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Fracture patella

Transverse fracture Comminuted fracture

⁕ Aetiology: • Indirect injury due to • Direct injury due to fall on

sudden flexion of extended
knee
⁕ Classification • Shape : transverse .
• Undisplaced or displaced .
⁕ Displacement
• Separation of the 2
fragments in displaced
fracture due to rupture of
quadriceps expansion .
the patella .
• Stellate ( star ) .
• Undisplaced or displaced .
• No separation of the fragments
due to intact quadriceps
expansion .

⁕ Complications • Haemoarthrosis , osteoarthritis & stiffness of knee

⁕ C/P • Pain & tenderness over the patella .

• Knee swelling wih +ve patellar tap ( haemoarthrosis)
• Active extension is intact but painful except in
displaced transverse fracture there is loss of active
extension.
• A gap is felt in the patella in displaced transverse
fracture .

⁕ Investigation • Plain x-ray ( as before in general rules of fractures ) .

⁕ Treatment : • Undisplaced :Above knee • Patellectomy with

• In all cases , cast for 6 weeks . reconstruction of
physiotherapy • Displaced :Open extensor apparatus .
for quadriceps reduction & internal
muscle . fixation by wire suture or
screw .
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Injuries of the menisci

⁕ Incidence :

• A common condition usually occurs in athletes particularly footballers.

• Medial meniscus is 10 times more affected than the lateral meniscus

because the medial meniscus is less mobile ( attached to the capsule of
knee joint ) while the lateral meniscus is more mobile ( separated from
the capsule by the tendon of popliteus muscle ) .

⁕ Aetiology : While standing on one limb with the knee flexed , forcible
rotation of body with extension of the knee will cruch the meniscus between
the condyles of femur and tibia .

⁕ Pathology :

• The tear is usually longitudinal ( bucket handle ) but may be transverse (

parrot beak ) .

• Tears in the peripheral third ( vascularized from the capsule ) can

heal but central 2/3 is avascular , therefore tear in this portion cannot
heal .
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⁕ Clinical picture :

1- History of characteristic trauma during playing a match , the player

suddenly feel pain in the knee , fall and cannot resume the
match .

2- Swelling & effusion in the knee .

3- Locking of the knee .

4- Tenderness on the medial aspect of the joint line .

5- Positive McMurry’s sign :

• The knee is flexed then the leg is externally rotated and abducted .

• If pain & click felt during extension of the knee , tear in the medial
meniscus is diagnosed .

⁕ Investigations :

1- MRI : It is the most reliable imaging modality .

2- Arthroscopy is diagnostic and therapeutic .

⁕ Treatment :

1- Conservative treatment is acceptable if the knee does not lock .

• Intial treatment : Rest , ice , compression , elevation and NSAID.

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• Fixation of knee for 2-3 weeks and physiotherapy to strength the

muscles around the knee .

2- Surgical treatment for recurrent symptoms interfere with daily activity

• Meniscal suture in peripheral tear .

• Partial meniscectomy : For central tear , excision of the affected

part of the meniscus, usually through arthroscopy or rarely nowadays

by open surgery .

• Total meniscectomy not recommended as it causes more

instability and so predisposes to secondary osteoarthritis.

Arthroscopic partial meniscectomy

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Injuries of cruciate ligaments

⁕ Incidence :

• A common condition usually occurs in athletes particularly footballers.

• Anterior cruciate ligament ( ACL) is commonly affected .

⁕ Aetiology :

• ACL is usually torn by sudden severe twisting trauma of the leg .

• Posterior cruciate ligament (PCL) is stretched and torn by severe

trauma to front of the leg .

⁕ Clinical picture :

1- History of characteristic trauma during playing a match , the player

suddenly feel pain in the knee , fall and cannot resume the
match .

2- The patient may hear a popping sound .

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3- The leg may collapse when the patient try to stand .

4- Rapid development of a swelling in the knee ( hemoarthrosis ).

5- Lachman’s test : It is the most sensitive test to diagnose ACL tear .

• With the patient spupine and the knee 20-30o flexion , fix the lower
part of femur by one hand and try to glide the upper part of tibia
anteriorly by the other hand .

• If there is tear in ACL , abnormal anterior movement of tibia is

noticed .

6- Anterior and posterior Drawer’s sign :

• With the patient spupine and the knee 90o flexion , try to glide the
upper part of tibia anteriorly and posteriorly .

• Abnormal anterior or posterior gliding movements of tibia in injury

of ACL or PCL respectively .

Lachman’s test Drawer’s sign

⁕ Investigations :

1- MRI : It is the most reliable imaging modality .

2- Arthroscopy is diagnostic and therapeutic .

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⁕ Treatment :

1- Conservative treatment :

• Intial treatment : Rest , ice , compression , elevation and NSAID.

• Fixation of knee for 2-3 weeks and physiotherapy to strength the

muscles around the knee .

•Isolated tears of the PCL are treated in most cases conservatively.

2- Surgical treatment:

• Indication : failure of conservative treatment or in athletes who require

full joint function .

• Method :

▪ Arthroscopic replacement of the torn ACL by a segment of patellar

ligament .

▪ Rarely isolated tear in the PCL need surgery .

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Replacement of anterior

& posterior cruciate

ligaments
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FRACTURE of BOTH BONES of THE LEG

⁕ Incidence : A common condition suspected in any severe trauma .

⁕ Aetiology: Trauma may be:

1. Direct e.g. traffic accident → transverse or comminuted fracture of

both bones at the same level.

