Knee Fractures Research Articles

(ii) Paediatric epiphyseal fractures around the knee

<h2>Summary</h2> Physeal fractures around the knee are most common in children aged 9–14. The majority of these fractures will have a good outcome if they are adequately treated initially. There is a fairly clear consensus on how these fractures should be managed. Undisplaced fractures are treated with cast immobilisation and almost universally have a good outcome. Displaced Salter Harris I and II fractures of the proximal tibia and distal femur can usually be treated with closed reduction and fixation. Intraarticular fractures often require open reduction prior to internal fixation. Displaced fractures of the tibial spine, tibial tuberosity and patella are more difficult to reduce closed and an open reduction is frequently required. Most osteochondral fractures are simply excised arthroscopically. There are well recognised complications associated with paediatric knee fractures. Early complications include popliteal artery damage, ligament damage and compartment syndrome. Late complications are usually related to damage to the physis with leg length discrepancies and angular deformity.

Knee pain, knee osteoarthritis, and the risk of fracture

Patients with osteoarthritis (OA) have increased bone mineral density; however, the association between knee OA and fracture is controversial. Few data exist on the association between knee pain and fracture. We examined the association of knee OA and knee pain with fracture and falls in elderly men and women. The study group comprised 6,641 men and women ages > or =75 years who participated in a 3-year randomized controlled trial of intramuscular vitamin D therapy. Patients completed a questionnaire about knee pain and OA. Fracture and fall data were collected prospectively every 6 months. Knee pain prevalence and a clinician diagnosis of knee OA were 35.2% and 6.8%, respectively. A total of 436 incident nonvertebral fractures were reported, and 3,992 patients sustained a fall. Prevalent knee pain was associated with an increased risk of falls (hazard ratio [HR] 1.26, 95% confidence interval [95% CI] 1.17-1.36) and hip fracture (HR 2.0, 95% CI 1.18-3.37). Increasing severity of knee pain was associated with a greater risk of falls and hip fracture. Clinician diagnosis of knee OA was associated with an increased risk of nonvertebral fractures (HR 1.61, 95% CI 1.09-2.36). The increased risk of fracture was not substantially reduced by adjusting for falls, but was attenuated by adjustment for the use of walking aids. Patients with a clinical diagnosis of knee OA and with knee pain have an increased risk of nonvertebral and hip fracture. This is not explained by the increased risk of falls, but is more likely to be due to the severity of falls sustained. Knee pain and OA should be regarded as independent risk factors for fracture.

Acute knee trauma: role of ultrasound

The purpose of this study was to determine the diagnostic accuracy of high spatial resolution ultrasonography (US) in the detection of lipohemarthrosis of the knee and to evaluate this sign as criteria of intra-articular fracture. Forty-eight patients with clinical suspicion of knee fracture were prospectively examined by conventional radiography, sonography examination and computed tomography (CT) within 48 h after trauma in order to depict direct (fracture line) and indirect (lipohemarthrosis) signs of intra-articular fracture. Lipohemarthrosis was defined as a multi-layered collection in the subquadricipital recess. CT was considered as the gold standard for both direct and indirect fracture criteria. CT imaging showed direct signs of intra-articular fracture in 31 patients (65%). Among these patients, 30 (97%) had a lipohemarthrosis. Conventional radiographs showed intra-articular fracture in 26 patients (54%). Among these, 18 (69%) had a lipohemarthrosis. Sonographic examinations could not depict any direct sign of intra-articular fracture but showed a lipohemarthrosis in 29 (93%) of patients with proven fracture via CT. This allowed the depiction of four out of five occult knee fractures. The sensitivity, specificity, positive predictive value, negative predictive value of sonography for the diagnosis of lipohemarthrosis was 97, 100, 100 and 94%, respectively, compared with 55, 100, 100 and 55% with conventional radiographs. Using lipohemarthrosis as criterion of fracture, the sensitivity, specificity, positive predictive value and negative predictive value of sonography for early detection of intra-articular knee fractures was 94, 94, 97 and 89%, respectively, compared with 84, 88, 93 and 75% with conventional radiographs. We concluded that, by showing lipohemarthrosis in the subquadricipital recess, high-resolution sonography is a reliable and accurate technique for the evaluation of intra-articular knee fractures.

