Diagnosis can be confirmed with plain radiographs of Type in at least one full word to see suggestions list. The Orthobullets Podcast. OBJECTIVE: The aim of the study was to review the treatment of deep wound infection after posterior instrumented lumbar fusion, and thereby to optimize the decision-making process of implant removal or retention on the basis of magnetic resonance imaging (MRI) assessment. Treatment is directed at safeguarding tissue vascularity and emphasizes restoration of joint congruity and the mechanical axis of the limb. Tibial Plafond Fracture External Fixation. A tibial plafond fracture (also known as a pilon fracture) is a fracture of the distal end of the tibia, most commonly associated with comminution, intra-articular extension, and significant Temporary joint-spanning external fixation facilitates soft-tissue recovery, whereas minimally invasive techniques and anatomically contoured plates can limit damage to the soft tissues and provide stable fixation. JAAOS A discoid meniscus is the abnormal development of the meniscus leading to a hypertrophic and discoid shaped meniscus.Diagnosis can be suspected on radiographs with (squaring of lateral condyle with cupping of lateral tibial plateau) but require MRI for confirmation (3 or more 5mm sagittal images with meniscal continuity). The severity of a tibial plateau fracture and the complexity of its treatment depend on the energy imparted to the limb. Read SpinePediatric Spondylolisthesis & Spondylolysis by with a free trial. Cancel. Application of a knee immobilizer, splinting of the ankle and forearm, External fixation of the femur and tibial plateau, splinting of the ankle and forearm, Retrograde intramedullary nailing of the femur, limited internal fixation of the tibial plateau, splinting of the ankle and forearm, External fixation of the femur, ORIF of the tibial plateau, splinting of the ankle and forearm, Retrograde intramedullary nailing of the femur, ORIF of the tibial plateau, ORIF of the ankle and forearm. Diagnosis can often be made on radiographs . Fractures of the tibial spine in children. A tibial plafond fracture (also known as a pilon fracture) is a fracture of the distal end of the tibia, most commonly associated with comminution, intra-articular extension, and significant soft tissue injury. When a spiral fracture of the tibia has been diagnosed, medical professionals have a number of options in treating it. One is to set the fracture and apply a cast to the lower leg and ankle of the injured person. Another option is to operate on the affected limb and insert pins into the bone to hold it in place. The computed tomography scan demonstrated a comminuted fracture through the tibial spine. Proximal tibia metaphyseal fractures are a fracture of the proximal tibia usually seen in children from 3 -6 years of age. Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. Also known as a compound fracture, the break to the tibia is so severe that the bone has torn through the soft tissues and punctured the skin. A stress fracture of the shin is a small crack in the tibia caused by overuse. Symptoms usually occur slowly over time and are associated with a sudden increase in running or jumping. In this episode, we review the high-yield topic of Discoid Meniscus from the Knee & Sports section. Tibial Eminence (Spine) Avulsion Fracture ORIF - Pediatrics - Orthobullets Topics Techniques Cards QBank Evidence Cases Videos Podcasts Events Products Help 910ms Tibial Eminence The Orthobullets Podcast. 0000004851 00000 n femoral shaft fracture antegrade intramedullary nailing - trauma - orthobullets 402ms topics trauma general trauma Treatment is usually closed reduction and casting in extension with a All rights reserved. 2022 Lineage Medical, Inc. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. Tibial Plateau Fracture External Fixation. 178 plays. Discovered by Player FM and our community copyright is owned by the publisher, not Player FM, and audio is streamed directly from their servers. PMID: 20086387 bytom@mc.duke.edu. Vascular complications are most commonly seen with which of the following fractures about the knee? (SBQ12TR.21) Evaluation includes appropriate radiographs and careful clinical assessment of the soft-tissue envelope. account for <10% of lower extremity injuries, incidence increasing as survival rates after motor vehicle collisions increase, talus is driven into the plafond resulting in articular impaction of the distal tibia, low energy rotational forces (less common), fracture patterns and comminution determined by position of foot, amplitude of force, and direction of force, 30% have an ipsilateral lower extremity injury, distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus articulates with the talus and fibula laterally via the fibula notch, anterior-inferior tibiofibular ligament (AITFL), originates from anterolateral tubercle of tibia (Chaput), inserts on anterior tubercle of fibula (Wagstaffe), posterior-inferior tibiofibular ligament (PITFL), originates from posterior tubercle of tibia (Volkmann), inserts on posterior part of lateral malleolus, distal continuation of the interosseous