Orthopedics 5th year, 6th/part two & 7th/part one lectures (Dr. Ali A.Nabi)

Supracondylar fractures of the

femur

Supracondylar fractures of the femur Supracondylar femur fractures usually

occur as a result 1. of low-energy trauma in osteoporotic

bone in elderly persons.2. high-energy trauma in young patients.3. Must also be aware of the potential for

pathologic fractures through metastatic lesions or primary bone tumors in this area.

Supracondylar fractures of the femur The fracture line usually above the condyles

and may extend between them. In sevsre trauma comminuted fracture

could be seen.

Supracondylar fractures of the femur The distal femur is funnel shaped, and the

area where the stronger diaphyseal bone meets the thinner and weaker metaphyseal bone is prone to fracture with direct or indirect trauma.

Supracondylar fractures of the femur Presentation

1. Patients present with pain, deformity, weakness, and inability to use the leg.

2. The knee is swollen and deformed. 3. Elderly patients usually have a history of a

fall.

Supracondylar fractures of the femur

4. Younger patients usually have had high-energy trauma. Especially for the younger patient, in whom significant soft-tissue injury may also be present, careful assessment of the whole limb is required.

5. Observe for compartment syndrome, vascular injury, and open wounds.

6. Fractures in other areas need to be identified.

Supracondylar fractures of the femur Imaging Studies Patients with supracondylar femur

fractures require anteroposterior (AP) and lateral radiographs of the entire femur to assess associated fractures and deformity; however, views centered at the knee are also important to assess the specific fracture pattern.

Supracondylar fractures of the femur Treatment1. No specific medical therapy for

supracondylar femur fractures exists. If the patient is unable to tolerate surgery, temporary traction can be used to maintain length and alignment.

Supracondylar fractures of the femur Supracondylar femur fracture treated in

traction. Traction allows nonoperative restoration of length and alignment while the patient is stabilized for surgery, but it is associated with the major complications of prolonged bed rest when used as definitive treatment.

Supracondylar fractures of the femur2. For nondisplaced and stable fractures,

bracing can provide enough stability to control pain and allow healing; however, bracing cannot control alignment or length because immobilizing the joint above and below is impossible.

Supracondylar fractures of the femur3. Surgical therapy requires reduction

followed by fixation to maintain alignment. Options include external fixation or internal fixation. Internal fixation is with intramedullary devices (e.g., flexible rods, more rigid retrograde or antegrade rods) or extramedullary plates and screws.

Supracondylar fractures of the femur Complications Early includes arterial injury Late Complications include 1. Nonunion.2. loss of alignment (malunion). 3. Infection.4. joint stiffness. 5. medical complications (e.g. thromboembolic

disease).

Knee injuries

Injuries involve the knee include1. fractures around the knee.2. dislocations (patella and knee).3. soft tissue injuries (Ligaments, tendons

and muscles).4. meniscal injuries.

Knee injuries Patellar and tibial plateau fractures each

account for 1% of all skeletal fractures. Distal femoral condyle fractures account for 4% of all femur fractures.

Knee injuries Fractures of the knee This involve the followings1. fractures of the patella.2. femoral condyles.3. tibial eminence (spine).4. tibial tuberosity ( tubercle).5. tibial plateau (condyles).

Fractures of the patellaPatients with patella fractures may have a

history of the following: Direct or indirect trauma with resultant

pain and edema Caused by a direct blow, such as a dashboard

injury in a motor vehicle accident or a fall on a flexed knee

Also caused by forceful quadriceps contraction while the knee is in the semiflexed position (e.g., in a stumble or fall).

Fractures of the patella Clinically When examining a patient for a knee

fracture, one should first examine the patient for edema, ecchymosis, and point tenderness. Ask the patient to perform a straight-leg raise against gravity to check the integrity of the extensor mechanism, which commonly is disrupted with transverse patellar fractures caused by indirect forces. 

Fractures of the patella The patient may have pain with leg extension

or be unable to extend the knee with a severe fracture.

Patients present with pain directly over the patella.

Fractures of the patella X – Ray May show One or more fracture lines without

displacement. Multiple fracture lines with irregular

displacement. Transverse fracture with a gap between

the fragments.

Fractures of the patella Other knee should be checked to exclude

bipartite patella which usually bilateral. An axial (or sunrise) view of the patella is

useful for detecting vertical patellar fractures, which frequently are missed and nondisplaced. Transverse fractures are most common, followed by comminuted and avulsion fractures.

Fractures of the patella Patellar fractures can be classified into

Transverse. Longitudinal (vertical). Polar. Comminuted.

Fractures of the patella Treatment

1. Nondisplaced transverse fractures with an intact extensor mechanism are treated with a knee immobilizer, crutches, restriction to only partial weight bearing, and 6 weeks of immobilization.

Fractures of the patella2. Displaced fractures, or fractures associated

with a disrupted extensor mechanism, are referred to orthopedics for possible open reduction and internal fixation usually by 2 K. wires and tension band wire or by screw. A partial or total patellectomy may be required for severe comminution.

Fractures of the patella3. Patients with open fractures should receive

antibiotics and orthopedics should be consulted for emergency irrigation and debridement.

