my presentation during ortho posting,.

1. PATELLA DISLOCATION
WAN AWATIF WAN
MOHD ZOHDI

5. MECHANISM OF
INJURY
• Knee flexed, quadriceps relaxed >> patella
forced laterally by direct force.:RARE
• Common: due to indirect force
Sudden, severe contraction of quadriceps muscle
While the knees is stretch in VALGUS & EXTERNAL
ROTATION

7. Lateral patellar dislocation. (a) Drawing shows the
classic mechanism of injury: fixed tibia, internal femoral
rotation, and quadriceps contraction.

9. CLINICAL FEATURES
• Tearing sensation
• Knee has gone ; out of joint
• When running : they may collapse and fall to
the ground
• Patella springs back into position
spontaneously
• remains unreduced >>deformity

11. • Downward dislocation
 Stuck btw condyles
 Marked prominence on front of the knee
• If spontaneous reduction:
-swollen knee
-bruising tenderness on medial side
• Joint aspiration
-blood stained
-fat droplets (concurrent osteochondral #)

12. X-RAY
MRI
IMAGING

13. X-
MRI
RAY Soft tissue lesion-
disruption of medial
VIEW: AP, lateral
patellofemoral
ligament
In unreduced
dislocation:
Patella is laterally
displaced
-tilted/rotated

14. SURGICAL CONSERVATIVE
MANAGEMENT

15. CONSERVATIVE MX
Push back w/o difficulty & anesthesia
Cast splintage;
• If no sign of soft tissue lesion
• Retained for 2-3 weeks
• Quadriceps strengthening exercise ; 2-3
months
• Jt aspiration and immobilized it in full
extension

16. SURGICAL MX
In intra articular (intercondylar) dislocation >>
open reduction
If swelling, tenderness, bruising (medially)
>> d/t patellofemoral ligaments torn, retinacular
t/s torn

17. COMPLICATION
• Recurrent dislocation
• 1st time –treated as non-operatively
• 15-20% recurrent dislocations.

18. TIBIAL PLATEAU FRACTURES

19. DEFINITION
• A tibial plateau fracture is a fracture involving
the proximal (upper) portion of the tibia
which extends through the articular surface .

22. MECHANISM OF INJURY
• Caused by a varus/valgus force combined with
axial loading
• Eg: car striking a pedestrian (bumper #)
• Often: fall from a height in which the knee is
forced into valgus/varus
• Tibial condyle is crushed/split by opposing
femoral condyle.
• Combination of both the above

23. • 60% lateral pleateau
• 15% medial plateau
• 25% bicondylar lesions.

24. PATHOLOGICAL ANATOMY
TYPE 2: vertical split of
TYPE 3 : depression of
the lateral condyle +
TYPE 1:vertical split of the articular surface
depression of an
the lateral condyle with an intact condylar
adjacent loadbearing
rim
part of the condyle
TYPE 6 : combined
TYPE 4 : # of the medial TYPE 5 : # of both
condylar & subcondylar
tibial condyle condyles
#
Schatzker classification

26. • In younger people
• Virtually undisplaced
Type 1 • Condylar fragment may be pushed inferiorly or tilted
• Joint is widened
• If # is not reduced : >> valgus deformity
Type 2
• Split to the edge of the plateau is absent
• Stable joint
Type 3 • May tolerate early movement
• 2 types #
• Low energy lesion : depressed, crush # of osteoporotic bone in elderly pt
Type 4 • High energy l/s : condylar spilt that runs obliquely
• Column of metaphysis wedged in btw that remains in continuity with the tibial shaft
Type 5
• High energy injury
• >>severe comminution
Type 6 • Tibial shaft disconnected from tibial condyles.

27. Clinical features
• Swollen knee
• Deformed
• Extensive bruising
• Doughy tissue (d/t haemarthrosis)
• Medial/lateral instability
• Examined leg/foot carefully TRO
neuro/vascular injury

28. Imaging
• X-ray View : AP, Lateral , oblique
• CT : amount of comminuted and depression #
• Give information on the location of the main #
lines, site and size portion of condyle that is
depressed
• Crushed lateral condyle, >>medial ligament is
intact
• Crushed medial condyle >> lateral ligament
may be torn

31. Management
TYPE 1 #
Undisplaced
• Conservatively
• Haemarthrosis is aspirated
• Apply compression bandage
• Limb is rest on CPM machine
• Acute pain and swelling is subsided >> hinged cast-brace
• Weight bearing –delayed ` 8 weeks
Displaced
• Open reduction
• Internal fixation

32. TYPE 2 #
Slight depression(<5mm), stable
Depression >5mm
knee, old patient, osteoporotic pt
• # is treated closed to gain • Open reduction with elevation
mobility and fx ( not anatomical of plateau
restitution) • Internal fixation
• Aspiration • Small 3.5 mm screws // beneath
• Compression bandage the subchondral bone hold up
• Skeletal traction via threaded elevated fragments : raft screws
pin. • Buttress plate :-in type 2,,5 or 6
• Active exercises every day
• # -sticky in 3-4 weeks >> remove
traction pin
• Apply hinge cast brace
• Full weight bearing deferred ; 6
weeks

35. TYPE 3 #
• Similar to type 2
• But lateral rim of the condyle is INTACT
• Stable knee
• Depressed fragments :elevated through a
window in the metaphysis
• Elevated fragements :supported by bone graft
, raft screws.
• Post op :exercises, cast –brace till # is united.