人工靭帯を用いた膝伸展機構再建術後に機能不全をきたした１例

We report a case of dysfunction following reconstruction of the knee extensor mechanism using artificial ligament. Three years ago, a 49-year-old man sustained an injury of the patella fracture of the left knee in a traumatic event. Since then, he had not been able to walk without crutches or extend his left knee completely. Plain radiograph showed two divided bony fragments of the patella and that the periarticular bone had changed atrophically. The distance between the two fragments was approximately 7cm. The knee extensor apparatus recontruction was performed using the Leeds-Keio artificial ligament, which was fixed to the tibia with double staples. The rehabilitation program was controlled strictly. Eighteen weeks after the operation, no extension lag was found and he could walk by himself. At 28 weeks after the operation, however, he had not been able to extend the operated knee on his own and the extension lag increased to 20°suddenly. On examination at 47 weeks after operation, the MRI showed loosening of the artificial ligament resulting from weak fixation due to the tibial atrophy. Although the knee extensor apparatus recontruction using artificial ligament is a good method, results for this case were poor. We concluded that it is necessary to reinforce the fixation of the artificial ligament in such bone atrophy cases by the addition of another augmentation.

Acute knee trauma: analysis of multidetector computed tomography findings and comparison with conventional radiography

To evaluate the multidetector computed tomography (MDCT) findings of acute knee trauma and to compare radiography with MDCT in patients referred to a level 1 trauma center. During a 5-year period, a total of 415 MDCT examinations were performed on 409 patients with acute knee trauma to reveal complex fracture anatomy or rule out a fracture. MDCT and primary radiographs were re-evaluated with respect to fracture location and trauma mechanism. Tibial plateau fractures were further analyzed depending on anatomical location: anterior-medial, anterior-lateral, posterior-lateral, and posterior-medial regions. Maximal depression of the tibial articular surface was measured. Findings on the primary knee radiographs were compared with MDCT findings. Of the 409 patients, 356 (87%) had a knee fracture. A total of 451 fractures were found in all anatomic regions: distal femur (n=49), proximal tibia (n=307), patella (n=23), and proximal fibula (n=72). Primary radiographs were available in 316 (76%) cases. Of these, 225 (71%) had MDCT in order to reveal the fracture anatomy better, and 91 (29%) had a subsequent MDCT after negative plain radiographs. Overall sensitivity of radiography was 83%, while negative predictive value was 49%. On radiography, tibial plateau articular depression was underestimated in all regions except when the fracture consisted of the whole half of the anterior or posterior plateau. The three main injury mechanisms were traffic accident, a simple fall, and sport. In 49 cases (15%), primary radiographs were suboptimal due to positioning. In severely injured patients, diagnostically sufficient radiographs are difficult to obtain, and therefore a negative radiograph is not reliable in ruling out a fracture. In these patients, MDCT is a fast and accurate examination and is also recommended in patients with tibial plateau fractures or complex knee injuries in order to evaluate the fracture adequately.

Extensor Mechanism Disruption After Contralateral Middle Third Patellar Tendon Harvest for Anterior Cruciate Ligament Revision Reconstruction

The contralateral central third patellar tendon autograft is a reliable graft choice for revision, and recently, for primary reconstruction of the anterior cruciate ligament (ACL). We report 2 complications including a lateral third tibial tuberosity fracture and a distal patellar tendon avulsion with contralateral patellar tendon autograft with disruption of the extensor mechanism of the donor knee. A patient sustained a lateral tibial tuberosity fracture of the donor knee and underwent open reduction and internal fixation. At 1-year follow-up, she had no extensor lag and full range of motion. Another patient sustained a distal patellar tendon avulsion of the donor knee and underwent primary repair. Three years postoperatively, she had a full range of motion and no extensor lag. Although contralateral middle third patellar tendon autograft for primary and revision ACL reconstruction is established in the literature, extensor mechanism complications can occur. Technical considerations are important to avoid weakening the remaining patellar tendon insertion. Postoperative nerve blocks or local anesthetics may alter pain feedback for regulation of weight bearing and contribute to overload of the donor knee.

