Knee dislocation. Rare in children Physeal seperation > dislocation or ligament injury If dislocation occurs: Vascular compromise Compartment syndrome

Size: px

Start display at page:

Download "Knee dislocation. Rare in children Physeal seperation > dislocation or ligament injury If dislocation occurs: Vascular compromise Compartment syndrome"

Barnard Anderson
5 years ago
Views:

1 인제대학교일산백병원 주석규

2 Knee dislocation Rare in children Physeal seperation > dislocation or ligament injury If dislocation occurs: Vascular compromise Compartment syndrome

3 Patellar dislocation Common in adolescent and teenager Typically Female Loose jointed Genu valgum with increased femoral anteversion Who are trying sports

Patellar dislocation Reduced before patient

X-ray Loose fragment Lateral femoral condyle

4 Patellar dislocation Reduced before patient comes to the hospital P/E Hemarthrosis, tenderness along medial border of patella Lateral position of patella Fairbanks sign X-ray Loose fragment Lateral femoral condyle Medial edge of the patella 5-10% osteochondral fracture

5 Patellar dislocation F/13

6 Patellar dislocation F/13

7 Patellar dislocation Treatment 3-4wks of immobilization Early PT to strengthen vastus medialis Fracture of medial patella or lateral femoral condyle Acute arthrotomy Ligament repair Excision or fixation of the fracture Repair of the medial capsule and patellofemoral ligament

Patellar dislocation Recurrent dislocation 15-20% Due to faulty anatomy Increased quadriceps angle Femoral condyle hypoplasia Shallow femoral sulcus Atrophy of vastus medialis Lateral patellar tilt

8 Patellar dislocation Recurrent dislocation 15-20% Due to faulty anatomy Increased quadriceps angle Femoral condyle hypoplasia Shallow femoral sulcus Atrophy of vastus medialis Lateral patellar tilt Lax joint Treatment Soft tissue realignment Semitenidnosus tenodesis to patella Tibial tubercle transfer (after physeal closure) A. Lateral retinacular release and medial imbrication. B. Semitendinosis tenodesis. C. Elmslie-Trillat procedure.

$Patellar fractures Bipartite$ 40% bilateral Fracture line may

$Sleeve fracture Avulsion fracture$ of the lower pole With little or

9 Patellar fractures Bipartite patella Located superolaterally 40% bilateral Fracture line may propagate through the synchondrosis difficult diagnosis Sleeve fracture Avulsion fracture of the lower pole With little or no bone Difficult to recognizeextensor lag Open reduction

$Tibial eminance fracture 8 to 14 yrs old Bicycle injury and other sports$

10 Tibial eminance fracture 8 to 14 yrs old Bicycle injury and other sports activity 40%: meniscus, capsule or collateral ligaments or with osteochondral fracture

11 ACL insertion 10 to 14 mm behind the anterior border of the tibia Extends to the medial and lateral tibial eminence

12 Classification Meyer and McKeever(1959) Type I: Nondisplaced Type II: Anterior cortical displacement with intact posterior cortex Type III: completely displaced with no bone contact Type IV: comminuted Type I Type II Type III Type IV

$Immobilization 6wks 20 degrees flexion or full extension Late displacement of type I does occur Unreduced displaced fracture Impingement Extension limitation Irreducible fracture Bowstringing or$

13 Immobilization 6wks 20 degrees flexion or full extension Late displacement of type I does occur Unreduced displaced fracture Impingement Extension limitation Irreducible fracture Bowstringing or bucket-handle mechanism Anterior horn of the lateral meniscus is torn from its tibial attachment but remains attached to the fracture piece Interposition of Anterior horn of the medial meniscus, Anterior horn of the lateral meniscus Intermeniscal ligament

LOM: impingement, arthrofibrosis Nonunion Maluniondebridement and

14 Suture or screw fixation Suture: small comminuted frgament Screws: larger than 15mm fragment Irritate the joint May require removal Complications LOM: impingement, arthrofibrosis Nonunion Maluniondebridement and notchplasty Quadriceps atrophy Growth arrest Ligament laxity: elongation of the ACL?

$Tibial tubercle fracture Closure of the physis of the tubercle Girls: 13-15 Boys:$

15 Tibial tubercle fracture Closure of the physis of the tubercle Girls: Boys: Injury Common in boys between 12 and 17 Eccentric contracture of the quadriceps

Watson-Jones, Ogden classification Type I: avulsion of a small fragment of the distal tubercle (subtype B: fragment seperated from metaphysis) Type II: involves the entire secondary ossification

16 Watson-Jones, Ogden classification Type I: avulsion of a small fragment of the distal tubercle (subtype B: fragment seperated from metaphysis) Type II: involves the entire secondary ossification center, apex is at the level of the proximal tibial physis (subtype B: comminuted ossification center) Type III: Extends into the knee joint (subtype B: comminuted fragment) X-ray: better viewed with knee slight internal rotation

17 4-6wks of immobilization ORIF from type IB Complications Anterior tibial recurrent artery Physeal arrest

