Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are...

Other lower extremity trauma2011년 소아정형외과학 연수강좌

인제대학교 일산백병원

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Knee dislocation

• Rare in children

• Physeal seperation > dislocation or ligament injury

• If dislocation occurs:

– Vascular compromise

– Compartment syndrome

Patellar dislocation

• Common in adolescent and teenager

• Typically

– Female

– Loose jointed

– Genu valgum with increased femoral anteversion

– Who are trying sports

Patellar dislocation

• Reduced before patient comes to the hospital

• P/E– Hemarthrosis, – tenderness along medial

border of patella– Lateral position of patella– Fairbanks sign

• X-ray– Loose fragment

• Lateral femoral condyle• Medial edge of the

patella

– 5-10% osteochondralfracture

Patellar dislocation F/13

Patellar dislocation F/13

Patellar dislocation

• Treatment– 3-4wks of immobilization

– Early PT to strengthen vastus medialis

– Fracture of medial patella or lateral femoral condyle• Acute arthrotomy

• Ligament repair

• Excision or fixation of the fracture

• Repair of the medial capsule and patellofemoralligament

Patellar dislocation

• Recurrent dislocation– 15-20%– Due to faulty anatomy

• Increased quadriceps angle• Femoral condyle hypoplasia• Shallow femoral sulcus• Atrophy of vastus medialis• Lateral patellar tilt• Lax joint

– Treatment• Soft tissue realignment• Semitenidnosus tenodesis to

patella• Tibial tubercle transfer (after

physeal closure)

A. Lateral retinacular release and medial imbrication. B. Semitendinosis tenodesis. C. Elmslie-Trillat procedure.

Patellar fractures

• Bipartite patella– Located superolaterally– 40% bilateral– Fracture line may propagate

through the synchondrosisdifficult diagnosis

• Sleeve fracture– Avulsion fracture of the lower

pole– With little or no bone– Difficult to

recognizeextensor lag– Open reduction

Tibial eminance fracture

• 8 to 14 yrs old

• Bicycle injury and other sports activity

• 40%: meniscus, capsule or collateral ligaments or with osteochondral fracture

ACL insertion

• 10 to 14 mm behind the anterior border of the tibia

• Extends to the medial and lateral tibial eminence

Classification

• Meyer and McKeever(1959)– Type I: Nondisplaced

– Type II: Anterior cortical displacement with intact posterior cortex

– Type III: completely displaced with no bone contact

– Type IV: comminuted

Type I Type II Type III Type IV

• Immobilization 6wks– 20 degrees flexion or full extension– Late displacement of type I does occur

• Unreduced displaced fracture– Impingement– Extension limitation

• Irreducible fracture– Bowstringing or bucket-handle

mechanism• Anterior horn of the lateral meniscus is

torn from its tibial attachment but remains attached to the fracture piece

– Interposition of • Anaterior horn of the medial meniscus, • Anterior horn of the lateral meniscus • Intermeniscal ligament

• Suture or screw fixation– Suture: small comminuted frgament– Screws: larger than 15mm fragment

• Irritate the joint• May require removal

• Complications– LOM: impingement, arthrofibrosis– Nonunion– Maluniondebridement and notchplasty– Quadriceps atrophy– Growth arrest – Ligament laxity: elongation of the ACL?

Tibial tubercle fracture

• Closure of the physis of the tubercle

– Girls: 13-15

– Boys: 15-19

• Injury

– Common in boys between 12 and 17

– Eccentric contracture of the quadriceps

• Watson-Jones, Ogden classification

Type I: avulsion of a small fragment of the distal tubercle

(subtype B: fragment seperated from metaphysis)

Type II: involves the entire secondary ossification center, apex is at the level of the proximal tibial physis

(subtype B: comminuted ossification center)

Type III: Extends into the knee joint

(subtype B: comminuted fragment)

• X-ray: better viewed with knee slight internal rotation

• 4-6wks of immobilization

• ORIF from type IB

• Complications

– Anterior tibialrecurrent artery

– Physeal arrest

Proximal tibial physeal fracture• More physeal seperation in distal

femur than proximal tibia

1) MCL attached to tibialmetaphysis and femoral epiphysis, protecting from valgus injury

2) Upper end of fibula acts as lateral buttress

3) Semimembranosus muscle inserts distal to the physisposteromedially

4) Tibial tubercle projects from the epiphysis over the metaphysis

Proximal tibial physeal fracture• More physeal seperation in distal

femur than proximal tibia

1) MCL attached to tibialmetaphysis and femoral epiphysis, protecting from valgus injury

