Fractures and Dislocations about the Knee in Pediatric Patients - PowerPoint PPT Presentation

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Fractures and Dislocations about the Knee in Pediatric Patients

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Largest sesamoid bone, gives extensor mechanism improved lever arm ... for recurrent dislocation/subluxation if fail extensive rehabilitation/exercises ... – PowerPoint PPT presentation

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Title: Fractures and Dislocations about the Knee in Pediatric Patients


1
Fractures and Dislocations about the Knee in
Pediatric Patients
  • Steven Frick, MD
  • Created March 2004 Revised August 2006

2
Anatomy
  • Distal femoral physis- large, undulating-
    irregular
  • Proximal tibial physis- contiguous with tibial
    tubercle apophysis
  • Ligament and muscular attachments may lead to
    avulsion injuries, fracture angulation

3
Anatomy- Neurologic and Vascular Structures
  • Popliteal artery tethered above and below knee
  • Common peroneal nerve vulnerable at fibular
    neck/head

4
Growth about the Knee
  • 70 of lower extremity length
  • Distal femur- average 10mm/year
  • Proximal tibia- average 6mm/year
  • Tibial tubercle apophysis- premature growth
    arrest can lead to recurvatum
  • Proximal fibular physis- important for fibular
    growth relative to tibia and ankle alignment

5
Fractures of the Distal Femoral and the Proximal
Tibial Physis
  • Account for only a small percentage of the total
    number of physeal fractures
  • Are responsible for the majority of complications
    due to partial physeal arrest
  • High incidence of growth arrest based on anatomy,
    energy of injuries
  • Specific treatment recommendations to minimize
    the incidence of growth arrest

6
Peterson, et.al. JOP 94 Olmstead County Study
  • Experience of the Mayo clinic 1979 - 1988
  • 951 physeal fractures
  • 2.2 involved the physis of the distal femur or
    the proximal tibia
  • Fractures of the distal femoral and proximal
    tibial physis account for 51 of partial growth
    plate arrest

7
Anatomy Predisposingto Growth Arrest
  • Peterson 94 noted that the distal femoral and
    proximal tibial physes are large and multiplanar
    (irregular in contour) and account for 70 and 60
    of the growth of their respective bones

8
Anatomy, continued
  • Ogden, JOP 82 - undulations of the physis,
    which may include small mammillary processes
    extending into the metaphysis, or larger curves
    such as the quadrinodal contour of the distal
    femoral physis, may cause propagation of the
    fracture into regions of the germinal and resting
    zones of the physis

9
Anatomy, continued
  • Ogden JPO, 82 - distal femur develops binodal
    curves in coronal and sagital planes with central
    conical region - susceptible to damage during
    varus/valgus injury
  • Peripheral growth arrest related to damage to
    zone of Ranvier stripping it away from physis and
    periosteum

10
Distal Femoral Physeal Fractures
  • direct blow mechanism
  • Salter I or II common
  • check neurologic / vascular status

11
Treatment Recommendations
  • Anatomic reduction is key
  • Propensity for losing reduction
  • Hold reduction with pins and casting

12
Thompson et.al. JPO 95
  • 30 consecutive fractures of the distal femoral
    epiphysis
  • No displacement of fx treated with anatomic
    reduction and pin fixation
  • Three of seven patients treated closed lost
    reduction
  • proved maintenance of reduction, but not
    prevention of growth disturbances

13
Graham Gross, CORR 90
  • Ten patients with distal femoral physeal
    fractures retrospectively reviewed
  • All treated from 77 - 87 with closed reduction
    and casting or skeletal traction
  • Most SHII
  • Resulted in seven losing reduction and nine
    eventually developing deformities

14
Graham Gross cont.
  • Angular deformity and LLD related to the amount
    of initial deformity and the quality of reduction
  • Recommended rigid internal fixation

15
Riseborough, et.al., JBJS 83
  • Retrospective study of 66 distal femoral physeal
    fracture-separations
  • Only 16 seen primarily, others referred at
    different stages of treatment/complications
  • Noted improved results with anatomic reduction
    and internal fixation in types II,III and IV, and
    early detection and mgmnt of growth arrest

16
Lombardo Harvey, JBJS 77
  • 34 distal femoral physeal fx. Followed avg. four
    years
  • gt2cm LLD in 36
  • Varus/valgus deformity in 33
  • Osteotomy, epiphyseodesis or both in 20
  • Development of deformity related to amount of
    initial displacement and anatomic reduction
    rather than fracture type

17
Be Wary of Fixation only in Thurston-Holland
Fragment
Loss of reduction at 2 weeks
18
Distal Femoral Physeal Fractures
  • closed reduction and pinning for displaced
    fractures
  • long leg cast

19
Distal Femoral Physeal Fractures
  • high rate of premature growth arrest rare lt 2
    yo 80 2 - 11 yo 50 gt 11 yo
  • angular deformity
  • leg length discrepancy

20
Salter IV Distal Femur Fracture Lateral Growth
Arrest led toValgus Deformity
21
Salter IV Distal Femur Fracture
22
Distal Femur Physeal Bar
23
Patella Fractures in Children
  • Largest sesamoid bone, gives extensor mechanism
    improved lever arm
  • Uncommon fracture in skeletally immature patients
  • May have bipartite (superolateral) patella- avoid
    misdiagnosis

24
Physeal Bars
  • male female - 2 1
  • distal femur, distal tibia, proximal tibia,
    distal radius

25
Valgus deformity, short limb following distal
femur SII fx with growth arrest, failed bar
excision
26
Distal osteotomy first to correct alignment, then
lengthening over nail to restore length
27
Patellar Sleeve Fracture
  • 8-12 year old
  • Inferior pole sleeve of cartilage may displace
  • May have small ossified portion
  • lt2mm displaced, intact extensor mechanism- treat
    non-operatively