38. TYPE 4 #
• Osteoporotic # crush –difficult to be reduced
• >> varus deformity
• Principles mx similar in type 2 #
• Medial condylar split # : d/t high energy
impact.
• Underlying lateral ligament injury

39. Stable fixation on medial side
Assess ligament injury
If unstable joint after the
fixation
Repair the torn structure on
the lateral side.

40. TYPE 5 and 6 #
• Risk to compartment syndrome
• In a simple condylar # and in an elderly pt:
-reduced by traction
-treated as type 2 injury
• Usually internal fixation, early joint movement.
• Danger of wide exposure to access both condyles:
-increase wound breakdown
-delayed or non-union

41. COMPLICATTIONS
LATE EARLY
COMPARTMENT
JOINT STIFFNESS DEFORMITY OSTEOARTHRITIS
SYNDROME

42. FRATURES OF TIBIA AND FIBULA

44. Mechanism of injury
• Twisting force >> spiral # of both bones at different
levels
• Angulatory force >> transverse, short oblique #, at the
same level
• Indirect injury :
-low energy
-spiral or long oblique # , one of the bone fragments may
pierce the skin
• Direct injury:
-crushes/splits skin over the #
Common in motorcycle accident

45. Pathological anatomy
• Behaviour of these injuries will depends on
mode of treatment
• It depends on following factors:

46. State of Severity of Stability of
soft tissues bone injury #
LOW ENERGY :
Risk and CX depends on -closed # Consider displacement when
amount and type of soft
-Gustilo 1, 2 weight bearing is allowed
tissue damage
- spiral
HIGH ENERGY:
-direct trauma
open# : Gustilo classification -open # Sevely comminuted : least
stable, need mechanical
closed # : Tscherne’s -Gustilo 3 fixation
-transverse
-comminuted

47. TSCHERNE’s classification of skin lesions in
CLOSED #
IC1 •No skin lesion
IC2 •No skin laceration but contusion
IC3 •Circumscribed degloving
IC4 •Extensive, closed degloving
IC5 •Necrosis from contusion

50. Clinical features
 Examine limbs for signs of soft tissue damage
• severe swelling,
• bruising,
• crushing or tenting of skin,
• open wound,
• circulatory changes,
• weak or absent pulses,
• loss of sensation, Alert for the
• Inability to move toes compartment
syndrome!!!!
• Deformity

51. Imaging
• X-ray of entire length of the tibia and
fibula.(knee and ankle joints can be seen)
• Notes the :
-types of #
-level
-angulation and displacement

53. MANAGEMENT
Limit soft t/s
damage
Prevent/recognize
Start joint
compartment
movements ASAP
syndrome
Start early Obtain & hold the
weightbearing # alignment

54. LOW ENERGY #
• Gustilo type 1.
• Conservative mx

55. LOW ENERGY #
UNDISPLACED/
MINIMALLY DISPLACED
DISPLACED Reduced under
GA with X-ray
control
Full length cast fr
upper thigh to
metatarsal necks Alignment and
rotation must be
perfect
Knee is slightly
flexed, ankle at a
right angle Full length cast.
Position checked
by x-ray
Limb is elevated,
observe for 48-72
hours.
Discharged home
on 2/3 rd day.
With crutches

56. EXERCISE
EXTERNAL FUNCTIONAL
FIXATION BRACING
PLATE FIXATION SKELETAL FIXATION
CLOSED
INTRAMEDULLARY
NAILING

57. HIGH ENERGY #
Transverse #
• Usually stable after reduction
• Treated as closed
• Look for signs and symptoms of cx (excessive
pain, swelling, tightness, sensory change)
Comminuted and segmental #
• If a/w bone loss, unstable >> treat with early
surgical stabilization.

58. Closed #
• External fixation
• Closed nailing
Open #
• Antibiotics
• Debridement
• Stabilization
• rehabilitation

59. COMPLICATIONS
EARLY LATE
VASCULAR COMPARTMENT
INFECTION MALUNION DELAYED UNION NON-UNION JOINT STIFFNESS OSTEOPOROSIS
INJURY SYNDROME