Fractures at the Tibia and Fibula

November 26, 2015 at 11:35 pm | Posted in Uncategorized | Leave a comment

P/s: As usual, I did not owe this note. Credit should be given to Appley and Netter’s Concise Orthopaedic and of course my lecturers 😉

1. Patella #
Most important is to look at the extensor mechanism, is it intact or not.

Extensor mechanism comprises of:
➡ Quadriceps
➡ Patella
➡ Patella tendon

How to test?
Ask the patient to lift up the leg.

MOI
1. Direct injury to patella. Usually result in undisplaced and comminuted fracture (stellate #). Extensor mechanism usually intact.
2. Avulsion #. Sudden forceful contraction of the extensors. Usually result in displace transverse # with involvement of the extensor mechanism.

Management:
Huge hemarthrosis
➡ requires aspiration as it can damage the articular surface, however this may cause it to become an open #.
➡ aspiration is done using an aseptic technique, hence no need to treat as open #.
➡ small hemarthrosis usually resolves spontaneously

Definitive Management
🔴 Undisplaced # – knee brace/casting for 6 weeks + exercise to prevent joint stiffness.
🔴 Comminuted, displaced, with intact extensor mechanism – partial or full patellectomy.
🔴 Displaced with involvement of extensor mechanism – ORIF (tension bands wire) and repair of extensor mechanism.

Complications:
Patellofemoral OA
Decreased ROM

2. Patella Dislocation
MOI:
Direct force to patella – rare.
Sudden forceful contraction of the extensors muscle – more common MOI  esp in sports

Clinical features:
Usually patella has reduced spontaneously or else, obvious deformity.
Bruises and swelling.
Fluid aspiration, may contain blood. If contain fat meaning that there is osteochondral #.

Management:
💟 Closed reduction. Usually did not need anaesthesia.
After that, put in braces for 2-3 weeks followed by 2-3 months exercise of the extensors.
💟 Intraarticular dislocation usually need operative treatment.
💟 Severe bruising indicates severe soft tissue injury. It requires surgical exploration and repoir of the damaged structures.

Complications:
Recurrent dislocation

♠Recurrent Dislocation♠
2x in a year.
It may follows patella dislocation or can be due to other factors such as ligamentous laxity, underdeveloped femoral condyle or underdeveloped patella.

Dislocation occurs unexpectedly when the quadriceps muscle is contracted with the knee in flexion. Painful.

Dislocation usually reduce spontaneously.
Positive apprehension test – patient worried that dislocation happened again.

♣ Habitual Dislocation ♣
Dislocates even with sitting to standing position. It is painless.

Long term, patella may permanently dislocate.

3. Tibial Spine #
MOI:
Varus or valgus stress, or twisting injury damage the ligamentsband caused # of the tibial spine.

Usually in paeds and is a traction injury.

Management:
Close reduction under anaesthesia.
If failed, OR & IF (screw)
Post reduction, casting for 6 weeks.

4. Tibial Plateau #
MOI:
Varus or valgus force combined with axial loading (intact femoral condyle hit the tibial plateau).
It will result in tibial plateau fracture, meniscus injury, with/without ligament tear.

Classification:
Schatzker
Type 1 ➡ lateral plateau #
Type 2 ➡ lateral plateau # with depression #
Type 3 ➡ depression #
Type 4 ➡ medial plateau #
Type 5 ➡ bicondylar plateau #
Type 6 ➡ # with metaphyseal and diaphyseal seperation

CT scan will visualize the # clearer.

Management:
🔘 Aspirate the hemarthrosis
🔘 Undisplaced ➡ casting for 6-8 weeks. NWB until # unites
🔘 Displaced ➡ IF (Buttress plating)
🔘 Depression # (type 2&3) ➡ Bone graft/rafting using screws
🔘 Severe swelling ➡ use ex-fix to stabalize until swelling subsides before IF
🔘 Ligamentotaxis ➡ using traction to achieve close reduction.
🔘 Old and frail ➡ conservative mx

🔱 later ligaments and meniscus repair

Complications:
1. Compartment syndrome (esp Type 4 onwards due to severe bleeding)
2. Joint stiffness (multiple op and prolonged immobilization)
3. OA
4. Popliteal artery injury
5. Common peroneal nerve or tibial nerve injury.
6. Deformity

5. # of Tibia and Fibula
MOI:
Twisting force ➡ spiral #
Angulatory force ➡ transverse or oblique #
Low energy usually caused by indirect injury.
High energy may cause open # and comminution.
Why open #?
Tibia is located very superficial.
Hence, evaluation of surrounding soft tissue is very important.

