FRACTURE CRURIS AND

DISLOCATION OF GENUE

Dr. dr. Erwien Isparnadi, Sp.OT

By:
Egin Fergian Axpreydasta 201810401011034
Sri Setya Wahyu N 201810401011147

RSU HAJI SURABAYA

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH MALANG
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TAHUN 2016
• A fracture is a loss of continuity of bone, joint
cartilage and epiphyseal cartilage both total or
partial.

• Cruris fracture is a term for a broken tibia and

fibula which usually occurs at proximal region,
the diaphysis or ankle joints.

• Fractures of the tibia is the type of fracture of

long bones that often occur. Frequency ± 26 cases
per 100,000 population per year. Incident 3 times
more in men than women.

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ANATOMY

Os. Tibia and fibula looked anterior and posterior

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 FRACTURE CRURIS

• Fracture cruris include fractures of the tibia and fibula. Of

these two bones, the tibia is the only weightbearing bone.
• Fractures of the tibia generally are associated with fibula
fracture, because the force is transmitted along the
interosseous membrane to the fibula.
• The skin and subcutaneous tissue are very thin over the
anterior and medial tibia and as a result of this, a significant
number of fractures to the lower leg are open.

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 FRACTURED TIBIAL SPINE
• Severe valgus or varus stress, or twisting injuries, may damage
the knee ligaments and fracture the tibial spine.
• The patient – usually an older child or adolescent – presents with
a swollen, immobile knee. The joint feels tense, tender and
‘doughy’ and aspiration will reveal a haemarthrosis. There may
also be associated ligament injuries; always test for varus and
valgus stability and cruciate laxity.

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FRACTURED TIBIAL SPINE
Treatment
• Under anaesthesia the joint is aspirated and gently manipulated into
full extension.
• As long as the knee extends fully, small amounts of fragment
elevation can be accepted.
• If there is a block to full extension or if the bone fragment remains
displaced, operative reduction is essential.
• The fragment is restored to its bed and anchored by small screws.
• After either closed or open reduction, a long plaster cylinder is
applied with the knee almost straight; it is worn for 6 weeks and then
movements are encouraged.

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TIBIAL PLATEAU FRACTURES

• Fractures of the tibial plateau are caused by a varus or

valgus force combined with axial loading (a pure valgus
force is more likely to rupture the ligaments)
• More often it is due to a fall from a height in which the
knee is forced into valgus or varus.
• The tibial condyle is crushed or split by the opposing
femoral condyle, which remains intact.

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TIBIAL PLATEAU FRACTURES

Clinical features :
• The knee is swollen and may be deformed.
• Bruising is usually extensive and the tissues feel ‘doughy’
because of haemarthrosis.
• Examining the knee may suggest medial or lateral
instability but this is usually painful and adds little to the x-
ray diagnosis.
• More importantly, the leg and foot should be carefully
examined for signs of vascular or neurological injury

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 TIBIAL PLATEAU FRACTURES

Shatzker Classification

Type I: lateral condyle fracture vertically

Type II: Fracture of the lateral condyle
vertically with depression in the condyles
Type III: Depression on the articular
surface of the condyle intact
Type IV: Fracture of the medial tibial
condyle
Type V: Fractures of the medial and
lateral condyles
Type VI: The combination of fracture
condilar and subkcondilar
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TIBIAL PLATEAU FRACTURES

IMAGING

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 TIBIAL PLATEAU FRACTURES
MANAGEMENT BASED ON CLASSIFICATION
1. Fractures of the tibial condyle
Type I : If not treated conservative shift. Dislocated fracture,
treated with open reduction and internal fixation.

Type II: If the depression is mild (<5 mm) / elderly patients

treated in private (the objective of restoring mobility and
function). After aspiration and compression plaster mounted,
performed skeletal traction. While young patients with
depression> 5 mm, performed open reduction with internal
fixation and elevation plateau.
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 TIBIAL PLATEAU FRACTURES

Type III: Fragment which depressed raised to reach the

metaphysical. Fragment that elevated assisted with bone
grafts.
Type IV: Fractures are usually more complex than it looks.
There is damage to the ligaments on the lateral side. If the
joint is still unstable after fracture fixation, who suffered a
torn structures on the lateral side should be corrected.
V and VI fractures: a severe trauma which poses a risk of
compartment syndrome. Treatment is immediate internal
fixation or external fixation.

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TIBIAL PLATEAU FRACTURES

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TIBIAL PLATEAU FRACTURES

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TIBIAL PLATEAU FRACTURES

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TIBIAL PLATEAU FRACTURES

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TIBIAL PLATEAU FRACTURES

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TIBIAL PLATEAU FRACTURES
Complications
EARLY
Compartment syndrome  closed types 4 and 5 fractures

LATE
Joint stiffness
Deformity
Osteoarthritis

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 FRACTURES OF TIBIA AND FIBULA
• Because of its subcutaneous position, the tibia is more
commonly fractured, and more often sustains an open
fracture, than any other long bone.
• Mechanism of injury:
o Indirect injury  usually low energy; with a spiral or long
oblique fracture one of the bone fragments may pierce the
skin from within.
o Direct injury  usually a high-energy injury; crushes or
splits the skin over the fracture; the most common cause is
a motorcycle accident

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FRACTURES OF TIBIA AND FIBULA

Clinical features
• Signs of soft-tissue damage: bruising, severe swelling,
crushing or tenting of the skin, an open wound,
circulatory changes, weak or absent pulses, diminution
or loss of sensation and inability to move the toes.
• Deformity
• Signs of an impending compartment syndrome.

