Mark D. Stringer, MS, FRCP, FRCS, FRCS Ed

• Professor of Anatomy,
• Department of Anatomy and Structural Biology,
• Otago School of Medical Sciences,
• University of Otago, Dunedin, New Zealand

Plates with locking screws function as internal fixators and have a possible biological advantage over conventional plates pain medication for dogs after neuter cheap artane online mastercard. The plate is not compressed against a cortex and therefore periosteal blood supply may be preserved wrist pain treatment exercises buy cheap artane line. Another disadvantage of locking plate fixation is that the surgeon has no tactile feedback as to the quality of the bone when tightening the screws myofascial pain treatment center watertown ma order artane 2 mg line. The screws stop abruptly when the threads are completely seated into the plate regardless of the bone quality pain treatment medicine clifton springs ny buy artane 2mg. Devices that combine locking screw technology with conventional screw capacity allow the surgeon to utilize the mechanical advantages of both systems treatment pain during intercourse proven 2 mg artane. The nailing is preferable done in supine position on a fracture table because lateral position can predispose varus and valgus prealignment pain treatment medication discount 2 mg artane with amex. Undisplaced and simple sagittal split type C fractures are held by percutaneously placed clamps or interfragmentary screws which do not interfere with the placement of the nail. A reamed nail has a much lesser chance of displacing the fractures than an undreamed nail. Retrograde nails: the patient is positioned on a radiolucent table, provisional articular reconstruction and stabilization is done without interfering with the proposed path of the intramedullary nail. For undisplaced fractures the entry to the joint can be made percutaneously with a small midline longitudinal incision. If in more complex intra-articular fractures a midline incision, and a standard parapatellar medial arthrotomy approach is used. The entry point of the nail is just anterior to the femoral insertion of the posterior cruciate ligament in the intercondylar area. The constructs can be considerably stiff and act like rigid internal fixator preventing callus formation. In general a longer plate is preferred than would be selected for traditional plating. Retrograde Locked Intramedullary Nails Retrograde nailing has the advantage of conferring distal fixation and allowing intramedullary fixation in patients with proximal femoral deformity or instrumentation. Note this is neither conforming to splinting nor compression system of fracture fixation; (D and E) the plate should have been longer to make it flexible. Note that the proximal fragment had migrated into the knee joint; (B and C) intraoperatively, a big defect was found in the metaphyseal area of the femur anteriorly and posteriorly; (D to F) A decision of using the patella as a graft was made, soft tissue was excised of the patella. Patella was fixed to the distal femur using K-wires External Fixation Comminuted fractures of the distal femur can be open, or associated to soft tissue damage or major trauma to other parts of the body. Closed reduction and external fixation import minimum surgical trauma and allow early mobilization of the knee joint. Individual Fractures Reduction of the Articular Segment to the Shaft the entire articular block can then be reduced to the femoral shaft, spanning any areas of metaphyseal comminution. If the metaphyseal fracture component is simple, then a direct, open, lateral reduction can be used. Similarly, if multiple intercalary fracture fragments exist, the temptation to directly reduce and stabilize these components should be avoided. The distal, femoral, articular segment is usually posteriorly angulated in an extended position relative to the shaft due to the attachment of the gastrocnemius. With increasing longitudinal traction applied to the limb, this deformity frequently increases. Length is best accomplished with either manual traction or a femoral distractor placed anteriorly from the femoral diaphysis to the proximal tibia. Translational and angulatory deformities are best corrected manually with joysticks, mallets, pushers or bumps. If some deformity persists, joysticks placed from anterior to posterior in the distal segment can be used to restore the proper flexion. The coronal plane alignment can usually be corrected with manual angulation of the extremity. Minimally Invasive Reduction Techniques 19 An accurate articular reduction through an open approach is necessary prior to stabilization of the distal articular block to the shaft. Minimally invasive techniques are useful primarily for reduction of the articular block to the femoral shaft. Virtually all implants can be fixed to the femoral shaft using minimally Type A Fracture (Extra-articular) the principles for treatment of these extra-articular fractures are to restore length, alignment and rotation to the femur. Extra-articular A1 Simple (two-part) Groups A2 Metaphyseal wedge A3 Metaphyseal complex (comminuted) B. Partial articular (unicondylar) B1 Lateral condyle (fracture in the sagittal plane) B2 Medial condyle (fracture in the sagittal plane) B3 Frontal (fracture in the coronal plane) C. Antigrade or retrograde nail may be used if two locking bolts can be inserted in the nail. Type B Fracture (Unicondylar) Type B fracture is treated by two interfragmentary compression screws inserted perpendicular to the fracture plane. Coronal fractures of the distal femoral articular surface for two screws are inserted form anterior to posterior or posterior to anterior. Avoid Narrowing the Joint Surface A second medial buttress plate was applied through a separate media; exposure (dual plating in those situations locking plate had been a major advance for these C3 fracture. Type C Fracture (Bicondylar) They should be countersunk type C fracture (complete articular): the type C3 fracture patterns is not only the most complex distal femur fracture; it is the most common. The surgical approach must provide exposure of joint surface so all articular fragments can be reduced and fixed. The second step is equally important and involves reduction and fixation of the extra-articular component of the fracture, to shaft of femur, bypassing the fracture zone. Individual Fractures In complete articular fractures (type C), the initial anatomic articular reconstruction usually depends upon screws either outside or through the buttress plate. In patients with communication of the intercondylar region, noncompressing position screws may be required to avoid narrowing of the distal femur. Postoperative Rehabilitation Immediate mobilization of the involved knee and a continuous passive motion machine