18 Proximal tibial physeal fracture More physeal seperation in distal femur than proximal tibia 1) MCL attached to tibial metaphysis and femoral epiphysis, protecting from valgus injury 2) Upper end of fibula acts as lateral buttress 3) Semimembranosus muscle inserts distal to the physis posteromedially 4) Tibial tubercle projects from the epiphysis over the metaphysis

19 Proximal tibial physeal fracture More physeal seperation in distal femur than proximal tibia 1) MCL attached to tibial metaphysis and femoral epiphysis, protecting from valgus injury 2) Upper end of fibula acts as lateral buttress 3) Semimembranosus muscle inserts distal to the physis posteromedially 4) Tibial tubercle projects from the epiphysis over the metaphysis

20 Proximal tibial physeal fracture More physeal seperation in distal femur than proximal tibia 1) MCL attached to tibial metaphysis and femoral epiphysis, protecting from valgus injury 2) Upper end of fibula acts as lateral buttress 3) Semimembranosus muscle inserts distal to the physis posteromedially 4) Tibial tubercle projects from the epiphysis over the metaphysis

$Proximal tibial physeal fracture More physeal seperation in distal femur than proximal tibia 1) MCL attached to tibial metaphysis and femoral epiphysis, protecting from valgus injury$

21 Proximal tibial physeal fracture More physeal seperation in distal femur than proximal tibia 1) MCL attached to tibial metaphysis and femoral epiphysis, protecting from valgus injury 2) Upper end of fibula acts as lateral buttress 3) Semimembranosus muscle inserts distal to the physis posteromedially 4) Tibial tubercle projects from the epiphysis over the metaphysis

$Proximal tibial metaphyseal fracture Posterior tibial artery injury Post union valgus deformity Asymmetrical growth stimulation of the proximal tibial physis Asymmetrical growth$

23 Proximal tibial metaphyseal fracture Posterior tibial artery injury Post union valgus deformity Asymmetrical growth stimulation of the proximal tibial physis Asymmetrical growth stimulation of the medial proximal metaphysis Tibial physis stimulated more or longer than fibular physis Valgus at the time of fracture Soft tissue interposition(ex: pes anserinus) Physeal injury

24 7 post-traumatic tibia valga 11 mths to 6 yrs old Valgus appeared during fracture healing and after union Most rapid progression during 1 st year Overgrowth may accompany Clinical correction in 6/7 Conservative approach

25 32 proximal tibia fracture Avg age 7.1 yrs 28 post traumatic tibia valga(90.3%) Avg angulation 5.5 degrees 5.3mm overgrowth 11 patients more than 5 degrees angulation 6 partial and 3 complete remodeling

26 Diaphyseal fractures of tibia 15% of long bone fracture Avg age 8 yrs old Boys>girls With fibular fracture 30% Complete fracture by high energy Valgus shortening of distal fragment Without fibular fracture Rotational force Varus shortening Low energy injury A. Fractures involving the mid 1/3 of the tibia and fibula may shift into a valgus alignment due to the activity of the muscles in the anterior and the lateral compartments of the lower leg. B. Fracture of the mid tibia without fibular fracture tend to shift into varus d/t the force created by the anterior compartment musculature of the lower leg and the tethering effect of the intact fibula.

27 Isolated tibia fracture(m/7)

28 Isolated tibia fracture(m/7) Union with little callus

29 Isolated tibia fracture(m/7) 7months later

30 Acceptable reduction Varus valgus: 5 degrees Sagital deformity: 5 degrees Shortening: 1cm Rotation 0 Reduction correction: within 3 weeks Remodeling potential under 8 Varus 10 degrees Sagital 10 degrees Complete translation No remodeling of rotation

$Surgery: Comminuted fracture Irreducible fracture$

31 Better remodeling in Anterior, varus than posterior, valgus, deformity Overgrowth: 5 mm Surgery: Comminuted fracture Irreducible fracture Compartment syndrome Open fracture Multiple fracture Floating knee

32 Valgus tibia 1 yr 18 months

33 Valgus remodeling?

34 Stress fracture Osteoclastic breakdown>natural healing process #1 Military recruits, #2 young athletes Tibia m/c Endurance runnermetatarsal stress fracture Sports involving sudden stops(tennis, basketball, handballtibial stress fracture Heyworth and Green, Current Opinion in Pediatrics, 2008

$Stress fracture Risk$ male Late menarche: BMD

35 Stress fracture Risk factors Female: x4 than male Late menarche: BMD increases after menarche and growth spurt Disordered eating: calcium, Vit D Threshold quantity of activity: 16hrs/week

36 16 years old girl Left leg pain for 2 months Dance practice 4 hrs/day Tenderness distal 1/3 Cortical thickening Activity modication recommended. But?