Screening for extermity arterial injury with the arterial injury with the arterial pressure index

Certain extremity injuries presenting to the ED or Trauma Unit warrant increased suspicion for underlying arterial trauma. Such injuries include knee dislocations, displaced medial tibial plateau fractures and other displaced bicondylar fractures around the knee, open or segmental distal femoral shaft fractures, floating joints, gunshot wounds in proximity to neurovascular structures, or mangled extremities. Once the diagnosis of arterial trauma is made, a multi-disciplinary approach is warranted. The diagnostic strategies for vascular injury have undergone an evolution over the past 2 decades. One and a half percent to 4.6% of patients hospitalized with blunt extremity trauma have associated vascular compromise [Bunt TJ, Malone JM, Moody M, et al. Am J Surg 1990;160(2):226-8; Reid JD, Weigelt JA, Thal ER, et al. Arch Surg 1988;123(8):942-6; Applebaum R, Yellin AE, Weaver FA, et al. Am J Surg 1990;160(2):221-4; discussion 224-5; Dennis JW, Frykberg ER, Veldenz HC, et al. J Trauma 1998;44(2):243-52; discussion 242-3]. An efficient and effective evidence-based approach to diagnosing vascular injury is necessary, as the difficulty in diagnosis, the multiplicity of diagnostic strategies, the limited time frame in which to initiate appropriate treatment, the limb threatening complications of a missed diagnosis, and the increased awareness of health care expenditures make this entity an intimidating diagnostic challenge [Johansen K, Lynch K, Paun M, et al. J Trauma 1991;31(4):515-9; discussion 519-22; Lynch K, Johansen K. Ann Surg 1991;214(6):737-41; Walker ML, Poindexter Jr JM, Stovall I. Surg Gynecol Obstet 1990;170(2):97-105; Kendall RW, Taylor DC, Salvian AJ, et al. J Trauma 1993;35(6):875-8]. The purpose of this article is to present an evidence-based algorithm for patients who present with either arterial injury or a high-risk of arterial injury. A diagnostic algorithm will be presented, and the rationale for diagnostic interventions will be discussed in the context of current medical literature.

Pathologic Extremity Fracture Care in Spinal Cord Injury

Fracture management in chronic SCI can be summarized by the following principles. Fractures in the upper extremity and in incomplete SCI are treated by standard orthopedic guidelines. Nondisplaced femoral neck fractures require cannulated screw fixation, whereas displaced fractures require an endoprosthesis. Nondisplaced intertrochanteric and subtrochanteric hip fractures may be treated nonoperatively in the elderly or medically ill, but those who require mobilization and a predictable outcome require intramedullary hip screw (IMHS) fixation. Femoral shaft and displaced tibia shaft fractures require intramedullary locked nails. Most periarticular knee fractures may be managed by nonoperative splinting. Nondisplaced fractures of the tibia and below are treated by nonoperative means.

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

Should Plain X-rays be Routinely Performed After Blunt Knee Trauma? A Prospective Analysis

We tested the hypothesis that it was possible to decrease the number of performed x-rays after a knee trauma without delayed fracture diagnosis by using the Ottawa knee rules. Patients had routine x-rays of the injured knee during the first stage of the study and selective x-rays during the second stage. All patients were followed up to 6 months after the trauma. 138 patients were included in the first stage; 57 had negative Ottawa criteria: no fracture was observed; following the Ottawa rules, 41% of the x-rays could have been avoided. 178 patients were included in the second stage; 63 patients had negative Ottawa criteria: no fracture was diagnosed during the whole follow-up; 35% of the x-rays have been avoided. Ottawa rules allowed decreasing the number of x-rays performed after a knee trauma by 35% with a sensitivity for a knee fracture detection of 100%.