Fractures of the patella Complications 1. Soft-tissue infection 2. Osteomyelitis secondary to an open

fracture 3. Delayed union or nonunion 4. Posttraumatic arthritis or knee stiffness 5. Chondromalacia patella

Femoral condyles fractures

Either medial condyle fracture or lateral condyle fracture or both condyles fractures.

Often associated with supracondylar fractures. Femoral condyle fractures due to axial loading

with valgus or varus stress like fall from hieght.

Femoral condyles fractures Clinically

When examining a patient for a knee fracture, one should first examine the patient for edema, ecchymosis, and point tenderness. A careful neurovascular examination should be performed.

Patient will present with pain over the distal femur and often will have a hemarthrosis.

Patients are often unable to bear weight.

Femoral condyles fractures X –ray show T or Y- shaped fracture if the

fracture involve both condyles.

Femoral condyles fractures Treatment

These may be supracondylar, intercondylar, or condylar.

Nonoperative management may be used for nondisplaced or incomplete fractures.

Open fractures, displaced fractures, and those with neurovascular injury will need operative fixation.

Femoral condyles fractures Complications 1. Neurovascular injury.2. Genu varum or valgum deformities.3. Other bone and joint complications.

Tibial eminence (spine) fracture Due to a direct blow to the proximal tibia

with the knee flexed such as falling off a bicycle

Also due to hyperextension with varus or valgus stress, such as in motor vehicle collisions or athletic accidents

Tibial eminence avulsion fractures occur most often in children aged 8-14 years but can also occur in the skeletally mature patient.

Tibial eminence (spine) fracture Clinically Patients may present with a knee effusion

and pain. Patients may represent with an avulsion of

the tibial attachment of the anterior cruciate ligament.

Tibial eminence (spine) fracture X – Ray fracture may easily miss unless

the x-ray is carefully examined.

Tibial eminence (spine) fracture Treatment

For a nondisplaced fracture (and stable knee joint), immobilize the knee.

A complete avulsion of the tibial spine, or a displaced fracture for possible surgical fixation.

Tibial eminence (spine) fracture Complications1. Stiff knee.2. Locked knee due to non-union and

entrapment of the piece.3. Osteoarthritis.

Tibial tubercle (tuberosity) fracture

Usually occur with jumping activities such as basketball, diving, gymnastics, and football. 

Tibial tubercle (tuberosity) fracture Clinically

More common in males than in females. Patients present with pain over the anterior

tibia about 3 cm distal to the articular surface. In severe fractures, the patient may be unable

to extend the knee. More common in adolescents; infrequent in

adults.

Tibial tubercle (tuberosity) fracture X – Ray is obvious

Tibial tubercle (tuberosity) fracture Treatment

1. For nondisplaced fractures, immobilize the knee.

2. Displaced fracture treated with open reduction and internal fixation.

Tibial plateau (condyles) fracturesCaused by axial loading with valgus or varus

forces, such as in a fall from a height or collision with the bumper of a car Due to the impaction of the femoral condyle

into the tibial plateau In elderly persons and those with osteoporosis,

tibial plateau fracture can occur with minor trauma.

Tibial plateau (condyles) fractures Clinically

Patient is generally unable to bear weight. The lateral tibial plateau is fractured more

frequently than the medial plateau. Often, patients present with a knee effusion,

and tenderness will be present over the medial or lateral plateau.

Tibial plateau (condyles) fractures

Up to 30% of tibial plateau fractures are associated with knee ligamentous injuries (medial collateral or anterior cruciate ligaments with lateral plateau fractures, lateral collateral or posterior cruciate ligaments with medial plateau fractures).

Tibial plateau (condyles) fractures X –Ray Obtain anteroposterior, lateral, and

oblique radiographs of the knee. Four views have been shown to be superior to two views in detecting fractures.

Oblique views are particularly useful in detecting subtle tibial plateau fractures (internal oblique profiles lateral plateau, external oblique profiles medial plateau).

Tibial plateau (condyles) fractures C-T scan

CT scans may be necessary to fully delineate the extent of tibial plateau fractures and other complex knee fractures.

Compared to CT scans, plain radiography underestimates the amount of articular depression of tibial plateau fractures in most tibial regions. This is significant as the amount of tibial plateau depression is an indicator for operative repair.

Tibial plateau (condyles) fractures Classification Schatzker in 1987 classify the tibial

plateau fractures into Type I – Vertical split of the lateral

condyle, Type II - Vertical split of the lateral condyle

combined with depression of the adjacent load-bearing part of the condyle.

Tibial plateau (condyles) fractures Type III – central depression of the

articular surface with an intact condylar rim.

Type IV – fracture of the medial tibial condyle.

Type V – fracture of both condyles. Type VI – combined condylar and

subcondylar fractures.

Tibial plateau (condyles) fractures Treatment

Immobilize nondisplaced fractures and have patient remain non weight bearing.

Tibial plateau (condyles) fractures

displaced (depressed) fractures require open reduction and internal fixation. Articular depression of greater than 3 mm may be considered for surgery.

Tibial plateau (condyles) fractures

The goal of treatment is a stable, aligned, mobile, and painless knee joint to minimize risk of posttraumatic osteoarthritis.

Tibial plateau (condyles) fractures Complications 1. Vascular injury and compartmental

syndrome.2. Knee stiffness.3. Non-union.4. Malunion and deformity.5. Osteoarthritis