is begun postoperatively. In cases of extreme osteoporosis and/ or poor fixation of the distal femoral segment, additional support provided by an unlocked hinged knee brace may be helpful. Future Directions the minimally invasive techniques for fracture treatment all continue to evolve. Current methods need refining, particularly in the areas of implant and instrument design, the closed reduction of fractures, and the determination of limb alignment. By avoiding direct exposure of the fracture site, minimally invasive techniques appear to provide for improved fracture healing and a decreased incidence of complications. Compared with the traditional open reduction techniques, the assessment of frontal and sagittal plane axial alignment, length and rotation can be difficult. As a result, intraoperative fluoroscopic times are usually higher compared to open procedures. Supracondylar and intercondylar fractures of the femur treated with a supracondylar plate and lag screw. Closed reduction and early cast brace ambulation in the treatment of femoral fractures. Implant Removal Implant induced bone loss when a plate has been present for a long duration even after complete union of the fracture can be due to fracture configuration, soft tissue manipulation during plate fixation, type of fracture fixation, loss of vascularity, stress shielding and chronic inflammatory response in the bone in the vicinity of plate. Open Reduction Internal Fixation: Master Techniques in Orthopaedic Surgery-Fractures. Angulated screw placement in the lateral condylar buttress plate for supracondylar femoral fractures. Locking plating of distal femur fractures leads to inconsistent and asymmetric callus formation. The use of the supracondylar nail in the management of femoral fractures in the presence of other femoral implants in the very elderly. Treatment of distal femoral fractures with intramedullary supracondylar nails in elderly patients. Study of long term effects of plate osteosynthesis on bone in patients of lower limb fractures. This is a strong facial structure formed by blending of the quadriceps tendon, fascia lata and iliotibial band. The patella, the largest sesamoid bone in the human body, is firmly invested in this apparatus occupying the quadriceps tendon. Medial and lateral retinaculi form the strong expansions from these structures on either side. The patellar retinaculum, derived from aponeurotic expansion of vastus tendon and connective tissue fibers running from the sides of the patella, inserts on to the front and sides of tibial condyle. Patellar lateral and medial retinaculum are dense ligamentous condensation of capsular tissue on either side of patella. The patella retinaculum and iliotibial band serve as the auxiliary extensors of the knee. Tendon of rectus femoris, common tendons of vastus lateralis and vastus medialis form its anterior and intermediate parts of extensor apparatus. Posterior part of the extensor apparatus is formed by vastus intermedialis and is joined by genu articularis tendon. A slip from genu articularis tendon inserts into the apex of the suprapatellar synovial potch between the adjacent margins of vasti, a fascial sling is formed to act as cradle for rectus tendon. The undersurface of upper three-fourth of patella is covered by hyaline cartilage; its thickness may be greater than 1 cm that is thickest in the body, rendering the patella susceptible to chondromalacia and patellofemoral arthritis. It is present more in males than females and is usually bilateral but unilateral is not rare. A second vertical ridge near the medial border defines another facet as a small strip known as odd facet. Biomechanics Extensor apparatus functions to keep the body erect and overcome the force of gravity. It serves as a pulley and increases the leverage of the quadriceps muscles, allowing it to act over a greater angle. The insertion of patella tendon in the proximal tibia makes it biomechanically inefficient; therefore, large forces must be generated by the extensor mechanism for various activities. It is established in the trochlear shape of distal femur as it tracks through a range of motion. The lower portion of the patella comes in contact with the femur with knee in full extension. From the anastomotic ring, branches converge Development of Patella the patella develops as an "Anlage" in ninth embryonic week. Initially, it is placed deep to the quadriceps tendon and is not embedded in the tendon. Often there are more than one central ossicle, may be as many as six irregular centers. Ossification proceeds peripherally until all but the articular surface is replaced by bone. Before completion of ossification, the edges of the enlarging ossification nucleus appear irregular on radiograph. Thus, entire blood supply comes from anterior surface or distal pole with essentially no penetration of vessels from medial, proximal or lateral margins; hence, marginal fractures of the patella rarely unite (Scapinelli 1967). It should always be assumed that there are variable injuries to the extensor expansion, tear of the capsule of the knee, tear of the synovial lining of the capsule, and collection of intra-articular and subcutaneous hematoma. The patella breaks over the femoral condyle of the bent knee during forceful flexion of the quadriceps to avoid a sudden fall and results in a transverse fracture with some inferior pole comminution. The patella in children is more vulnerable to osteochondral fracture or avulsion of the medial margin associated with lateral patellar dislocation. This is difficult to diagnose because only small ossified portion is visible on X-ray and not the larger cartilage portion. There could be a sudden contraction of extensor mechanism either isolated or combined with direct blow. Predisposing factor to avulsion fracture could be pre-existing abnormalities in the extensor mechanism like scarring of quadriceps mechanism with stiffness. These fragmentations represented stress fractures caused by excessive tension in flexed-knee gait. An injection of more than 50 mL of saline into the swelling with leakage from the wound is diagnostic of an open injury. In late presentation, large hemarthrosis develops with fat globules contained in it. In closed injuries, intra-articular injection of local anesthetic after aspiration of hemarthrosis may facilitate active knee extension suggesting an intact extensor mechanism even in the presence of a fracture. Tear in both medial and lateral retinaculum will not allow active extension of knee in the presence of a fracture patella. Careful stress test for stability of knee should be a must so that the diagnosis of ligamentous injuries of the knee is not missed out. Hip examination should also be performed to rule out fracture or dislocation in this region.

