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Clinical Features

Patients with patellar fractures present with focal tenderness, swelling, and often a loss of the extensor mechanism. Patients with femoral condyle fractures present with pain, swelling, deformity, rotation, shortening, and an inability to ambulate. Popliteal artery injury, deep peroneal nerve injury, ipsilateral hip dislocation or fracture, and quadriceps mechanism injury can be associated with femoral condyle fractures. Tibial spine fractures present with tenderness, swelling, inability to extend the knee, and a positive Lachman's test. Patients with tibial plateau fractures have pain, swelling, and limited range of motion. Ligamentous instability is present in about one-third of these fractures. Patients with tibial shaft fractures present with pain, swelling, and crepitance about the knee. Distal tibial fractures involving the articular surface (tibial plafond or Pilon fracture) present with pain, swelling, and tenderness about the ankle. The risk of compartment syndrome is high with tibial fractures and mandates a thorough neurovascular exam. Proximal fibular fractures may be associated with ankle injuries. Patients with isolated fibular shaft fractures may be able to bear weight.

Diagnosis and Differential

The Pittsburgh Knee Rules (Fig. 174-1) or the Ottawa Knee Rules (Table 174-1) should be used to determine if radiography is needed. These rules have been validated in both children and adults. In suspected tibial and fibular injuries, radiographs of the ankle and knee may be necessary to exclude associated fractures. CT scanning may be considered if x-rays are negative, and the patient is unable to bear weight.

Figure 174-1

Pittsburgh Knee Rules for radiography. Reproduced with permission from Seaberg DC, Yealy DM, Lukens T, et al: Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries, Ann Emerg Med. 1998;Jul;32(1):8-13.

Table 174-1

Ottawa Knee Rules: Radiograph If One Criterion Is Met

Emergency Department Care and Disposition

Table 174-2 describes the mechanism and treatment for the various knee fractures. Most tibial fractures require emergent orthopedic consultation. Indications for emergent operative repair include open fractures, vascular compromise, or compartment syndrome. Patients may be placed in long-leg immobilization and discharged home if they have a low-energy mechanism, have their pain well controlled, and are not at risk for compartment syndrome. Treatment for isolated fibular shaft fractures includes splinting, ice, elevation, and orthopedic or primary care physician follow-up. Proximal fibular fractures associated with ...

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