The intercondylar eminence is an internal tubercle on the tibia, located between its condyles, on the sides of which the anterior and posterior cruciate ligaments are attached. Fractures of the intercondylar eminence of the tibia occur extremely rarely. This fracture is an avulsion fracture, preceded by excessive stretching of the cruciate ligaments. There are three types of this injury:
Type 1: incomplete tear-off without displacement
Type 2: incomplete tear with displacement
Type 3: complete separation of the intercondylar eminence.
Treatment.
Treatment for this injury depends on the severity of the fracture. For injuries without displacement of fragments and for fractures of the apex of the intercondylar eminence, conservative treatment is prescribed:
- They perform a puncture of the joint (remove accumulated blood and fluid from the knee joint, inject an anesthetic solution)
- Fix the limb with a plaster cast (for 1.5-2 months)
- Next, rehabilitation procedures are prescribed.
If the displacement of the fragments of the eminence is very significant, then surgical intervention is indicated, in which the fragments are removed or fixed in their place with help. If there are significant displacements of the fragments of the intercondylar eminence, surgical treatment is undertaken. It consists of removing the fragments or fixing them in place using a special suture. Next, restorative treatment is carried out.
Our experience in treating impression fractures of the tibial condyles
The results of treatment of impression-compression fractures of the tibial condyles using a clinically proven method and device for repositioning the articular surface developed by the authors are presented. Excellent and good results were obtained in 88.6% of cases, which is 1.2 times higher than previously presented data in the specialized literature.
Our experience of treating impressional fractures condyles of the tibia
Results of treatment of impression-compressional fractures of condyles of the tibia with application by the developed authors, clinically reasonable method and apparatus for repositioning of the articular surface are presented. Excellent and good results were obtained in 88.6% of cases, which is 1.2 times higher than previously reported data in the special literature.
Fractures of the knee joint area are severe fractures of the bones of the limb. The frequency of such fractures, according to various authors, ranges from 4 to 6.1% of all fractures of the lower extremities [1, 2, 4]. Features of fractures of this location include the location of the fracture plane inside the joint, often accompanied by damage to soft tissue elements. Violation of the congruence of the articular surfaces that make up the knee joint aggravates the nature of the damage and the course of the recovery process. The healing of fractures in the knee joint area often occurs with the formation of excess regenerate tissue, which leads to deformation of the joint and disruption of the congruence of the articular surfaces, and is the cause of the development of stiffness and deforming arthrosis of the joint. The presence of intra-articular hematomas contributes to the formation of adhesions and scars, which can cause persistent contractures of the knee joint. The complexity of fractures in the knee joint area determines the difficulty of repositioning and ensuring adequate stable fixation of fragments during the healing period.
Most authors indicate a significantly higher incidence of tibial condyle fractures compared to femoral condyle fractures. According to O.V. Oganesyan (2005, 2008), fractures of the proximal articular end (condyles) of the tibia account for up to 7.0% of all skeletal bone fractures. The condyles of the tibia are less resistant to force than the condyles of the femur, which is explained by the anatomical features of the metaepiphysis of the femur and tibia [2, 8, 9].
A characteristic feature of most fractures of the tibial condyles is the formation at the time of injury of a primary defect in the cancellous bone of the condyles, otherwise, the zone of primary indentation of the articular surface of the bone plateau, which in most classifications is defined as impression-compression fractures [8, 9].
Treatment of fractures of the knee joint area is a difficult task. Various complications and unsatisfactory treatment outcomes, according to various authors, account for about 50.0% [5, 7, 8]. The surgical method is the main one in the treatment of impression-compression fractures of the knee joint [2, 4, 7, 10].
Since the mid-60s - early 70s of the last century, the method of transosseous osteosynthesis using external fixation devices and, first of all, the method of G.A. has been successfully developing in our country. Ilizarov, which has become the most optimal, including for the treatment of fractures of the knee joint [2, 3, 5, 6, 10]. The advantages of the transosseous osteosynthesis method are as follows: firstly, the Ilizarov apparatus allows you to achieve precise reposition with the elimination of all types of displacements and with minimal tissue trauma without compromising blood circulation in the damaged limb segment; secondly, it provides controlled osteosynthesis with the ability to correct the position of fragments during the treatment process. Stable fixation of fragments in the apparatus does not exclude, in many cases, the loading of the injured limb and the possibility of early movements in the joints, which is the prevention of the development of contractures of the joints of the lower extremities. Methods developed at the Russian Research Center "WTO" named after Academician G.A. Ilizarov, made it possible to further improve the method of transosseous osteosynthesis.
