1. 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

2. 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

3. 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. 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

5. 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

6. 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)

7. CT evaluation—transverse plane2 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

8. 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.

9. 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?

10. 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.

11. 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

12. 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.

13. 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.

14. 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.

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

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

17. 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.