Fractures Around the Knee PDF
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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 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. T he publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG Switzerland 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.
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