At the same time, the developed classical methods of osteosynthesis with the Ilizarov apparatus are not without certain disadvantages, primarily the inability to use it in the treatment of impression-compression fractures of the tibial condyles, which is associated with its constructive abilities. Within the walls of the Research Center “VTO”, the PCOS method was further developed. Original configurations of rod and pin-and-rod external fixation devices based on the Ilizarov apparatus have been developed and are successfully used in clinical practice, which have improved the outcomes of treatment of fractures of the knee joint, including impression-compression ones.
However, the problem of treating fractures of the knee joint cannot be considered completely resolved. In this regard, we have made an attempt to improve the results of treatment of fractures of the knee joint by improving treatment methods and creating clinically proven methods and devices.
In the department of emergency traumatology of the National Research Center for Clinical Hospital "VIO", 45 patients with impression-compression fractures of the tibial condyles aged from 20 to 70 years were treated. The structure of fractures according to the mechanism of injury is represented by simple fractures of the internal and external condyles due to depression - 17 (38%) and 20 (44%). In 8 cases (18%) fractures of both condyles were observed. For the treatment of this group of patients, the method of transosseous osteosynthesis was chosen using a device we developed that ensures congruence and restoration of the articular surfaces of the bones of the knee joint (RF patent for utility model No. 98896).
This task was achieved due to the fact that in the device for repositioning the articular surface, containing a hollow cylindrical body with a cutting edge and a pusher placed inside it with the possibility of longitudinal movement, the diameter of the pusher corresponds to the inner diameter of the body. The pusher is equipped with a locking head, while the body is equipped with a removable support in the form of a cylindrical rod, at one end of which there is an annular groove with a split ring placed in it, and at the other - a cylindrical head with a handle installed perpendicularly in it (Fig. 1).
Figure 1. Device for repositioning the articular surface: a) diagram; b) appearance of the device (RF utility model patent No. 98896)
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b)
The device was used as follows (Fig. 2 a, b, c): after preparing the surgical field, surgical access is carried out: an incision is made along the anterior outer surface of the damaged tibial condyle, exposing the proximal epimetaphysis of the tibia with a rasp.
Figure 2 (a, b, c). Method and device for repositioning the articular surface (Utility model patent No. 98896)
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b)
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In the paracapsular zone, the anterior section of the meniscus is cut off, which is sutured after osteosynthesis. A removable support is installed in the device body. A visual inspection of the fracture is performed.
On the extra-articular side of the condyle, the device is installed in the direction of the conditional center of indentation. Holding the device by the handle, strike the fixing head of the support with a hammer, moving the device to the desired level . After the body is deepened into the condyle to the required depth, the support is removed from the cylindrical hollow body and replaced with a pusher. The pusher is advanced along the cylindrical hollow body, manually or using a hammer, thereby pushing the bone cylinder located inside the body to the level of the articular surface of the condyle.
Reposition control is carried out visually. The device is removed from the operational area. The defect of the bone substance of the condyle from below is filled with an autograft or osteoinductive material and fixed with knitting needles in the support of the external fixation apparatus. The wound is sutured according to general surgical rules and drained.
Analysis of the treatment outcomes of patients with impression-compression fractures of the tibial condyles indicates the relative majority of excellent and good treatment outcomes when using the transosseous osteosynthesis method with external fixation devices developed by us - 88.6% of the total number, which is 1.2 times higher, according to published earlier than the number of positive outcomes when using classic Ilizarov apparatus configurations.
Let's give a clinical example
Patient G., born in 1973, was treated in the traumatology department No. 1 of the State Autonomous Institution of the Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan from 10/19/11 to 11/23/11. Being the driver of a car, I got into an accident. Delivered to the emergency department by ambulance. Diagnosis: closed impression-compression fracture of the lateral condyle of the left tibia. On October 26, 2011, an operation was performed - open transosseous osteosynthesis using an external fixation device for an impression-compression fracture of the lateral condyle of the left tibia. Reposition of the condyle was performed using a device developed by us (Fig. 3 a-d). After achieving reposition, an external fixation device was installed.
