Immobilize for 6-8 weeks • Surgery (indications) • Vascular injury • Irreducible dislocation • Open fracture/dislocation
- 24. Initial management • Reduce knee • Usually need relaxation and sedation • If knee remains reduced, brace or splint can be adequate temporarily • If knee re-dislocates, ex-fix • If unable to close reduce, then open reduction needed with placement of ex-fix
- 27. Anatomy • Consist of medial and lateral plateau • Medial larger • Medial lower (concave) • Medial bone harder (thus less likely to fracture) • Lateral higher (convex) • Lateral cartilage thicker (3 vs.. 4 mm) MedialLateral
- 29. Anatomy • Bony prominences • Intercondylar eminence (menisci & cruciate ligaments attachment) • Tibial tubercle (patellar tendon) • Gerdy’s tubercle (Iliotibial band)
- 30. Anatomy • Lateral Meniscus • Larger (cover more articular surface) • Commonly torn with lateral plateau fracture • Medial Meniscus • “C” shaped MedialLateral
- 31. Tibial Plateau Fracture • Mechanism • Varus/valgus load with or without axial load • Like fall from height
- 32. Mechanism of Injury • Valgus producing force • Lateral plateau • Varus producing force • Medial plateau • Axial compressive force • Bicondylar plateau • Combination • High energy • Bicondylar plateau • Soft tissue injury
- 33. Mechanism of Injury • Valgus producing force • Lateral plateau • Varus producing force • Medial plateau • Axial compressive force • Bicondylar plateau • Combination • High energy • Bicondylar plateau • Soft tissue injury
- 34. Mechanism of Injury • Valgus producing force • Lateral plateau • Varus producing force • Medial plateau • Axial compressive force • Bicondylar plateau • Combination • High energy • Bicondylar plateau
- 35. Associated Injuries • Ligaments • MCL, LCL • ACL, PCL • Menisci • Popliteal artery • Peroneal nerve • Compartment syndrome MCL tear
- 36. Associated Injuries • Lateral plateau • Tear of meniscus • MCL / ACL tear • Medial Plateau • Fracture / dislocation variant • Popliteal artery injury • Peroneal nerve injury • Bicondylar • Open injury • Compartment syndrome
- 39. Tibial Plateau Fracture • Presentation • Swelling • Effusion • Inability to bear weight • Always rule out open fractures • Always check for compartment syndrome • Always check NV status
- 40. Evaluation - History • Mechanism of injury • Injury factors • Patient factors • Age • Bone quality • Comorbidities • Previous level of activity • Function demands
- 41. Evaluation – Physical Exam • Initial Inspection • Skin integrity • Soft tissue swelling • Open fracture • Gross deformity • Shortened limb • Neurovascular status • Document the Exam
- 42. Evaluation – Physical Exam • Low energy mechanism • Knee swelling • Limited knee ROM • Tender to palpation • Able to assess knee stability • Varus/valgus stress • 0 and 30 degrees • Lachman’s exam for ACL deficiency • High energy mechanism • ATLS • Resuscitation • Limb threatened • Soft tissue integrity • Open fracture • Abrasions • Blisters • Compartment syndrome
- 43. Evaluation – Physical Exam • Soft tissue assessment • Know • Gustilo open fractures classification • Avoid missing compartment syndrome • Determine timing of surgery
- 44. Evaluation – Physical Exam • Document NV status • Neurologic • Peroneal nerve • Vascular • Ankle-Brachial Index • ABI > 0.9
- 45. Evaluation – Physical Exam • ABI < 0.90 • Predictable of arterial injury • Vascular consult • Proceed with arteriogram • ABI > 0.90 • Admit for observation • Followed with serial reassessments
- 46. Tibial Plateau Fracture • Imaging: • X-Ray: AP, Lateral • CT for preop planning, assessing articular depression • MRI • ABI if any differences in pulses between limbs
- 48. Evaluation - Radiographic • CT scan • Surgical consideration exists • Complex fractures to assist in surgical planning • Obtain CT after applying traction (ex fix)
- 49. Evaluation - Radiographic • MRI scan? • Subtle nondisplaced fracture line
- 50. Treatment • Non-operative • Minimally displaced frx (˂ 3 mm) • Hinged knee brace + immediate passive ROM • Operative • Delayed ORIF and temporary external fixator • Significant soft tissue injury • ORIF • Displaced ˃ 3 mm • All bicondylar fracture • All medial plateau fractures
- 51. Treatment Principles • Soft tissue management • Surgical timing is important • Wrinkles in the skin • Temporary Stabilization • Staged protocol
- 52. Treatment Principles • Anatomic reduction of articular surface • Reduce condylar width • Restore mechanical axis • Stable fixation • Early ROM
- 53. Treatment Options: Nonsurgical • Patient factors • Elderly • Nonambulatory • Injury factors • Articular congruity • Stable Varus / Valgus stress
- 54. Nonsurgical • Immobilize 1-2 weeks • Knee immobilizer or hinge knee brace • Start ROM • NWB 6-8 weeks
