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knee fractures/dislocations - Coggle Diagram
knee fractures/dislocations
Patellar fractures
frequency of occurrence (high to low)
-transverse
-comminuted or stellate
-vertical
-osteochondral
-polar (apical or basal)
MOI is direct (blow or fall) or indirect (jumping)
indications for nonsurgical treatment
-minimal displacement (<2-3 mm)
-intact extensor mechanism
-minimal articular step off (1-2 mm)
conservative treatment
-full extension cast for 3-6 weeks
-quad set and SLR with return to WBing as tolerated
-progression of knee flexion and strengthening after cast removal
-CKC at 6 weeks, full ROM/strength at 12 weeks
outcomes
-most have full ROM and return to normal quad strength
-complications in <2%
-95% pt satisfaction
surgical treatment
outcomes following ORIF
-good to excellent in 70-80% of cases
-fair to poor in 20-30%
-loss of extensor mechanism in 20-49%
-refracture 5%
-prolonged immobilization increases likelihood of poor results
tension banding technique: inc knee flexion tenses bands to intensify compression
-partial WBing for 6 weeks
-AAROM at 3-6 weeks
patellectomy: good to excellent outcomes in 22-85%, loss of quad strength in 50%, prolonged return to function (6-8 months)
quad tendon rupture
-80% occur in those over 40
-forced knee flexion with max quad contraction
repair
-locked in knee extension for 6 weeks
-acute repairs result in good recovery of ROM and strength
-late repairs at risk for significant extension deficits
patellar tendon disruption
-usually occurs in those <40
-h/o patellar tendinitis or steroid injections
-ruptures associated with high energy trauma
re-rupture rate <10%
ligament is sutured to bone
-<50% PWBing, immobilized in extension for 6-8 weeks
-earlier repairs have better outcomes
-complications include patella baja and decreased knee flexion
distal femoral fractures
supracondylar distal fracture: distal fragment is flexed by gastroc, causing post displacement
-pull of hamstrings/quads shorten femur
-cast brace for 6-8 weeks, ORIF if not reducible and displaced
commonly associated injuries
-ipsi hip fracture/dislocation
-peroneal nerve injury
-vascular injury
-damage to quad apparatus
age distribution: young males have high incidence of high energy trauma and intra-articular damage
-elderly women have high incidence of low energy trauma with fractures secondary to osteopenia
indications
-absolute: displaced intra-articular, open, NV injury, ipsi LE fracture, pathologic fracture
-relative: isolated extra-articular and severe osteoporosis
contraindications: preexisting infection, marked obesity, comorbid conditions, poor bone quality, systemic infection
nonop indications: nondisplaced, impacted stable fracture, sig underlying medical disease, advanced osteoporosis, nonambulatory pts
fat embolism: associated more often with intramedullary instrumentation
-typically occurs in high energy tibial/femoral fx in those bw 20-40 y.o.
-common in 60-80 y.o. with low energy trauma
outcomes (minimally invasive, low profile)
-ROM: 1-109 deg
-nearly all maintian fixation
-6% malreduction, 3% infection
children
-most common is salter harris type 2
-MOI: indirect varus/valgus stress, breech birth, minimal trauma in conditions that weaken growth plate
-nondisplaced: hip spica or long leg cast 4-6 weeks
-displaced SH type 1/2: closed reduction with traction followed by immobilization
-displaced SH 3/4: open anatomic reduction
indications for ORIF
-irreducible SH 1/2, unstable reductions, SH 3/4
complications with fracture
-acute: peroneal nerve palsy, popliteal artery
-late: angulation deformity, leg length discrepancy, knee stiffness, avascular necrosis, nonunion