membrane, Simple displacement with incongruous joint, ankle tenderness, swelling, abrasions, ecchymosis, fracture blisters, open wounds, and chronic skin/vascular changes, examine for associated musculoskeletal injuries, consider ABIs and CT angiography if clinically warranted, check for signs/symptoms of compartment syndrome, full-length tibia/fibula and foot x-rays performed for fracture extension, lumbar films if appropriate based on exam, important to obtain after spanning external fixation as ligamentotaxis allows for better surgical planning, stable fracture patterns without articular surface displacement, critically ill or non-ambulatory patients, significant risk of skin problems (diabetes, vascular disease, peripheral neuropathy), intra-articular fragments are unlikely to reduce with manipulation of displaced fractures, inability to monitor soft tissue injuries is a major disadvantage, acute management of most length unstable fractures, provides stabilization to allow for soft tissue healing and monitoring, capsuloligamentotaxis to indirectly reduce the fracture by tensioning the soft tissues about the ankle, fractures with significant joint depression or displacement, leave until swelling resolves (generally 10-14 days), not always warranted in length stable pilon fractures, placement of pins out of the zone of injury and planned surgical site is important to reduce infection risks, definitive fixation for a majority of pilon fractures, limited or definitive ORIF can be performed acutely with low complications in certain situations, high rates of wound complications and infections are associated with early open fixation through compromised soft tissue, brake travel time returns to normal 6 weeks after weight bearing, not a necessary step in the reconstruction of pilon fractures, may be helpful in specific cases to aid in tibial plafond reduction or augment external fixation, external fixation/circular frame fixation alone, select cases where bone or soft tissue injury precludes internal fixation, thin wire frames and hybrid fixators have high union rate, osteomyelitis and deep infection are rare, meta-analysis comparing this method with open reduction and internal fixation found no difference in infection or complication rates between the two groups, alternative to ORIF for fractures with simple intra-articular component, minimizes soft tissue stripping and useful in patients with soft tissue compromise, increased valgus malunion and recurvatum seen with IMN compared to plate osteosynthesis, severely comminuted, non-reconstructable plafond fractures, select elderly populations who cannot tolerate multiple surgeries or prolonged immobilization, theorized quicker recovery process and decreased long term pain, increases the risk of adjacent joint arthritis including the subtalar joint and midfoot, long leg cast for 6 weeks followed by fracture brace and ROM exercises, close follow-up and imaging needed to ensure articular congruity and axial alignment, fixator constructs vary with delta and A frames assemblies being most common, 2 tibial shaft half pins outside the zone of injury connected to a single transcalcaneal pin, consider trans-navicular pin if associated calcaneal fracture, consider connecting fixator to the forefoot 1, joint-spanning articulated vs. nonspanning hybrid ring, none have been shown to be superior with respect to ankle stiffness, can combine with limited percutaneous fixation using lag screws, anatomic articular reconstruction may not be possible, especially with central depression, tibial shaft is used as a fixation base to reduce the fracture, two half-pins in the AP plane with rings in an orthogonal position, used to support the distal fixation rings, determined by the configuration of the fracture and the soft-tissue injury, rings placed at the level of the plafond or calcaneus to distract and reduce the fracture, pins should be placed at least 1-2 cm from the joint line in order to avoid possible septic arthritis, safe zones for wire placement form a 60-degree arc in the medial-lateral plane, can include limited internal fixation if soft tissues permit, consider the need for soft tissue coverage with position of the fixator, provides better fixation and decreases frequency of loosening, once skin wrinkles present, blister epithelization, and ecchymosis resolution (10-14 days), single or multiple incisions based on fracture pattern and goals of fixation, keep full thickness skin bridge >7cm between incisions, positioning of patient dependent on approach(es) being utilized, useful with fractures impacted in valgus or with an intact fibula, goal is for anatomic reduction of articular surface, location of plates/screws are fracture and soft-tissue dependent, consider provisionally leaving the external fixator in place, can be with intramedullary screw/wire or plate/screw construct, ankle ROM exercises beginning 2 weeks post-op, non-weightbearing for ~6-12 weeks depending on radiographic evidence of fracture consolidation, debride fibrous tissue, fracture callous, and cartilage, small comminuted articular fragments are removed, pack metaphyseal defects and the tibiotalar joint with