other lower extremity trauma - kpos · –genu valgum with increased femoral anteversion –who are...
TRANSCRIPT
![Page 1: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/1.jpg)
Other lower extremity trauma2011년 소아정형외과학 연수강좌
인제대학교 일산백병원
주 석규
![Page 2: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/2.jpg)
Knee dislocation
• Rare in children
• Physeal seperation > dislocation or ligament injury
• If dislocation occurs:
– Vascular compromise
– Compartment syndrome
![Page 3: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/3.jpg)
Patellar dislocation
• Common in adolescent and teenager
• Typically
– Female
– Loose jointed
– Genu valgum with increased femoral anteversion
– Who are trying sports
![Page 4: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/4.jpg)
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% osteochondralfracture
![Page 5: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/5.jpg)
Patellar dislocation F/13
![Page 6: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/6.jpg)
Patellar dislocation F/13
![Page 7: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/7.jpg)
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 patellofemoralligament
![Page 8: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/8.jpg)
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.
![Page 9: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/9.jpg)
Patellar fractures
• Bipartite patella– Located superolaterally– 40% bilateral– Fracture line may propagate
through the synchondrosisdifficult diagnosis
• Sleeve fracture– Avulsion fracture of the lower
pole– With little or no bone– Difficult to
recognizeextensor lag– Open reduction
![Page 10: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/10.jpg)
Tibial eminance fracture
• 8 to 14 yrs old
• Bicycle injury and other sports activity
• 40%: meniscus, capsule or collateral ligaments or with osteochondral fracture
![Page 11: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/11.jpg)
ACL insertion
• 10 to 14 mm behind the anterior border of the tibia
• Extends to the medial and lateral tibial eminence
![Page 12: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/12.jpg)
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
![Page 13: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/13.jpg)
• 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 • Anaterior horn of the medial meniscus, • Anterior horn of the lateral meniscus • Intermeniscal ligament
![Page 14: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/14.jpg)
• 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?
![Page 15: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/15.jpg)
Tibial tubercle fracture
• Closure of the physis of the tubercle
– Girls: 13-15
– Boys: 15-19
• Injury
– Common in boys between 12 and 17
– Eccentric contracture of the quadriceps
![Page 16: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/16.jpg)
• 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
![Page 17: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/17.jpg)
• 4-6wks of immobilization
• ORIF from type IB
• Complications
– Anterior tibialrecurrent artery
– Physeal arrest
![Page 18: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/18.jpg)
Proximal tibial physeal fracture• More physeal seperation in distal
femur than proximal tibia
1) MCL attached to tibialmetaphysis and femoral epiphysis, protecting from valgus injury
2) Upper end of fibula acts as lateral buttress
3) Semimembranosus muscle inserts distal to the physisposteromedially
4) Tibial tubercle projects from the epiphysis over the metaphysis
![Page 19: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/19.jpg)
Proximal tibial physeal fracture• More physeal seperation in distal
femur than proximal tibia
1) MCL attached to tibialmetaphysis and femoral epiphysis, protecting from valgus injury
2) Upper end of fibula acts as lateral buttress
3) Semimembranosus muscle inserts distal to the physisposteromedially
4) Tibial tubercle projects from the epiphysis over the metaphysis
![Page 20: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/20.jpg)
Proximal tibial physeal fracture• More physeal seperation in distal
femur than proximal tibia
1) MCL attached to tibialmetaphysis and femoral epiphysis, protecting from valgus injury
2) Upper end of fibula acts as lateral buttress
3) Semimembranosus muscle inserts distal to the physisposteromedially
4) Tibial tubercle projects from the epiphysis over the metaphysis
![Page 21: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/21.jpg)
Proximal tibial physeal fracture• More physeal seperation in distal
femur than proximal tibia
1) MCL attached to tibialmetaphysis and femoral epiphysis, protecting from valgus injury
2) Upper end of fibula acts as lateral buttress
3) Semimembranosus muscle inserts distal to the physisposteromedially
4) Tibial tubercle projects from the epiphysis over the metaphysis
![Page 22: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/22.jpg)
![Page 23: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/23.jpg)
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: pesanserinus)
– Physeal injury
![Page 24: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/24.jpg)
7 post-traumatic tibia valga
• 11 mths to 6 yrs old
• Valgus appeared during fracture healing and after union
• Most rapid progression during 1st year
• Overgrowth may accompany
• Clinical correction in 6/7
• Conservative approach
![Page 25: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/25.jpg)
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
![Page 26: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/26.jpg)
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.
![Page 27: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/27.jpg)
Isolated tibia fracture(M/7)
![Page 28: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/28.jpg)
Isolated tibia fracture(M/7)
![Page 29: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/29.jpg)
Isolated tibia fracture(M/7)
7months later
![Page 30: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/30.jpg)
• Varus valgus: 5 degrees
• Sagital deformity: 5 degrees
• Shortening: 1cm
• Reduction correction: within 3 weeks
• Remodeling potential
– under 8
• Varus 10 degrees
• Sagital 10 degrees
• Complete translation
• No remodeling of rotation
![Page 31: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/31.jpg)
• Anterior, varus > posterior, valgus, combined deformity
• Overgrowth: 5 mm
• Surgery:
– Comminuted fracture
– Irreducible fracture
– Compartment syndrome
– Open fracture
– Multiple fracture
– Floating knee
![Page 32: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/32.jpg)
1 yr
18 months
Valgus tibia
![Page 33: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/33.jpg)
Valgus remodeling?
