Patella and tibial plateau fractures

presented by

Aisha Motaher Abutaleb

Patella f ractures

Anatomy

Mechanism

Fractures of the patella are caused by

A. Direct violence (injury)Due to trauma to anterior aspect of the flexed knee leading to comminuted fractures.

B. Indirect violence (injury)Due to forced flexion of the knee when the sudden quadriceps muscle is contracting In these case the fracture is transfers

Types of fractures

1. Undisplaced transverse fractureDue to direct injury , the two fragment of the patella are undisplaced as they are held in position by the pre patellar expansion of the quadriceps tendon and patellar tendon

2. Displaced transverse fracture

Due to more sever trauma with gap between the fragment

(this is indirect injury due to forced , passive flexion of the knee while the quadriceps muscle is contracted

Active knee extension is impossible

3.Comminuted (stellate) fractureDue to fall or direct injury on the front of the knee

4.Vertical fractureOne or two small fragments are separated from the medial or

lateral border of the patella

Clinical features

1. Local pain and tenderness3. Swelling 1. Palpable gap between the fragment2. presence of crepitus is felt 3. An x- ray examination Fissure or crack fracture Transverse fracture with dislocation Comminuted fracture

Treatment1. Undisplaced transvers fractures

Immobilization of knee by long leg plaster splintage for 4-6 weeks combined with quadriceps exercise

If there is a heamarthrosis , it is aspirated under aseptic condition

2. Displaced transverse fractures Open reduction and internal fixation with screw

especially if pt is young

Small pollar fragment may be excised

Reduction and maintenance of the reduced position may also be gained by strong wire passed around periphery of the patella

In all these cases , the leg is splinted in long leg plaster for 8 weeks

3. Comminuted fractures Undisplacemen-A fracture with little or no displacement

can be treated conservatively by a posterior slab of plaster that is removed several times a day for gentle active exercises.

Displacement Reduction is impossible and so the best treatment are

1. partial patelloectomy with the segment held by circlage wire and the leg is splinted in the extended position for 2

weeks

2. Total patelloectomy is excision of all the segment and the quadriceps aponeurosis is reconstructed by absorbable suture

early physiotherapy after the operation prevent knee

stiffness

Patella-hinged brace

Complications Knee Stiffness Most common complication

OsteoarthritisMay result from articular damage

ChondromalagiaUnunion loss of fixation

Dislocation of the patellais almost always over the lateral

femoral condyle

Mechanism

1. Direct trauma

2. sudden muscular contraction

In the presence of

Flattening of the lateral femoral condyle

Genu valgus and external rotation

Ligamentous laxity

Anatomical bony abnormalities :-

Small or high patella

clinical feature Locking of the knee in the flexed position

Swelling of the knee due to haemarthrosis

Tenderness over the anteromedial aspect of the knee joint

Positive patellar apprehension test

An x-ray examination would reveal the dislocation

1. Traumatic acute dislocation this result from an injury on the medial side of the knee while the knee in flexed position

TreatmentReduced under sedation the knee is immobilized in the extended position in a plaster of Paris cylinder for 3 weeks

Complication

Osteoarthritis

Recurrent dislocation

2. Recurrent dislocation predisposing factors

Post traumatic as rupture or weakness of medial patellar retinaculum

Anatomical bony abnormalities Small and high patella Unequal pull of the quadriceps muscle

component • Weakened vastus medialis • Shorter vastus lateralis• Genu valgus

surgical reconstruction

1. Direct medial patello-femoral ligament repair

2. Suprapatellar realignment (Insall)

3. Infrapatellar soft-tissue realignment (Goldthwaite)

3 4. Infrapatellar bony realignment (Elmslie–Trillat)

Treatment

TIBIAL PLATEAU FRACTURES

Anatomy

Mechanism of injury -:Fractures of the tibial plateau are caused

by varus or valgus force

force is more likely to rupture the ligaments

a car striking

fall from a height

Classification of Schatzker -:Type 1 – simple split of the lateral condyle

Type 2 – a split of the lateralcondyle with a more central area of depression.

Type 3the articular surface with an intact condylar rim

Type 4 – a fracture of the medial condyle.

Type 5

–fractures of both condyles, but with the central

portion of the metaphysis still connected to the tibial

shaft.

Type 6– combined condylar and subcondylar fractures

effectively a disconnection of the shaft from the

metaphysis.

Clinical feature1. Sever pain

2. Swelling

3. Valgus deformity

4. Local tenderness

on examination:-The knee may suggest medial or lateral instability

the leg and foot should be carefully examined

for signs of vascular or neurological

X-ray:-X-rays provide information about the position

of the main fracture lines

and areas of articular surface depression

CT :-for reveal direction and extent of displacement

Treatment

Type1 Undisplaced type 1 fractures can be treated

conservatively

Displaced fractures should be treated by open reduction and internal fixation

Type2 1. If the depression is slight (less than 5 mm)or

patient is old , the fracture is treated closed with the aim of

regaining mobility and function rather than anatomical

restitution. skeletal traction is applied with 5kg for 4 – 6 w

2. In younger patients, and in those with a central

depression of more than 5 mm, open reduction with

elevation of the plateau and internal fixation is often

preferred

Type3 Depression of more than 5 mm in a type 3 fracture

can be treated by elevation from below and supported by bone

grafts and fixation

Type 4

Treated by open reduction and internal fixation .

Type 5,6 Open reduction and internal fixation with plate

and screw.

A combination of screw fixation and circular external fixation is lower risk complication .

Complication EARLY:-

Compartment syndrome

Late :-

Joint stiffness.

Deformity.

Osteoarthritis

Thanks