fractures, typically involving a direct hit to the thigh or an indirect force transmitted through the knee. Younger patients are often injured in high-energy mechanisms such as automobile accidents (Denisiuk, 2020). Depending on fracture type, the medical treatment may or may not involve surgery. Assistive devices are recommended as needed, with range of motion, strengthening, and functional training implemented according to prescribing physician protocol. Epiphyseal fractures Epiphyseal fractures of the proximal tibia and distal femur are relatively rare and most commonly seen in the pediatric population. They may result from strains and sprains, and involve disruption in the cartilaginous physis of long bones. They are commonly classified by the five-part Salter-Harris Classification (SH). SH I fractures typically traverse the hypertrophic zone of the physis, splitting it longitudinally, thus separating the epiphysis from the metaphysis. When these fractures are nondisplaced, they may not be apparent on radiograph. Mild to moderate soft tissue swelling may be visible on radiographic film, and clinical signs may evident by swelling at the location of the epiphysis. Generally, closed reduction is necessary for displaced fractures, but open reduction with internal fixation may be required. Outcomes for this fracture are generally good. SH II fractures split partially through the physis and include a triangular bone fragment of the metaphysis. Surgical intervention is required and prognosis is variable. SH III fractures involve both physeal injury and articular discontinuity, involving the physis and extending through the epiphysis joint, with potential to disrupt the joint surface. This injury is less common and often requires open reduction and internal fixation to promote proper alignment of the physis and joint surface. SH IV fractures run obliquely through the metaphysis, traverse the physis and epiphysis, and enter the joint itself. Surgical reduction is required. SH V fractures result from compression or crush injuries to the physis. This form of fracture is rare and can be disruptive to bone growth. SH V fractures include injury to the peripheral portion of the physis resulting in angular deformity with damage to the periosteum. These are seen in burn injuries or significant trauma to the surface of the limb such as crushing injuries (Rabin, 2019). Tibial plateau fractures Tibial plateau fractures must be managed with extreme care, as the tibial plateau is one of the most crucial load-bearing anatomical structures in the body. Fractures of the tibial plateau Patellofemoral disorders There are several conditions that affect the patellofemoral joint, including general patellofemoral pain, patellar instability and subluxation, and patellar tendinosis. To understand the patellofemoral joint under impaired conditions, it is important to remember the ideal mechanics of the knee. The patella is a sesamoid bone. The posterior surface articulates with the femur and varies in thickness from approximately 2 mm to 5.5mm. This posterior surface is composed of medial and lateral facets, which are subdivided into thirds, with an additional medial portion referred to as the “odd facet” resulting in seven facets. The patella itself increases the mechanical advantage of the quadriceps muscle and reduces friction between the quadriceps tendon and the femoral condyles. During knee extension, there is little patella contact with the femoral condyles because the quadriceps tendon and patellar tendon are on slack, thus suspending the patella. In 10 to 20° of knee flexion, the inferior portion of the lateral and medial facets makes contact with the femur. As knee flexion increases, the contact area of the patella changes from distal to proximal. By 90°of flexion, all aspects of the medial and lateral facets have made contact with the femoral condyles. Knee flexion beyond 90° includes contact of the odd facet with the femur (Levangie & Norkin, 2011). Patient exams are heavily reliant on gait observation and deductive reasoning, as often many impairments are found and grouped together through deductive reasoning to diagnose this
can have detrimental effects on the alignment of the knee, stability, and motion. More than 50% of tibial plateau fracture sufferers are females over the age of 50, which is most likely attributed to postmenopausal osteoporosis (Vidyadhara, 2020). The second most prevalent population to sustain this injury is highly active youth where the mechanism of injury is high- energy trauma. The most common mechanism of injury resulting in a tibial plateau fracture is a valgus force with axial loading. Of these injuries, 80% are motor vehicle– related injuries and the remainder are sports-related injuries. A bumper- or fender- related injury from a vehicle-pedestrian collision constitutes more than 25% of tibial plateau fractures (Vidyadhara, 2020). Tibial plateau fractures presenting with fracture displacement ranging from 4 to 10 mm can be treated non-operatively; however, a fragment with gapping >5 mm should be elevated and grafted, most commonly with ORIF technique (Vidyadhara, 2020). Tibial spinal fractures Tibial spinal fractures are most prevalent in active youth who are not fully skeletally mature. The mechanism of injury tends to be forceful knee extension with twisting, or high-energy excessive flexion of the knee. Generally, this force is enough to disrupt the ACL from its fixture on the tibia, resulting in ACL tear as well. Signs and symptoms of this injury tend to mimic ACL tear with resulting knee swelling, pain, and patient report of an audible “pop” at the mechanism of injury. Well-aligned fractures can be medically managed without surgery, and may involve use of a full- length cast with the knee in extension. Displaced fractures, or fractures with fragmentation, require surgical intervention. Avulsion fractures Avulsion fracture at the proximal tibia may occur at the tibial tubercle or proximal tibial epiphysis. These are uncommon injuries that typically affect the insertion of the anterior cruciate ligament on the tibia. They typically occur in skeletally immature patients aged 8 to 14 years and result from hyperextension of the knee with a valgus or rotational force. Diagnosis is based on history, physical examination, and standard radiographs. MRI imaging can identify problematic areas that require surgical intervention. Open or arthroscopic repair is indicated in patients with partially displaced fractures. Surgical intervention may be required in patients who have undergone unsuccessful nonsurgical reduction and long leg casting or bracing, and in patients with completely displaced fractures. Arthroscopy offers reduced invasiveness and decreased morbidity (Strauss, 2018). condition. The patella should be observed and palpated during knee flexion and extension both in weight-bearing and non- weight–bearing conditions. This is especially important because during weight bearing, as the knee flexes the joint reaction forces increase and the medial facet accepts the majority of this compressive force. In non-weightbearing phase, as knee flexion decreases (during knee extension phase), the joint reaction forces increase. Important characteristics to observe include excessive medial or lateral gliding during the extension to flexion motion. Furthermore, knee alignment itself should be observed during these conditions. Generally, hip abductor weakness, particularly gluteus medius, is attributed to poor knee mechanics and anterior knee pain (Lee et al., 2003). Foot involvement in knee mechanics cannot be discounted. Subtalar joint, navicular height, and forefoot position should be observed in standing position, and assessed for mobility in non-weightbearing conditions. Patellofemoral pain is most prevalent in adolescents and young adults. Patients generally present clinically with reports of anterior knee pain, retropatellar pain, or peripatellar pain while ascending or descending stairs, squatting, or sitting with knees flexed. The exact etiology is still debated; however, this condition is generally attributed to muscular weakness, imbalance between tight and weak muscles around the knee, or restrictions in the iliotibial band or lateral retinaculum. Bony
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