Among fractures of the joint surface of the tibia , fractures of the external condyle are most common, followed by fractures of both condyles and, most rarely, fractures of the internal condyle. Distinguish between full and incomplete condyle fractures. With complete fractures, the entire condyle is removed or part of it. Incomplete fractures include cracks, limited impressions, crushing of the cartilage of the articular surfaces and the superficial layer of the bone tissue of the pineal glands. It is practically most expedient to divide all fractures of the tibial condyles into 2 groups: 1) fractures without compromising the joint surface of the tibia and 2) fractures with violation of the congruency of the joint surface of the tibia.
Fractures of the condyles can be accompanied by fractures of the fibula, damage to the ligamentous apparatus of the knee joint, fractures of the intercondylar elevation, as well as damage to the menisci, which sometimes penetrate into the depth of the destroyed condyle.
Symptoms of fractures of the condyles of the tibia
In case of fractures of the tibial condyles, there are a sufficient number of signs that make it possible to correctly diagnose: pain, hemarthrosis, typical deformation of genu valgum or genu varum , lateral movements in the knee joint, impaired joint function. The intensity of the pain does not always correspond to the degree of damage. Of great diagnostic value is local pain. It is determined by pressure with one finger. Hemarthrosis can reach large sizes and lead to a sharp expansion of the knee joint, impaired blood circulation. In such cases, an urgent need to do a puncture to remove blood. Faster blood resorption is facilitated by early active movements in the joint. A characteristic sign of condyle fractures is a typical deformation of genu varum or genu valgum , which is explained by the displacement of fragments, as well as lateral mobility in the joint area. Active movements are sharply limited, painful. Radiographs allow us to clarify the nature of the fracture and the degree of displacement of the fragments.
Treatment of tibial condyle fractures
The treatment is based on the following principles:
1) early and, if possible, anatomical reduction of fragments to restore the congruence of the articular surfaces;
2) reliable fixation of fragments before the onset of fracture consolidation;
3) the appointment of early active movements in the damaged joint;
4) late limb load.
The treatment of tibial condyle fractures should be differentiated.
In the presence of a marginal fracture without displacement, crack or incomplete fracture, the limb is immobilized with a posterior gypsum splint from the fingers to the upper third of the thigh for 3-4 weeks. Bed rest is indicated for 3-4 days. Then the patient can walk with crutches. During the day, the tire is removed for the duration of active movements in the knee joint. Gradually during the day, increase the number of such exercises.
In stationary conditions, the technique of glue or skeletal traction and the technique of simultaneous manual reposition with subsequent fixation using constant traction are used.
In case of fractures of one condyle with displacement, glue traction for the lower leg is used with an extended limb. At the same time, two side adjusting loops are used. The goods dlinniku shin 2-5 kg on hinges reduce a 1.5-2 kg.
When the external condyle is fractured, a lateral loop is applied to the femoral condyles so that the thrust is directed from the inside to the outside, and the loop located above the ankles has a direction from the outside to the inside . This achieves the elimination of typical deformation during fracture of the external condyle, as well as the reduction of the shifted condyle and its retention in the corrected position.
In case of fractures of the internal condyle, the location of the lateral adjusting loops is opposite to that described.
For fractures of one condyle with a large displacement, for fractures of one condyle with a dislocation or subluxation of the other, as well as for fractures of both condyles with a significant displacement, skeletal traction is used with the ankle clamp. To approach the condyles diverging to the sides, a special apparatus of the construction of N. P. Novachenko or side loops are used.
In these cases, sometimes you have to resort to simultaneous manual reduction of displaced fragments. Local, spinal, or general anesthesia.
When stretched, active movements in the joint begin on the 3-4th day after the elimination of acute pain. Early movements in the knee joint during traction contribute to the further reduction of fragments and the creation of congruence of the articular surfaces.
Glue traction is removed on average after 4 weeks, skeletal traction is also removed after 4 weeks, then glue traction is applied for another 2 weeks.
After removing the traction, patients rise to their feet with crutches, without loading the injured leg. Given the delayed consolidation of intraarticular fractures and the possibility of secondary condyle settling, a full load on the limb is allowed no earlier than after 4-6 months.
Surgical intervention for fresh condyle fractures is used: 1) for infringement of a fragment in the joint cavity with impaired movement in the joint; 2) with a significant displacement of fragments and the failure of conservative methods of reduction; 3) with pronounced compression of the condyles; 4) in cases of intermuscular elevation fractures with displacement and unsuccessful conservative reduction; 5) upon compression of the neurovascular bundle by a displaced fragment. If there is a free fragment in the joint cavity, an arthrotomy is performed and the fragment is removed when the fragment is significantly displaced, and when the neurovascular bundle is squeezed by the displaced fragment, open reduction is performed with subsequent fixation of the set fragment. Can be fixed with a bone auto-pin , a bone hetero-pin , a nail or a stainless steel screw. If the adjusted fragment is firmly held in place, you can do without additional fixation. Manual fragments can be fixed with steel knitting needles, which are carried out using an electric drill . In cases of pronounced compression of the condyles with fresh fractures, chronic, unintended fractures, as well as secondary condyle settling due to early limb loading, a bone-plastic surgery according to the Sitenko method is used . The technique of the operation is as follows. The condyle is exposed in an arcuate incision. The condyle is dissected with a wide chisel placed parallel to the articular surface and carefully raised with the chisel and elevator so that its articular surface is on the same plane as the articular surface of the other condyle. A bone wedge is inserted into the resulting gap hetero-bones . The angle at which the condyle needs to be raised, and accordingly the size of the wedge is calculated before the x-ray operation.