autologous or allograft bone graft, fixation with an anterior plate and screw construct, progress weight bearing between 8 and 12 weeks in removable boot, full weight bearing with ankle brace at 12 weeks post-op, CT at 3 months to assess for successful fusion, tibiotalocalcaneal (TTC) fusion with retrograde intramedullary nail, accelerates transverse tarsal joint arthritis, wait for soft tissue edema to subside before ORIF (1-2 weeks), free flap for postoperative wound breakdown, significant soft tissue swelling at time of definitive surgery, irrigation and debridement, antibiotics, possible hardware removal, joint-preserving correction with secondary anatomic reconstruction, must rule out infected non-union (labs to obtain CRP, ESR, WBC), other non-union labs (PTH, calcium, total protein, serum albumin, vitamin D, TSH), chondrocyte cell death at fracture margins is a contributing factor, IL-6 is elevated in the synovial fluid following an intra-articular ankle fracture, most commonly begins 1-2 years postinjury, first line is conservative management (bracing, injections, NSAIDs, activity modification), Poor outcomes and lower return to work associated with, Outcomes correlate with severity of the fracture pattern and the quality of reduction, at 2 year follow-up, the majority of type C pilon fractures report lower SF-36 scores than patients with pelvic fractures, AIDS, or coronary artery disease, clinical improvement seen for up to 2 years after injury, 6 weeks after initiation of weight bearing, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Some rare fracture types are unclassi-able, such as a horizontal shear of the entire plateau reported by Diagnosis can be confirmed with radiographs of the knee. 0.0 (0) ORTHO BULLETS Orthopaedic Surgeons & Providers Tibial eminence fracture in an adult: a possibility with rotational injuries Phys Sportsmed. 29. By Orthobullets. Currently we define this condition as persisting or recurring low back pain with or without radiating leg pain following one or more back . "Bucket handle meniscal tears can be diagnosed on MRI as a double PCL sign on sagittal imaging. It was called failed back syndrome . 2004 Jan;32 (1):21-31. doi: 10.3810/psm.2004.01.86. ages 12 - 15 (approaching skeletal maturity), most common in basketball, football, sprinting and high jump, a concentric contraction of the quadriceps during jumping, proximal tibia has two ossification centers, primary ossification center (proximal tibial physis), secondary ossification center (tibial tubercle physis or apophysis), physeal closure occurs from posterior to anterior and proximal to distal, with the tibial tubercle the last to fuse, places distal secondary center at greater risk of injury in older children, extensor mechanism exerts great force at secondary ossification center, recurrent anterior tibial artery can be lacerated, Based on level of fracture and presence of fragment displacement, Ogden Classification (modification of Watson-Jones), Fracture of the secondary ossification center near the insertion of the patellar tendon, Fracture propagates proximal between primary and secondary ossification centers, Coronal fracture extending posteriorly to cross the primary ossification center, Fracture through the entire proximal tibial physis, Periosteal sleeve avulsion of the extensor mechanism from the secondary ossification center, Modifier: A (nondisplaced), B (displaced), generally occurs during the initiation of jumping or sprinting, knee swelling/hemarthrosis with Type III injuries, evaluate for anterior compartment firmness, retinacular fibers may allow for active extension, monitor for increasing pain suggestive of compartment syndrome, widening or hinging open of the apophysis, fracture line may be seen extending proximally and variable distance posteriorly, anterior swelling may be the only sign in the setting of a periosteal sleeve avulsion (type V injury), can be useful to evaluate for intra-articular or posterior extension, arteriogram if concern for popliteal arterty injury, should not delay intervention in setting of compartment syndrome, useful for determining fracture extension in a nondisplaced Type II injury or type V injury, Type I injuries or those with minimal displacement (< 2 mm), acceptable displacement after closed reduction/cast application, open reduction internal fixation with arthrotomy +/- arthroscopy, +/- soft tissue repair, Type II-IV fractures - need to visualize joint surface for perfect reduction and evaluate for intra-articular pathology, soft tissue repair for Type V (periosteal sleeve) fracture, remove any soft tissue (periosteum) interposition, internal fixation with 4.0 cancellous, partially threaded screws, larger screws can be used but may cause soft tissue irritation in the long-term, smooth K wires for younger child (>3y from skeletal maturity), non-weightbearing in long leg cast or brace for 4-6 weeks, progressive extensor mechanism strengthening, hardware irritation can necessitate implant removal, midline approach and parapatellar arthrotomy, joint surface must be visualized to assure anatomic reduction, alternatively, arthroscopy can be used to directly