- 55. Indications for Surgery • Relative indications • Malalignment • Articular incongruity • >3mm in young, active • Condyle widening • Absolute indications • Open tibial plateau • Associated compartment syndrome • Associated vascular injury
- 56. Timing of Surgery Low Energy: Fixed electively and early High Energy: Be patient
- 57. Temporary External Fixation • Knee external fixation • Improve fracture fragment gross alignment • Length and alignment • Minimize further damage to articular surface
- 58. Complications • Infection • Nonunion • Stiffness • Posttraumatic arthritis
- 60. Tibia shaft fractures • Mechanism • Low energy usually torsional injury • High energy, e.g. road-traffic accident
- 61. Tibia shaft fractures • Presentation • Swelling • Pain • Inability to bear weight • Always rule out open fractures • Always check for compartment syndrome • Always check neurovascular status
- 62. Tibial Plateau Fracture • Imaging: • X-Ray: AP, Lateral • Full length • Knee and ankle also
- 68. Treatment • Non-operative • Closed and minimally displaced • or adequate closed reduction • Long leg cast for 8-12 wks • Operative • Displaced or open • If displaced and closed • Standard treatment is reamed IM nail • If open frx – treat as per open fracture guidelines
- 69. Closed Tibial Shaft Fracture • Broad Spectrum of Injures w/ many treatments • Closed Management • Intramedullary Nails • Plates • External Fixation
- 70. Non-Operative Treatment Indications •Stable fracture pattern • < 5° varus/valgus • < 10° pro/recurvatum • < 1 cm shortening
- 71. Surgical Indications • Injury Characteristics • Open Fracture • Compartment Syndrome • Ipsilateral Femur Fx • Vascular Injury • Fracture Characteristics • Oblique fracture pattern • Coronal Angulation > 5° • Sagittal Angulation > 10° • Rotation > 5° • Shortening > 1cm • Intact fibula
- 72. Surgical Options • Intramedullary Nail • ORIF with Plate • External Fixation • Combination of fixation
- 73. Advantage of IM Nail • Less malunion • Early weight-bearing • Early motion • Early WB
- 74. Too Low! Too Medial! Procurvatum Valgus
- 75. Plating of Tibial Fractures • A plate can be used for shaft fractures • Newer periarticular plates available for metaphyseal fractures
- 76. Advantages of Plating • Anatomic reduction usually obtained
- 77. Disadvantages of Plating • Increased risk of infection and soft tissue problems, especially in high energy fractures • Higher rate hardware failure than IM nail • Delayed WB
- 78. External Fixator • Generally reserved for open tibia fractures
- 79. Ankle Fractures
- 88. Imaging • AP, Lateral • Mortise view • CT scan • Especially posterior malleolus
- 89. Initial treatment- reduce dislocations
- 90. Treatment • Isolated lateral malleolus fractures • Isolated medial malleolus fractures • Bimalleolar fractures • Posterior malleolus fractures
- 97. Special consideration • Diabetics • Enhance fixation • Delay weight-bearing for 8-12 wks
- 98. Complications • Wound complications • Deep infections • Posttraumatic arthritis
- 99. Talus Fractures
- 100. Talus Fractures • Most common at talar neck • Axial load with forced dorsiflexion
- 102. Imaging • AP, Lateral • Canale view • CT scan • Best for delineating fractures
- 103. Treatment • Non-displaced • Short-leg cast for 8-12 wks • Displaced • ORIF
- 104. Complications • Osteonecrosis • Varus malunion • Posttraumatic arthritis
- 105. Calcaneal Fractures
- 106. Calcaneal Fractures • Most frequent tarsal fracture • High energy, axial loading • fall from height onto heels • 10% of fractures associated with compression fractures of thoracic or lumbar spine (rule out spine injury) • 75% intra-articular and 10% are bilateral
- 107. Imaging • AP, Lateral • Harris view • CT scan • Gold standard • MRI • For calcaneal stress fractures
- 108. Harris view
- 111. Treatment • Controversial • Mostly conservative • Immobilization and NWB for 10-12 weeks • Indications for surgery • Tongue type • Displaced articular • Other general indications for surgery in fractures
- 113. Complications • Wound complications • Posttraumatic arthritis • Compartment syndrome • Malunion
- 115. Fifth metatarsal fractures • Common injury • Divided into 3 zones • Zone 2 is Jones fracture • Zone 1 is Pseudojones fracture
- 121. Lisfranc Injury
Notas del editor
- Direct anterior blow Typically with knee flexed Failure in compression Often comminuted Extensor mechanism may be intact Indirect mechanism Forceful extensor mechanism contraction that exceeds patellar tensile strength 2 part transverse fracture
- Lateral is most helpful.
- Goals Maintain biomechanical/functional integrity Restoration of articular congruity
- Classification based on position of tibia in relation to femur.