Fracture of the internal epicondyle of the tibia. Terms of treatment of a fracture of the condyle of the knee joint


Fractures of the proximal tibia include fractures located above the tibial tuberosity. They should be divided into extra-articular and intra-articular. Intra-articular fractures include damage to the condyles, while extra-articular fractures include fractures of the intercondylar eminence, tubercles, and subcondylar fractures. Epiphyseal fractures of the tibia are considered intra-articular. Fractures of the proximal fibula are not of particular importance, since the fibula does not carry a weight load.

Internal and external condyles of the tibia form a platform that transmits body weight from the condyles of the thigh to the diaphysis of the tibia. Condylar fractures are usually associated with some degree of crushing of the bone due to axial transfer of body weight. In addition, crushing of the condyle leads to valgus or varus deformity of the knee joint. As shown in the figure, the condylar eminence is made up of tubercles to which the cruciate ligaments and menisci are attached.

Fundamentals of the anatomy of the knee joint

Based on anatomical features fractures of the proximal tibia can be divided into five categories:
Grade A: condylar fractures
Class B: tubercles fractures
Class B: fractures of the tibial tuberosity
Class D: subcondylar fractures
Class D: fractures of the epiphysiolysis, fractures of the proximal fibula

Grade A: tibial condyle fractures

Meet often. They have been classified by Hohl based on anatomical findings and treatment principles. Considering fractures of the condyles of the tibia, it should be noted that under the fracture of the condyle they mean a downward displacement of more than 4 mm. Serious deformity of the knee joint can occur after seemingly minor fractures of the proximal tibia in children. Its reason remains unclear. It appears in children under 4 years of age and manifests itself as valgus deformity of the knee joint 6-15 months after the injury.

It seems that the development of this deformations occurs primarily due to the curvature of the tibial shaft below the fracture site. Therefore, the emergency physician should not treat proximal tibial fractures in children, no matter how simple they may seem at first glance.

Hidden tibial condyle fractures possible in the elderly. Primary radiographs appear normal; nevertheless patients continue to complain of pains, especially in the field of an internal condyle. These fractures are fatigue fractures and should be scanned if suspected.


Forces normally acting on the joint playground tibia, include compression along the axis with simultaneous rotation. Fractures occur when one of the forces exceeds the strength of the bone. Fractures resulting from a direct mechanism, such as falls from a height, account for about 20% of condylar fractures. Road traffic accidents, where the bumper of a car strikes the proximal tibia, are responsible for approximately 50% of these fractures. The remaining fractures are caused by a combination of axial compression and simultaneous rotational stress.

Fractures of the outer tibial platforms usually occur with forcible abduction of the leg. Fractures of the medial platform are usually the result of strong adduction of the distal tibia. If the knee is extended at the time of injury, an anterior fracture is more likely to occur. Most late condylar fractures occur with trauma when the knee joint was bent at the time of impact.

As a rule, the patient complains for pain and swelling, with his knee slightly bent. On examination, there is often an abrasion indicating the site of impact, as well as effusion and decreased range of motion due to pain. Valgus or varus deformity usually indicates a broken condyle. After plain radiographs are taken, stress radiographs may be required to diagnose occult ligament or meniscus injuries.

For identifying these fractures usually enough pictures in the lateral and oblique projections. In addition, a snapshot of the articular site can be very informative for assessing the degree of depression. Anatomically, the articular platform has a bevel back and down. On routine radiographs, this bevel will not be visible, masking some depressed fractures. The projection of the articular site compensates for this bevel and will more accurately identify depressed fractures of the articular site. When determining the extent of the fracture, oblique radiographs are always useful.

All radiographs The knee joint should be carefully examined for avulsion fragments of the head of the fibula, femoral condyles, and intercondylar eminence, indicating damage to the ligamentous apparatus. Joint space expansion combined with a fracture of the opposite condyle suggests ligament injury. CT scans may be needed to detect hidden compression fractures.

Projection of the articular area of ​​the tibia

Fractures of the condyles of the tibia often combined with a number of serious injuries of the knee joint.
1. These fractures are often accompanied by damage to the ligaments and menisci, both individually and in combination. A fracture of the lateral condyle should be suspected of injury to the collateral ligament, anterior cruciate ligament, and lateral meniscus.
2. After these fractures, either acute or later vascular damage can be observed.