37 Fracture of distal tibia

38 Closure of distal tibial physis Physis closes at 15 for girls, 17 for boys Centermedialanterolateral Distal fibula closes 1 year later

39 Treatment CR & long leg cast Closed reduction Knee flexed Recreate force of injury: Plantar flexion, supination or adduction Longitudinal traction Bring foot around to neutral position Internal rotation Entrapped soft tissue: Remaining growth Gap

41 Ankle Fractures Pediatric ankle fracture by Poland 1) The growth plate forms a plane of weakness 2) Ligaments are stronger than bone 3) Certain injuries will affect growth Plus 1) Fracture rarely disturb talo-tibial relationship 2) From age 14 to 15 years onward, adult pattern of fracture emerges

42 Ankle Fractures Pediatric ankle fracture by Poland 1) The growth plate forms a plane of weakness 2) Ligaments are stronger than bone 3) Certain injuries will affect growth Plus 1) Fracture rarely disturb talo-tibial relationship 2) From age 14 to 15 years onward, adult pattern of fracture emerges

43 Classification and mechanism of injury Salter-Harris classification Lauge-Hansen classification Abduction, external rotation, extension S-H I or II Adduction S-H III Axial compression S-H V

$fracture 1 year$ before distal

44 Tilleaux fracture 1 year before distal tibial physis closes Medial and central physis closed, anterolateral open External rotation force

45 Triplane fracture Sagital, transverse, coronal plane Along and through the physis Mostly d/t external rotation but sometimes internal rotation force Between 12 to 15, younger than Tilleaux fracture group Sports, scooter, skate, snowboard injury Fibula fracture 50%

46 X-ray AP plane: S-H III Lateral view: S-H II Axial CT: Merceds-Benz sign 2 fragment, 3fragment, 4 fragment fractures

47 4 fragment variant External rotation plus axial compression Metaphyseal comminution Extra articular variant

48 CR and cast: < 2 mm OR and IF: > 3 mm Open reduction: For articular restoration rather than to prevent growth arrest

49 Distal tibial physeal injury 45 % growth of tibia 4-6 mm / yr growth 6 to 12 months of monitor Harris growth line Growth arrest: Bone bridge resection Osteotomy Epiphyseodesis

50 Distal tibial physeal injury 50% growth of tibia 4-6 mm / yr growth 6 to 12 months of monitor Harris growth line Growth arrest: Bone bridge resection Osteotomy Epiphyseodesis

51 Distal tibial physeal injury 50% growth of tibia 4-6 mm / yr growth 6 to 12 months of monitor Harris gorwth line Growth arrest: Bone bridge resection Osteotomy Epiphyseodesis

52 Sesamoid bones of the foot

$medial and lateral process, osteochondral injuries m/c fracture: neck of the$

53 Fracture of talus Head, constricted neck, and body Fracture occurs in neck, body, medial and lateral process, osteochondral injuries m/c fracture: neck of the talus

54 Blood supply from Posterior tibial Dorsalis pedis Peroneal arteries

55 Forced dorsiflexion of the foot neck impinges against anteror lip of the tibia

$Hawkins classification Hawkins I No displacement of fracture line and no incongruity of subtalar joint Hawkins II Associated with dislocation or$

56 Hawkins classification Hawkins I No displacement of fracture line and no incongruity of subtalar joint Hawkins II Associated with dislocation or subluxation of subtalar joint Hawkins III Talar neck fracture with dislocation of subtalar and ankle joints Hawkins IV- Associated disruption of talonavicular joint

57 X-ray: AP: 15 degrees pronation, tube 75 degrees Lateral and oblique 5 mm displacement and 5 degrees malalignment acceptable Hawkin s sign: may not appear in children!

$Osteochondral fracture M/C in young adults but may$ Usually symptomatic, associated with trauma

58 Osteochondral fracture M/C in young adults but may occur under 10 Anterolateral(44%) Thin wafer like Usually symptomatic, associated with trauma Posteromedial(56%) Deep, cup shaped Less symptomatic, repetitive microtrauma

59 Fractures of the calcaneus Rare in children Better prognosis than adult Less intraarticular damage Occult fractures in toddlers Do well with conservative treatment

60 Lisfranc injuries Direct injury Less common Objects falling on foot and rupture of plantar ligament May associate with severe soft tissue damage Indirect injury More common Violent plantar flexion or abduction force or in combination (vertical loading in plantar flexion, heel to toe compression)

62 Fractures of metatarsal Most common fracture of the foot Good remodeling potential Proximal fracture Beware of Lisfranc injury

$5th metatarsal base avulsion fracture Jones Fracture Inversion or adduction of the foot$ perpendicular to long axis of the shaft Ddx: Os peroneum, Os vesalianum(line parallel to

perpendicular to long axis of the shaft Ddx: Os peroneum, Os vesalianum(line parallel to

63 5th metatarsal base avulsion fracture Jones Fracture Inversion or adduction of the foot Peroneus brevis, abd digiti minimi quinti, lateral cord of plantar aponeuroisis Fractrure perpendicular to long axis of the shaft Ddx: Os peroneum, Os vesalianum(line parallel to long axis) Proximal diaphysis of the 5 th metatarsal Delayed union, nonunion Internal fixation

General Concepts. Growth Around the Knee. Topics. Evaluation

General Concepts. Growth Around the Knee. Topics. Evaluation General Concepts Knee Injuries in Skeletally Immature Athletes Zachary Stinson, M.D. Increased rate and ability of healing Higher strength of ligaments compared to growth plates Continued growth Children