This document discusses patella and tibial plateau fractures. It describes the anatomy and mechanisms of injury for each. For patella fractures, it outlines types including undisplaced transverse, displaced transverse, comminuted, and vertical fractures. Clinical features and treatment options are provided for each type, including closed reduction, open reduction and internal fixation, and partial/total patellectomy. For tibial plateau fractures, the Schatzker classification system is described along with clinical features and treatment depending on fracture type, including closed treatment, open reduction and internal fixation. Complications of each injury are also mentioned.
5. Mechanism
Fractures of the patella are caused by
A. Direct violence (injury)
Due to trauma to anterior aspect of the flexed knee
leading to comminuted fractures.
B. Indirect violence (injury)
Due to forced flexion of the knee when the
sudden quadriceps muscle is contracting
In these case the fracture is transfers
7. 1. Undisplaced transverse fracture
Due to direct injury , the two fragment of
the patella are undisplaced as they are
held in position by the pre patellar
expansion of the quadriceps tendon and
patellar tendon
8. 2. Displaced transverse
fracture
Due to more sever trauma with gap between
the fragment
(this is indirect injury due to forced , passive
flexion of the knee while the quadriceps
muscle is contracted
Active knee extension is impossible
9. 3.Comminuted (stellate) fracture
Due to fall or direct injury on the front of the knee
4.Vertical fracture
One or two small fragments are separated from the medial or
lateral border of the patella
10. Clinical features
1. Local pain and tenderness
3. Swelling
1. Palpable gap between the fragment
2. presence of crepitus is felt
3. An x- ray examination
Fissure or crack fracture
Transverse fracture with dislocation
Comminuted fracture
11. Treatment
1. Undisplaced transvers fractures
Immobilization of knee by long leg plaster
splintage for 4-6 weeks combined with quadriceps
exercise
If there is a heamarthrosis , it is aspirated under
aseptic condition
12. 2. Displaced transverse fractures
Open reduction and internal fixation with screw
especially if pt is young
Small pollar fragment may be excised
Reduction and maintenance of the reduced position may
also be gained by strong wire passed around periphery of
the patella
In all these cases , the leg is splinted in long leg plaster
for 8 weeks
13.
14. 3. Comminuted fractures
Undisplacemen-A fracture with little or no displacement
can be treated conservatively by a posterior slab of
plaster that is removed several times a day for gentle
active exercises.
Displacement Reduction is impossible and so the best
treatment are
1. partial patelloectomy with the segment held by circlage
wire and the leg is splinted in the extended position for 2
weeks
2. Total patelloectomy is excision of all the segment and
the quadriceps aponeurosis is reconstructed by absorbable
suture
18. Complications
Knee Stiffness
Most common complication
Osteoarthritis
May result from articular damage
Chondromalagia
Ununion loss of fixation
19. Dislocation of the patella
is almost always over the lateral
femoral condyle
20. Mechanism
1. Direct trauma
2. sudden muscular contraction
In the presence of
Flattening of the lateral femoral condyle
Genu valgus and external rotation
Ligamentous laxity
Anatomical bony abnormalities :-
Small or high patella
21. clinical feature
Locking of the knee in the flexed position
Swelling of the knee due to haemarthrosis
Tenderness over the anteromedial aspect of the knee joint
Positive patellar apprehension test
An x-ray examination would reveal the dislocation
1. Traumatic acute dislocation
this result from an injury on the medial side of
the knee while the knee in flexed position
25. 2. Recurrent dislocation
predisposing factors
Post traumatic as rupture or weakness of
medial patellar retinaculum
Anatomical bony abnormalities
Small and high patella
Unequal pull of the quadriceps muscle
component
• Weakened vastus medialis
• Shorter vastus lateralis
• Genu valgus
33. Mechanism of injury -:
Fractures of the tibial plateau are caused
by varus or valgus force
force is more likely to rupture the ligaments
a car striking
fall from a height
34. Classification of Schatzker -:
Type 1 – simple split of the lateral condyle
Type 2 – a split of the lateral
condyle with a more central area of depression.
35. Type 3
the articular surface with an intact condylar
rim
Type 4 – a fracture of the medial
condyle.
36. Type 5
–fractures of both condyles, but with the central
portion of the metaphysis still connected to the tibial
shaft.
37. Type 6
– combined condylar and subcondylar fractures
effectively a disconnection of the shaft from the
metaphysis.
38. Clinical feature
1. Sever pain
2. Swelling
3. Valgus deformity
4. Local tenderness
on examination:-The knee may suggest medial or lateral
instability
the leg and foot should be carefully examined
for signs of vascular or neurological
42. Type1
Undisplaced type 1 fractures can be treated
conservatively
Displaced fractures should be treated by open
reduction and internal fixation
43. Type2
1. If the depression is slight (less than 5 mm)or
patient is old , the fracture is treated closed with the aim of
regaining mobility and function rather than anatomical
restitution. skeletal traction is applied with 5kg for 4 – 6 w
44. 2. In younger patients, and in those with a central
depression of more than 5 mm, open reduction with
elevation of the plateau and internal fixation is often
preferred
45. Type3 Depression of more than 5 mm in a type 3 fracture
can be treated by elevation from below and supported by bone
grafts and fixation
47. Type 5,6
Open reduction and internal fixation with plate
and screw.
A combination of screw fixation and circular
external fixation is lower risk complication .