Treatment of fractures of the tibial condyles

The four most common fracture treatment in the area of ​​the knee joint include the imposition of a pressure bandage, closed reposition with the imposition of a plaster cast, skeletal traction and open reposition with internal fixation. Regardless of the method, the goals of treatment are:
1) restoration of a normal articular surface;
2) early onset of movement in the knee joint to prevent contracture; 3) abstinence from the load on the joint until complete healing.

Choice of treatment method depends on the type of fracture, the experience and skill of the orthopedic surgeon, the age of the patient and his discipline. Urgent consultation with an orthopedic surgeon is highly recommended.

Class A: I type (no offset). In an adherent outpatient without associated ligament injuries, a non-displaced condyle fracture can be treated with aspiration of the hemarthrosis followed by the application of a pressure dressing. An ice pack is applied to the limb and an elevated position is given to it for at least 48 hours. If after 48 hours the radiographs remain unchanged, movements in the knee joint and exercises for the quadriceps femoris can begin. Until complete recovery, the leg should not be fully loaded. You can use a partial load with walking on crutches or a plaster splint.

Staying in a plaster cast for more than 4-8 weeks from the moment of injury is not recommended for a disciplined patient due to the high incidence of contractures of the knee joint. If the patient is an outpatient and does not have ligament injuries, but at the same time is undisciplined, immobilization with a plaster cast is recommended. Active isometric exercises for training the quadriceps femoris should be started early, and the cast should be left until complete healing. Hospitalized patients without ligament injuries are usually treated with skeletal traction combined with early movement exercises.

Class A: Type II (local compression). The urgent treatment of these fractures depends on the following points: 1) an avulsion fracture of the condyle with its downward displacement of more than 8 mm requires surgical correction (raising the fragment): 2) the localization of the depression in the anterior or middle sections is more dangerous than in the posterior; 3) the presence of concomitant ligament injuries.

When diagnosing these fractures a picture with the removal of the projection of the articular area and carrying out stress tests are needed to determine the integrity of the ligaments of the knee joint. If the ligaments are damaged, prompt repair is indicated. Conservative treatment of a fracture without displacement and damage to the ligaments includes: 1) aspiration of blood in case of hemarthrosis; 2) the imposition of a pressure bandage or back splint for a period of several days to 3 weeks with complete unloading of the limb; 3) early consultation with an orthopedist.
If sick hospitalized, Buck skeletal traction with active motor exercises is recommended.

Class A: III type (compression, with detachment of the condyle). Emergency management of these fractures includes ice, posterior splint immobilization, and accurate x-ray diagnosis with prompt referral. Treatment varies from plaster immobilization with unloading of the limb to operative reposition or skeletal traction.

Class A: Type IV (complete detachment of the condyle). Emergency treatment for these fractures includes ice, immobilization, and accurate x-ray diagnosis with urgent referral to an orthopedist. Detachment of 8 mm or more is considered significant displacement and is best treated by open or closed reduction.

Class A: V type (split). These fractures usually involve the internal condyle and may be anterior or posterior. The recommended method of treatment is open reposition with internal fixation.

Chronic fractures, disorders with severe compression or secondary subsidence of the condyle require the use of osteoplastic surgery according to the Sitenko method. The joint is opened, small bone fragments are removed, and then one condyle is aligned in height with the other by inserting a piece of one's own or a donor bone. Fastening is carried out by screws and plates. The wound is sutured, a drain is inserted into it, which is removed after 4 days, provided there are no complications.

Rehabilitation

The duration of rehabilitation depends on the severity of the fracture, the speed of reparative processes, the presence of torn ligaments, compression of nerves and blood vessels. In each case, only a specialist can determine the duration of recovery.

Light load even with a slight fracture to the leg is allowed only 3-4 weeks after the injury using crutches. Only in this case the possibility of subsidence of the damaged condyle is excluded.