Corticosteroid injections pain treatment for postherpetic neuralgia order artane without prescription, physiotherapy pain treatment center of tempe purchase cheapest artane and artane, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial pain treatment center pasadena drive lexington ky discount artane 2 mg free shipping. Cost effectiveness of interventions for lateral epicondylitis: results from a randomised controlled trial in primary care midsouth pain treatment center jobs order artane with mastercard. Arthroscopic versus open tennis elbow release: 3-6 year results of a case-control series of 305 elbows pain treatment center of the bluegrass ky purchase artane with a mastercard. Arthroscopic classification and treatment of lateral epicondylitis: Two-year clinical results treatment guidelines for diabetic neuropathic pain purchase artane 2mg amex. It is rare compared to compression at the wrist (carpal tunnel syndrome) or isolated injury of the anterior interosseous branch of the median nerve (anterior interosseous syndrome). The increase in repetitive motions associated with occupational and recreational environments usually is singled out as the primary cause of the problems of upper extremity nerve entrapment. It then runs between flexor digitorum superficialis and flexor digitorum profundus muscles and enters the hand through the carpal tunnel. Its sensory component supplies the skin of the palm, thumb, index and middle finger as well as half the ringfinger and the bones of the wrist. Compression of the proximal median nerve results in weakness of these three muscles, and can cause aching pain in the wrist on the basis of the sensory nerve to the carpal bones. Compression of the median nerve in the region of the elbow or proximal part of the forearm can cause pain and/ or numbness in the distribution of the distal median nerve, and weakness of the muscles innervated by the anterior interosseous nerve. Other causes are compression of the nerve from the fibrous arc of the flexor superficialis, or the thickening of the bicipital aponeurosis. Carpal tunnel syndrome is aggravated by wrist movements, and pain is not experienced as much in the forearm. In both cases, atrophy is possible in the thenar muscles of the hand, which are innervated by branches from the median nerve. Injection of corticosteroids into the pronator teres muscle may produce relief of symptoms. Massage therapy can also provide relief for individuals experiencing this condition. Prolonged wrist flexion during sleep aggravates carpal tunnel syndrome because it decreases the space in the carpal tunnel and presses on the median nerve. An evaluation procedure called the pronator teres test also is helpful in identifying the condition. If pain or discomfort to the patient is reproduced, there is a good chance of median nerve compression by the pronator teres. The patient should keep the elbow relaxed during the test, because holding the elbow firmly in flexion will not allow elbow extension. The median nerve passes in the distal upper arm between the brachialis and the medial intermuscular septum, with the brachial artery-sitting lateral to it. A rare supracondylar process may arise from the distal aspect of the humerus, giving origin to a fibrous band extending to the medial epicondyle. Miscellaneous lesion of the elbow At the elbow, the median nerve sits underneath the lacertus fibrosus and then typically passes between the superficial (humeral) head and the deep (ulnar) head of the pronator teres. In 20% of individuals, the deep head is absent or consists of a small fibrous band. Motor branches to the palmaris longus, flexor carpi radialis, flexor digitorum superficialis, and flexor digitorum profundus typically branch from the median nerve in an ulnar direction proximal to the pronator teres. The surgeon should be cognizant of the cutaneous nerves passing over the antecubital and proximal forearm region. Damage to these nerves can result in numbness and paresthesia, as well as symptomatic neuromas in the forearm. Compression of the median nerve in the proximal forearm is rare compared with carpal tunnel syndrome. Median nerve compression in the proximal forearm has been labelled as either pronator or anterior interosseous syndromes. The true incidence of median nerve compression in the proximal forearm is difficult to ascertain, as is the relative contribution of the various potential impinging structures. Numerous studies have shown that the most common causes of median nerve compression in the region of the elbow and proximal forearm seem to be fascial bands and muscular anomalies of the pronator teres and the fibrous arcade of the flexor digitorum superficialis. A large number of additional structures have been identified as potential sources of compression of the median nerve. Space-occupying lesions such as lipomas or scarring from trauma can result in nerve compression. Anterior interosseous syndrome caused by nerve compression must be differentiated from Parsonage-Turner syndrome, or mononeuritis. Anterior interosseous nerve syndrome is now regarded as neuritis (inflammation of the nerve), in most cases; this is similar to Parsonage-Turner syndrome. Although the exact etiology is unknown, there is evidence that it is caused by an immunemediated response. It passes distally in the anterior interosseous membrane and innervates the long flexor muscles of the thumb, index and middle finger. The pain is sometimes referred into the cubital fossa, and elbow pain has been reported as being a primary complaint. The test is thought to be consistent with compression of the median nerve at the fibrous arcade of the flexor digitorum superficialis. Resisted pronation test: Paresthesia in the median nerve distribution and pain are considered a positive test. A positive finding is consistent with compression of the median nerve by the pronator teres. A positive test is thought to be consistent with lacertus fibrosis compression of the median nerve. This results in impairment of the pincer movement and the patient will have difficulty picking up a small item, such as a coin from a flat surface. Examples include supracondylar fractures, often associated with hemorrhage into the deep musculature; injury secondary to open reduction of a forearm fracture; or dislocation of the elbow. Soft tissue massage, stretches and exercises to directly mobilize the nerve tissue may be used. Syndromes of compression of the median nerve in the proximal forearm (pronator teres syndrome; Anterior interosseous nerve syndrome). Kiloh-Nevin syndrome: A clinical case of compression of the anterior interosseous nerve. This incision