Fractures Around the Knee

164 Pages·2016·14.46 MB·English

by  Filippo Castoldi

Fracture Management Joint by Joint
Series Editors: Filippo Castoldi · Davide Edoardo Bonasia
Filippo Castoldi
Davide Edoardo Bonasia
Editors
Fractures
Around the Knee
Fracture Management Joint by Joint
Series editors
Filippo Castoldi
Department of Orthopaedics
CTO Hospital Turin
Torino
Italy
Davide Edoardo Bonasia
University of Torino
AO Ordine Mauriziano
Torino
Italy
Th is book series aims to provide orthopedic surgeons with up-to-date
practical guidance on the assessment, preoperative work-up, and surgical
management of intra-articular fractures involving diff erent joints, including
the shoulder, knee, hip, elbow, ankle, and wrist. Complex articular fractures
are diffi cult to treat and sometimes require specifi c surgical skills appropriate
to the involved joint. In addition, arthroscopic-assisted fracture reduction is
increasing in popularity, but trauma surgeons are generally not trained in
arthroscopic techniques. For these reasons, articular fractures are oft en
referred by the trauma team to surgeons experienced in the management of
injuries to the joint in question. Th erefore, across the world it is becoming
common for orthopedic surgeons to specialize in treating fractures of only
one joint. Th is series is designed to fi ll a gap in the literature by presenting the
shared experience of surgeons skilled in the use of arthroscopic and open
techniques on individual joints.
More information about this series at http://www.springer.com/series/13619
Filippo Castoldi
Davide Edoardo Bonasia
Editors
Fractures Around
the Knee
Editors
Filippo Castoldi Davide Edoardo Bonasia
University of Torino University of Torino
CTO hospital AO Ordine Mauriziano
Torino Torino
Italy Italy

Fracture Management Joint by Joint
ISBN 978-3-319-28804-8 ISBN 978-3-319-28806-2 (eBook)
DOI 10.1007/978-3-319-28806-2
Library of Congress Control Number: 2016937325
© Springer International Publishing Switzerland 2016
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Contents
1 Patellar Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Stefano Zaffagnini , Federico Raggi , Alberto Grassi ,
Tommaso Roberti di Sarsina , Cecilia Signorelli ,
and Maurilio Marcacci
2 Tibial Eminence Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Jessica Hanley and Annunziato Amendola
3 Management of Distal Femoral Fractures
(Extra-articular) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Seth R. Yarboro and Robert F. Ostrum
4 Management of Distal Femoral Fractures
(Intra-articular) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Mario Ronga , Giuseppe La Barbera , Marco Valoroso ,
Giorgio Zappalà , Jacopo Tamini , and Paolo Cherubino
5 Management of Simple Proximal Tibia Fractures
(Schatzker Types I–IV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Davide Edoardo Bonasia
6 Management of Complex Proximal Tibia Fractures
(Schatzker Types V and VI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Jodi Siegel and Paul Tornetta III
7 Primary Total Knee Arthroplasty (TKA)
in Tibial Plateau Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Federica Rosso , Davide Blonna , Antonio Marmotti ,
Gianluca Collo , and Roberto Rossi
8 Floating Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Qiugen Wang , Lei Cao , Jianhong Wu , Jian Lin ,
and Xiaoxi Ji
9 Periprosthetic Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Gabriele Pisanu , Alessandro Crosio ,
and Filippo Castoldi
v
vi Contents
10 Management of the Complications Following
Fractures Around the Knee
(Infection and Non-union) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Daniele Santoro , Laura Ravera , Corrado Bertolo ,
Domenico Aloj , and Bruno Battiston
11 Management of the Complications Following
Fractures Around the Knee (Malalignment
and Unicompartmental Arthritis) . . . . . . . . . . . . . . . . . . . . . . . . 129
Davide Edoardo Bonasia , Filippo Castoldi ,
Massimiliano Dragoni , and Annunziato Amendola
12 Management of the Complications Following
Fractures Around the Knee (Post-traumatic
Bi- or Tricompartmental Arthritis) . . . . . . . . . . . . . . . . . . . . . . . 151
Federica Rosso , Umberto Cottino , Matteo Bruzzone ,
Federico Dettoni , and Roberto Rossi
1
Patellar Fractures
Stefano Zaffagnini , Federico Raggi ,
Alberto Grassi , Tommaso Roberti di Sarsina ,
Cecilia Signorelli , and Maurilio Marcacci
Abstract
Patella fractures are relatively rare compared to all skeletal injuries but
quite common for those who works with knee trauma. This type of frac-
tures are mainly caused by a direct trauma, and can generally be diagnosed
by clinical presentation and x-rays. Conservative treatment is reserved for
non-displaced fractures, for other surgical reduction and fi xation by ten-
sion band tachnique are the best choices.