The patient will be able to lead a normal life only six months after the start of treatment. And in severe types of pathology, this period is extended to one year. To restore the mobility of the knee and strengthen the muscles around it, physiotherapy exercises and physiotherapy methods are used.

It is recommended to take vitamin complexes and preparations containing calcium during rehabilitation. At this time, it is better to give up bad habits and reduce calorie intake to reduce excess body weight.

Possible Complications

After a fracture, the following complications may occur:

  • inflammation of the tissues of the joint with degeneration;
  • development of osteoporosis;
  • severe deformity of the knee;
  • loss of mobility and development of contracture (with prolonged use of a plaster cast);
  • infection with an open fracture with soft tissue damage or after surgery.

Important! These types of complications can be easily avoided with timely and competent treatment. Therefore, you should not delay in contacting a doctor, even if the injury seems minor.

Conclusion

A fracture of the tibial condyle is a complex pathology that requires immediate conservative therapy, and, if necessary, surgical intervention. Otherwise, arthrosis of the knee joint with deformity may develop, and the person will become disabled.

In contact with

There are fractures of the condyles of the tibia due to a fall from a height on straight legs. In this case, the victim develops severe pain and limited mobility in the knee. After some time, deformation of the limb is observed and significant edema appears. Treatment and rehabilitation of the patient consists in immobilization and elimination of pain and inflammatory syndrome. If necessary, surgical intervention with reposition of the fragments is performed.

How to recognize?

The condyle is a thickening at the end of the lower leg facing the femur. There are 2 of them - external and internal. It is to them on the tibia that the most massive muscles and ligaments are attached, so a fracture of even one of them is very traumatic, and disrupts the functioning of the entire limb. Most often, this type of injury occurs when falling from a height on straight legs, and this provokes a compression fracture. The frequency of this injury is due to the significant fragility of this part of the bone due to the fact that it has a subchondral coating.

The knee swells and hurts, possibly intra-articular hemorrhage.

The resulting transcondylar fracture causes the development of the following symptoms in the victim:

  • significant pain at the site of injury;
  • the appearance of a bruise or hematoma;
  • inability to perform joint movements;
  • swelling in the knee;
  • the presence of pathological lateral mobility in the joint.

It is possible to distinguish a fracture of one of the condyles only by the nature of the deformation. When the lower leg moves outward, a fracture of the lateral condyle of the tibia occurs, and if inward, then the medial condyle is broken. Displaced trauma causes a crackling sound on palpation of the damaged area, and when crepitus is not detected, this more often indicates an injury without displacement.

More often there is a fracture of the lateral condyle of the tibia.

First aid


The injured limb is immobilized and a cold compress is applied.

Immediately after injury, the patient must be immobilized limb. For this purpose, tires or means at hand are used. This type of assistance will help prevent significant displacement of bone fragments, and damage to nearby vessels and nerves. In addition, it is important to anesthetize the injured limb. To do this, the patient is given a novocaine blockade along the nerve trunks or intramuscularly administered analgesics. Local application of cold is indicated. This will help to avoid traumatic shock and a sharp drop in blood pressure. If the main vascular plexus is damaged, bleeding is stopped with a tourniquet. A sheet must be attached to it indicating the time of clamping the vessel, since its prolonged use can lead to irreversible ischemia of the limb.

Diagnosis of a fracture of the condyle of the tibia

A traumatologist can suspect impression damage to the tibia by the presence of characteristic signs of deformity and the lack of mobility of the limb. To confirm the diagnosis, an x-ray examination of the leg is performed in frontal and lateral projections. The patient also needs to pass a general blood and urine test. When difficulties arise in the diagnosis of injury, magnetic resonance and computed tomography are used. When a pathological fracture occurs, it is important to conduct a blood test for calcium and vitamin D content, as well as a diagnosis to determine bone density.

Treatment and rehabilitation


An injured joint requires prolonged immobilization and complex treatment.

Fractures of the condyles of the tibia require complex and long-term therapy. In case of minor injuries without displacement of the fragments, permanent anesthesia and immobilization of the leg with a plaster cast are performed. Comparison of bone parts in this case is not carried out. When a bone fracture has occurred in the region of the condyles, where cartilage is contained and fragmentation or displacement of fragments is observed, the patient is shown to undergo surgery with reposition of the fragments.

