• absolute
• neuropathic joint
• infection
• extensor mechanism dysfunction
• medically unstable 
• relative- young active patients

• patellofemoral complications (MOST COMMON)
• arthrofibrosis
• extensor mechanism failure (via patellar tendon rupture or avulsion
• loosening
• NV injury
• peroneal N.
• superiolat. geniculate A.
• DVT/PE

• medial parapatellar approach
• reflect back rectus femoris tendon and patellar tendon
• beware of infrapatellar branch of saphenous N. 

• origin- prox lat tibia (Gerdy's turbercle)
• insertion- medial cuneiform, plantar 1st metatarsal base
• innerv.- deep peroneal
• action- dorsiflex, invert foot 

• origin- med. fibula, interosseous membrane
• insertion- base of distal phalanx of great toe
• innerv- deep peroneal N.
• action- dorsiflex, extend great toe 

• origin- lat. tibia condyle, prox. tibia
• insertion- base of middle and distal phalanges (4 toes)
• innerv- deep peroneal N.
• action- dorsiflex extend 2-5th digit 

• origin- prox lat. fibula
• insertion- plantar medial cuneiform, 1st metatarsal base
• innerv.- superficial peroneal N.
• action- plantarflexion

• origin- distal lat. fibula
• insertion- base of 5th metatarsal
• innervation- superficial peroneal N.
• action- evert foot 

gastrocnemius

• origin- lat. and medial femoral condyles
• insertion- calcaneus via Achilles tendon
• innervation- tibial N.
• action- plantarflexion 

• origin- post. fibular head/soleal line of tibia
• insertion- calcaneus via Achilles tendon
• innervation- tibial N.
• action- plantarflexion 

• origin- lat. femoral supracondylar line
• insertion- calcaneus via Achilles tendon
• innervation- tibial N.
• action- weak plantarflexion 

• origin- lat. femoral condyle (ant/distal to LCL)
• insertion- prox post tibia
• innervation- tibial N.
• action- internal rotation of knee during swing phase of walking gait 

• origin- post fibula
• insertion- base of distal phalanx of great toe
• innervation- tibial N.
• action- plantarflex great toe 

• origin- posterior tibia
• insertion- bases of distal phalanges of 4 toes
• innervation- tibial N.
• action- plantarflex lateral 4 toes 

• origin- post. tibia, fibula, interosseous membrane
• insertion- plantar navicular cuneiforms, MT bases
• innervation- tibial N.
• action- plantarflex, invert foot (in heel off phase of walking gait) 

• prone
• knee flexed 115 degrees with beam at patella 15 degrees cephaled
• clinical application- malalignment or patellar tilt

• location- above the joint line, 1 cm inf to patella, 1 cm med to patellar tendon
• dangers- ant. horn of medial meniscus
• use- view lateral compartment (most common portal for instrumentation)

• location- just above jt line, 1 cm inf. to patella, 1 cm lat. to patellar tendon
• dangers- ant. horn of lat. meniscus
• use- most common portal for arthroscope

• location- 2.5 vm above joint line, lat/med to quadriceps tendon
• use- view patellofemoral articulation, patella tracking, also inflow/outflow

• location- with knee flexed to 90 degrees, 1 cm above jt line, post to MCL
• dangers- saphenous N.
• use- view PCL, post. horns of menisci, retrieve loose bodies

• location, with knee flexed to 90 degrees, 1 cm above jt line, post. to LCL
• dangers- peroneal N.
• use- view PCL, post horns of menisci, retrieve loose bodies

• location- 1 cm below inf. pole of patella in midline
• dangers- patellar tendon
• uses- central joints and notch viewing

• mechanism- varus/valgus force + axial load
• associated injuries- meniscal tears, ligamentous injury, peroneal N. injuries (esp. w/medial tibial plateau)
• complications- compartment syndrome, posttraumatic OA, persistent knee pain, popliteal A. injury

• indications
• open fx
• associated compartment syndrome
• associated vascular injury
• instability greater than 10 degrees of extended knee compared to contralateral side
• tx principles (can use plate and screws, screws alone, or external fixation)
• goal- reconstruct articular surface followed by re-establishing tibial alignment
• reduce and buttress elevated articular segments with bone graft or bone graft substitute
• address meniscal repair as well as ligamentous structure injury

• arthrofibrosis (common)
• compartment syndrome (uncommon but devastating)
• infection
• malunion/nonunion
• posttraumatic OA
• peroneal N. injury (esp. if lateral tibial plateu fx)
• avascular necrosis of small articular fragments
• popliteal A. laceration (rare)

• keep patient NWB w/ or w/o continuous passive motion and active ROM
• weight bearing allowed at 8-12 weeks

• mechanism of injury
• axial compression (fall from height)
• axially directed force through talus into tibial plafond, causing impaction of articular surface
• if dorsiflexed at time of injury, ant. plafond injury
• if plantarflexed at time of injury, post. plafond injury
• rotational (low energy)- torsion w/varus or valgus stress
• associated injuries- calcaneal fx, tibial plateau fx, pelvic fx, vertebral body burst fx, fibula fx (transverse or short oblique)

• nondisplaced- nonoperative w/long leg cast for 6 weeks followed by ROM exercises
• displaced- surgery
• goals
• maintenance of fibula length and stability
• restoration of tibial articular surface
• bone grafting of metaphyseal defects
• stabilizing distal tibia
• post op
• splint placement in neutral DF w/careful monitoring of soft tissue
• early ankle/foot motion when wounds and fixation allow
• NWB 12-16 wks, progress to WBAT once radiographic evidence of healing

• post-traumatic OA (100% in comminuted fx)
• ST slough, necrosis, and hematoma
• nonunion
• malunion (esp. w/nonanatomic reduction)
• infection (esp. open injuries)
• tibial shortening
• decreased ankle ROM

• description- complete syndesmosis disruption with diastasis and prox fibula fx
• mechanism- pronation, ext. rot.
• tx- reduce and stabilize syndesmosis by putting screw at distal fibula

• direct trauma
• indirect (most common)- transverse fx pattern w/ variable inferior pole comminution
• forcible eccentric quadriceps contraction while knee is semiflex
• intrinsic strength of patella is exceeded by pull of muscular and ligament structures

degree of displacement of fragments pos. correlated with degree of retinacular disruption

• nonoperative- if minimally displaced
• knee immobilizer 4-6 wks
• encourage early weight bearing
• operative- ORIF if loss of active extension, extensor lag, articular incongruity, fragment displacement, open fx
• post op care- splint 3-6 wks w/early knee motion (active assisted ROM exercises)
• full weight bearing by 6 wks
• if severly comminuted- patellectomy (full or partial)

• posttraumatic OA
• fixation failure
• nonunion
• refracture
• osteonecrosis of prox. fragment
• loss of knee motion
• painful retained hardwair
• loss of extensor strength and extensor lag (about 5 degrees)- rarely clinically significant

• mechanism- eccentric contraction
• PE: inable to do straight leg raise
• XR: patella baja 

• anterior
  • TA, EHL, EDL, peroneus tertius
  • deep peroneal N., anterior tibial A.
• lateral
  • peroneus longus, peroneus brevis
  • superficial peroneal N.
• superficial posterior
  • gastroc, soleus, planteris
  • sural N.
• deep posterior
  • popliteus, FHL, FDL, TP
  • posterior tibal A./V.; peroneal A./V; tibial N.