sometimes is associated with unsightly scarring and injuries to the cutaneous nerves. Lesser incisions have been described, therefore; these include a lazy S-shape incision in the proximal volar forearm, as well as two longitudinal,3 oblique2 and transverse6 incisions. Limited incisions require significant retraction to ensure decompression both proximally and distally. Anterior interosseous nerve entrapment (KilohNevin syndrome): Report of seven cases. The anterior interosseous nerve syndrome (the KilohNevin syndrome): Report and follow-up study of three cases. Case study: Isolated anterior interosseous nerve paralysis: the Kiloh-Nevin syndrome. The functional attitude of the hand afflicted with an anterior interosseous nerve paralysis. Valgus extension overload is characterized by posteromedial olecranon osteophytes, chondromalacia of the medial wall of the olecranon fossa, tension on the medial ulnar collateral ligament and compression of the radiocapitellar joint; may be caused by repetitive hyperextension injury such as in gymnasts, football lineman, boxers1 and weightlifters. Valgus stress test is positive, which reveals valgus instability or medial and posteromedial pain indicating posteromedial elbow impingement. Diagnostic Tests: Xray Anteroposterior, lateral and oblique elbow X-rays are indicated to evaluate for olecranon fossa, olecranon tip osteophytes and loose bodies. Clinical Findings Posterior elbow pain is reproduced with forced elbow hyperextension. There is loss of full extension (flexion contracture) Miscellaneous lesion of the elbow Surgical Treatment 2033 Surgical treatment includes arthroscopic assessment and excision of osteophytes, if conservative treatment fails. Arthroscopic treatment of posterolateral elbow impingement from lateral synovial plicae in throwing athletes and golfers. It is a problem that typically develops over time rather than with one particular throw or event. A condition characterized by pathology in posteromedial elbow among sportsman, especially competitive players. This leads to chondrolysis, osteophyte formation (posteromedial humerus and olecranon), and loose bodies. Patient usually reports for pain in posteromedial elbow with full extension of elbow pain typically occurs during the active sports activities. There is tenderness over posteromedial olecranon along with crepitus and pain with forced elbow extension. Typically, they notice a sharp pain or even a snapping sensation as they release the ball. This pain typically increases overtime and only manifests with throwing and not with other activities of daily living. Often numbness and tingling, loss of velocity or control, and other symptoms can accompany this pain. Surgeon can reproduce this pain by quickly bringing the elbow into full extension with a valgus stress applied to the elbow. X-rays can often show a bone spur at the posteromedial tip of the olecranon but they can often be negative. Initially, treatment centers on rest or avoiding activities that recreate the pain. Ice, anti-inflammatory medications, and even physical therapy can be helpful for early symptoms of valgus extension overload. Unfortunately, athletes with bone spurs at the posteromedial tip of the olecranon often have recurrence of their symptoms when they go back to throwing. In these athletes, arthroscopically removing the bone spurs and even a small amount of the olecranon can decrease symptoms. If the ulnar collateral ligament is also injured, often ulnar collateral ligament reconstruction (Tommy John surgery) is needed. These injuries are present with early partial or complete tears and require acute or delayed repair. It is most often associated with anabolic steroid use, weight lifting and laceration. Other local and systemic risk factors include: Local steroid injection, olecranon bursitis, and hyperparathyroidism. Complete destruction of the entire extensor mechanism is uncommon because continuity laterally with anconeus is usually preserved for most patients. The triceps brachii is a pennate muscle with three heads: (1) Lateral, (2) Long, and (3) Medial. The triceps extends the entire length of the posterior humerus and is the only muscle located in the posterior compartment of the arm. The insertion of the medial aspect of the triceps expansion is located on the posterior crest of the ulna, adjacent to the medial head. Laterally, the triceps expansion has a wide insertion on the fascia of the extensor carpi ulnaris muscle and the deep fascia of the anconeus muscle. The distal portion of the medial head has been shown to have a distinct muscle belly and a tendon that is separate from and deep to the common triceps tendon. This distinct insertion may provide the rationale for a distinct medial (proximal) repair to achieve anatomic restoration of the medial insertion, along with primary repair of the lateral head insertion. The main function of the triceps is to extend the forearm at the ulnohumeral joint but also aid in arm adduction and extension because of its origin at the infraglenoid tuberosity. The most common mechanism of injury is a sudden contraction of triceps muscle, such as during weight lifting or from a fall onto an outstretched hand. Distal triceps rupture is usually caused by a fall on an outstretched hand or a direct blow. Eccentric loading of a contracting triceps has been implicated, particularly in professional athletes. Regardless of mechanism of injury, triceps tendon ruptures are usually seen at the osseous insertion. Initial diagnosis may be difficult because a palpable defect is not always present. Pain and swelling may limit the ability to evaluate strength and elbow range of motion. A palpable defect proximal to the olecranon can also be apparent and may confirm the clinical diagnosis. However, the converse is not always true, that is, not all complete tears result in the inability to actively extend against resistance. This finding is likely secondary to an intact lateral expansion or a compensating anconeus muscle. Anteroposterior and lateral radiographs of the involved elbow should be obtained at presentation. The lateral radiograph may show the presence of flecks of avulsed osseous material from the olecranon. It is also important to note the integrity of the lateral expansion (intact versus torn). Management of triceps tears is generally guided by tear location and by the functional extension strength of the extremity. The amount of extension strength is important because in triceps injuries, complete anatomic ruptures do not necessarily cause full loss of function. Incomplete tears with active elbow extension against resistance are managed nonsurgically.