Previously, the patient is given skeletal traction, which helps to relax the muscles and make it easier to match the bone. Its duration is no more than a week. The operation is performed under general anesthesia. During this period, the damaged area is revised with suturing of the injured vessels and the musculoskeletal apparatus, as well as the removal of small fragments and the strengthening of the main fragments with the help of an osteosynthesis plate or pins.

After surgery, the patient requires antibiotic therapy to eliminate the risk of bacterial infection.

It also shows long-term analgesic and anti-inflammatory therapy. Vitamins and chondroprotectors are prescribed, which restore damaged cartilage. When the pain syndrome passes, and signs of bone fusion are visible on the control radiography, the victim is shown restorative therapy. It consists in physiotherapy, massage and physiotherapy exercises. They will help restore lost limb functions by restoring the strength of the musculo-ligamentous corset of the leg.


Articular cartilage damage(osteochondral injuries) of the knee joint are a common pathology in children, contributing to the development of post-traumatic degenerative-dystrophic conditions, and account for up to 30% of all injuries of the knee joint, and in the long-term period after injury, the percentage of cartilage lesions, combined with other intra-articular pathology or existing in isolation, reaches more than 60%. Predisposing factors for the development of osteochondral injuries (OCI) can be intense sports, chronic instability or habitual dislocations of the patella against the background of insufficiency of medial stabilizing patellofemoral joint structures, etc.

It should be noted that due to the lack or low availability of reliable methods for diagnosing the pathology of the knee joint, many cases of intra-articular osteochondral injuries in children and adolescents are diagnosed and treated as damage to the meniscus or capsular-ligamentous apparatus, especially at the outpatient level.

Diagnostics OCP of the knee joint, like any other pathology, should begin with clarifying the patient's complaints. The most common complaint with such injuries is acute, sharp pain in the knee joint immediately after the injury. In addition, pain in case of damage to the articular cartilage may have a specific characteristic depending on the localization of the defect, i.e., it may increase with certain movements or flexion to a certain angle, and be absent during other diagnostic manipulations. It is also possible to block the knee joint with limited extension, severe pain during passive movements and load of the limb as a result of the separation of a free cartilage fragment into the joint cavity, which is infringed between the structures of the joint.

After collecting an anamnesis, you should proceed to examine the area of ​​​​the joint and the entire limb. Examination is carried out in comparison with a healthy leg. Pay attention to the shape of the joint: due to the frequent development of hemarthrosis or effusion, the contours of the joint are smoothed out, its circumference increases. Non-stressful hemarthrosis is characteristic of OHP, however, in some cases, with significant trauma, the size and depth of the osteochondral defect, as well as damage to the synovial membrane of the joint, stressful hemarthrosis may also develop. When analyzing the punctate of the knee joint, the presence of adipose tissue in the suspension is also possible.

Following the examination of the joint, active and passive movements in it are examined. In the presence of hemarthrosis, all types of movements are limited. Palpation of the patella or condyles is sharply painful, and if a fracture develops against the background of dislocation of the patella, instability and pain are noted during lateral mobilization of the latter. Palpation of the joint ends with a study of the presence of crepitus during movement: a slight crunch during friction of the torn cartilage may be indistinguishable by palpation, however, the patient, as a rule, notes a subjective sensation of “rubbing in the joint”. A characteristic sign of intraarticular damage to the cartilage of the knee joint in the area of ​​the patellofemoral joint is a positive symptom of friction of the patella, which consists in the appearance of a sharp pain in the focus of the cartilaginous defect during passive movements of the patella inward and outward with the knee joint extended.

Instrumental studies have different diagnostic significance in determining intra-articular osteochondral lesions. In the pathology of articular cartilage, radiography is ineffective, although it provides information for the diagnosis of dysplastic and degenerative-dystrophic processes in the joint, predisposing to damage to cartilage. The method is also effective in cases of migration of detached osteochondral X-ray positive fragments into the joint cavity.