Pediatric knee fractures

Fractures about the knee are a common occurrence in children, and characteristics of the growing skeleton make children susceptible to specific fractures that do not occur in adults. The purpose of this review is to help the clinician to recognize, understand, and appropriately treat these injuries. Pediatric knee fractures are diagnosed by a comprehensive history and physical examination supplemented with appropriate imaging modalities. Depending on the injury, treatment may include immobilization, arthroscopic treatment, or open reduction and internal fixation. A thorough understanding of pediatric knee fractures will enable clinicians to appropriately manage these injuries and provide patients with a rapid return to preinjury activities.

Ｆｌｏａｔｉｎｇ Ｋｎｅｅを伴った小児距骨骨折の一例

A 5-year-old boy was caught in a landslide and sustained injuries including with severe floating knee fracture and Hawkins Type I talus neck fracture. Other fractures were subtrochanteric part of the femur, tibia, fibula, and ankle dislocation fracture. Distal diaphisis of the tibia showed Gustilo Type III a open fracture, for which we performed operative treatment. Other fractures including the talus were treated conservatively. The injured leg was fixed with a long hip spica casting for eight weeks. After eight weeks, Hawkins sign was seen in the talus and considerable callus formations at each fracture site. We started weight bearing. Twelve weeks after the accident, all fracture sites healed, and 16 months after the accident, he had no limited range of motion in his hip, knee, and ankle. He also had no motion pain at each joint. X-ray pictures showed complete union and no avascular necrosis of the talus.

Hybrid external fixation in complex tibial plateau and plafond fractures: an Australian audit of outcomes

Hybrid external fixators are useful for the management of complex tibial plateau and plafond fractures, as they provide rigid fixation with relatively minimal soft tissue disruption. We reviewed the outcomes of patients with proximal (plateau) and distal (plafond) tibial fractures who were treated with hybrid frames at the Royal North Shore Hospital from 1998 to 2001. Twenty-four patients were identified from the hospital operating records and chart, X-ray and clinical reviews were performed. Follow-up periods averaged 13 months. Fractures were classified using the Ruedi classification for ankle fractures, and the Schatzker classification for the knee fractures. Clinical outcome was assessed using the Iowa knee score and the AOFAS ankle score. As one of the first Australian audits our outcomes were consistent with international standards.

Investigation into MRI diagnostic value of occult fracture of knee

目的 探讨膝关节隐匿性骨折的MRI特征和临床应用价值.方法选择35例膝关节外伤后X线检查阴性但有明显疼痛等症状的患者进行研究,所有患者全部进行MRI检查,重点观察股骨下端、胫腓骨上端及髌骨的骨质信号,前后交叉韧带、内外侧副韧带、内外侧半月板的完整性和信号异常情况.结果隐匿性骨折的好发部位为:胫骨内外侧平台(14/35)、股骨内外侧髁(13/35).35例患者中X线检查全部阴性,其中CT检查11例,3例阳性(27%),MRI检查全部阳性(100%).结论MRI是检查隐匿性骨折的最佳影像学方法,对于X线或CT显示正常但又有明显症状的膝关节外伤患者,应做MRI检查,以防漏诊和误诊。

Review: the Ottawa knee rule accurately rules out knee fractures and can substantially reduce the need for x rays in patients with acute knee injuries

Bachmann LM, Haberzeth S, Steurer J, et al . The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review. Ann Intern Med 2004;140:121–4. [OpenUrl][1][CrossRef][2][PubMed][3][Web of...

The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review.