Risk of non-union is high due to poor blood supply.
Risk of compartment syndrome is also high owing to the presence of a lot of compartments in a small space.

Management
🌞 Tibia/fibula # less than 7 cm from ankle joint, treat as intraarticular #, hence need anatomical reduction.
🌞 Undisplaced # ➡ casting for about 8 weeks.
Start with above knee POP, when # unite can gradually change to below knee POP.
🌞 Displaced ➡ close reduction followed by casting.
Few precautions:
1. Angulation allowed for AP is only up to 5°. Why? May predispose to secondary OA of knee joint due to unequal force exerted to the knee joint.
For lateral, up to 15°. Why? Because it is in the axis of movement.
2. Reduced # may displaced back ofter reduction once swelling subsides➡ need to check the x-ray frequently.
3. Compartment syndrome.

That is why tibial # seldom treated close in adult.

🌞 The best choice of IF will be ILN.
🌞 Plating still indicated in metaphysial tibial # where nailing is difficult.
🌞 Unstable # (high comminution or segmental # need early stabalization)

Complications:
1. Malunion
2. Delayed/non-union
3. Compartment syndrome
4. Osteoporosis (distal part. To avoid, allow early weight bearing)
5. Joint stiffness due to prolong immobilization
6. Vascular injury ➡ popliteal vessels

Fracture of the tibia alone
🔶 Low energy trauma
🔶 Reduction is harder due to intact fibula
🔶 Rate of non-union is higher also due to intact fibula.
🔶 Otherwise, management remain the same.

6. Fracture of the Malleoli
MOI:
Low energy injury, usually due to twisting force (ankle goes into inversion)

Classification:
Denis-Weber classification (Classify according to fibular # in relation to the syndesmotic joint)
✳ A: Transverse fibular # below the syndesmotic joint.
MOI: Adduction injury.
Usually results in oblique or vertical # of medial malleolus.
✳ B: Oblique fibular # at the syndesmotic joint.
Usually result in deltoid ligament and anterior tibiofibular ligament injury.
MOI: External rotation injury.
✳ C: Fibular # above syndesmotic joint ➡ part if the syndesmotic joint and tibiofibular ligament are torn.
MOI: Abduction injury
Associated injury: Avulsion # of the medial malleolus, a posterior malleolar # and diastasis of the tibiofibular joint.

Other classification is Lauge Hansen. Classification is based on MOI and foot position.

Intraarticular injuries❗
Hence need perfect reduction.
Post CR, check X-ray needed. Must meet 4 criterias:
1. Normal length of fibula restored.
2. Thalus sit squarely on the mortise.
3. Normal width of medial joint line.
4. No tibiofibular diastasis

# often unstable, hence frequent checking of the x-ray.

Management:
Dislocated joint ➡ need to reduce immediately.
Check X-ray.
Undisplaced joint ➡ Casting for 4-6 weeks.
Except:
🔵 Type B if involve the tibiofibular ligament
🔵 Type C often unstable. Hence better fix earlier.
Unstable/Displaced # ➡ ORIF. Aim for restoration of fibular length. Add syndesmosis fixation if unstable syndesmosis

7. Pilon Fracture
MOI:
High energy axial loading. Fall from height.
Thalus drives upwards towards the tibial plafond.

Slow to heal.

Injury:
1. Comminuted # of the metaphysis of tibia.
2. Severe soft tissue injury ➡ # blisters. This may lead to complication (soft tissue cannot tolerate, predispose to wound breakdown and infection) with early open treatment.
3. Seperation of malleoli and fibula #
4. Compression of articular surface of tibia.

Classification (Reudi/Allgower)
Type 1 ➡ non or minimally displaced
Type 2 ➡ displaced, articular surface incongruous
Type 3 ➡ comminuted articular surface

CT needed to clearly visualize # site.

Management (staged treatment)
1. Elevate the ankle & put ex-fix to hold the # until swelling subsides.
2. May plan IF. Usually ORIF (plating KIV bone graft)
However, severe injury might need indirect reduction using legamentotaxis.
3. Post fixation, elevation and early mobilization reduce edema.

Complications
1. Joint stiffness
2. Secondary OA (degree of cartilage injury plays and important role)