A good image of a detached fragment, regardless of its location, can be provided by computed tomography with 3D reconstruction, although cartilage fragments can not always be identified. The most effective diagnostic tool in detecting chondral lesions is magnetic resonance imaging (MRI). With the expansion of the use of this method, it was possible to isolate a special type of damage, called "hidden" fractures. This pathology is a subchondral intraosseous fractures, in which the knee joint appears intact on the radiograph, however, as a rule, there is hemarthrosis with severe pain. At the same time, a subchondral fracture is visualized on the MRI image in the form of subchondral edema and a violation of the bone-and-beam structure. Histologically, such foci of subchondral lesions are characterized by softening, cracking, necrosis of subchondral osteocytes, edema, hemorrhages, and inflammatory changes in the tissue.

It should be noted that today the diagnosis of "hidden" fractures in children and adolescents is possible only by means of MRI, since other imaging methods, including arthroscopy, cannot detect such injuries.

Treatment. When choosing a method of treating ACP, the size of the damage, its stability, localization and time since the injury are taken into account. Small stable injuries outside the loaded area of ​​the articular cartilage are treated conservatively with a fixation method with limited axial load on the limb. In other cases, it is necessary to consider indications for surgical treatment. Surgical treatment of ACP in cases of their early diagnosis should be performed as early as possible using one of two methods: fixation or removal of fragments. At the same time, the higher reparative capabilities of the child's body in comparison with adults should be taken into account, and therefore priority should be given to organ-preserving interventions. Recently, there has been a transition from the practice of removing a detached fragment by arthrotomy to its arthroscopic (or semi-arthroscopic) fixation when the damage is located in the loaded zone of the tibiofemoral joint or in the contact zone of the patellofemoral joint. In the presence of stable lesions that do not require refixation, osteoperforation under arthroscopic control is indicated to stimulate regeneration, however, both in this case and in the case of refixation using metal structures, care should be taken to prevent damage to the metaphyseal growth zone.

Limb injuries are especially common in winter - due to icing, the number of unsuccessful falls increases dramatically. Joint injuries are the most severe. Bringing a lot of inconvenience, they are difficult to cure and heal for a long time.

Fracture of the condyle of the tibia, compression or impression (inside the joint) is one of the most common. It can happen when the victim falls with extended limbs or under other circumstances.

Fracture of the condyles of the tibia - damage to the thickening at its end. In this place, the attachment of ligaments with muscles occurs. There are two of them - internal (medial) and external (lateral). The condyles are quite fragile because they are covered with cartilage. This tissue differs from bone elasticity, it is not so resistant to external influences.



A comminuted fracture of the condyle of the tibia is a consequence of its displacement. When a person falls, they are sharply squeezed. A dense layer of the metaphysis is pressed into the epiphyseal spongy composition. The epiphysis is divided into a couple of parts, breaking the condyles.

You can determine which part is broken by external signs:

  • the lower leg moved outward - there was a fracture of the internal condyle of the tibia due to displacement;
  • the lower leg moved inward - the internal condyle was damaged.

Complete breaks are also isolated when the condyle is separated. With an incomplete fracture, indentation or cracks are likely - but without separation. Also, a fracture of the fibula or tibia with an affected condyle may be with or without displacement.



Often such injuries are accompanied by accompanying troubles:

  • fibula injury;
  • ligamentous and meniscal tears, ruptures;
  • fractures of the elevation between the condyles.

Symptoms and Diagnosis

Fractures of the condyles of the tibia have characteristic symptoms:

  • pain;
  • joint dysfunction;
  • hemoarthritis;
  • specific deformation;
  • lateral movement of the knee joint.



Pain does not always depend on the severity of the injury. A displaced fracture of the lateral condyle of the tibia may not be felt. Therefore, the damaged area should be probed by a specialist. So the doctor determines the presence of pain in certain points. On your own, you can simply put pressure on the knee joint. If the sensations are unpleasant, it is better to visit a traumatologist.

Hemoarthrosis, sometimes reaching a significant size, is also characteristic of such injuries. The fact is that the joint increases in volume, while violating blood circulation. In this case, the doctor sends the victim to a puncture, which consists in getting rid of the accumulated blood.