Figure 3. Patient G., born in 1973. Diagnosis: closed impression-compression fracture of the lateral condyle of the left tibia: a) radiograph before surgery: b, c - stage of the operation, d - during treatment
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b)
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G)
Thus, the use of the method and device we developed for the treatment of impression-compression fractures of the knee joint area made it possible to achieve both precise reposition with the elimination of all types of displacements and restoration of the anatomy of the damaged limb segment, and in the vast majority of cases, stable fixation of the proximal articular end of the tibia on period of fusion. The technology we have developed allows us to restore the congruence of the articular surfaces of the knee joint, which in turn sharply reduces the development of gonarthrosis and disability.
H.Z. Gafarov, A.L. Emelin
Kazan State Medical Academy
Gafarov Khaidar Zainullovich - Doctor of Medical Sciences, Professor, Head of the Department of Traumatology and Orthopedics
Literature:
1. Balakina V.S. Intra-articular fractures of the bones of the knee joint / V.S. Balakina; LITO named after. R.R. Vredena: V.G. Weinstein (ed.) and others // Intra-articular fractures: - L. Medgiz, 1958. - P. 138-179.
2. Gorodnichenko A.I. Treatment of peri- and intra-articular fractures of the knee joint with devices / A.I. Gorodnichenko // New technologies in medicine. - Kurgan, 2000. - Part 1. - P. 62-63.
3. Kaplunov O.A. Transosseous osteosynthesis according to Ilizarov in traumatology and orthopedics / O.A. Kaplunov. - M.: GEOTAR-Media, 2002. - P. 62-78.
4. Linnik S.A. Indications and methods of treatment of patients with fractures of the condyles of the knee joint / S.A. Linnik, A.M. Khlynov, K.A. Novoselov and others // Bulletin of the All-Union Guild of Prosthetists and Orthopedists. - Special release. St. Petersburg, 2009. - P. 34.
5. Nigmatullin N.K. Transosseous osteosynthesis in the treatment of fractures in the knee joint / K.K. Nigmatullin // Genius of Orthopedics, 1996. - No. 1. - P. 71-73.
6. Noskov V.K. Treatment of patients with fractures of the condyles of the knee joint bones using the Ilizarov apparatus / V.K. Noskov // Orthopedist, traumatol., 1988. - No. 9. - P. 26-28.
7. Oganesyan O.V. Treatment of chronic fractures of the tibial condyles using a hinge-distraction device / O.V. Oganesyan // Bulletin of traumatology. and orthopedist. them. N.N. Priorova, 2005. - No. 2. - P. 53-56.
8. Plotkin G.L. The problem of impression fractures of the tibial condyles / G.L. Plotkin, V.P. Moskalev, A.A. Domashenko et al. // Bulletin of the All-Union Guild of Prosthetists and Orthopedists. - Special release. St. Petersburg, 2009. - P. 52.
9. Khlynov A.M. Causes of intra-articular fractures of the condyles of the knee joint / A.M. Khlynov, E.G. Lapshinov, F.V. Artemyev et al. // Bulletin of the All-Union Guild of Prosthetists and Orthopedists. - Special release. St. Petersburg, 2009. - P. 69.
10. Shelukhin N.I. Treatment of intra-articular fractures of the condyles of the femur and tibia using various methods / N.I. Shelukhin // Outpatient surgery: Russian quarterly scientific and practical publication. magazine. - St. Petersburg: JSC Rosmedium - North-West, 2004. - No. 1/2. — P. 37-38.
Symptoms
These fractures are easily identified. Specialists initially carefully study the characteristic symptoms of damage:
- Presence of hemarthrosis;
- Soreness;
- Leg deformity;
- Improper functioning of the joint;
- Lateral displacement of the knee joint.
It happens that the pain accompanying a fracture of the medial condyle of the tibia is completely inconsistent with the complexity of the injury. In this case, it is important to carefully feel the area of damage (palpate the leg). It is important for the specialist what sensations the victim will experience during the process of applying force to specific points.
It is easy to find out the nature of the fracture yourself by pressing just a little on or near the knee joint. Unpleasant sensations will indicate the need for an urgent visit to a medical facility.
