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Tuberosity fractures

Definition

Weber Classification of fibula fractures

Indications

Osteoarthritis

Rheumatoid arthritis

Avascular necrosis

Indications 

1. Significant functional impairment

2. PIPJ contracture

- originally thought to intervene early

- Macfarlane showed residual FFD always about 30^o

- may need to release  check rein ligaments / accessory collateral ligaments

3. MCPJ contracture >30^o

4. Trigger fingers

- must do limited fasciectomy 

Anatomy

Osseous canal between talus and calcaneum

- interosseous talo-calcaneal ligament

- cervical ligament

- joint capsule

- nerve endings / arterial anastomoses

Aetiology

Flat foot / overpronation

Inversion / sprain

Pathology

Basic Concepts

Proximal tibia

- gastrocnemius local muscle flap

- gracilis free muscle flap if gastroc damaged

Middle tibia

- soleus local muscle flap

- gracilis free muscle flap

Distal tibia

- posterior tibial fasciocutaneous local flap

- gracilis free muscle flap

Epidemiology

Usually young patients

- 15 - 40

15% compound

Aetiology

High velocity injury

- MBA

- MVA

- pedestrian v car

- fall from height

Emergency Managment

EMST principles

- need for transfusion not uncommon

Surgical Options

1.  Open antero-lateral approach 

Large / Massive Cuff Tear

2.  Deltopectoral approach

Large Subscapularis tear

3.  Arthroscopic Assisted Mini-open

Indication

- Small / Moderate Cuff Tear < 3cm

- no retraction

Technique

- arthroscopic SAD

Definitions

Massive tear 

1.  > 5cm 

- retracted to humerus / glenoid margin

2.  At least 2 complete tendons

- lose SS / IS or SS / SC

Classification

Issues

Rotator cuff

- often deficient

Bone stock

- often deficient

Glenoid

- often posterior version 

Management

Options

1.  TSR

Indications

- cuff intact