Subluxation of the knee as a complication of femoral lengthening by the Wagner technique valley pain treatment center az order generic artane canada. This discovery in 1957 by Professor Ilizarov of Kurgan treatment pain genital herpes discount artane 2 mg on line, Russia has been increasingly used to treat a variety of clinical conditions such as leg length discrepancy chronic pelvic pain treatment guidelines purchase discount artane online, limb deformities visceral pain treatment buy discount artane 2 mg on line, nonunion and segmental bone loss pain management for dogs otc purchase artane 2mg amex. Although this method yields a high degree of success for bone regeneration sacroiliac pain treatment options purchase artane 2mg free shipping, complications are reported in the muscle, nerve, joints and cartilage. Soft tissue complications arise because of the inadequate accommodation of the soft tissues as compared to the change in length of the bone and rate of change in length. Normal growth at the distal femur occurs at 50 mm/day, while limb lengthening occurs at 1000 mm/day,2 20 times faster than natural growth. Current opinion on this topic is that temporary soft tissue dysfunction will be permanent unless treated by customized, intensive and aggressive rehabilitation. Thus, the role of physical therapy for limb lengthening procedures is to treat soft tissue complications and prevent permanent sequelae. Complications can occur within three specific times during limb lengthening procedures. Consolidation phase: this is when the external fixator is left in place long enough for the bone to harden. Causes of these complications are different and need different treatment strategies accordingly. Soft tissue complications that occur in limb lengthening include: (i) muscle contractures, (ii) muscle weakness (iii) joint stiffness (iv) weight bearing (v) joint subluxation, (vi) nerve injury, and (vii) refracture. Muscle Contractures Muscle contractures occur during the lengthening phase and are caused by inadequate accommodation of the series of elastic tissue and contractile elements to make a corresponding change in length. A relative shortening of two joint muscles to new bone length is often a cause of contracture since these muscles do not accommodate change in length. In addition, some muscles (for example, the gastrocnemius) develop passive tension more rapidly in response to a passive stretch. The primary treatment measures include physical therapy, static splints and dynamic splints. It is important to identify problematic muscles for a particular bone segment, which is being lengthened to treat contractures effectively. In tibial lengthenings, problematic muscles are the gastrocnemius and the toe flexors. The lack of stretching of these muscles causes knee flexion contractures, ankle plantar flexion contractures and toe flexion contractures. For femoral lengthenings, both the rectus femoris and long hamstrings muscles resist lengthening. This results in fixed flexion deformity of the knee and knee flexion range of motion deficit. If problems do arise, it is usually tightness of the biceps and brachioradialis muscles. In forearm lengthenings, finger flexors get tight causing a proximal and distal interphalangeal flexion and hyperextension of the metacarpophalangeal joints. Loss of motion due to tethering is more rapid postoperatively compared to the loss of the motion due to limb lengthening. Patients exhibit loss of motion in the immediate postoperative phase with painful spasm of the muscle. This is done by applying moist heat for 15 minutes prior to stretching, having the CompliCations of limb lengthening: Role of physiCal theRapy patient take pain medications 30 minutes prior to physical therapy, and always using antagonist activation before stretching the agonist muscle. Another technique that works well in some patients is the use of electrical stimulation of the tight muscle. Stimulation is performed at the maximal tolerated intensity to a point of fatigue, this is followed by stretching. In patients with inflamed pin sites near the fascial and muscle planes, massage around the pin site is especially effective before stretching. When stretching biarticular muscles, one must obtain maximum stretch in the opposite direction of the muscle action at both the proximal and distal joints. For example, in tibia lengthenings, the knee should be maximally extended and the ankle dorsiflexed, in femoral lengthenings, the knee should be extended and the hip abducted, in humeral lengthenings, the elbow should be extended, and in forearm lengthenings, the wrist and fingers should be extended. These optimal positions can be attained by a variety of overthecounter or custommade devices. Therapeutic passive stretching alone sometimes is not suffi cient to stretch a contracture because of the elastic response of connective tissue in which the tissue returns to its original length. Therefore, the principle of avoiding a contracture is to place muscle under tension for as many hours as possible. Dynamic splinting produces optimal plastic elongation of the connective tissue4 through biochemical response. Dynamic splints work most effectively in the treatment of knee flexion contracture. It is important when using dynamic splints that the muscles are only in optimal positions as described above and that tension on the splint be increased gradually. Intensity of the stimulation should be gradually increased to maximal toleration by the patient. Another effective way to avoid significant muscle weakness, especially in patients with bilateral external fixators or a unilateral femur plus tibial fixator, is hydrotherapy. Hydrotherapy promotes active range of motion, and the buoyancy helps patients offset the weight of the fixator and facilitates strengthening of the muscles. Patients with external fixators should be allowed to use chlorinated pools followed by rigorous pin care. Weight Bearing Patients are encouraged to ambulate bearing full weight as tolerated with two crutches during the lengthening phase. In some patients, an increase in weight bearing can cause undue stress on the pins or wires (especially around the ankle joint) which is associated with pain. A normal progression goes from two crutches to one crutch to no crutches during ambulation while encouraging closed kinetic chain exercises. It