classification and treatment

3.  Muscle Attachments
› TFL – Gerdy’s tubercle
› Patellar tendon – Tibial tuberosity
› Sartorius + Gracillis + Semitendinosus – Pes
Anserinus.
› Semimembranosus(Horizontal head) –
Medial Condyle.
› Biceps femoris – small slip to lateral condyle

4.  Articular surface
› Medial condyle bigger than Lateral condyle
› Medial condyle concave in both coronal
and saggital axes.
› Lateral condyle convex in both coronal and
saggital axes.

5.  1 % of all fractures
 8 % of all fractures in elderly
 Lateral condyle # - 55 – 70%
 Medial condyle # - 10 – 25%
 Bicondylar # - 10 – 30%
 Open # - 1-3%

6.  Varus or valgus
force with axial
loading in fully
extended or
partially flexed
knee.
 A result of high
energy trauma
in adults.
 A result of tivial
fall in
osteopenic
elderly.

7.  Pain
 Swelling & Haemarthroses knee
 Inability to bear weight
 Restricted mobility
 Instability
 Deformity Around the Knee
 Pale, Cool Foot

8.  Neurovascular injury
 Compartment syndrome
 DVT
 Contussion & crush injury with open
wounds.
 Ligamentous injury – more with #
dislocation pattern (60%) as compared
to pure # pattern (4-33%)

9.  Given by Tscherne & Lobenhoffer in
association with # dislocation patterns.
› Meniscal injuries – 67%
› MCL injury – 85%
› Cruciate ligaments injury – 96%

10.  Palpation
1.Elicit tenderness.
2.Any Ligamentous disruption.
 Careful neurovascular examination is
done
 Skin condition
 Pulses
 Compartment syndrome

11.  X-rays
› Antero posterior
› Lateral
› Oblique
› Beam at a 10 degree angle caudally
 Computed tomography.
 Magnetic Resonance Imaging.

12. •Moore and Hohl classification of
primary # pattern

14.  AO classification

15.  Schatzker’s classification

16.  Type -1
› 4-6%
› Valgus force + Axial loading
 Type – 2
› 60-75%
› Valgus force
 Type – 3
› Very rare
› Pure compression
 Type – 4
› 7-10%
› High energy varus force +/- Axial loading
 Type – 5
› 2-3%
› High energy complex varus and valgus force
 Type – 6
› 16-20%
› High energy complex varus and valgus force

17. Goals
›Restore articular congruity.
›Axial alignment.
›Joint stability.
›Functional motion at knee.

18.  Indications
› Unstable # + ligament injury + articular
displacement
 Instability - > 10 degrees of varus or valgus
 Depression or displacement > 10 mm
› Open #
› # with compartment syndrome
› # with vascular injury

19.  Tscherne and lobenhoffer recommended surgical
reduction of fractures with more than 2mm of
articular incongruity
 Bennet and Browner >5 mm of joint displacement
or >5 mm degree of axial malalignment indication
of operative treatment
 If depression or displacement
› <5 mm in stable fracture non operative treatment is
considered
› If 5to 8 mm –
 Age
 Motion demands
› >10 mm - surgical fixation.

20. 1. Percutaneous screw fixation
› Indications - Nondisplaced type I fractures
› Advantages - Simple technique with minimal
soft-tissue injury.
› Disadvantages - Not applicable for other
patterns of fracture.

21. 1. Percutaneous screw fixation
› Advantages - Simple technique with minimal
soft-tissue injury.

22. 1. Percutaneous screw fixation
› Disadvantages - Not applicable for other
patterns of fractures.

23. 2. Percutaneous elevation and screw
fixation
› Indications - Type II and III fractures in
osteoporotic bone.

24. 2. Percutaneous elevation and screw
fixation
› Advantages - Simple technique with minimal
soft-tissue injury.

25. 2. Percutaneous elevation and screw
fixation
› Disadvantages - Not useful for high-energy
fractures with ligamentous and meniscal
injuries.

26. 3. Arthroscopic-assisted elevation and
screw fixation
› Indications - Types I, II, III, and IV fractures
with ligamentous and meniscal injuries.

27. 3. Arthroscopic-assisted elevation and
screw fixation
› Advantages –
 Minimal soft-tissue injury.
 Helps to diagnose and treat intra-articular
injuries.
 Aids in reduction of depressed articular
fractures.
 Allows for joint lavage.

28. 3. Arthroscopic-assisted elevation and
screw fixation.
› Disadvantages - Not useful in high-energy
fractures

29. 4. Open reduction and internal fixation with
or without bone grafting.
› Indications - Types II,III, IV, V, and VI fractures
without soft-tissue injury.

30. 4. Open reduction and internal fixation
with or without bone grafting.
› Advantages –
 Allows anatomic reduction.
 rigid internal fixation and bone grafting.
 facilitates joint exploration and treatment of
intra-articular injuries.

31. 4. Open reduction and internal fixation
with or without bone grafting.
› Disadvantages –
 Should not be performed in the acute setting
in the presence of soft-tissue injury.
 unnecessary for type I fractures

32. 5. External fixators - Half-pin fixator, ring
fixator, hybrid fixator
› Indications –
 Open injuries and high-energy (types IV, V,
and VI) fractures with soft-tissue injury.
 fractures with vascular injury with or without
compartment syndrome.
 polytrauma patients

33. 5. External fixators - Half-pin fixator, ring
fixator, hybrid fixator
› Advantages –
 Minimal soft-tissue injury.

34. 5. External fixators - Half-pin fixator, ring
fixator, hybrid fixator
› Disadvantages –
 Nonrigid fixation.
 difficult to achieve anatomic fracture
reduction.
 joint stiffness.
 pin-tract infections.
 septic arthritis.

35.  Recovering range of motion is a challenge for
patients who
› cannot actively participate in rehabilitation,
› may have soft-tissue injuries that preclude immediate
range of motion, and
› have had external-fixation pins inserted near their
quadriceps. .
 Motion is restricted until surgical and traumatic
wounds are dry.
 Continuous passive motion begins when wounds are
dry; the goal is full extension and 90° of flexion within
5-7 days.
 If other injuries allow, the patient is mobilized with a
hinged brace locked in extension for 6 weeks.

36.  Non – weight-bearing precautions
generally continue for 12 weeks.
 Active flexion and passive extension are
encouraged for 6 weeks, after
which active knee extension is started.

37.  Early complications
 Compartment syndrome
 Vascular injuries
 Swelling and wound-healing problems
 Infections
 Deep vein thrombosis

38.  Late complications
 Knee stiffness
 Knee instability
 Angular deformities
 Late collapse
 Malunion
 Post traumatic arthritis