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INCIDENCE OF INTERNAL
DERANGEMENTS OF KNEE WITH
IPSILATERAL FEMORAL SHAFT
FRACTURE
ABSTRACT NUMBER : 120
Diaphyseal femur fractures are mostly the result of high
energy trauma .
Femoral shaft fractures are often associated with bony and
soft tissue injuries to the ipsilateral knee, and a high index of
suspicion is necessary to identify these lesions.
These ligament injuries are usually silent or occult and many
of them progress undiagnosed at this stage, with negative
consequences for patients and orthopedicians.
INTRODUCTION
Assessment of the ligaments of the knee by clinical
examination in the emergency room is difficult to perform as
the distal segment of the fractured femur is unstable; and
movement of the affected knee may cause more pain or
discomfort to the patient.
The clinical methods to assess the knee joint for
intraarticular soft tissue injuries are either under anesthesia
preoperatively or after fixation postoperatively.
The disadvantage of examination under anesthesia
preoperatively is meniscal injuries cannot be assessed
optimally.
Hence we hypothesised that a preoperative MRI of the
affected knee joint, will aid in the diagnosis of a soft tissue
injury.
OBJECTIVES
To anticipate meniscal, ligamentous and retinacular injuries of
the knee in patients sustaining ipsilateral femoral shaft
fractures.
To identify the type and character of intraarticular ligamentous
injuries of the knee joint following ipsilateral femoral shaft
fractures.
To emphasize the need for an MRI of the knee with ipsilateral
femoral shaft fractures in the preoperative period.
To establish the advantages of MRI knee in tailoring the
management strategy of femoral shaft fracture and to address
the issue of intraarticular soft tissue injuries.
METHODOLOGY
STEP 1
• Patients with femoral shaft of femur fracture• Patients fulfilling the inclusion criteria and
exclusion criteria were selected
STEP 2
• Patient explained about the advantage of the investigation
• Written consent was obtained
STEP 3
• MRI of ipsilateral knee was done and findings were noted
• All findings were tabulated in a master sheet and incidence was calculated.
Methodology
INCLUSION CRITERIA :1) Age group: >15 years.2) Patients with fracture shaft of femur.
EXCLUSION CRITERIA:1) Patients with periprosthetic, pathologic fractures or
polytrauma.2) All patients with previous knee injuries or previous
knee surgery.3) Patients on cardiac pace makers or metal implants.4) Any other contraindications for an MRI.
Out of 40 patients, there was incidence of intraarticular soft tissue injuries in 26 patients (65%) .
RESULTS
Injury Number of Cases Anterior cruciate ligamentComplete tearPartial tearTotal ACL
8 (20%)5 (12.5%)
13 (32.5%)
Posterior cruciate ligamentComplete avulsionComplete tearPartial tearTotal PCL
2 (5%)2 (5%)
5 (12.5%)9 (22.5%)
Medial collateral ligament (MCL)Complete tearPartial tear
4 (10%)2 (5%)2 (5%)
Lateral collateral ligament (LCL)Complete tearPartial tear
4 (10%)2 (5%)2 (5%)
MenisciMedialAnterior horn Posterior horn LateralAnterior horn Posterior horn Total menisci
10 (25%)1 (2.5%)5 (2.5%)6 (15%)2 (5%)2 (5%)
16 (40%)
Extensor mechanismPatellar tendon partial tear Patellar tendon complete tear Quadriceps tendon partial tear Total extensor mechanism
1 (2.5%)1 (2.5%)2 (5%)
4 (10%)
Retinacular tears 3 (7.5%)Cartilage 0 (0%)BoneContusion Occult fracture
32 (80%)3 (7.5%)
NUMBER OF CASES PERCENTAGE
Effusion 40 / 40 100 %