is customary to find that patients walk without an assistive device with no limp in the latter part of the consolidation phase. If there is delayed consolidation of the new bone, patients should be encouraged to continue or to increase weight bearing and to use closed chain exercises. Patients also need to be educated about the possible causes of delayed consolidation, such as smoking and tobacco chewing. Joint Subluxation the etiologies of joint subluxation are (i) lack of opposition, (ii) contracture, and (iii) ligamentous laxity. Knee subluxation in femur lengthening is usually posterolateral subluxation of the proximal tibia. It is important to recognize that some patients with knee subluxation have (i) cruciate deficient knee joints,6 (ii) hamstring muscle contracture and a tight iliotibial band, and (iii) flexed knee posturing. Treatment for a knee subluxation is vigorous knee extension with proper tracking of the proximal tibia and use of slings and manual mobilization techniques. Terminal knee extension strengthening exercises in conjunction with electrical muscle stimulation will augment the strength of the quadriceps muscles. Milder forms of subluxations can be treated by conservative regimens, while more severe forms may need surgery (fixation to the tibia in combination with posterolateral release). This occurs in patients with insufficient coverage of the acetabulum in the presence of an adductor contracture during proximal femur lengthening. Preventing hip subluxation includes stretching the adductor and using an abduction pillow. If hip subluxation occurs nonetheless, then it is treated by surgery for adductor release followed by tibial skin traction and intensive therapy. Joint Stiffness If not treated aggressively, muscle contracture can lead to capsular and intraarticular adhesions. In addition to this, contracture of two joint muscles introduces compressive forces on the articular cartilage5 that leads to a stiff joint. Not only is motion lost in a stiff joint, but the joint also loses its smoothness of movement within the available excursion space. Electrical stimulation of the muscle is the only effective way to bypass this neural inhibition, which occurs at the spinal level. Electrical stimulation should never be used as a passive modality, only as an adjunct to a strengthening program to augment voluntary contraction. Nerve injury occurs most commonly in tibial lengthenings and mainly involves the peroneal nerve. Referred pain in the dorsum of the foot is usually how this nerve injury manifests. Sometimes weakness in the extensor hallucis longus muscle, the extensor digitorum longus muscle, and the tibialis anterior muscle is observed. Referred pain in the dorsum of the foot is increased with knee extension and relieved by flexing the knee. In face of peroneal nerve irritation signs, it is best to stop use of dynamic splints and decrease knee extension exercises. However, in some cases that do not respond to slowing the rate, a peroneal nerve decompression surgery will allow continued lengthening without permanent nerve injury. Extreme caution should be used in the first 6 weeks of rehabilitation after removal of an external fixator. Treatment strategies that neutralize residual tension work best to prevent this complication. Closed kinetic chain exercises should always be used before open chain strengthening exercises. Use of an isokinetic machine in the passive mode to improve range of motion is strictly contraindicated. Manual mobilization with adequate stabilization of the lengthened bone is a safe and effective way to obtain motion. Successful functional outcome is dependent on the quality and amount of physical therapy the patient receives. They should attend physical therapy sessions, learn optimal positions for stretching, and should be willing to perform stretching exercises on the patient as shown by the therapist. A family working with health care professionals can make this process easier for the patient and help him or her to achieve a successful outcome. The decision to remove an external fixator is based on radiological findings, and not on mechanical testing. A bone can fracture either through the newly lengthened area or through a pin site. Chronic osteomyelitis is often associated with (1) angular or rotational deformity, the angle may be in any plane such as a procurvatum, recurvatum, varus, valgus or in the oblique plane; (2) deformities of the neighboring joints; (3) limb length discrepancy; (4) a deep cavity in the bone, and (5) a large sequestrum or dead removal of which creates a large gap. Thrombosis of the blood vessel surrounding the infected area reduces the blood supply. The infections tend to be polymicrobial in terms aerobic and anaerobic microorganisms. If recurrence occurs, it is not due to resistant organisms but due to "my inadequate debridement". Cierny-Mader Classification Cierny and Mader have developed a classification system wherein anatomical situation of the chronic osteomyelitis and physiological response of the host are taken into consideration. Another advantage of Ilizarov method is one can simultaneously correct all the associated deformities. It is known that implant per se does not cause infection but it perpetuates the infection because of the bacterial adhesion to the implant surface due to glycocalyx biofilm. The patient is evaluated and clinical staging as per Cierny-Mader classification is noted down. One can prepare the beads as the commercially available beads in the market are costly. Powdered antibiotic and cement are thoroughly mixed, and then stirred with the liquid monomer. The infected intramedullary canal contains of infected granulation tissue, small sequestrii and pus. Radical Resections the whitish color of the bone indicates dead bone, which must be removed. The treatment of chronic osteomyelitis should be similar to the treatment of giant cell tumor of bone. Careful surgical debridement remains to be the sheet anchor of the treatment (radical resection). This bold step can now be taken, because the large gap created can be filled by bone transport or bone graft and beads. Unless the entire dead bone is removed and oozing haversian systems are visualized, the surgery is not complete. Treatment of Cavity After thorough debridement and saucerization, a bone cavity created which must be filled.

