1. Management principles for articular fractures―How do they differ from diaphyseal fractures?
Acknowledgements:
Cleber AJ, Paccola BR
Mahmoud Odat, JO
AOT Basic Principles Course

2. Learning outcomes
Describe the healing mechanisms of articular cartilage and how they can be impacted by different treatments
Appreciate the importance of anatomical reduction, rigid fixation, and early active movement for treatment of the articular surface, including the importance of restoring the correct mechanical axis
Discuss the early management of articular fractures with severe soft-tissue injury (bridging external fixation, staged procedures)
Teaching points:
Anatomical reduction for articular surfaces must be combined with absolute stability to achieve healing with no callus. Length and alignment of an extremity should be attained before attempting approach and reduction of articular surfaces.

3. Reduction? Stability? Implants? Healing?
This is a case of intra articular fracture
At the end of the lecture we should answer the follpwing questions
What type of reduction, stability, is needed? The implantes needed and their function? Looking to what type of bone healing?

4. Articular cartilage Composition: Chondrocytes Proteoglycan
Type II collagen
Water

5. Articular cartilage
Articular cartilage:
Resilient
Elastic
Avascular

6. Functions of articular cartilage
Provides frictionless surface to joints
Shock absorber
Distributes forces evenly

7. Nutrition of articular cartilage
Avascular
Nutrition comes from synovial fluid
Flow of synovial fluid requires motion and load

8. Articular cartilage response to trauma
Very sensitive to injury
Poor healing potential
Heals with a mixture of fibrous tissue and fibrocartilage

9. History of treatment of articular fractures
Immobilization of joint injury was common practice in the 19th and early 20th century
Lambotte recommended:
Anatomical reduction of the articular surface
Alignment of the diaphyseal/epiphyseal fragments
Sound fixation of the articular portion to the diaphysis
Bone graft

10. History of treatment of articular fractures
“Perfect anatomical restoration and perfect freedom of joint movement can be obtained simultaneously only by internal fixation.”
Sir John Charnley, 1961

11. Clinical and experimental evidence
Immobilization results in joint stiffness
Immobilization after ORIF results in much greater stiffness

12. Outcome after articular fractures depends on:
Trauma energy
Residual malalignment
Ligamentary instability
Step-offs in articular cartilage

13. Treatment of articular fractures
Anatomical reduction of fragments:
No step-offs
No depression
No gaps
Stable internal fixation
Can withstand early mobilization
Early motion of joint
Important for hyaline cartilage healing
Prevents stiffness

14. Principles of treatment
Understand the injury
Evaluation of soft tissues
Preoperative planning
Timing
Articular reduction
Buttress of metaphysis

15. Principles of treatment
Understand the injury

16. Principles of treatment
Understand the injury
Evaluation of soft tissues

17. Principles of treatment
Understand the injury
Evaluation of soft tissues
Preoperative planning:
X-rays: AP, lateral, oblique CT
MRI

18. Principles of treatment
Understand the injury
Evaluate soft tissues
Preoperative planning
Timing:
Early (< 1–2 days)
Late

19. Principles of treatment
Early timing:
Little edema
Good skin condition
Recent trauma < 2 days

20. Principles of treatment
Timing:
Avoid surgery after 3 days
Soft tissue??

21. Principles of treatment
Timing:
Traction or external fixator

22. Principles of treatment
Timing:
Traction or external fixator
Photos courtesy of Christoph Sommer, Switzerland

23. Principles of treatment
Timing:
Traction or external fixator
Definitive fixation 1–2 weeks later
Photos courtesy of Christoph Sommer, Switzerland
Wrinkle signs

24. Principles of treatment
Articular reduction
Gaps more forgiving, step-offs dangerous.

25. Principles of treatment
Buttressing of the metaphysis
Depressed articular fractures
Comminuted articular fractures
Movement of the joint
Mobilization of patient

26. Principles of treatment

27. Principles of treatment

28. Principles of treatment
Explanation regarding the use of fine-wire fixation to augment management, to treat metaphyseal/diaphyseal component.
Articular component still requires absolute stability and most often direct reduction technique.

29. Principles of treatment

30. Type of fixation

33. 6 weeks postoperative
Reduction?
Stability?
Implants?
Healing?

34. Take-home messages Flow of synovial fluid requires motion and load
Anatomical reduction
Absolute stability  early mobilization  enhances healing
Multiple types of fixations

35. Healing with hyaline cartilage
Take-home messages
Anatomical reduction +
Absolute stability
Early movement
Healing with hyaline cartilage
Respect soft tissues