Tibial plateau fracture Case for small group discussion: Management principles for the treatment of articular fractures This case of a complex articular fracture of the tibial plateau exemplifies the processes of bone and soft-tissue evaluation, preoperative planning, and principles of articular fracture treatment. Use of spanning external fixator for soft-tissue management is introduced. Reduction techniques with distractors and clamps can be mentioned. Learning outcomes: Associate the severity of the bone and soft–tissue injury with the fracture classification Develop a logical thought process in evaluating and planning a complex case Review the 4 steps in preoperative planning Emphasize the role of soft–tissue condition in determining surgical timing AOT Principles Basic Course

X-ray evaluation 45-year-old MC rider hit from the side while stepping off of MC NV intact, no other injuries Soft-tissue condition: local swelling of the knee, but lower leg presents with marked soft-tissue contusions and blisters. Is this a high or low energy injury? What information do you want next? - Anteroposterior and lateral x-rays

X-ray evaluation 2 1 3 4 5 Good AP view. Lateral and long alignment views are helpful. What do the arrows show? Answer: Depressed articular fragments in center acting as wedge to separate medial and lateral side (arrow 1) Relatively intact lateral articular surface, although subluxed laterally (arrow 2) Frontal plane split of medial condyle (arrow 3) Double contour on medial side indicating frontal plane split with displacement (arrows 4 and 5)

4 1 - C 3 Bicondylar fracture Depressed central fragment Intact medial and lateral articular surface 4 1 - C 3 How would you classify this fracture? Click after each answer to show results: Bone? - tibia (4) Segment? - proximal (1) Type of fracture? - complete articular (C) Which group? - complex articular and complex metaphyseal (C3) Classification: 41-C3

AO/OTA classification Complete articular fragments separated from shaft Multifragmentary Medial and lateral side involved 41-C3 Most severe injury Worst prognosis The important concept is to emphasize that the classification indicates not only the severity of the injury but the prognosis. The C3 fracture is on the most severe side of the scale. Articular fractures

CT evaluation—sagittal plane What do the arrows indicate? - A displaced frontal plane split on the medial side What kind of forces caused this? - Axial load (shear forces)

CT evaluation—transverse plane 2 1 3 What do the arrows indicate? Lateral cortex intact at Gerdy’s tubercle Cortex split anteriorly just lateral to tibial tuberosity and patellar tendon Frontal plane split on medial side Depressed and rotated central articular fragment What would you like to see next? - Clinical information, skin condition How does this help in planning your approach? 4

Clinical picture of leg on admission What do the blisters indicate? - Severe soft-tissue trauma to the overlying skin with vascular compromise. A surgical approach through this area at this time will likely cause would necrosis How does this affect the timing of surgery? - Wait until soft-tissue swelling and blisters resolve. What next? - Joint-spanning external fixation.

Joint-spanning external fixator What is the purpose of the spanning external fixator? Maintain alignment through longitudinal traction Stabilize boney tissues Stabilize soft tissues Pain control Maintain length of extremity How long do you need to wait until you can safely operate on the fracture? - Until the swelling resolves and the skin wrinkles (“wrinkle test”) How do you decide?

Considerations for timing Skin condition Abrasions Swelling Blisters Neurovascular status Compartment syndrome Spanning external fixator until skin is ready (see above) Due to the large amount of swelling, what are some considerations for timing of surgery? - Vascular supply to the skin as manifest by swelling, tenseness, fracture blisters. Compartment syndrome must always be considered.

Preoperative planning Preoperative planning involves 4 steps: Evaluating the injury and templating the fracture Developing a surgical tactic Developing an instrument and implant list Communicating the plan with the team in the operating room

Goals for treatment? Restore articular surfaces Absolute stability of articular surfaces Requires interfragmentary compression Restore joint alignment with tibia Relative stability of diaphyseal fragments Avoid secondary deformity Avoid medial collapse Maintain soft–tissue integrity for healing Review some of the treatment goals of articular fractures.

Thought process in preoperative planning Build on stability Lateral side is easiest to stabilize to shaft Restore medial side to lateral side Must restore medial side first Must remove depressed fragments before you can reduce medial side to lateral side Support medial side to prevent varus Directly with medial plate Indirectly with lateral fixed angle device A logical thought process is important during the planning process. You want to build on the stability of the fracture in a logical sequence. In this case, the three steps in the process of stabilizing this fracture can quickly be reviewed as an example.

Preoperative planning step 2: surgical tactic/reduction techniques Sequence of steps… Step 2 in the preoperative planning is to develop a surgical tactic. This is an example of the plan for this case. You can be as complete as possible to prompt you to think through each step. Think about the methods of reduction as well.

Distractor pin What are examples of reduction aids? Femoral distractor Reduction clamps from pelvic reduction clamp set

Intraoperative results Results of reduction and fixation. Discuss postoperative care. What is the use for CPM? When to weight-bear?

Summary and take-home message Every injury has two components: A bone injury and a soft–tissue injury. Careful evaluation of both components is needed. Joint-spanning external fixation is indicated in severe soft-tissue swelling. Preoperative planning is critical to success. Limb alignment is as important as articular congruity. Ask participants to summarize the case discussion.