Arterial injury requires prompt diagnosis and treatment to ensure preservation of the lower extremity treatment for pain due to shingles cheapest artane. Compartmental Syndrome Compartment syndrome of the thigh with femur fracture is extremely rare because of large volume of the thigh compartments pain treatment for pinched nerve buy artane toronto, which blend with those of the hip pain management treatment cheap artane online american express. Compartmental syndrome occurs because of an increase in volume or pressure or because a force decreases the capacity of the compartments flourtown pain evaluation treatment center artane 2 mg free shipping. If this is suspected pain treatment for psoriatic arthritis purchase artane 2mg, pressure should be measured and rechecked after fracture reduction pain stomach treatment order 2mg artane with amex. Pulmonary Complications Pulmonary complications include fat embolism, thromboembolic event and pneumonia. The further development of fat embolism 186 Chapter Fractures of the Distal Femur Narinder Kumar Magu Introduction Fractures involving the lower end of femur up to 9 cm from the articular surface are included in distal femoral fractures. They can be either supracondylar (metaphyseal) or intercondylar (articular) fractures. Limitation of motion, progressive degenerative arthritis, angular deformity, nonunion and infection are common complications after the treatment of these fractures. Dissatisfaction with frequent poor results has led to evolution of different methods of internal fixation instead of traction, casts or cast-braces. Wagner and Frigg 10 developed locking plate which has revolutionized the treatment of supracondylar fractures, especially in osteoporotic and periprosthetic fractures. Bony anatomy: the shaft of femur is nearly cylindrical, but at its lower end it broadens into two curved condyles. Anteriorly, the articular surfaces of two condyles join together to form a surface for patellar articulation with predominant articulation on the lateral condyle. The lateral condyle projects further forward than the medial stabilizing the patella. Posteriorly, they are separated by a deep intercondylar fossa that gives attachment to the cruciate ligaments of the knee. Deforming forces: the deformities that result from fractures of distal third femur are produced primarily by two forces: (1) initial trauma and (2) muscle imbalance. However, muscle pull exerts deforming forces continuously until union is strong enough to withstand this stress. Four large muscle groups play dominant roles: (1) quadriceps, (2) adductors, (3) hamstrings and (4) gastrocnemius. In intercondylar and supracondylar fractures, the gastrocnemius may produce joint incongruity History Supracondylar fractures of the femur in the past were treated most often with skeletal traction as the techniques of implants for open reduction and internal fixation were very limited. Mahorner and Bradburn7 (1933) reported that a large percentage of distal femoral fractures had poor results regardless of the method of treatment used. The quadriceps and hamstrings produce longitudinal tension which tends to produce over-riding and angulation of the fragments, driving the proximal fragment into the suprapatellar pouch and causing further displacement and hemorrhage. Valgus deformity, which is seen frequently, may be caused by the strong pull of the adductors on the proximal femoral fragment. When instituting measures to correct deformity and to prevent its recurrence, one must consider these dynamic deforming forces. In T and Y condylar fractures, the proximal fragment may be driven into the distal fragment, wedging the condyles apart. Neurovascular bundle: Vascular and neurological damage is rare, but the possibility must always be considered because of the proximity of the popliteal vessels and the nerves. The popliteal artery extends from the opening in the adductor magnus, at the junction of the middle and lower thirds of the thigh, downward and lateral to the intercondylar fossa of the femur, and then vertically downward to the lower border of the popliteus, where it divides into anterior and posterior tibial arteries. As the sciatic nerve descends toward the knee, the two components eventually diverge in the popliteal fossa, giving rise to tibial and common peroneal nerves. This division of the sciatic nerve occurs usually between 50 and 120 mm proximal to the popliteal fossa crease. This combination of distal femoral fracture with a proximal tibial fracture is diagnosed in approximately 5% of all patients with distal femoral fracture. Low energy trauma: In elderly patients a minor slip and fall on a flexed knee may be sufficient to produce a fracture of the distal femur. After fracture, deformities are usually those of femoral shortening, posterior angulation and the posterior displacement of the distal fragment. In elderly patients, extreme osteoporosis represents a particular problem for anchoring the implant. High energy trauma: In young patients who sustain a severe direct trauma to the knee like road traffic accidents, results in comminuted metaphyseal and displaced intra-articular fracture. The fracture pattern is dependent solely upon the amount and direction of application of the applied load. It is the direction and force of the applied load and not the muscle pull that consistently deforms the fracture and that has to be overcome to achieve appropriate reduction. In high-energy trauma, the problem of restoring the function in a destroyed knee joint persists. Complex knee ligament injuries frequently occur additionally to extensive cartilage injuries. A well-known pathomechanism in road-traffic accidents is the so-called "dashboard injury" whereby an impact on the, flexed knee joint forces the patella back in between the femoral condyles like a wedge. This explains the combined injuries of patellar fractures and intra-articular distal femoral fractures. Clinical Features Patients present with pain, swelling, deformity and inability to weight bear. In younger patients with significant soft tissue injury, careful assessment of the whole limb is required to rule out associated injuries. The treating surgeon must also address the condition of the soft tissue envelope, associated vascular injury and impending signs of compartment syndrome. Gentle stress testing of the knee is performed with knee in extension in order to evaluate the integrity of the ligaments. Preoperative Assessment and Planning Unlike many tibial plateau or pilon fractures, the majority of distal femoral fractures can be treated definitively with early operative fixation. In certain circumstances (open fractures with significant contamination, severe soft-tissue swelling, significant patient comorbidities, unavailability of the proper implants and/or surgical personnel). The lateral radiograph is carefully examined to look for the presence of a Hoffa frontal plane fracture. Etiology Distal femoral fractures mainly arise from two different injury mechanisms and both groups differ with respect to inherent problems and complications encountered. In this classification the fracture types and groups are arranged in an ascending order of severity has a bearing on the treatment and on the outcome. Therefore, once the fracture has been classified