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FRACTURES OF TIBIA AND FIBULA
The choice of treatment –depends on the following factors:
1. The state of the soft tissues
2. The severity of the bone injury
3. Stability of the fracture
4. Degree of contamination  In open fractures

Gustilo’s classification of open fractures

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FRACTURES OF TIBIA AND FIBULA
• Conservative:
o Conservative include reduction close, cast immobilization
(long leg cast), functional bracing, and traction.
o Sarmiento way: starting from the toes to the top of the joints in
the molding around the malleolus talokrural continue up to 1
inch below the tibial tuberosity. Only at designated for fracture
of the distal third cruris and ankle fractures.
o To be able to be closed reduction requirements must be
acceptable positions are:
a. No rotation.
b. Angulation ≤ 5º.
c. There are contacts ≥ 50%
o If no acceptable terms, then do repositioning through surgery

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FRACTURES OF TIBIA AND FIBULA
Sarmiento Way

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 FRACTURES OF TIBIA AND FIBULA
Operatif:
Indications:
a)open fracture
b)Failed with conservative therapy
c)The position is not acceptable (unstable fractures include segmental fracture,
oblique, fragmented)
d)The presence of non-union
•It is reduced under general anaesthesia with x-ray control. Alignment must be near-
perfect (no more than 7 degrees of angulation) and rotation absolutely perfect. It can
be done with:
oClosed intramedullary nailing
oPlate fixation
oExternal fixation

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FRACTURES OF TIBIA AND FIBULA

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FRACTURES OF TIBIA AND FIBULA

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FRACTURES OF TIBIA AND FIBULA
•For open fractures, principle of treatment is:
oAntibiotics
oDebridement
oStabilization
oPrompt soft-tissue cover
oRehabilitation

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FRACTURES OF TIBIA AND FIBULA
Early complications
• VASCULAR INJURY  damage the popliteal artery
• COMPARTMENT SYNDROME
• INFECTION

Late complications
• Malunion
• Delayed union
• Non-union
• Joint stiffness
• Osteoporosis
• Regional complex pain syndrome

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 TIBIAL PILON FRACTURE
• Fracture of the distal part of the tibia,
involving its articular surface at the
ankle joint.
• Pilon fractures are caused by
rotational or axial forces, mostly as a
result of falls from a height or motor
vehicle accidents.

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Tibial Pilon Fracture

Ruedi Allgower
Classification
Type I: No significant
artikuler involvement,
fracture without shifting of
the bone fragment
Type II: There articular
involvement with minimal
impaction or kominutif
Type III: Kominutif
significant articular
impaction metafiseal. 35
PATELLAR FRACTURES - MECHANISM
Indirect trauma
 Forceful knee flexion against contracted quadriceps
 Horizontal fractures common
Direct trauma
 Direct blow / fall on knee
 comminution
PATELLAR FRACTURES
Clinical Manifestation
•Pain
•Hemarthrosis
•Crepitus
•Disruption of extensor mechanism (must be
able to fully extend knee against gravity)
PATELLAR FRACTURES
 PATELLAR FRACTURES - MANAGEMENT
Undisplaced or minimally displaced fractures
• If there is a haemarthrosis it should be aspirated.
• A plaster cylinder holding the knee straight should be worn for
3–4 weeks, and during this time quadriceps exercises are to be
practised every day.
Displaced (>3mm bony separation or > 2mm articular
surface disruption)
 Orthopedic referral
 Tension band / K-wires
 Possible patellectomy – surgical connection of quadriceps and
patellar tendons
 DISLOCATION OF KNEE
• The knee can be dislocated only by considerable violence, as in a road
accident. The cruciate ligaments and one or both lateral ligaments are torn
• Clinical manifestation:
o Rupture of the joint capsule produces a leak of the haemarthrosis, leading
to severe bruising and swelling.
o Deformity
o The circulation  the popliteal artery may be torn or obstructed.
o Compartment syndrome signs
o Common peroneal nerve injury occurs in nearly 20 per cent of cases;
distal sensation and movement should be tested
o Examine if there is avulsion of a fragment from the near the edge of the
lateral tibial condyle (the Segond fracture).

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 DISLOCATION OF KNEE

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 DISLOCATION OF KNEE

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 DISLOCATION OF KNEE
Treatment
•Reduction under anaesthesia is urgent; by pulling directly
in the line of the leg, but hyperextension must be avoided
because of the danger to the popliteal vessels.
•The circulation is checked repeatedly during the 48 hours
• A vascular injury will need immediate repair and the limb
is then more conveniently splinted with an anterior
external fixator
•The cruciate ligaments can be reconstructed after knee
movement has recovered, usually some 6–12 months later

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 DISLOCATION OF KNEE
Complications
EARLY
• Arterial damage Popliteal artery damage occurs in nearly 20
per cent of patients and needs immediate repair
• Nerve injury The lateral popliteal nerve may be injured

LATE
• Joint instability
• Stiffness : Loss of movement, due to prolonged immobilization,
is a common problem and may be even more troublesome than
instability

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