INJURIES OF

KNEE AND LEG

Done by- FATEMA BURHAN RAVAT
DTMU, 4th year
Objectives
1. Anatomy of the knee jointKnee ligament injuries
2. Chronic ligamentous instability
3. Fracture of Patella
4. Tibial plateau fractures
5. Fractures of Tibia and Fibula
Knee ligament injury
❖ Mechanism of Injury
➢ Bent knee, straight thrust
➢ Combined rotation and thrust
❖ Most common valgus stress- medial structures -> MCL, ACL (if twist),
medial meniscus
❖ Varus stress- LCL, cruciate ligaments, capsule
❖ ACL most common cruciate ligament injured (PCL is relatively strong)
 Clinical features

● Hx- twisting or wrenching, pop

● Painful knee, swollen immediately
● Tenderness over the ligament
● Complete tear- little or no pain; partial tear- painful
● Meniscus injury- effusion; Ligament injury-
haemarthrosis
● Bruising

Diagnoses

● X-ray; stress films

● MRI
● Arthroscopy
Tests to assess the injury
● Anterior drawer test
● Posterior drawer test
● Pivot shift maneuver- ACL
injury
● Lachman test PIVOT SHIFT TEST

LACHMAN TEST
Treatment
Sprains and partial tears

● Spontaneous healing
● Active exercises (prevents adhesions)
● Aspirating effusions, ice-packs, local anesthetics
● brace/bandage (prevent rotational strain)
● Return to usual activities by 6-8 weeks
Complete tears

● MCL, LCL, PCL - treat conservatively

● Long cast brace - 6 weeks
● ACL - early operative reconstruction
● Combined tears - first joint support and physiotherapy -> operative
reconstruction (autograft)
Complications
1) Adhesions -
a) torn fibers stick to intact fibers and bone
b) Pain, tenderness
c) Tx- physiotherapy
2) Ossification of ligament (pellegrini-stieda’s disease)
3) Instability
Chronic ligamentous instability
Anterolateral rotatory instability Posterolateral rotatory instability

● Torn ACL, lateral capsule and LCL ● Torn PCL and arcuate ligaments
● Anterior drawer test (+) [ACL] ● Posterior drawer test (+)
● Pivot shift phenomenon [capsule ● Reverse pivot shift phenomenon
and LCL]

Clinical features

1. Feeling of insecurity/ “giving away”

2. Subtle symptoms
3. Slight wasting
 Treatment
● First approach- exercise programmes to strengthen quadriceps and
hamstrings
● Indications for operation-
a. Meniscal tear
b. Intolerable symptoms
c. Demanding occupations
d. Ligament injuries in adolescents
e. Combined injuries
● Operative treatment done by reconstruction with tendons or synthetic grafts
● PCL injury - indication in those who have more than 10-15 mm posterior tibial
translation in drawer test. All damaged structures repaired
 Fractured Patella
● Direct force - fall onto knee or blow
against car dashboard
● Indirect traction force - catches foot
against solid obstacle- transverse fracture

Clinical features

● Swollen, painful knee

● Abrasions, bruising, tender
Classification -

● Transverse, longitudinal, polar, comminuted

Diagnoses

● X-ray - one or more fracture lines visible

● Gap visible
● Compare with opposite knee
Treatment
Undisplaced or minimally displaced fractures-

➔ Aspirate haemarthrosis
➔ Plaster cylinder - 3-4 weeks
➔ Quadriceps exercises

Displaced

➔ Operative- tension band wiring,

repair tears of extensor expansions
➔ Plaster backslab/ hinged brace

Comminuted

➔ patellectomy/ hinged brace

Tibial Plateau Fractures
● Mechanism - varus or valgus force + axial loading- hit by car, fall from
height
● Classification by Schatzker
Clinical features

● Knee is swollen
● Bruising, doughy feeling -
haemarthrosis
● Injury of peroneal or tibial nerves

Imaging

● AP, lateral, oblique view X-ray

● CT - comminution
 Treatment
● Undisplaced - treated conservatively
○ Aspirate haemarthrosis, reduce swelling, compression bandage
● Minimally displaced- Closed reduction
○ Traction - 5kg for 3-4 weeks
○ Followed by hinged cast-braces - 6 weeks
● Displaced - open reduction and internal fixation
○ Screws, buttress plates, raft screws
○ Bone grafts for depressed fractures
● CPM machine for partial exercises to regain motion
● Post op- limb elevated, splinted
● Partial weight-bearing - 6 weeks; full weight-bearing - 12-16 weeks
2-3 lag >5mm depression -> Bone grafts and fixation
Buttress plate and
screws- type 1 elevation - type 3 - type 2 and 3
screws- type 2 & 4
Complications
1. Compartment syndrome
2. Joint stiffness - avoid prolonged
immobilization
3. Deformity - varus or valgus; due
to incomplete reduction or
redisplacement
4. Osteoarthritis
Fractures of Tibia and Fibula
● Tibia > fibula
● Open > closed
● Indirect injury - low energy; spiral or long oblique
● Direct injury - high energy; crush or split

GUSTILO’S CLASSIFICATION FOR OPEN FRACTURES

Clinical features

● Signs of soft tissue damage-

bruising, swelling, crushing or
tenting of skin
● Circulatory changes, weak or
absent pulses
● Neurologic- loss of sensation,
inability to move toes

X-ray - to assess the type of fracture

Management

Objectives

1. Limit soft tissue damage and preserve skin cover

2. Prevent or recognize compartment syndrome
3. To obtain and hold fracture alignment
4. To start early weight-bearing
5. To start joint movements as soon as possible
Low energy fractures
● Most treated nonoperatively (including Gustilo-1)
● Undisplaced or minimally displaced - full-length cast
● Displaced -
○ reduced
○ full length cast
○ Leg elevated for 48-72 hours
○ Swelling - split cast
● Exercise - from the start
● Functional brace- after 4-6 weeks of full length cast- allows weight
bearing
● Operative - if malalignment persists-> Intramedullary nail, plating or
external fixation
High energy fractures
● Tissues around fracture should not be disturbed
● Transverse fractures- stable after reduction - closed treatment
● Comminuted and segmental fractures - unstable -> surgical stabilization
○ External fixation
● If bone loss- bone grafting
 Open fractures
1. Antibiotics - cephalosporins + gentamicin 24-72 hours
2. Debridement - remove dead and foreign material,
washed with normal saline, close wound within 2-3 days
3. Stabilization
a. Gustilo I,II,IIIA - locked intramedullary nailing
b. Use external fixator for severe grade injury
4. Prompt soft tissue cover
a. Within 5 days
b. done before stabilization for severe grade injury
5. Rehabilitation
6. Post op- elevate leg, weight bearing in few days
 COMPLICATIONS

Early Late

Compartment Vascular Joint Delayed

Infection Malunion union/non-
Syndrome Injury stiffness
union
 Thank You
for your attention