it becomes much easier to evolve the correct rationale for its treatment. Radiographs of the pelvis, the ipsilateral hip, femoral shaft and proximal tibia should also be obtained to rule out the presence of associated injuries. Traction films: Traction radiographs are helpful in aiding visualization of the articular surface and in assessing potential "closed" reduction of the metaphyseal-diaphyseal components of the fracture. Tunnel view: Tunnel view of the intercondylar notch is helpful in judging the displacement of vertical fractures into the joint and displays the profile of the intercondylar notch. Type A Metaphyseal component of the fracture may be either a simple fracture or a multifragmentary fracture. If multifragmentary, the fracture can be either a wedge fracture where after reduction there is contact between the main fragments, or it can be a complex fracture where the contact between the main fragments is completely lost. Computed Tomography In case of complex multiplane fractures, axial computerized tomography, with frontal and sagittal plane reconstructions may be helpful in planning the surgical stabilization. It is helpful to "map out" the articular involvement in multiplane fractures and to verify the presence or absence of intercondylar notch fragments. Type B Partial articular fractures reflect the condyle which has lost the continuity with the metaphysis and the shaft of the femur. These unicondylar fractures involve articular surface of only one condyle and do not cross the midline. Type C Complete articular fractures must reflect the severity of the articular injury and the injury to the metaphysic. Thus, the complete articular simple fractures may have either a simple metaphyseal fracture or one that is multifragmentary. The multifragmentary nature of the articular fracture is the distinguishing feature of this fracture because it is the severity of the articular fracture that will determine the prognosis rather than its metaphyseal component. A bone bruise is indicated by epiphyseal and metaphyseal changes in T1 and T2 weighted images. Treatment the factors that determine the treatment and outcome of distal femoral fractures includes the amount of fracture displacement, instability, comminution, injury to surrounding soft tissues, neurovascular involvement, bone quality, an intra-articular component, ipsilateral injuries, multiple injuries, elderly patient and involvement of other organ systems. All high energy fractures need to be immediately checked for soft tissue integrity and impending compartment syndrome. Antiedema measures: Joint aspiration, rest, immobilization, compression, elevation are advocated in patients with high energy fracture surrounded by evidence of compromised soft eight tissues such as the skin blisters, edema, etc. Limbs with features suggestive of compartment syndrome should not be treated with antiedema measures. Traction: Traction can be used as a temporary or rarely definitive management modality. The calcaneal traction can be continued during the traction mobilization treatment of selected plateau fractures without gross articular incongruity. Angiography/Doppler the Ankle-Brachial Index or Ankle-Ankle Index is helpful as a screening tool for possible arterial injury. Arteriography is indicated when there is an associated knee dislocation, severe displacement of the fracture fragments, expanding hematoma at the fracture site and in the absence of distal pulses. Significant displacement of the fracture may potentially cause a venous intimal injury. Although an association with deep venous thrombosis is not described in the literature, surveillance for it is warranted. Classification A good classification system of femoral fractures should identify the site of involvement, good interobserver reliability, and assist in deciding the optimal treatment. Many different systems of classifications have been used for fractures of the distal part of the femur including those of Stewart et al. Debridement of open injuries: Open fractures need to be addressed based on the universal guidelines. Patients optimally should undergo surgical debridement of open traumatic wounds within 6 hours of injury. Aggressive debridement of open fracture wounds including removal of contaminating debris as well as any devitalized fascia, muscle and bone is performed. Fasciotomy for impending compartment syndrome: this requires an emergency treatment as duration is synonymous with damage. If signs of compartmental syndrome are present, four compartment fasciotomies are performed. Spanning external fixator: Closed fractures are taken for external fixator placement based on patient stability and operating room availability, unless there are signs of compartmental syndrome. Patients undergoing debridement for open fractures and fasciotomy for compartment syndrome can be on temporary external fixator till the soft tissue condition improves. In stable, undisplaced fractures, immediate mobilization of the patient in a hinged knee brace, with restricted weight bearing, can be undertaken. A traction pin is placed in the proximal tibia, and the limb is supported on a Thomas splint with a Pearson knee attachment or on a Bohler Braun frame. Nonoperative treatment is associated with complications of nonunion, malunion, joint incongruity of these fractures are treated surgically. Treatment Options in the Management of Distal Femoral Fractures Nonoperative treatment 1. Surgical Principles the principles of operative management of distal femoral fractures are anatomic reduction of the articular component and indirect reduction or biological fixation of the reconstructed articular component to the metaphysis. An anatomic reduction of the articular component of the fracture continues to be the first step in the reconstruction of any articular fracture. Three important advances in the management of distal fracture of the femur in terms of surgical technique are: 1. Minimally invasive approaches caused less iatrogenic damage to the blood supply and led to increased restitution with very good results. Locking compression plates: these internal fixators have revolutionized the treatment of distal femur fractures. These when indicated are the treatment of choice, especially in severely comminuted and osteoporotic fractures. Nonoperative Treatment the objective of closed management is not absolute anatomic reduction of all fracture fragments, but the basic restoration of the knee joint axis to a normal relationship with the axis of the hip and ankle. Closed fracture management using a cast brace technique depends on early fracture reduction before deformities develop, as well as the use of knee motion, which will assist in the Surgical Approaches the "rediscovered" relevance of iatrogenic soft-tissue trauma and the influence of blood supply to the fragments led to new concepts in terms of surgical techniques: 1. The entire articular surface can be visualized and joint surface is reconstructed manually. The lag screws may be used through the required surface and countersunk or headless screws may be used. Lateral Approach: A fracture table (and traction) should not be used, because the resulting muscle tension will make exposure and reduction more difficult.

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