2) Upper end of fibula acts as lateral buttress

3) Semimembranosus muscle inserts distal to the physisposteromedially

4) Tibial tubercle projects from the epiphysis over the metaphysis

Proximal tibial physeal fracture• More physeal seperation in distal

femur than proximal tibia

1) MCL attached to tibialmetaphysis and femoral epiphysis, protecting from valgus injury

2) Upper end of fibula acts as lateral buttress

3) Semimembranosus muscle inserts distal to the physisposteromedially

4) Tibial tubercle projects from the epiphysis over the metaphysis

Proximal tibial physeal fracture• More physeal seperation in distal

femur than proximal tibia

1) MCL attached to tibialmetaphysis and femoral epiphysis, protecting from valgus injury

2) Upper end of fibula acts as lateral buttress

3) Semimembranosus muscle inserts distal to the physisposteromedially

4) Tibial tubercle projects from the epiphysis over the metaphysis

Proximal tibial metaphyseal fracture

• Posterior tibial artery injury

• Post union valgus deformity

– Asymmetrical growth stimulation of the proximal tibial physis

– Asymmetrical growth stimulation of the medial proximal metaphysis

– Tibial physis stimulated more or longer than fibular physis

– Valgus at the time of fracture

– Soft tissue interposition(ex: pesanserinus)

– Physeal injury

7 post-traumatic tibia valga

• 11 mths to 6 yrs old

• Valgus appeared during fracture healing and after union

• Most rapid progression during 1st year

• Overgrowth may accompany

• Clinical correction in 6/7

• Conservative approach

32 proximal tibia fracture

• Avg age 7.1 yrs

• 28 post traumatic tibia valga(90.3%)

• Avg angulation 5.5 degrees

• 5.3mm overgrowth

• 11 patients more than 5 degrees angulation

6 partial and 3 complete remodeling

Diaphyseal fractures of tibia

• 15% of long bone fracture

• Avg age 8 yrs old

• Boys>girls

• With fibular fracture

– 30%

– Complete fracture by high energy

– Valgus shortening of distal fragment

• Without fibular fracture

– Rotational force

– Varus shortening

– Low energy injury

A. Fractures involving the mid 1/3 of the tibia and fibula may shift into a valgus alignment due to the activity of the muscles in the anterior and the lateral compartments of the lower leg.

B. Fracture of the mid tibia without fibular fracture tend to shift into varus d/t the force created by the anterior compartment musculature of the lower leg and the tethering effect of the intact fibula.

Isolated tibia fracture(M/7)

Isolated tibia fracture(M/7)

Isolated tibia fracture(M/7)

7months later

• Varus valgus: 5 degrees

• Sagital deformity: 5 degrees

• Shortening: 1cm

• Reduction correction: within 3 weeks

• Remodeling potential

– under 8

• Varus 10 degrees

• Sagital 10 degrees

• Complete translation

• No remodeling of rotation

• Anterior, varus > posterior, valgus, combined deformity

• Overgrowth: 5 mm

• Surgery:

– Comminuted fracture

– Irreducible fracture

– Compartment syndrome

– Open fracture

– Multiple fracture

– Floating knee

1 yr

18 months

Valgus tibia

Valgus remodeling?

Stress fracture

• Osteoclastic breakdown>natural healing process

• #1 Military recruits,

#2 young athletes

• Tibia m/c

– Endurance runnermetatarsal stress fracture

– Sports involving sudden stops(tennis, basketball, handballtibial stress fracture

Heyworth and Green, Current Opinion in Pediatrics, 2008

Stress fracture

Risk factors

• Female: x4 than male

• Late menarche: BMD increases after menarche and growth spurt

• Disordered eating: calcium, Vit D

• Threshold quantity of activity: 16hrs/week

16 years old girlLeft leg pain for 2 months

Dance practice 4 hrs/day

Tenderness distal 1/3

Cortical thickening

16 years old girlLeft leg pain for 2 months

Dance practice 4 hrs/day

Tenderness distal 1/3

Cortical thickening

16 years old girlLeft leg pain for 2 months

Dance practice 4 hrs/day

Tenderness distal 1/3

Cortical thickening

Activity modicationrecommended. But?

