Editors

JukkaRistiniemi

Knee Fractures

Conservative treatment may be used in vertical non-displaced fractures (step-off < 2 mm) and in horizontal fissure fractures. The patient must be able to move the knee. If there is the slightest horizontal articular step-off, the treatment is operative.
The limb is supported with an adjustable hinged knee orthosis (brace) with the lockout set at 0-30° for the first 2 weeks and at 0-60° for the subsequent 2-4 weeks; after 4 weeks there are no restrictions on mobilization.
Full weight bearing with the aid of crutches is allowed. Isometric exercises are used in the beginning to strengthen the thigh muscle.

A displaced or comminuted fracture requires surgical treatment. The aim is to restore both the extension power and the smooth joint surface.
Postoperative management is the same as in conservative treatment.

In fractures of the lateral tibial condyle, dislocation or depression of not more than 1-2 mm is acceptable. However, in medial condyle fractures buckling with consequent malunion is a common feature, and even fissures merit surgical fixation. In practice, all bicondylar fractures are displaced and require surgery.
A plain x-ray does not reliably show the degree of displacement, and a CT scan should therefore always be taken in intra-articular fractures. The scan results should be interpreted by an orthopaedic surgeon who will also define treatment guidelines.
Conservative treatment
- Aspiration of haemarthrosis if it is distended and painful
- Hinged knee orthosis worn for 6 weeks
- Weight bearing is reduced to the weight of the limb. The knee may be fully mobilised and the thigh muscle exercised, and no hinge lockout is therefore needed.

All other displaced fractures of the tibial condyle require surgical management.
The fracture should be analysed with the aid of a CT scan.
The type and timing of surgery are dependent on the amount of energy that caused the fracture and the degree of tissue damage. In high-energy trauma, the initial treatment should target the soft tissue damage, and the fracture should be stabilised with an external fixation device that extends over the knee. After the initial situation settles, final repair of the bone injury is carried out with the aid of internal fixation.
The treatment of condylar fractures often necessitates the use of bone grafts or bone substitute materials to fill cancellous bone defects.

Bone union is slow to take place in condylar fractures. Severe complications include arthrofibrosis, which restricts the movement of the knee, and considerable atrophy of the thigh muscle. Therefore, the aim of surgery is to obtain a stable osteosynthesis that allows early mobilization.
The patient should expect some degree of pain and also be prepared to carry out both self-directed and organised rehabilitation regimes.

An isolated fibular fracture is rare, resulting from a direct blow.
The fracture is usually associated with other injuries.
- Identify possible injury of the peroneal nerve and ligamentous injuries of the knee.
- Always examine whether there is any pain in the ankle. If a fibular fracture is associated with a fracture of the ankle (and with a rupture of the syndesmosis) as a result of trauma that involved twisting of the ankle, surgical treatment is indicated.
Immobiliztion is not required.
Full weight bearing from the onset