assess the articular reduction, visualize joint surface to achieve anatomic reduction, evaluate for meniscal tears and repair or debride as appropriate if soft tissue repair indicated, addresses intraarticular extension and soft tissue injuries, arthrotomy may require longer immobilization and/or rehabilitation, remove any soft tissue interposition (periosteum), heavy suture repair of periosteum back to the secondary ossification center, prolonged immobilization needed due to soft tissue (rather than bone) healing, prolonged healing time given to soft tissue healing, growth arrest anteriorly and posterior growth continues leading to decrease in tibial slope, most common complication following surgical repair, due to prominence of screws and hardware about the knee, resolved upon hardware removal, to popliteal artery as it passes posteriorly over distal metaphyseal fragment, High rate of fracture union and return to sports with approriate treatment, Low incidence of leg length discrepancy given age at which this injury occurs, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). Tibial plateau fractures are complex injuries of the knee. The tibial plateau is one of the most critical load-bearing areas in the human body. Early detection and appropriate treatment of these fractures are essential in minimizing patient's disability in range of movement, stability and reducing the risk of documented complications. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. frequently associated with soft tissue injuries, associated with Schatzker II fracture pattern, associated with >10mm articular depression, most commonly associated with Schatzker IV fractures, more common in type IV and VI fractures (25%), commonly associated with Schatzker IV fracture-dislocations, one column fracture is defined as an independent articular depression with a break in the column, anteromedial + posteromedial fractures = 2-column fracture, anterolateral fracture + separate posterolateral depression fractures = 2-column fracture, more common with Schatzker type IV and VI, more common with Schatzker type II with 10mm of articular depression, popliteal artery run posterior to knee and branches, located more proximal than medial tibial condyle, fracture patterns that do not fit into the Schatzker classification (10% of all tibial plateau fractures), fractures associated with knee instability, Hohl and Moore Classification of proximal tibia fracture-dislocations, assess soft-tissues for timing of operative intervention, often difficult to perform in acute setting given pain, oblique is helpful to determine amount of depression, sclerotic band of bone indicating compression fx, negative radiographs with high index of suspicion for tibial plateau fracture, assess articular depression and comminution, minimally displaced split or depressed fractures, low energy fracture stable to varus/valgus alignment, external fixation/Ilizarov +/- limited open/percutaneous fixation of articular segment, severe open fracture with marked contamination, highly comminuted fractures where internal fixation not possible, usually requires delayed arthroplasty in the setting of highly comminuted fractures in the elderly, temporizing bridging external fixation w/ delayed ORIF, postoperative infection after ORIF associated with, timing of definitive fixation (before, during or after) relative to fasciotomy closure does not increase the risk of infection, alteration of limb mechanical axis > 5 degrees, consider in patients >65-years-old with osteoporotic bone, improved outcomes for primary TKA compared to TKA for failed ORIF, two 5-mm half-pins in distal femur, two in distal tibia, allows soft tissue swelling to decrease before definitive fixation, decreases rate of infection and wound healing complications, transient increase in leg compartment pressures during external fixator placement, this has not been shown to increase risk of compartment syndrome, reduce articular surface either percutaneously or with small incisions, stabilize reduction with lag screws or wires, apply external fixator or hybrid ring fixation, begin weight bearing when callus is visible on radiographs, incidence as high as 15% after temporizing external fixator, straight or hockey stick incision anterolaterally from just proximal to joint line to just lateral to the tibial tubercle, midline incision (if planning TKA in future), can lead to significant soft tissue stripping and, dual surgical incisions with dual plate fixation, can be used for posterior shearing fractures, restore joint surface with direct or indirect reduction, calcium phosphate cement has high compressive strength for filling metaphyseal void, absolute stability constructs should be used to maintain the joint reduction, depression fractures that were elevated percutaneously, non-locked buttress plates best indicated for simple partial articular fractures in healthy bone, less compression of periosteum and soft tissue, gentle mechanical compression on repaired osteoarticular segments improves chondrocyte survival, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. 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