Fibula Bone Fracture

Cure Arthritis Naturally

Beat Arthritis Naturally

Get Instant Access

Postoperative Care

The experiments of Salter et al. (1980) and Mitchell and Shepard (1980) have underlined the importance of early motion. Our clinical experience, as well as that of many other investigators, bears this out. After their reconstruction, most major intra-articular injuries are placed on a continuous passive motion machine; passive mobilization is started in the recovery room and is continued for 5-7 days. In late joint reconstructions this may be continued for up to 3 or 4 weeks. Although the general enthusiasm for continuous passive motion (CPM) has waned, we still feel that it is a most worthy adjunct in the management of serious major intra-articular injuries.

It must be remembered that mobilization and its benefits need to be in balance with the degree of stability obtained at the time of surgery. At times, the degree of stability of the internal fixation is insufficient to permit unprotected mobilization. In these instances we have combined internal fixation with fracture bracing. The fracture brace can be applied on the first day or two without jeopardizing the internal fixation or wound care. Similarly, it must be remembered that in at least 25%-30% of cases, major intra-articular fractures, particularly around the knee, are associated with major liga-mentous disruptions, which must be repaired at the time of the initial surgery. The usual practice is to protect any ligamentous repair in plaster. As we have

Late intra-articular deformities arise (a) as a result of failed nonoperative treatment, (b) because of incomplete surgical reduction of the fracture, or (c) because of loss of position due to unstable fixation. Such articular deformities have usually been considered as permanent and not amenable to any surgical reconstruction. We have subjected many such intra-articular deformities to late intra-articular reconstruction, at varying intervals from the time of injury (Figs. 2.7-2.10). This has often required intra-articular osteotomies with meticulous excision of the fibrocartilage from the joint and of the callus from the metaphysis, in order to redefine the original fragments and permit an anatomical reconstruction. We have also treated a number of intra-articular nonunions. The principle followed with these, as with the malunions, has been meticulous reconstruction of the joint, stable fixation of the joint and of the metaphyseal component with bone grafting where necessary, arthroly-sis and soft tissue mobilization periarticularly to regain a satisfactory range of motion, and then mobilization of the joint on a continuous passive motion machine. Although we have never managed to achieve a return to a perfectly normal degree of joint function, we have been impressed with the successes attained and feel that unless there is evidence of serious post-traumatic arthritis, a late joint reconstruction should be undertaken if it is at all technically feasible. This is preferable to joint arthroplasty or arthrodesis.

Failed Sclerotic Pilon Fracture

Fig. 2.7. a An intra-articular pilon fracture at 6 weeks after surgery. A number of surgical principles have been violated. The fibula was not reduced, the metaphysis was not bone-grafted, and the lesion was not properly buttressed. b Note the excellent correction of the deformity achieved by reduction of the fibula, by bone grafting of the metaphyseal defect created once the valgus was corrected, and by proper buttressing of the metaphysis b

Fig. 2.7. a An intra-articular pilon fracture at 6 weeks after surgery. A number of surgical principles have been violated. The fibula was not reduced, the metaphysis was not bone-grafted, and the lesion was not properly buttressed. b Note the excellent correction of the deformity achieved by reduction of the fibula, by bone grafting of the metaphyseal defect created once the valgus was corrected, and by proper buttressing of the metaphysis a

Fig. 2.8. a Serious malreduction of a difficult tibial plateau fracture. b Stability was restored by an intra-articular wedge excision of the depressed area. This allowed us to narrow the lateral plateau and reduce the remaining intact portion, which carried the meniscus under the lateral femoral condyle

Fig. 2.8. a Serious malreduction of a difficult tibial plateau fracture. b Stability was restored by an intra-articular wedge excision of the depressed area. This allowed us to narrow the lateral plateau and reduce the remaining intact portion, which carried the meniscus under the lateral femoral condyle

Fig. 2.9. a,b Malunion of the lateral femoral condyle and fracture of the cancellous screw. Note the double contour of the lateral femoral condyle, best seen in b. This malunion distorted the intercondylar groove and markedly restricted knee motion. c An intra-articular osteotomy was carried out. The excessive fibrocarti-lage and all callus were carefully excised, recreating the original fracture fragment. This allowed an anatomical reduction of the joint. Note the unorthodox position of a buttress plate on the posterolateral aspects of the distal femoral metaphysis. Anatomical reduction and stable fixation led to an excellent recovery of the joint

Fig. 2.9. a,b Malunion of the lateral femoral condyle and fracture of the cancellous screw. Note the double contour of the lateral femoral condyle, best seen in b. This malunion distorted the intercondylar groove and markedly restricted knee motion. c An intra-articular osteotomy was carried out. The excessive fibrocarti-lage and all callus were carefully excised, recreating the original fracture fragment. This allowed an anatomical reduction of the joint. Note the unorthodox position of a buttress plate on the posterolateral aspects of the distal femoral metaphysis. Anatomical reduction and stable fixation led to an excellent recovery of the joint c a c