2. Indirect (e.g.Falling from height on the feet or twisting trauma) →

oblique fracture at the weakest point of each bone → fracture lower 1/3
of tibia and upper 1/3 of fibula.

* Complications: (as general). The commonest complications are:

1- Compound fracture & skin loss (subcutaneous bone) → infection.

2- Non union or delayed union are common in open fractures. The tibia
is subcutaneous bone → poor vascularity → delay healing .

3- Malunion → osteoarthritis of knee & ankle.

4- Soft tissue & vascular (popliteal , tibial & fibular nerves &vessels)
damage.

5- Compartment syndrome in closed fractures.

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⁕ Clinical picture: (as general principles of fracture ) +

• Deformity: Angulation and overriding is very common due to strong

surrounding muscles.

⁕ Investigations : (as general principles of fracture )

⁕ Treatment: (as general principles of fracture )

I. Simple fracture: Depends on:

a) Stable fracture

1 - Closed reduction under general anaesthesia.

2. External fixation by above knee cast for 8-10 weeks.

b) Unstable fracture: One of the following can be done:

1. Skeletal traction by insertion of Steinmann's pin in the calcaneus or

distal tibia .

2. Open reduction and internal fixation by: ( The best if possible )

▪ Intramedullary nail (allows early partial weight bearing ).

▪ plate and screws (weight bearing is delayed until the fracture

unites )

II. Compound fracture: (as general principles of fracture)

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ANKLE FRACTURES
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⁕ Definition: It includes all fractures of the lower ends of tibia and fibula
involving the ankle joint.

⁕ Incidence : Ankle fractures are among the most common injuries .

⁕ Aetiology:

1- External rotation fracture: (Pott’s fracture) , commonest type .

• Occurs due to forcible external rotation of the foot.

2-Internal rotation fracture: ( very rare )

• Occurs due to forcible internal rotation of the foot.

3- Abduction fracture:

• Occurs due to fall on everted foot.

4- Adduction fracture:

• Occurs due to fall on inverted foot.

5- Vertical compression fractures:

• Occurs due to fall from a height on the foot.

⁕ Complications: (as general principles of fracture )

• Commonest complications are

1- Joint complications, Sudek's atrophy, osteoarthrosis, ankle stiffness.

2- Malunion & nonunion.

3- Injury of anterior & posterior tibial nerves & vessels or long & short
saphenous.

4- Injury of surrounding tendons.

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⁕ Classifications:

I) According to trauma :

1- First degree 2 Second Degree 3- Third Degree

1.External Oblique fracture First degree + either Second degree +
rotation of lateral rupture of deltoid fracture of posterior
fracture malleolus without ligament or avulsion malleolus → postero-
(Pott’s displacement . transverse fracture of lateral dislocation of
fracture) medial malleolus with talus.
lateral dislocation of
talus.
2. Adduction Rupture of lateral First degree + vertical Second degree +
fracture collateral fracture of medial fracture of posterior
(Produce ligament or malleolus with medial malleolus →
lateral traction avulsion dislocation of talus. posteromedial
force & medial transverse dislocation of talus.
compression fracture of the
force) lateral malleolus
3. Abduction Rupture of deltoid First degree + oblique Second degree
fracture: ligament or fracture of lateral fracture of posterior
(Produce avulsion malleolus with lateral malleolus → postero-
medial traction transverse dislocation of talus. lateral dislocation of
force & lateral fracture of medial talus.
compression malleolus.
force)

4. Internal rotation injuries: rare & produce injury similar to adduction

fracture.

5. Vertical compression fracture: It may lead to one of the followings :

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a) Fall on the dorsiflexed foot → fracture of anterior margin of lower end

of tibia with anterior dislocation of the ankle .

b) Fall on plantar flexed foot → fracture of posterior malleolus of tibia

with posterior dislocation of ankle joint.

c) Comminuted fracture of distal part of tibia.

d) Dupuytren's fracture: Rupture of the inferior tibio-fibular ligament,

separation of tibia & fibula, talus is derived between the 2 bone &
fracture of the 3 malleoli.
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II) According to level of fibular fracture :

• Type A :
▪ Fracture of fibula below the tibiofibular syndesmosis .
▪ It may be associated with a fracture of the medial malleolus or
tear of the medial ligament.
• Type B :
▪ Fibular fracture at the level of syndesmosis .
▪ It may be associated with tear of the anterior tibiofibular
ligament or fractures of the medial malleolus or the posterior
malleolus .
• Type C :
▪ Fibular fracture above the level of syndesmosis , which leads
to disruption of the syndesmosis, a part of the interosseous
membrane and wide separation of the tibiofibular joint.
▪ There may be associated fracture of the medial and third
malleolus.

⁕ Clinical picture & Investigations: (As general principles of fractures).

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⁕ Treatment: (As general principles of fractures).

A. Fracture of one malleolns without displacement:

• External fixation in a below knee cast for 6 weeks.

B. Fracture of 2 or 3 malleoli with displacement:

• Open reduction and internal fixation are necessary to restore

normal anatomical position and to achieve normal load

distribution .

• Surgery should be done within 6 hours after trauma before

development of edema or 6 days after edema subside.

• First, fibular fracture should be reduced anatomically to restore

its length & fixed by plate and screws

• Then the medial malleolus is reduced and fixed with screws .

• The third malleolus is fixed by screws .

• Collateral ligaments may need surgical repair

• Tibia-fibular syndesmosis reconstruction by protection screw which

removed after 6 weeks .

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