The injury is characterized by such a sign as hemarthrosis, which has reached a large size. The joint can increase noticeably in volume, because proper blood circulation is disrupted.
Having noted this, the specialist necessarily directs the patient to undergo a puncture. Puncture is the best procedure for removing blood accumulated in the joint tissues.
Causes
A fracture of the tibial condyle occurs as a result of a traumatic action of great force. As a rule, compression is performed with rotation along the axis. More than half of fractures of this type occur as a result of road accidents. Only a fifth of cases occur from falls from height. The type of injury is directly proportional to the fixation of the leg at the time of injury. Damage to the lateral condyle is possible when the leg is abducted to the side at the time of injury.
When the knee is extended, an anterior fracture occurs. In addition, a fracture of the tibial condyles can occur for a number of reasons, including diseases of the musculoskeletal system.
Complications
Usually, satisfactory prognosis can be achieved if all medical recommendations are correctly followed. Premature loads provoke subsidence of one of the fragments, which can result in the development of limb deformity and progression of arthrosis. Possible complications:
- Arthrosis;
- Loss of motor function of the knee;
- Nerve damage;
- Infectious infection with an open fracture;
- Angular deformity of the joint;
- Joint instability.
Timely initiation of treatment in full compliance with medical instructions will help to avoid any disappointing consequences and restore the activity of the limb in all cases.
Modern medicine can help choose the most appropriate method of highly effective treatment for condylar fractures.
Classification
The condyle is considered to be a certain thickening at the very top of the bone (at the end). It is to this area that the muscles and ligaments are attached. There are a total of 2 condyles on the tibia:
- External or external (lateral);
- Internal (medial).
As a rule, the thickening of the bone is a fragile part, since it is covered only by cartilage tissue, which has good elasticity, but at the same time it has poor resistance to damage.
The most common predisposing factors that accurately predict a fracture of the intercondylar eminence of the tibia are straight legs when falling from a great height. In such a deplorable case, strong compression of the condyles and subsequent division of the epiphysis into several parts is inevitable. The internal and external thickening of the bone is broken. There are several main types of fracture, strictly depending on the part of the joint:
- An outwardly displaced shin implies a fracture of the lateral condyle of the tibia or various kinds of problems with it;
- The shin shifted to the inside leads to a fracture of the medial condyle.
A broad classification is inherent in injuries of this type. Incomplete and complete damage should be distinguished. With the latter, partial or complete separation of part of the condyle is observed. With incomplete damage, in the vast majority of cases, cracks and indentation are noted, but without separation.
Rehabilitation
A period of rehabilitation after surgery and conservative treatment is mandatory as soon as the condyle fuses and the doctor decides to remove the plaster cast from the leg. Attentive attention to the doctor’s recommendations will help you quickly recover from an injury and strengthen your sore leg, thus eliminating the possibility of a re-fracture.
The following treatment is usually prescribed:
- Physiotherapy, which helps reduce pain, swelling in tissues, and improve blood circulation in them;
- Therapeutic exercise helps to develop the knee joint after a long passive state. In addition, with the help of properly selected exercises, the patient strengthens the muscles and returns them to their previous shape;
- Massage is very important during the rehabilitation period; it also helps develop the joint and improves blood circulation.
You should not engage in physical exercise or massage until it is recommended by your doctor. The fact is that too early and strong loads can lead to new injuries. You need to understand that the knee joint takes a long time to recover, so there is no need to rush.
The influence of running technique
Running on your heel more often leads to stress fractures, according to global statistics. This placement of the foot puts more stress on the hip, increasing the likelihood of injury to the tibia. However, running from the forefoot is not without sin. For untrained feet, it carries the risk of stress fractures in the foot and ankle bones.
You should also pay attention to the surface. Let’s say you’ve been running along dirt paths all the time, and then in winter you switch to the arena, maintaining the same volumes. A sudden change of surface is fraught with danger, especially considering that the track in the arena involves turns, and asphalt, for example, is much harder than natural soil.
Read on the topic: Where is the best place to run: 9 running surfaces and their features
Symptoms and diagnosis
The most common symptoms of a stress fracture are:
- Pain while running, walking and even at rest. If you experience pain while running that forces you to land on your foot differently than usual to avoid pain, consult a doctor.