Fracture of distal tibia

Closure of distal tibial physis

• Physis closes at 15 for girls, 17 for boys

• Centermedialanterolateral

• Distal fibula closes 1 year later

Treatment

• CR & long leg cast

• Closed reduction

– Knee flexed

– Recreate force of injury:

• Plantar flexion, supination or adduction

– Longitudinal traction

– Bring foot around to neutral position

– Internal rotation

• Entrapped soft tissue:

– Remaining growth

– Gap

Ankle Fractures

• Pediatric ankle fracture by Poland1) The growth plate forms a plane of weakness

2) Ligaments are stronger than bone

3) Certain injuries will affect growth

Plus

1) Fracture rarely disturb talo-tibial relationship

2) From age 14 to 15 years onward, adult pattern of fracture emerges

Ankle Fractures

• Pediatric ankle fracture by Poland1) The growth plate forms a plane of weakness

2) Ligaments are stronger than bone

3) Certain injuries will affect growth

Plus

1) Fracture rarely disturb talo-tibial relationship

2) From age 14 to 15 years onward, adult pattern of fracture emerges

Classification and mechanism of injury

• Salter-Harris classification

• Lauge-Hansen classification

• Abduction, external rotation, extension

– S-H I or II

• Adduction

– S-H III

• Axial compression

– S-H V

Tilleaux fracture

• 1 year before distal tibial physis closes

• Medial and central physis closed, anterolateral open

• External rotation force

Triplane fracture

• Sagital, transverse, coronal plane

• Along and through the physis

• Mostly d/t external rotation but sometimes internal rotation force

• Between 12 to 15, younger than Tilleauxfracture group

• Sports, scooter, skate, snowboard injury

• Fibula fracture 50%

• X-ray– AP plane: S-H III

– Lateral view: S-H II

– Axial CT: ‘Merceds-Benz’ sign

• 2 fragment,

• 3fragment,

• 4 fragment fractures

• 4 fragment variant

– External rotation plus axial compression

– Metaphyseal comminution

• Extra articular variant

• CR and cast: < 2 mm

• OR and IF: > 3 mm

• Open reduction:

– For articular restoration rather than to prevent growth arrest

Distal tibial physeal injury

• 45 % growth of tibia

• 4-6 mm / yr growth

• 6 to 12 months of monitor

– Harris gorwth line

• Growth arrest:

– Bone bridge resection

– Osteotomy

– Epiphyseodesis…

Distal tibial physeal injury

• 50% growth of tibia

• 4-6 mm / yr growth

• 6 to 12 months of monitor

– Harris gorwth line

• Growth arrest:

– Bone bridge resection

– Osteotomy

– Epiphyseodesis…

Distal tibial physeal injury

• 50% growth of tibia

• 4-6 mm / yr growth

• 6 to 12 months of monitor

– Harris gorwth line

• Growth arrest:

– Bone bridge resection

– Osteotomy

– Epiphyseodesis…

Sesamoid bones of the foot

Fracture of talus

• Head, constricted neck, and body

• Fracture occurs in neck, body, medial and lataeral process, osteochondral injuries

• m/c fracture: neck of the talus

• Blood supply from

– Posterior tibial

– Dorsalis pedis

– Peroneal arteries

• Forced dorsiflexion of the foot

neck impinges against anteror lip of the tibia

Hawkins classification

Hawkins I – No displacement of fracture line and no incongruity of subtalar jointHawkins II – Associated with dislocation or subluxation of subtalarjointHawkins III – Talar neck fracture with dislocation of subtalar and ankle jointsHawkins IV- Associated disruption of talonavicularjoint

• X-ray:

– AP: 15 degrees pronation, tube 75 degrees

– Lateral and oblique

• 5 mm displacement and 5 degrees malalignment acceptable

• Hawkin’s sign: may not appear in children!

Osteochondral fracture

• M/C in young adults but may occur under 10

• Anterolateral(44%)

– Thin wafer like

– Usually symptomatic, associated with trauma

• Posteromedial(56%)

– Deep, cup shaped

– Less symptomatic, repetitive microtrauma

Fractures of the calcaneus

• Rare in children

• Better prognosis than adult

• Less intraarticular damage

• Occult fractures in toddlers

• Do well with conservative treatment

Lisfranc injuries

• Direct injury

– Less common

– Objects falling on foot and rupture of plantar ligament

– May associate with severe soft tissue damage

• Indirect injury

– More common

– Violent plantar flexion or abduction force or in combination

(vertical loading in plantar flexion, heel to toe compression)

Fractures of metatarsal

• Most common fracture of the foot

• Good remodeling potential

• Proximal fracture Beware of Lisfranc injury

5th metatarsal base avulsion fracture

• Inversion or adduction of the foot

• Peroneus brevis, abd digitiminimi quinti, lateral cord of plantar aponeuroisis

• Fractrure perpendicular to long axis of the shaft

• Ddx: Os peroneum, Os vesalianum(line parallel

to long axis)

Jones Fracture

• Proximal diaphysis of the 5th metatarsal

• Delayed union, nonunion

• Internal fixation