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Case 308

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63 year-old female patient with a history of falling from her own height the day before and contuse trauma on her left knee. Seeks medical attention complaining left foot and ankle paresthesia and hypoaesthesia in the left leg. Reported seeking another service the day before, when she performed radiography and was sent home with analgesics. Denies any comorbidities.

After analyzing the clinical data and the radiography, which one is the most likely diagnosis and the respective complication presented by the patient?

a) Medial tibial plateau fracture and crush syndrome.

25%

b) Lateral tibial plateau fracture and compartment syndrome.

25%

c) Medial femoral condyle fracture and crush syndrome.

25%

d) Lateral femoral condyle fracture and compartment syndrome.

25%
   

Image analysis

 

Image 1 - Analysis: Left knee radiography, anteroposterior (AP) projection. Shear fracture (yellow arrow and green dashed line) and depression of the lateral tibial plateau with a small lateral displacement of bone fragment (red arrow).

 

 

Image 2 - Analysis: Left knee radiography, external anteroposterior oblique projection. Shear fracture and depression of the lateral tibial plateau (yellow arrow and green dashed line)with a small lateral displacement of bone fragment (red arrow).

 

 

Image 3 - Analysis: Left knee radiography, medial-lateral projection. Fracture (yellow arrows) and depression of the lateral tibial plateau, seen by the depression of the intercondylar eminence (green dashed line). Upper patellar enthesopathy and increase of suprapatellar soft tissue (red arrows).

 

 

Image 4 - Analysis: Left knee radiography, internal anteroposterior oblique projection. Shear fracture (yellow arrow and green dashed line) and depression of the lateral tibial plateau (red arrow).

Highlights

  • - Knee’s low-energy trauma radiography analysis must be precise, specially in osteoporosis patients;

  • - Femoral and tibial cortical must be whole and aligned. Any local bone unevenness must raise suspicion to tibial plateau fracture;

  • - Oblique projections may help seeing hidden fractures which were not visualized in AP and lateral projections;

  • - CT-scan allows to precisely characterize bone alteration, degree of fragment displacement and to plan the treatment;

  • - In selected cases, MRI may identify incomplete or hidden fractures.

References

  • - Júnior MG, Fogagnolo F, Bitar RC, Freitas RL, Salim R, Paccola CAJ. Fraturas do planalto tibial. Rev. bras. ortop. vol.44 num.6 São Paulo2009.

  • - Yacoubian SV, Nevins RT, Sallis JG, Potter HG, Lorich DG. Impact of MRI on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma. 2002;16(9):632-7.

  • - Lachiewicz PF, FuncikT. Factors influencing the results of open reduction and internal fixation of tibial plateau fractures. Clin Orthop Relat Res.1990;(259):210-5.

  • - S Rajagopalan. Crush Injuries and the Crush Syndrome. Med J Armed Forces India. 2010 Oct; 66(4): 317–320.

  • - Raul AT. Acute Compartment Syndrome. Jan 17, 2017. Medscape.

  • - Luciano RC, Krause M, Skaf AY. Fratura do Planalto Tibial. Projeto Diretrizes, Associação Médica Brasileira e Conselho Federal de Medicina, Sociedade Brasileira de Ortopedia e Traumatologia, Colégio Brasileiro de Radiologia. Oct. 9, 2007.

Author

Rafael Valério Gonçalves, 4th year medical student at Universidade Federal de Minas Gerais.

Email: rafaelvg[at]gmail.com

Supervisor

Túlio Vinícius de Oliveira Campos, MD. Assistant Professor and Doctor of the Department of Orthopedics at the Medical School of Universidade Federal de Minas Gerais.

Email: tuliovoc[at]gmail.com

Reviewers

Lucas Raso, Wellerson Mayrink, Giovanna Vieira, José Nelson M. Vieira, MD. PhD., Viviane Santuari Parisotto Marino, MD. PhD.

Translated by

Bruno Campos Santos, 4th year medical student at Universidade Federal de Minas Gerais.

Email: bruno_campos[at]outlook.com

Test question

In relation to low back pain, one of the pathologies that most incapacitate the individuals of economically active age, mark the correct option.

a) For patients with unilateral lumbar pain radiated to the ipsilateral flank, urinary symptoms, fever and pain to lumbar percussion, the main diagnostic hypothesis is infectious or septic discitis.

25%

b) Most episodes of low back pain are limited and have muscular origin (mechanical or idiopathic low back pain).

25%

c) Pain in the spine is always related to inflammatory rheumatism.

25%

d) Arthroses of the spine reach only the elderly.

25%

e) Most patients with low back pain due to disc herniation present symptoms of medullary compression and pain that evolves with sphincter dysfunction and paraparesis.

25%
   

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