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Tibial plateau fractures
Published: August 2013 Brian Bernstein, ZA AOT Basic Principles Course
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Learning outcomes Specify classification of tibial plateau fractures according to AO and Schatzker Differentiate fractures with and without ligamentous injuries Describe the management of tibial plateau fractures with soft-tissue injuries Outline the principles of the management of proximal tibial fractures as intraarticular injuries Discuss advantages and disadvantages of available implants Teaching points: Utilizing a management concept for each patient and planning each surgical procedure avoids complications and gives the orthopedic surgeon security in contemplating each step of treatment for which he or she is totally responsible.
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Objectives Understand complexity Appreciate mechanics Classify
Achieve a rational treatment plan Articular Metaphyseal Soft tissues
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Tibial plateau Articular fracture by definition Aim for:
Perfect reduction of articular surface Absolute stability (compression)
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Fracture mechanisms Caused by a variety of forces:
Valgus/varus deformation Axial compression Flexion/extension Direct trauma References: Kennedy JC, Bailey WH. Experimental tibial-plateau fractures. Studies of the mechanism and a classification. J Bone Joint Surg Am Dec;50(8):
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Fracture mechanisms 1% of all fractures: Lateral plateau: 60%
Medial plateau: 25% Bicondylar: 15% Two subgroups exist Young patients with good bone stock—high- energy Elderly patients with osteoporosis—low-energy
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Classification of proximal tibial fractures (41-A)
A: extraarticular A1: avulsion A2: metaphyseal simple A3: metaphyseal multifragmentary
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Classification of proximal tibial fractures (41-B)
B: partial articular B1: pure split B2: pure depression B3: split-depression
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Classification of proximal tibial fractures (41-C)
C: complete articular C1: articular simple, metaphyseal simple C2: articular simple, metaphyseal multifragmentary C3: articular multifragmentary
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Schatzker Classification
Schatzker I Split of the lateral tibial plateau without depression
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Schatzker Classification
Schatzker II Split and depressed fracture of the lateral tibial condyle
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Schatzker Classification
Schatzker III Isolated depression of the lateral tibial plateau
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Schatzker Classification
Schatzker IV Fractured medial plateau
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Schatzker Classification
Schatzker V Bicondylar fracture
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Schatzker Classification
Schatzker VI Bicondylar fracture and diaphyseal/metaphyseal dissociation
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Etiology: high-energy trauma
Extensive damage to the soft tissues: Contusions Open injuries Compartment syndrome Peroneal and tibial nerve injury Popliteal artery injury
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Etiology: low-energy trauma
Axial trauma No contusions Closed injuries Less soft-tissue problems Axis deviation Fixation problem (osteoporosis)
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Etiology In low-energy trauma the problem is:
Mechanical—fixation in osteoporotic bone In high-energy trauma the problem is: Biological and associated with damage to the soft tissues
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Investigations X-ray AP and lateral views 45°oblique views
Computed tomography (CT) Magnetic resonance imaging (MRI) Angiography
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Personality of the fracture
Soft-tissue damage Degree of fracture displacement Degree of comminution Degree of joint involvement Osteoporosis Neurovascular injury Complex ipsilateral injuries and polytrauma
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Goals of treatment Decompression and preservation of soft tissues
Reconstruction of joint surfaces Reconstruction of normal mechanical axis Early motion
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Nonoperative treatment
No joint step > 2 mm No axial instability Severe osteoporosis General and local contraindications (eg, medical illness) Selected gunshot wounds
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Schatzker’s principles of treatment
Immobilization > 4 weeks: residual stiffness ORIF and immobilization: even more residual stiffness Regardless of treatment: mobilize early As long as mobility is preserved a secondary reconstructive procedure is possible
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Schatzker’s principles of treatment
Impacted fractures cannot be dislodged by traction or manipulation Depressed articular surfaces remain permanent defects
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Nonoperative treatment
Traction may be of use in the short term Early active movements in a cast brace Touch weight bearing if patient’s condition allows Weight bearing to tolerance at 6 weeks Nonoperative treatment does well in the elderly with low demands
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Operative treatment ?
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Emergency operative treatment
Vascular injury Compartment syndrome Open fractures Gross dislocation Floating knee Polytrauma
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Delayed surgery (damage control surgery)
Use of a temporary spanning external fixator will allow: Optimal recovery of soft tissues Preserve length and axis Further imaging and preoperative planning
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Surgical approach Minimally invasive versus ORIF
ORIF: anterior, (postero)medial, lateral Prepare for bone grafting Knee flexed position Tourniquet Fluoroscopy
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Surgical approach Images courtesy of AO Surgery Reference.
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Intraoperative procedure
Expose ligamentous and meniscal structures Reconstruct the joint surface! Support the joint surface with bone or substitute Buttress with a plate (conventional) Repair the ligaments and menisci to achieve joint stability
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Percutaneous screw and washer fixation
In certain cases, simple percutaneous screw fixation is feasible Washers are advised to help with lag screw compression and buttress effect
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Preoperative Postoperative
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Locked internal fixators
Tibial locked internal fixators are available Locking head screws provide better support than conventional screws in a short metaphyseal fragment Percutaneous insertion preserves soft tissues
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Anatomical reduction Lag screw fixation Locking head screws for angular stability Improved pull-out resistance
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The screws indicated should probably be omitted in line with current bridging osteosynthesis practice. Lecturer can choose to challange participants on this point prior to showing this slide.
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Fine wire fixator for severe soft-tissue injuries
Reconstruction of the joint surface Reconstruction of stable axes Early motion Excellent results (Schatzker IV, V, and VI)
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Fine wire/Hybrid Exoskeleton allows: Problems:
Attention to soft tissues Application of relative stability to the metaphyseal/diaphyseal component Problems: Fine wire irritation Intracapsular portals Must get articular reduction first! Patients unhappy!
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Fine wire/Hybrid
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Results of ORIF on tibial plateau in general
Depends on the fracture type Depends on soft-tissue management Depends on realization of goals Can be excellent even in high-energy trauma: Average range of motion 0–120°(87%) No deterioration in the second 5 years Good prognosis
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Take-home messages Anatomical reduction and rigid fixation of joint surface—absolute stability Functional reduction and stable fixation of metaphysis—relative stability Restoration of joint stability by appropriate soft-tissue reconstruction Early active movement Respect the soft tissues!!!
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