- Sharp pain when pressing on the area where discomfort is felt.
- Swelling in the affected area, but most often swelling occurs in the top of the foot. For example, the outline of the veins on your injured leg may be more noticeable compared to the other foot.
To diagnose an injury, there is also a jump test: you need to jump several times on the leg that hurts, and if you feel pain when landing, this may indicate a fracture.
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Good news: bone has a certain margin of strength. This means that pain hinting at a stress fracture appears long before it occurs. Timely measures will allow you not to fall out of the running program for one and a half to two months.
Types of osteosynthesis
Osteosynthesis operations on the bones of the legs during fractures can be performed using the following techniques:
- intramedullary, using rods and pins that are inserted into the bone marrow canal;
- extramedullary, when the plates are secured to the bone with screws.
The use of Volkov-Oganesyan and Ilizarov extrafocal fixation structures has a huge impact on the quality of treatment and rehabilitation. Their use is based on compression-distraction osteosynthesis. These devices subject one area of the limbs to pressure and others to stretching.
The technique for installing a shin plate is constantly being improved. Among the devices used today there are wire and rod designs for external fixation. They are used for urgent surgery and for complex surgical fractures. They are implemented effectively and minimally invasively. The choice of surgical intervention is influenced by the severity of the injury, type of fracture, and the presence of complications.
A very important factor influencing the quality of the surgical intervention should be considered the experience of the doctor, the availability of modern equipment for diagnosis and operations, and the availability of materials for implantation. With the proper qualifications of the surgeon, the patient quickly recovers; an unsuccessful operation leads to repeated interventions and improper fusion of bones. High-quality implantation of a plate for a tibia fracture will ensure a quick return of the patient to normal life.
Second clinical example.
Patient B., 62 years old, suffering from osteoporosis, suffered a fracture of both bones of the right leg in the lower third in January 2021. After a preoperative examination, osteosynthesis of the fracture with 2 plates was performed on the day of treatment. The patient was discharged 4 days after treatment.
X-ray control after surgery.
X-ray control 3 months after surgery to determine the consolidation of fractures.
X-ray control 6 months after the injury, complete consolidation of the fractures is determined.
But our patient’s misadventures did not end there. Repeated injury, fall at home on the area of the right knee joint. Radiographs at presentation. A comminuted fracture of the upper third of the right tibia is determined.
After a preoperative examination, on the 2nd day after hospitalization, surgery was performed, open reduction, osteosynthesis of the fracture of the upper third of the tibia with a plate and screws. The patient was discharged on the 5th day after hospitalization in satisfactory condition.
The fractures have consolidated, the patient is being treated for severe osteoporosis by an endocrinologist.
Prevention
- Slowly increase the load and gradually make changes to the program. Experts recommend increasing volume by no more than 10 percent from week to week.
- Work on increasing your cadence: 80-90 steps per minute for one leg reduces the risk of injury.
- Don't do too much speed or tempo work. On easy days, run really easy;
- Include exercises to strengthen weak areas in your program. The key muscles are the gastrocnemius and tibialis anterior.
- If possible, consult a specialist who will evaluate your running technique.
- Vary your running surface.
- Eat a healthy diet: Get enough calcium and vitamin D. Take vitamin and mineral supplements for healthy bones.
- Give yourself recovery days after a tough session. Yes, you may feel full of energy, but the musculoskeletal system takes much longer to recover than the cardiovascular system.
First aid
If you have sustained a fracture of the lateral tibial condyle or any other fracture, the injury should be diagnosed immediately and appropriate treatment initiated. First aid will help the patient wait for qualified specialists to arrive if he is unable to get to the hospital himself. First aid includes:
- Call an ambulance and clarify with a specialist the list of necessary medications allowed for the victim to take in order to relieve pain;
- Anesthesia of the damaged area using analgesic drugs;
- Treating the edges of the wound with an antiseptic; if the wound is open and there is noticeable bone displacement, a mandatory step is to cover the wound with sterile bandages, but tight bandages should not be used;
- Plugging with a sterile cloth will help stop the bleeding in the first couple of days.
If there is no displacement, you need to fix the leg by immobilizing the limb and applying a special splint made from nearby materials.