Académique Documents
Professionnel Documents
Culture Documents
Greg M. Osgood, MD
Revised 2011
Intra-articular injuries
Overview
Extra-articular Knee Injuries
– Distal Femoral Epiphysis
– Proximal Tibia Epiphysis
– Tibia Tubercle
– Patella
Overview
Intra-articular Knee Injuries
– Tibial Eminence Fractures
– Osteochondral Fractures
– Patella Dislocation
– Menicus Injuries
– Ligament Injuries
Distal Femoral Epiphyseal Fractures
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Anatomy
– Distal femoral physis contributes 70% of
femoral growth and 37% of lower extremity
length
– Popliteal artery and geniculates lie posterior to
metaphysis and capsule
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Fracture Epidemiology
– Rare injury (<1% of pediatric fractures)
– Mechanism:
• Often the result of high energy trauma in <11 y.o. (pedestrian struck or
fall from a height)
• Sports injuries in teens (2/3 of distal femoral fractures)
• varus/valgus force
• hyperextension of the knee
Associated Injuries
– Do not miss VASCULAR INJURY or TIBIAL/PERONEAL
NERVE INJURY
– Do not miss COMPARTMENT SYNDROME
Classification
– Salter-Harris (I and II most common)
– Displacement (anterior, posterior, valgus/varus)
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Interventions
– Closed reduction and immobilization
– Closed reduction and internal fixation
– ORIF
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Closed Reduction and Casting
– Used only in truly nondisplaced and stable fractures
– Anatomical reduction is more important close to age
of skeletal maturity
– Remodeling potential is greatest in plane of knee
motion (flexion/extension)
– Discuss potential for growth disturbance or
malalignment with family when treatment is initiated
– Frequent follow-up is required to prevent malunion
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Closed Reduction and Casting
– Closed reduction usually successful within 10 days
– Well molded splint in slight knee flexion
– Periosteum is often intact on compression side of
fracture – compression side of fracture should be put
under tension in splint/cast
– Partial WB started at 2-3 weeks
– Splint/cast removal between 4-8 weeks
– 43-70% displace without internal fixation
Thomson J. JPO 1995;15:474.
Graham JM. CORR 1990;255:51.
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Closed Reduction and Internal
Fixation
– Reduction performed with
TRACTION and angular correction
– Fixation should not cross physis if
possible
• Screws may be placed parallel to
physis at the metaphysis (Salter II &
IV) or epiphysis (Salter III & IV)
– Use smooth pins to cross physis if
necessary
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Open Reduction and
Internal Fixation
– INDICATIONS
• Fractures that cannot be
satisfactorily reduced closed
• Salter III and IV fractures
• Open fractures
• Floating knee
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Open Reduction and Internal Fixation
– Preoperative CT may help plan fixation strategy
– Reduction facilitated by removal of interposed muscle and
periosteum
– Fixation parallel to physis
– Cross physis with smooth wire fixation only if necessary to
obtain stability
– Support fixation with postop splint or cast
– Repair associated collateral ligament injuries at time of
fixation if possible
– Remove pins at 3-6 weeks
– Remove splint at 6-8 weeks
Salter IV Distal Femur Fracture
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Open Reduction and Internal Fixation
– Plates spanning across growth plate should be
avoided unless patient is at skeletal maturity
– Skeletal maturity is often difficult to assess and
is easily overestimated
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Complications of Injury
– Ligamentous laxity
– Knee stiffness
– Compartment syndrome
– Malalignment
– Shortening
– Loss of reduction
Extra-articular Knee Injuries
Distal Femoral Epiphysis
SH II Fx
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Extra-articular Knee Injuries
Distal Femoral Epiphysis
6 mo postop
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Extra-articular Knee Injuries
Distal Femoral Epiphysis
SH IV FX with distal metaphyseal femur fx
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Outcomes
– Risk of damage to growth plate and growth
disturbance
• Assess leg length, alignment and gait at 6 months
• Follow patients 12-24 months
• Growth disturbance caused by direct trauma or lack
of anatomical reduction
• Transphyseal bridging may be demonstrated on
MRI
Distal Femur Physeal Bar
Valgus deformity, short limb following
distal femur SII fx with growth arrest,
failed bar excision
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Severe growth plate injury 9 years after SH II
