Type 2: Since ACL is a necessary for active person who dwells in active sports or going uphills, then i would strongly recommend for early reconstruction surgery to stabilize his unstable knee & strengthen his thigh & calf muscles. Usually sportsman or woman will take 3 to 6 month post ACL reconstruction surgery to return to sports. Any additional injuries such as meniscus injuries or chondral lesion will delay the recovery & rehabilitation.

Generally for patients aged more than 50 years old, ACL reconstruction is not performed in my practice due to his age & function. We strongly recommend for hamstring exercise & ambulation aided with hinged knee brace.

Many patients present to us with the above history. All would have experienced the crepitus sound arising from the knee in the past. Just because there was no pain earlier many do not seek treatment early.

In medical, this condition is known as “patella maltracking with chondromalacia”.

Many presents with this history:

1.  Able to walk but sit & stand pain

2. Difficult to squat.

3. Generalized pain at front of knee.

4. Pain worsen with cycling.

5. Both knee have ‘knock knee deformity or valgus deformity’

Most patella maltracking present with crepitus sound due to imbalance of its positioning between the femoral condyles. The intra-articular patella (knee cap) surface is covered with cartilage.

In patella maltracking, the patella pulled towards the outer side (lateral). The sound appears due to the imbalance rubs of the knee cap with the underlying condyles.  Initially its not painful due to presence of cartilage. However with time (3 to 5 years), this cartilage would worn out & pain presents.

What can you do if you hear crepitus sound in your knee joint?

After confirm the diagnosis of patella maltracking, we recommend the inner muscle of the thigh (vastus medial oblique) to be strengthen.

For a start, try using beach ball (inflatable ball). Position the ball between your knee & squeeze the ball using the inner thigh muscle. Repeat this work-out from 30 to 60 repetitions in a day. And gradually introduce the ‘harder balls’ such the the soccer ball & followed by the basket ball with the same style of repetitions.

Most individuals would gain pain relieve & diminished crepitus sound. If more than 3 months of such exercise did not yield benefits then seek further advice from your orthopaedic surgeon.

Kindly answer these questions first before looking into the answer below!

Question 1?
Can the above bone fractures unite?

Question 2?
Which one of the above diagrams of bone fractures that will not unite?

Question 3?
Can these fractures unite naturally?

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Answer 1 & 2:
All above bone fractures can unite.

Answer 3:
Yes, these fractures can heal naturally

How Orthopaedic Surgery does play its role in bone fracture healing?
With modern medicine, these fractures could be reduced to near normal alignment with surgery or manipulation (like solving the jig-saw puzzle).
Modern medicine reduces the risk of malunion, shortening & deformity.
Also with advancement of technology (XRay, CT scan, MRI), healing process could be monitored & achieved with satisfactory outcome.

How long does a long bone fracture take to unite in a 30yr old person?
For upper limb, it takes average of 6 to 8 weeks.
For lower limb, it takes average of 8 to 12 weeks.

Why some bone fracture cannot unite?
Fracture such as tibia bone (shin bone) does not heal easily due to the following reasons:
a) fracture complicated with contaminated wound
b) excessive swelling complicated with compartment syndrome
c) shin bone covered with skin only at the front, while the muscle bulk is at the back.
d) Fracture site separated by muscle or soft tissue

Can collarbone (clavicle) fracture unite?
Yes, it will heal with malunion.

How long does it take to unite & will collarbone (clavicle) fracture disturbs your future movement of the shoulder & its power (strength)?
The collarbone fracture takes 6 to 8 weeks for the healing. Most collarbone fracture heals well with no lost of shoulder movements nor its power.

What type of long bone fracture could complicate or results in death?
Femur (thigh) bone fracture could bleed internally. If excessive bleed, then patient could end into hypovolemic shock & death. Also within 36 to 72 hours, patient may develop fat embolism & eventually arrest patient’s breathing.

What type of treatment available in orthopaedic surgery for bone fractures?
For undisplaced bone fractures, i recommend fractures to be stabilized with fiberglass casting or special braces.
For displaced bone fractures, i recommend surgery to reduce the fracture & stabilized with special implants.

If could not walk without aid, limited joint movement or severe pain, then seek Specialist to assess your severity of your joint injury!
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DO NOT X
X MASSAGE
X APPLY HEAT

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Does the above story sounds familiar to you?

In my orthopaedic practice, the above cases presents to me commonly.
Most of the patients who suffer pain & difficulty to walk because of either meniscus tear or ligament (ACL / PCL) tear.

The situation arises due to either:
a. The soft tissue injuries such as meniscus or ligament (ACL / PCL) tear not diagnosed during the initial injury.
b. The initial severe pain could present due to the fracture site & Xray would have reveal femur fracture. The appropriate treatment would have been advocated such as surgery for the femur fracture. The subsequent moderate joint pain may not be given the importance.
c. The soft tissue injuries cannot be visualized in an XRay. So these diagnoses mostly get missed.
d. These patients who still complaints of pain at knee after their fracture were fixed, should be examined their joints to rule out the soft tissue injuries.

The ligamentous injuries usually presents with pain for 1 to 2 weeks. Then the pain starts to reduce. Most patients could walk & perform light activities.
The complication of delayed treatment to these soft tissue structures results in persistent knee pain & instability. Their joint function becomes limited & secondary osteoarthritis developed within 5 to 10 years.

Within 3 to 5 years, many would have developed knee pain. They would not be able to play their best like their previous sports performance. Some could not climb stairs well. The knee cap sounds starts & may worsen with years.

All these lesions could be detected if clinical joint examinations were done.

In my practice, the females are affected commonly such as the teachers, housewifes & clerks. The common age group occurs between 30 and 50 years old.

How could you diagnosed de Quervain’s disease?
The usual painful site is at the radial aspect of the wrist. On examination is tender to palpation at the radial aspect & associated with mild swelling. The Finkelstein’s test is positive. This test could is done with the thumb placed adducted at the palm & the rest of the finger closed over the thumb to form a fist. When the wrist bend ulnarly, if it produces pain then the test is positive.

How is the de Quervain’s disease treated?
Generally we recommend to immobilized the thumb with thumb spica & apply ice at the first dorsal compartment of the wrist. Also anti-inflammatory medication given for few days helps to subside the swelling. Simple conservative management works well in most patients. Only in 5 to 10 percent of the patient the symptoms worsen or did not respond to conservative management, then surgical release would be recommended.

How could you prevent de Quervain’s disease?
The stretching exercises followed by the strengthening exercises for the thumb are recommended. Simple use of soft ball with various resistances could strengthen the thumb muscles.