Suspicions of a fracture of the medial or lateral condyle of the tibia may also appear after tapping the axis of the leg with the fingers. If the pain is severe, then they are most likely broken. It will be very painful with every movement of the injured knee. A pose in which it will be easier is not easy to find. Any change in the position of the leg leads to new pain attacks.

Treatment



A fracture of the condyles or intercondylar eminence of the tibia is treated, taking into account the specifics of the injury. First, the fragments are set - if any. Then they are fixed until the onset of total consolidation. An ice bag is applied to the limb.

If there is a crack or incomplete fracture of the internal or external condyle of the tibia, plaster splints provide immobilization - from the upper third of the thigh to the fingers. It is set for a month.

In the hospital, traction is done, glue or skeletal, as well as one-stage reduction by hands, then fixing it at constant traction. When a small fracture of the condyle of the tibia occurs with an accompanying displacement, it is pulled out by the shin using the adhesive method. A pair of adjusting side loops is used.

With a marginal fracture of the lateral condyle of the tibia, the lateral loop is set so as to direct the traction outwards from the inside. This eliminates the typical deformity, and the displaced condyle is reduced and held in the correct position.



If a fracture occurs with a strong displacement, subluxation or dislocation of one or both condyles, skeletal traction has to be performed. For this, an ankle clamp is used.

To approach one to the other condyles that have gone to the sides, the apparatus of the N.P. system will do. Novachenko or side loops. Sometimes at the same time it is necessary to manually set the displaced fragments. Anesthesia is used:

  • in place;
  • into the spinal cord;
  • general.

In the case of traction, in the absence of acute pain, intensive movements can be switched over after a few days. Early activity contributes to the achievement of better reduction of fragments, the creation of congruence of the surfaces of the joints.

Adhesive, as well as skeletal, traction is usually eliminated a month after installation. After skeletal for half a month, an additional adhesive traction is put. When the traction is finally removed, the victim can stand on his feet without putting much strain on the injured leg. It will be possible to fully activate it no earlier than in another month.

Surgery



The operation is necessary if:

  • reduction of fragments did not help;
  • closed reposition with further traction did not help;
  • a fragment was infringed inside the joint;
  • there is a fracture between the condyles;
  • fragments are compressed brightly;
  • blood vessels and nerves were damaged.

Even skeletal traction does not always help, which usually provides the best comparison of fragments. So there are more indications for operations, doctors give such a recommendation to victims more often.

If the lesions are fresh, an arthrotomy is performed. At the same time, the smallest particles present in the joint are removed absolutely, and large ones are subjected to fixation:

  • carnation;
  • knitting needles;
  • screw;
  • special plates for support.



In open fractures or with multiple fragments, external osteosynthesis is performed using the Ilizarov apparatus. The osteoplastic procedure according to Sitenko is carried out if:

  • chronic closed fracture of the internal or external condyle;
  • subsidence of the condyles - secondary, due to intense load on the injured leg;
  • fresh trauma with high compression.

The joint is opened and then an osteotomy is performed. As a result, the upper part of the affected condyle rises to the height of the second condyle. Articular areas must be in a single plane. The resulting void is filled with a wedge. It is prepared in advance from bone - auto- or heterogeneous. The collected fragments are fixed with a plate and screws.

Then the wound is sutured, drainage is carried out. After the operation, immobilization is carried out. Drainage is removed after three to five days.



It is necessary to perform exercise therapy based on passive exercises to prevent articular contracture. Thermal procedures are shown. When the pain subsides, you can develop the affected joint.

After conventional osteosynthesis, a light load along the axis is allowed three months later, after bone grafting - after four months. It will be possible to rely entirely on the limb in five months. The results of the treatment will be positive if it is carried out correctly, and the patient follows all the recommendations of the doctor.

Complications

A compression or non-compression fracture of the tibial condyle requires a competent approach to treatment, following the recommendations. Diagnosis of fractures and intervention of doctors are made as early as possible. Experienced doctors should deal with trauma.

Otherwise, serious consequences are possible:

  • prolonged immobilization;
  • degenerative arthrosis;
  • angular deformities of the limb;
  • infection of the wound with infection during surgery.


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