JUNIORBONES
Orthopaedics and trauma for junior orthopaedic trainees and medical students
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Assessment and management of fractures about the knee
by James Donaldson

Scenario: called to A&E to assess a 24 year old woman who fell off her horse and injured her knee.

History:
Age, occupation, sporting level and aspirations
Time/date of injury

Past medical/surgical history

Medication/drugs and allergies

Last ate/drank (for timing of emergency surgery if needed)

AP and lateral X-rays of the knee are required in all injuries
  • Often an MRI scan will be requested if there is a suggestion of ligament or meniscal injury (see soft tissue knee section)
  • Bony injuries usually need surgery

Patella fracture

Mechanism: Direct trauma or eccentric quads contraction

Signs & symptoms:
  • Pain and bruising anteriorly
  • May be able to walk
  • Palpable patella defect
  • Haemarthrosis
  • Difficulty in performing a straight leg raise (SLR)
  • Assess for knee wounds or open fracture

Management:

  • If undisplaced and able to SLR – cylinder plaster, FWB and non-operative management. Can be discharged home if safe
  • If displaced or extensor mechanism disrupted admit for fixation, often tension band wire. AK backslab for comfort
patella fracture
Lateral x-ray demonstrating displaced patella fracture

Distal femoral fracture

Mechanism: High energy (young) or low energy (elderly)

Signs & symptoms:
  • Pain, swelling, deformity, unable to weight bear
  • Potential for popliteal artery injury – assess thoroughly
  • Call senior urgently if NV concerns

Management:
  • Analgesia, skin traction, admit
  • Hinged knee brace and NWB if undisplaced  Most will need ORIF
  • Assess neurovascular status and call senior urgently if there is a deficit
distal femur fracture
AP & lateral x-rays of comminuted distal femur fracture

Tibial plateau fracture

Mechanism: Varus or valgus force with axial load

Signs & symptoms:
  • Commonly associated with other intra-articular injuries
  • Significant soft tissue injury
  • Assess compartments and NV status
Management:
  • Admit, above-knee backslab, analgesia
  • Likely to need CT scan
  • Schatzker classification 1-6
  • If minimally displaced and low energy can be treated non-operatively
  • Most will need ORIF
  • If severe soft tissue swelling a temporary ex-fix can be applied whilst soft tissues improve
  • Call senior if open or neurovascular injury
tibial plateau fracture
AP x-ray demonstrating displaced, comminuted, intra-articular tibial plateau fracture

Tibial spine fracture

Mechanism: Similar to ACL injury. Associated with other intra-articular knee pathology in 40% of case.

Signs & symptoms:
  • Commonly in adolescents
  • Fracture of the bony attachment of the ACL
  • Pain, immediate knee effusion and limited ROM
  • Positive anterior drawer test
Management:
  • MRI needed to assess for other injuries
  • If undisplaced immobilize in 0-20 and treat non-operatively. # clinic follow up 1 week
  • Surgical fixation within 1-2 weeks if displaced
  • Without other significant injury, this can be investigated and managed on an out-patient basis
ACL avulsion fracture
AP and lateral x-rays showing displaced tibial spine fracture

Tibial tuberosity fracture

Mechanism: Active quads extension with knee flexed.

Signs & symptoms:
  • Adolescent fracture
  • Sudden pain
  • Unable to straight leg raise or quadriceps lag
  • Swelling and tenderness over tibial tuberosity
  • Assess for compartment syndrome anteriorly
Management:
  • Long leg cast in extension if minimal displacement (<2mm). Can be discharged if safe with follow up in 1 week
  • If displaced needs closed or open reduction and fixation.
  • Admit for surgery. Backslab for comfort, elevation and analgesia
  • If skin is compromised call senior
tibial tuberosity fracture
Lateral x-ray displaying displaced tibial tuberosity fracture
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