28
Patella Fractures
  • much less common than adults
  • avulsion mechanism
  • patellar sleeve fracture
  • management same as adults
  • Restore articular surface and knee extensor
    mechanism

29
Osteochondral Fractures
  • Usually secondary to patellar dislocation
  • Off medial patella or lateral femoral condyle
  • Size often under appreciated on plain films
  • Arthroscopic excision vs. open repair if large

30
Acute Hemarthrosis in Children-without Obvious
Fracture
  • Anterior Cruciate Tear
  • Meniscal tear
  • Patellar dislocation /- osteochondral fracture

31
Knee InjuriesAcute Hemarthrosis
  • ACL 50
  • Meniscal tear 40
  • Fracture 10

32
Tibial Eminence Fractures
  • Usually 8-14 year old children
  • Mechanism- hypertension or direct blow to flexed
    knee
  • Frequently mechanism is fall from bicycle

33
Myers- McKeever Classification
  • Type I- nondisplaced
  • Type II- hinged with posterior attachment
  • Type III- complete, displaced

34
Tibial Eminence Fracture- Treatment
  • 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

35
Tibial Spine Fracture
  • 8 to 14 yo
  • often bicycle accident
  • Myer-McKeever classification

36
Tibial Spine FractureTreatment
  • Reduction in extension
  • Immobilize in extension or slight knee flexion
  • Operative treatment for failed reduction or
    extension block

37
Tibial Spine Closed Reduction
Follow closely get full extension
38
Tibial Spine Malunion-Loss of Extension
Injury Film no reduction
2 years post-injury- lacks extension
39
Tibial Spine Fx- Arthroscopic OR,Suture Fixation
40
Tibial Eminence Fracture- Results
  • Generally good if full knee extension regained
  • Most have residual objective ACL laxity
    regardless of treatment technique
  • Most do not have symptomatic instability and can
    return to sport

41
Tibial Tubercle Fractures
  • Primary insertion of patellar tendon into
    secondary ossification center of proximal tibia
  • Mechanism- jumping or landing, quadriceps
    resisted contraction
  • Common just before completion of growth (around
    15 years in males)

42
Tibial Tubercle Fracture Classification- Ogden
  • Type I- fracture through secondary ossification
    center
  • Type II- fracture at junction of primary
    secondary ossification centers
  • Type III- fracture extends into primary
    ossification center, intraarticular

43
Tibial Tubercle Fractures- Treatment
  • Nondisplaced, intact extensor mechanism- above
    knee immobilization for 6 weeks in extension
  • Displaced, loss of extensor mechanism integrity-
    operative fixation

44
Tibial Tubercle Fracture
  • 10 - 14 year old
  • often during basketball
  • surgery for displaced fractures, inability to
    extend knee

45
Proximal Tibial Physeal Fractures
  • Usually Salter II fractures.
  • Occasionally Salter I or IV
  • Posterior displacement of epiphysis or metaphysis
    can cause vascular compromise

46
Proximal Tibia Fracture
47
Proximal Tibial Physeal Fractures- Salter I or II
  • Often hyperextension mechanism
  • Thus flexion needed to reduce
  • If unstable fracture or hyperflexion needed to
    maintain reduction, use percutaneous fixation
  • Above knee cast for 6 weeks

48
Proximal Tibia Salter I Fracture
49
Proximal Tibia Physeal Fractures
  • Open reduction for irreducible Salter I and II,
    displaced Salter IV
  • Observe closely for vascular compromise or
    compartment syndrome in first 24 hours
  • Follow for growth disturbance, angular deformity

50
Complications
  • angular deformity
  • malunion
  • physeal bar
  • leg length discrepancy

51
Proximal Tibial Metaphyseal Fractures
  • Younger patients, less than 6 years
  • Often nondisplaced, nonangulated
  • Later progressive valgus deformity can result
    from medial tibial overgrowth (Cozen Phenomenon)

52
Proximal Tibial Metaphyseal Fractures
  • Initial treatment- try to mold into varus to
    close any medial fracture gap
  • Notify parents initially of possible valgus
    deformity development
  • Follow 2-4 years

53
Valgus Deformity after Proximal Tibial
Metaphyseal Fracture
  • Observe, do not rush to corrective osteotomy
  • Typically remodels, may take years
  • Not all will remodel
  • Consider staple epiphyseodesis, osteotomy if
    severe

54
Genu Valgum following Proximal Tibia Metaphyseal
Fracture
55
Valgus after Proximal Tibia fx
56
Proximal Tibia Metaphyseal fx, Displaced- Often
Young Child, High Energy
Careful assessment of distal perfusion necessary,
monitor for compartment syndrome
3 yo boy
57
Patellar Dislocations
  • Almost always lateral
  • Younger age at initial dislocation, increased
    risk of recurrent dislocation
  • Often reduce spontaneously with knee extension
    and present with hemarthrosis
  • Immobilize in extension for 4 weeks

58
Patellar DislocationNote Medial Avulsion off
Patella and Laxity in Medial Retinaculum
59
Patellar Dislocations
  • Predisposing factors to recurrence- ligamentous
    laxity, increased genu valgum, torsional
    malalignment
  • Consider surgical treatment for recurrent
    dislocation/subluxation if fail extensive
    rehabilitation/exercises

60
Lateral Patellar Dislocation
61
Knee Dislocations
  • Unusual in children
  • More common in older teenagers
  • Indicator of severe trauma
  • Evaluate for possible vascular injury
  • Usually require operative treatment capsular
    repair, ligamentous reconstruction

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