The surgeon must know postoperative management and how to handle
the early and late complications of this type of fractures.
1.1 Epidemiology Only a third of the patellar fractures encoun-
tered in the emergency department require a sur-
Patellar fractures are relatively rare and represent gical intervention [7 ].
1 % of all skeletal injuries [ 1 , 2 ] with an overall
incidence of 10.7 per 100.000 people per year
[ 3 ]. This type of fractures is most common in the 1.2 Traumatic Mechanism
age range of 20–50 years, and the incidence in
men is almost twice than in women [4 , 5 ]. Patellar fractures can result from direct and indi-
Patellar fractures are rare in children because rect forces or a combined mechanism.
the patella is largely cartilaginous and has greater The majority of patella fractures occur from a
mobility compared to adults [6 ]. Of all patellar direct trauma to the front of the knee [8 ], for
fractures, less than 2 % occur in the skeletally example, a fall from a height, a blow to the patella
immature patients. from a direct fall, or a motor vehicle crash.
Usually the trauma occurs onto the fl exed knee. A
direct trauma may produce an incomplete, sim-
S. Zaffagnini (*) • F. Raggi • A. Grassi ple, or comminuted fracture. Displacement is
T. Roberti di Sarsina • C. Signorelli • M. Marcacci typically minimal owing to preservation of the
Laboratorio di Biomeccanica e Innovazione medial and lateral retinaculum expansion.
Tecnologica , Istituto Ortopedico Rizzoli ,
Abrasions over the area or open injuries are com-
Via Di Barbiano 1/10, 40136 , Bologna (BO) , Italy
e-mail: [email protected] mon. Active knee extension may be preserved.
© Springer International Publishing Switzerland 2016 1
F. Castoldi, D.E. Bonasia (eds.), Fractures Around the Knee, Fracture Management Joint by Joint,
DOI 10.1007/978-3-319-28806-2_1
2 S. Zaffagnini et al.
Indirect mechanism is secondary to forcible The damage to the extensor mechanism is
eccentric quadriceps contraction while the knee is tested by asking the patient to fully extend the leg
in a semifl exed position. The intrinsic strength of with a pillow placed under the affected knee. Full
the patella is exceeded by the pull of the musculo- active extension against gravity only indicates an
tendinous and ligamentous structures. Indirect intact extension mechanism but does not rule out
injuries occur from a near fall or a stumble. The the presence of a fracture. The inability to extend
injury usually results in a transverse fracture with the knee in the presence of a patella fracture indi-
some inferior pole comminution and the fragment cates a tear of both medial and lateral retinacula
displacement is dependent on the amount of dam- [1 ] . Testing the effi ciency of the extensor mecha-
age to the quadriceps retinaculum. Active knee nism is critical to determine whether a fracture
extension is lost in the majority of cases. will require closed or operative treatment.
Combined mechanism may be caused by a direct Full active or passive range of motion of the
and indirect injury to the knee, such as in a fall from knee should not be performed until a radiographic
a height. Combined injury can present with soft tis- study is taken, because this can potentially further
sue trauma and large fragment displacement. damage the retinaculum or displace the fracture.
Associated lower extremity injuries may be
present in the setting of high-energy trauma. The
1.3 Clinical Examination physician must carefully evaluate the ipsilateral
hip, femur, tibia, and ankle.
T he diagnosis of a patella fracture is made by A fter completion of the clinical examination,
collecting a complete history of the injury, per- the lower extremity is splinted in extension or
forming a physical examination, and obtaining slight fl exion.
appropriate radiographic studies [9 ].
P atients typically present with limited or no
ambulatory capacity, decreased strength, pain, 1.4 Imaging and Preoperative
swelling, and tenderness of the involved knee. A Work-Up
large hemarthrosis can develop from a patella
fracture, especially when a large retinaculum tear R adiographic studies of the patella fractures
is associated. include standard x-rays of the knee in anteropos-
Palpation of the subcutaneous patella can dem- terior (AP) and lateral views and patellar views,
onstrate the point of maximal tenderness, and, if computed tomography, and bone scanning.
the displacement is signifi cant, the physician can Comparison views of the contralateral knee
palpate a defect between the fragments. In non- may help defi ne the bony anatomy and soft tissue
displaced fractures clinical examination can only alignment, for the preoperative planning.