Fig. 2.10. a A 2-year-old nonunion of the lateral femoral condyle in an 18-year-old boy. c Note the excellent correction of the valgus deformity at 3 years after surgery, with union and an excellent preservation of joint function, despite the intra-articular step clearly evident in b soon after corrective surgery

Fig. 2.10. a A 2-year-old nonunion of the lateral femoral condyle in an 18-year-old boy. c Note the excellent correction of the valgus deformity at 3 years after surgery, with union and an excellent preservation of joint function, despite the intra-articular step clearly evident in b soon after corrective surgery a b c ences

Charnley J (1961) The closed treatment of common fractures.

Livingstone, Edinburgh Dickson KF, Galland MW, Barrack RL, Neitzschman HR, Harris MB, Myers L, Vrahas MS (2002) Magnetic resonance imaging of the knee after ipsilateral femur fractures. JOT 16(8):567-571

Keppler P, Meining R, Suger G, Kinzl L (1994) Long-term results of the operative reconstruction of the bicondylar tibial plateau fractures. Annual Orthopaedic Trauma Meeting, Los Angeles, CA Llinas A, McKellop HA, Marshall GJ, Sharpe F, Bin Lu MS, Kirchen M, Sarmiento A (1993) Healing and remodelling of articular incongruities in a rabbit fracture model. J Bone Joint Surg 75A:1508-1523 Llinas A, Lovasz G, Park SH (1994) Effect of joint incongruity on the opposing articular cartilage. Annual AAOS meeting

Manley P, Schatzker J (1982) Replacement of epiphyseal bone with methylmethacrylate. Its effects on articular cartilage. Arch Orthop Traum Surg 100:3-10 Marsh JL, Smith ST, Do TT (1994) Outcome of severe tibial plateau fractures. Annual Orthopaedic Trauma Association meeting, Los Angeles, CA Mitchell N, Shepard N (1980) Healing of articular cartilage in intra-articular fractures in rabbits. J Bone Joint Surg 62A:628-634

Mize RD, Bucholz RW, Grogan DP (1982) Surgical treatment of displaced comminuted fractures of the distal end of the femur. J Bone Joint Surg 64A:871-879 Müller ME, Allgöwer M, Schneider K, Willenegger H (1979) Manual of internal fixation, 2nd edn. Springer, Berlin Heidelberg New York Neer C, Graham SA, Shelton ML (1967) Supracondylar fracture of the adult femur. J Bone Joint Surg 49A:591-613

Olerud S (1972) Operative treatment of supracondylar-condy-lar fractures of the femur. Technique and results in fifteen cases. J Bone Joint Surg 54A:1015-1032 Pauwels F (1961) Neue Richtlinien für die operative Behandlung der Coxarthrose. Verh Dtsch Orthop Ges 48:332366

Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael D (1980) The biological effects of continuous passive motion on the healing of full thickness defects in articular cartilage: an experimental investigation in the rabbit. J Bone Joint Surg 62A:1232-1251 Salter RB, Hamilton HW, Wedge JH, Tile M, Torode IP, O'Driscoll SW, Murnaghan J, Saringer JH (1986) Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: a preliminary report of a feasibility study. Techniques Ortho-paed I(I):74-91 Schatzker J, Lampert DC (1979) Supracondylar fractures of the femur. Clin Orthop 138:77-83 Schatzker J, Horne G, Waddell J (1974) The Toronto experience with the supracondylar fractures of the femur 1966-1972. Injury 6:113-128 Schatzker J, McBroom R, Bruce D (1979) The tibial plateau fracture: the Toronto experience. Clin Orthop 138:94104

Stamer DT, Schenk R, Staggers B, Aurori K, Aurori B, Behrens F (1994) Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study. Annual Orthopaedic Trauma Association meeting. Los Angeles, CA

Stewart M, Sisk D, Wallace SL (1966) Fractures of the distal third of the femur. J Bone Joint Surg 48A:784-807 Vellet AD, Marks P, Fowler PJ, Munro TG (1991) Post-traumatic osteochondral lesions of the knee. Prevalence classification and short term sequela. Evaluation with MRI imaging. Radiology 178:271 Wenzl H, Casey PA, Hébert P, Belin J (1970) Die operative Behandlung der distalen Femurfraktur. AO Bulletin, Bern

Refer

Was this article helpful?

0 0
Osteoarthritis

Osteoarthritis

Thank you for deciding to learn more about the disorder, Osteoarthritis. Inside these pages, you will learn what it is, who is most at risk for developing it, what causes it, and some treatment plans to help those that do have it feel better. While there is no definitive “cure” for Osteoarthritis, there are ways in which individuals can improve their quality of life and change the discomfort level to one that can be tolerated on a daily basis.

Get My Free Ebook


Post a comment