distal femoral physeal injury in 4 y.o. girl
Proximal Tibial Epiphyseal Fractures
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Fracture Epidemiology
– Rare injury (<1% of pediatric fractures)
– Mechanism:
• Often the result of high energy trauma (MVC or fall
from a height)
• varus/valgus force
• hyperextension of the knee
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Physical Examination
– Pain
– Knee effusion/hemarthrosis
– Tenderness at physis
– Limb deformity
– Document pulse and neurological examination before and
after reduction
Associated Injuries
– Do not miss VASCULAR INJURY or TIBIAL/PERONEAL
NERVE INJURY
– Do not miss COMPARTMENT SYNDROME
Extra-articular Knee Injuries
Distal Femoral Epiphysis
Associated Injuries
– Knee ligament injury
• Requires close follow-up of knee stability as fracture heals
– Vascular Injury
• May be associated with posterior displacement of metaphysis
• Remember pulseless limb may regain normal pulses after fracture
reduction and splinting
• Revascularization should be coordinated with vascular surgery
team if necessary
– Compartment Syndrome
• Tethering of popliteal artery, posterior tibial artery, and anterior
tibial artery place limb at compartment syndrome risk
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Radiographs
– AP & LAT xrays
– Frequently minimally displaced & easily
overlooked
– Stress xrays may help
– CT may help assess possible Salter III or IV
– MRI
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Intervention
– Closed reduction and immobilization
– Closed reduction and internal fixation
– ORIF
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Closed Reduction and Casting
– Indicated in non-displaced fractures
– Possible if stable anatomical reduction achieved with
Salter I and II fractures
– TRACTION is key to reduction
– Monitor for iatrogenic peroneal injury after reduction
– Splint/cast (bivalved) reduction in slight knee flexion
– Cast may be removed 6 weeks after injury once
radiographic evidence of healing
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Closed Reduction and Internal Fixation
– Indicated if UNSTABLE reduction is achieved
in Salter I and II fractures
– Percutaneous fixation parallel to physis
– Crossed pins that traverse the physis may be
used if stable extra-physeal fixation is not
possible
– Splint reduction in slight knee flexion
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Open Reduction and Internal Fixation
– Indications:
• Non-anatomical closed reduction
• Displaced Salter III & IV fractures
– Open reduction to remove soft tissue interposition
– Internal fixation with screws parallel to physis or
crossed K-wires traversing the physis
– Protect fixation with splint in slight knee flexion
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
SH IV Proximal Tibia Fx
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Complications
– Loss of reduction
– Compartment syndrome
– Growth disturbance
– Ligamentous instability
Extra-articular Knee Injuries
Proximal Tibial Epiphysis
Growth disturbance
– Incidence is limited by anatomical reduction
– May be corrected with resection of bony bridge
or osteotomy depending on patient age
Tibial Tubercle Avulsion
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Anatomy
– Tibia tubercle physeal development
• Cartilaginous stage: through 9-10 y.o.
• Apophyseal stage: ossification center appears 8-14
y.o.
• Epiphyseal stage: ossification centers of tubercle
and epiphysis merge 10-17 y.o.
• Bony stage: physis is closed btw tuberosity and
metaphysis
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Fracture Epidemiology
– Mechanism
• Jumping sports – eccentric contraction of extensor
mechanism during landing
• 98% males
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Physical Examination
– Anterior proximal tibia swelling and tenderness
– Joint effusion/hemarthrosis
– Palpable bony fragment
– Tented skin
– Patella alta may be present
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Associated Injuries
– Knee ligament injury
– Meniscal injury
– Extensor mechanism disruption
– Tibia plateau fracture
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Radiographs
– AP and LAT xrays
– Slightly internally rotated
lateral view may aid
visualization of tibial tubercle
due to anatomical location
lateral to tibial midline
– Fracture is differentiated from
Osgood-Schlatter by acute
fracture line through physis
(Osgood-Schlatter does not
involve the physis)
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Classification (Watson-Jones, with modifications of
Ogden, Ryu, and Inoue)
– Type I: Fracture through the tubercle apophysis
– Type II: Fracture through the apophysis that extends