The Ottawa knee rule is a clinical decision aid that helps rule out fractures and avoid unnecessary radiography. To summarize evidence about the accuracy of the Ottawa knee rule. Relevant English- and non-English-language articles were identified from PreMEDLINE and MEDLINE (1966-2003), EMBASE (1980-2003), CINAHL (1982-2003), BIOSIS (1990-2003), the Cochrane Library (2002, Issue 3), the Science Citation Index database, reference lists of included studies, and experts. Articles were included if they reported enough information to determine the sensitivity and specificity of the Ottawa knee rule for detecting fractures confirmed either radiologically or in combination with follow-up. Two reviewers independently extracted data on study samples, the ways that the Ottawa knee rule was used, and methodologic characteristics of studies. Of 11 identified studies, 6 involving 4249 adult patients were considered appropriate for pooled analysis. The pooled negative likelihood ratio was 0.05 (95% CI, 0.02 to 0.23), the pooled sensitivity was 98.5% (CI, 93.2% to 100%), and the pooled specificity was 48.6% (CI, 43.4% to 51.0%). A negative result on an Ottawa knee rule test accurately excluded knee fractures after acute knee injury. However, because the rule is calibrated toward 100% sensitivity and actual fracture prevalences are usually low, large-scale, multicentered studies are still needed to establish the cost-effectiveness of routinely implementing the rule.

Fondaparinux Sodium

Fondaparinux sodium (Arixtra; fondaparinux) is the first of a new class of synthetic pentasaccharide anticoagulants that bind to antithrombin and inhibit the action of factor Xa. In three large, well designed trials, subcutaneous fondaparinux 2.5mg once daily was more effective than subcutaneous enoxaparin sodium (enoxaparin) 30 mg twice daily or 40 mg once daily at preventing venous thromboembolism (VTE) at day 11 in patients undergoing hip replacement, elective major knee or hip fracture surgery; a fourth trial demonstrated similar efficacy to enoxaparin 30 mg twice daily in hip replacement. Fondaparinux recipients had a lower incidence of proximal deep vein thrombosis (DVT) in two studies. In a meta-analysis of the four trials, patients receiving fondaparinux had a >50% reduction in the relative risk of VTE at day 11. Fondaparinux compared favourably with enoxaparin in several pharmacoeconomic analyses. In a large, controlled trial in hip fracture patients, extended prophylaxis with fondaparinux (duration 25-31 days) substantially reduced the incidence of VTE at day 25-32 compared with prophylaxis for 6-8 days, and was a cost-effective treatment strategy. Moreover, extended prophylaxis significantly decreased the rate of proximal, total and distal DVT and symptomatic VTE. Fondaparinux was generally well tolerated in clinical trials in patients undergoing major orthopaedic surgery. However, following major knee surgery and in a meta-analysis of pooled data from four trials, fondaparinux recipients had a significantly higher incidence of overt bleeding with a bleeding index > or =2, but no increase in fatal bleeding, bleeding into a critical organ or bleeding leading to reoperation. The bleeding risk is related to the timing of the first dose and when fondaparinux was initiated between 6 and 8 hours after surgery, the bleeding risk was similar to enoxaparin. Extended prophylaxis with fondaparinux was not associated with a significantly increased risk of bleeding events. In conclusion, fondaparinux is more effective than enoxaparin at preventing postoperative VTE in patients undergoing elective hip replacement, major knee or hip fracture surgery. Extended therapy with fondaparinux considerably increases its efficacy without a significant increase in the incidence of bleeding episodes. Fondaparinux was generally well tolerated in clinical trials. Fondaparinux is an effective and useful alternative to low molecular weight heparins for the prevention of VTE following major orthopaedic surgery.

A negative result on the Ottawa knee rules excludes fracture in patients with acute knee injury

Summary of Bachmann LM, Haberzeth S, Steurer J and ter Riet G (2004): The accuracy of the Ottawa knee rule to rule out knee fractures. A systematic review. Annals of Internal Medicine 140: 121–124. [Prepared by Chris Maher, Editorial Board Member]

The Ottawa Knee Rules accurately identified fractures in children with knee injuries

Bulloch B, Neto G, Plint A, et al ; Pediatric Emergency Researchers of Canada. Validation of the Ottawa Knee Rule in children: a multicenter study. Ann Emerg Med 2003;42:48–55.[OpenUrl][1][CrossRef][2][PubMed][3][Web of...