![Page 34: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/34.jpg)
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
![Page 35: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/35.jpg)
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
![Page 36: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/36.jpg)
16 years old girlLeft leg pain for 2 months
Dance practice 4 hrs/day
Tenderness distal 1/3
Cortical thickening
![Page 37: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/37.jpg)
16 years old girlLeft leg pain for 2 months
Dance practice 4 hrs/day
Tenderness distal 1/3
Cortical thickening
![Page 38: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/38.jpg)
16 years old girlLeft leg pain for 2 months
Dance practice 4 hrs/day
Tenderness distal 1/3
Cortical thickening
Activity modicationrecommended. But?
![Page 39: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/39.jpg)
Fracture of distal tibia
![Page 40: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/40.jpg)
Closure of distal tibial physis
• Physis closes at 15 for girls, 17 for boys
• Centermedialanterolateral
• Distal fibula closes 1 year later
![Page 41: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/41.jpg)
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
![Page 42: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/42.jpg)
![Page 43: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/43.jpg)
![Page 44: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/44.jpg)
![Page 45: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/45.jpg)
Ankle Fractures
• Pediatric ankle fracture by Poland1) 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
![Page 46: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/46.jpg)
Ankle Fractures
• Pediatric ankle fracture by Poland1) 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
![Page 47: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/47.jpg)
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
![Page 48: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/48.jpg)
Tilleaux fracture
• 1 year before distal tibial physis closes
• Medial and central physis closed, anterolateral open
• External rotation force
![Page 49: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/49.jpg)
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 Tilleauxfracture group
• Sports, scooter, skate, snowboard injury
• Fibula fracture 50%
![Page 50: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/50.jpg)
• X-ray– AP plane: S-H III
– Lateral view: S-H II
– Axial CT: ‘Merceds-Benz’ sign
• 2 fragment,
• 3fragment,
• 4 fragment fractures
![Page 51: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/51.jpg)
• 4 fragment variant
– External rotation plus axial compression
– Metaphyseal comminution
• Extra articular variant
![Page 52: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/52.jpg)
• CR and cast: < 2 mm
• OR and IF: > 3 mm
• Open reduction:
– For articular restoration rather than to prevent growth arrest
![Page 53: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/53.jpg)
Distal tibial physeal injury
• 45 % growth of tibia
• 4-6 mm / yr growth
• 6 to 12 months of monitor
– Harris gorwth line
• Growth arrest:
– Bone bridge resection
– Osteotomy
– Epiphyseodesis…
![Page 54: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/54.jpg)
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…
![Page 55: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/55.jpg)
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…
![Page 56: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/56.jpg)
Sesamoid bones of the foot
![Page 57: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/57.jpg)
Fracture of talus
• Head, constricted neck, and body
• Fracture occurs in neck, body, medial and lataeral process, osteochondral injuries
• m/c fracture: neck of the talus
![Page 58: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/58.jpg)
• Blood supply from
– Posterior tibial
– Dorsalis pedis
– Peroneal arteries
![Page 59: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/59.jpg)
• Forced dorsiflexion of the foot
neck impinges against anteror lip of the tibia
![Page 60: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/60.jpg)
Hawkins classification
Hawkins I – No displacement of fracture line and no incongruity of subtalar jointHawkins II – Associated with dislocation or subluxation of subtalarjointHawkins III – Talar neck fracture with dislocation of subtalar and ankle jointsHawkins IV- Associated disruption of talonavicularjoint
![Page 61: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/61.jpg)
• 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!
![Page 62: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/62.jpg)
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
![Page 63: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/63.jpg)
Fractures of the calcaneus
• Rare in children
• Better prognosis than adult
• Less intraarticular damage
• Occult fractures in toddlers
• Do well with conservative treatment
![Page 64: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/64.jpg)
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)
![Page 65: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/65.jpg)
![Page 66: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/66.jpg)
Fractures of metatarsal
• Most common fracture of the foot
• Good remodeling potential
• Proximal fracture Beware of Lisfranc injury
![Page 67: Other lower extremity trauma - KPOS · –Genu valgum with increased femoral anteversion –Who are trying sports. Patellar dislocation • Reduced before patient comes to the hospital](https://reader031.vdocuments.net/reader031/viewer/2022041601/5e30df1cd5b8470fa3211763/html5/thumbnails/67.jpg)
5th metatarsal base avulsion fracture
• Inversion or adduction of the foot
• Peroneus brevis, abd digitiminimi quinti, lateral cord of plantar aponeuroisis
• Fractrure perpendicular to long axis of the shaft
• Ddx: Os peroneum, Os vesalianum(line parallel
to long axis)
Jones Fracture
• Proximal diaphysis of the 5th metatarsal
• Delayed union, nonunion
• Internal fixation