between ossification centers of apophysis and epiphysis
– Type III: Fracture through apophysis extends across
epiphysis
– Type IV: Fracture through apophysis extends
posteriorly at level of tibial phsysis
– Type V: Avulsion of patellar tendon off tubercle physis
(sleeve fracture)
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Type III Avulsion Fx
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Intervention
– Closed reduction and casting
– ORIF
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Closed treatment and casting
– Indications: minimally displaced fractures after
closed reduction
– Reduction with knee in extension
– Cast molding above patella is important to
maintain reduction
– Maintain in cast for 6 weeks
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Open Reduction and Internal Fixation
– Midline incision
– Periosteum is debrided from fracture line
– Reduction by knee extension
– Screw or pin fixation should be supported by
soft tissue repair
– Protect repair with cylinder cast for 6 weeks
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Type II Avulsion Fx
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Type III Avulsion Fx
Extra-articular Knee Injuries
Tibial Tubercle Avulsion
Complications
– Growth disturbance
– Compartment syndrome
– Symptomatic hardware (approx. 50%)
– Stiffness (loss of flexion)
Patella Fracture
Extra-articular Knee Injuries
Patella Fracture
Mechanism:
– Avulsion fractures of patella more likely in
children than adults
– Eccentric contraction
– Direct blow (comminuted fracture)
Extra-articular Knee Injuries
Patella Fracture
Physical Examination
– Painful swollen knee
– Inability to extend knee
– Inability to bear weight
– High riding patella
– Apprehension test may be positive if patient has
avulsion fracture secondary to patellar
dislocation
Extra-articular Knee Injuries
Patella Fracture
Radiographs
– AP & LAT knee xrays
– Sagittal plane fractures may be best seen with
sunrise view
– Sleeve fracture – small fleck of bone in extensor
mechanism may be only sign of disruption
– Comparison views of normal knee may be
required
Extra-articular Knee Injuries
Patella Fracture
Classification
– Primary osseous fractures
– Avulsion fractures
• Avulsion of pole of patella without significant
avulsion of cartilage
– Sleeve fractures
• Avulsion of pole of patella WITH a large portion of
articular cartilage (cartilage, retinaculum, and
periosteum may be involved)
Extra-articular Knee Injuries
Patella Fracture
Intervention
– Closed treatment with casting
– Open reduction and internal fixation
Extra-articular Knee Injuries
Patella Fracture
Closed treatment
– Extensor mechanism is intact
– No significant displacement (<2-3mm at
articular surface)
Extra-articular Knee Injuries
Patella Fracture
Open reduction and internal
fixation
– Midline incision
– ORIF with tension band
wire, cerclage wire,
nonabsorbable suture,
screws
– Sutures alone sufficient for
patella sleeve fractures
– Repair of retinaculum is
recommended
– Splint for 4-6 weeks
recommended
Extra-articular Knee Injuries
Summary
ANATOMICAL REDUCTION
– Key to preventing physeal arrest, malalignment,
and LLD
PREVENT LOSS OF REDUCTION
– Loss of reduction is common if not treated with
stable reduction and fixation
TEMPORARY PROTECTION OF FIXATION
– Postop splint/cast important in treatment
Intra-articular Knee Injuries
Overview
Intra-articular Knee Injuries
– Tibial Eminence Fractures
– Osteochondral Fractures
– Patella Dislocation
– Menicus Injuries
– Ligament Injuries
Acute Hemarthrosis in Children-without
Obvious Fracture
Anterior Cruciate Tear
Meniscal tear
Patellar dislocation +/- osteochondral fracture
Knee Injuries
Acute Hemarthrosis
ACL 50%
Meniscal tear 40%
Fracture 10%
Intra-articular Knee Injuries
Tibial Eminence Fractures
Epidemiology
– Usually 8-14 year old children
– Mechanism:
• Hypertension or direct blow to flexed knee
• Frequently mechanism is fall from bicycle
Intra-articular Knee Injuries
Tibial Eminence Fractures
Myers- McKeever Classification
– Type I- nondisplaced
– Type II- hinged with posterior attachment
– Type III- complete, displaced
Intra-articular Knee Injuries
Tibial Eminence Fractures
Intervention
– Attempt reduction with hypertension
– Above knee cast immobilization
– Operative treatment for block to extension,
displacement, entrapped meniscus
– Arthroscopic-assisted versus open arthrotomy
– Consider more aggressive treatment in patients
12 and older
Intra-articular Knee Injuries
Tibial Eminence Fractures
8 to 14 yo
often bicycle accident
Myer-McKeever
classification
Tibial Spine Fracture
Treatment
Reduction in extension
Immobilize in extension or slight knee flexion
Operative treatment for failed reduction or
extension block
Tibial Spine Closed Reduction