demonstrate tenderness with little or no swelling. In the AP view, the patella normally projects
Any major contusion, abrasion, or blister should onto the midline of the femoral sulcus. Its apex is
be carefully examined to rule out an open fracture, located just above a line drawn across the distal
because these constitute a surgical urgency and profi le of the femoral condyles. In the AP view,
require surgical debridement within 6–8 h. Delays the patella is diffi cult to evaluate, because of the
in treatment can lead to infection of the fracture superimposition of the distal femoral condyles.
site and knee joint. A simple test by the injection of The lateral view provides a profi le of the
more than 100 ml of saline into the knee is useful patella, fracture fragment displacement, and con-
to determine if there is communication between gruity of the articular surface. This view must be
the joint and the soft tissue injury [1 0 ]. examined for fracture lines, fracture displace-
In closed fractures, removal of the hemarthro- ment, and patella height abnormalities. The prox-
sis decreases the intra-articular pressure, and an imal tibia must be visible to exclude bony
intra-articular injection of local anesthetic can be avulsions of the patellar tendon from the tibial
performed to decrease the pain and facilitate the tuberosity. A “patella baja” may be indicative of
evaluation of the extensor mechanism. a quadriceps tendon rupture, while a “patella
1 Patellar Fractures 3
alta” may be the sign of a patellar tendon rupture. OTA classifi cation each fracture type has a code,
The best way to recognize an abnormal position consisting of three elements (Fig. 1.1 ). The fi rst
of the patella is the Insall-Salvati method [1 1 ]. number identifi es the bone (34 for the patella),
This technique uses the ratio between the greatest and the fi rst letter (A, B, C) describes three differ-
diagonal patella length and the patellar tendon ent fracture types:
length. This ratio is normally around 1. A ratio < 1
suggests a high-riding patella (“patella alta”) or A. Extra-articular, extensor mechanism disrupted
patellar tendon rupture. B. Partial articular, extensor mechanism intact,
T he 30° Merchant view is obtained with 45° often vertical fractures
of knee fl exion and the central beam directed C. Complete articular, extensor mechanism
caudally at a 30° angle from horizontal. If a disrupted
longitudinal or an osteochondral fracture is sus-
pected, the Merchant view can be helpful. The two following numbers describe the loca-
Tendon rupture, patellar dislocation, and tion of the fracture and the number of fragments.
growth abnormality (bipartite patella) must be Patella fractures can be classifi ed also in
ruled out by imaging. geometric terms (Fig. 1.2 ) such as transverse,
I solated rupture of the quadriceps or patellar stellate or comminute, longitudinal or marginal,
tendon must be excluded by clinical evaluation proximal, or distal pole [1 3 ].
and by the lateral x-ray view that may indicate an
abnormal position of the patella.
Dislocation, most common on the lateral side, 1.6 Indications
may result in an osteochondral shear fracture
with lesion of the medial margin of the patella. T he choice of the treatment depends on the type
T he AP radiograph may demonstrate bipartite of fracture and clinical presentation. Fractures of
or tripartite patella, resulting from failure of the patella can be treated conservatively or
fusion of two or more ossifi cation centers. This surgically [1 4 ].
abnormality has usually one or two fragments in Surgery should be avoided in patients with
the superior lateral patellar pole, with irregular, high preoperative risk or joint ankylosis and prior
rounded, and sclerotic margins. Bipartite patella failed extensor mechanism or in nonambulatory
is bilateral in 50 % of cases. patients [ 15 ].
Computed tomography scan may be used to Nonoperative treatment is possible in case of
better delineate fracture patterns and free closed, non-displaced fractures with an intact
osteochondral fragments or evaluate articular extensor mechanism (34-B). Conservative
incongruity in case of nonunion, malunion, and treatment should meet the indications of fragment
patellofemoral malalignment. separation of less than 3 mm and articular incon-
Bone scintigraphy with Tc-99m can be helpful gruity less than 2 mm [1 2 , 15 ].
in the diagnosis of stress fractures, while C onservative management involves immobili-
indium-111 leukocyte scintigraphy can reveal zation of the knee in nearly full extension for 5–6
infection. weeks through the use of a long-leg plaster cast or
a brace. The patient is allowed to partially weight-
bear using crutches, advancing to full weight
1.5 Classifi cation bearing with crutches as tolerated. Quadriceps
exercise with straight-leg raising and isometric
The majority of patella fracture classifi cations strengthening exercises should be started within a
use descriptive terms of the fracture pattern or few days from the injury.
location. A fter radiographic evidence of healing, pro-
The Orthopaedic Trauma Association (OTA) gressive active fl exion and extension strengthen-
classifi cation system is widely accepted for the ing exercises are begun with a hinged knee brace
classifi cation of patellar fractures [1 2] . In the initially locked in extension for ambulation.