Bone contusions 32 / 40 80 %
ACL injury 13 / 40 32 %
PCL injury 9 / 40 22 %
MCL injury 4 / 40 10 %
LCL injury 4 / 40 10 %
Medial meniscus injury 10 / 40 25 %
Lateral meniscus injury 6 / 40 15 %
Capsular tears 3 / 40 8 %
Patellar tendon injury 2 / 40 5 %
STRUCTURE INVOLVED
NUMBER OF CASES PERCENTAGE
ACL 4 10 %
PCL 4 10 %
LCL 1 2.5 %
MCL 3 7.5 %
MM 2 5 %
LM 1 2.5 %
MM + LM 1 2.5 %
ACL + PCL 2 5 %
ACL + MM 2 5 %
ACL + PCL + MM 1 2.5 %
ACL + PCL +LCL + MM + LM 1 2.5 %
PCL + LCL + MM 1 2.5 %
ACL + PCL + LM 1 2.5 %
ACL + LCL + MM + LM 1 2.5 %
ACL + MM + LM 1 2.5 % No ligamental or meniscal
injury 1435 %
TOTAL NUMBER OF CASES 40 100 %
ACL
PCL
LCL
MCL
MM
LM
MM + LM
ACL + PCL
ACL + MM
ACL + PCL + MM
ACL + PCL +LCL + MM + LM
PCL + LCL + MM
ACL + PCL + LM
ACL + LCL + MM + LM
ACL + MM + LM
No ligamental or meniscal injury
De Campos 1994
(Arthroscopy)
Blacksin 1998
(MRI)
Dickson 2002
(MRI)
Our study 2014
(MRI)
Number of patients
40 34 27 40
Total abnormal 22 (55%) 34 (100%)+ 19 (70%) 26 (65%)
ACL 21 (53%) 2 (6%) 5 (19%) 13 (32.5%)
PCL 3 (7.5%) 7 (21%) 2 (7%) 9 (22.5 %)
LCL 5 (12.5%) 2 (6%) 8 (30%) 4 (10%)
MCL 11 (27.5%) 13 (38%) 11 (41%) 4 (10%)
Total meniscus 13 (32%) knees 10 (30%) 11 (41%) 16 (40%)
Lateral meniscus
8 (20%) 4 (12%) 7 (26%) 6 (15%)
Medial meniscus
5 (12%) 6 (18%) 4 (15%) 10 (25%)
Bone bruise N/A 32%
1 (3%) occult tibial plateau
fracture
25 (93%) 32 (80%)
Effusion N/A 33 (97%) N/A 40 (100%)
Why a pre-operative MRI? Why not post-operative MRI?
In order to reduce the error factors addressed in the
previous studies like iatrogenic MCL tears during
interlocking screw fixation,
MRI of patients with stainless steel induced artifacts in
retrograde intramedullary nailing were excluded in the
previous study, which may have caused variation in the
true incidence of internal derangements of the knee.
Antero – Lateral ligament (ALL)
ALL injury in MRI
Proximal ALL injury Distal ALL injury
Incidence of ALL injury in our study
Incidence – 11 cases (44%) Proximal ALL injury – 4 cases
(16%) Distal ALL injury – 5 cases
(20%) Proximal + Distal ALL injury – 2 cases (8%)
Conclusion
Femoral shaft fractures exerted by high velocity forces have been
proven to cause internal derangements in the ipsilateral knee along
with soft tissue injuries, by exhaustive analysis by various
orthopedists, radiologists through physical examination, X-rays
analysis, MR imaging and arthroscopic evaluation.
The incidence of internal derangements of the knee in our study
using MRI is similar to those reported in the previous studies using
arthroscopy and/or MRI as diagnostic tools.
MR imaging of the knee is considered advantageous to have
shown
a significant increase in the incidence of ligamentous injuries
in the knee from 5% in earlier studies to 70% in recent studies;
in the identification of clinically suspected meniscal injuries
through a non-invasive approach;
and a suitable non- radiational imaging modality for
arthroscopic blind spots.
In a case of femoral shaft fracture due to a high velocity trauma,
the attending surgeon must beware of an internal derangement
of the knee and must investigate for knee instability, ligament
laxity.
Currently there is no general consensus on the use of the MRI
scan as a standard diagnostic preoperative tool. It is usually
preserved for patients who develop joint instability or soft tissue
related symptoms(knee locking, persistent joint pain) at a
secondary stage following fracture healing and weight bearing.
Take home message