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Management of tibial plateau fracture
This document provides an overview of the management of tibial plateau fractures. The goals of management are to restore joint congruity, preserve the normal mechanical axis, achieve a stable joint, and restore knee motion. Surgical treatment is indicated for fractures with articular depression over 2mm, condylar widening over 5mm, or instability. Implant options include plating, screws, external fixation, and hybrid fixation depending on the fracture pattern and soft tissue injury. Schatzker classification and AO/OTA classification are discussed to characterize the fracture personality and guide appropriate treatment.
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Management of tibial plateau fracture
- 1. MANAGEMENT OF TIBIAL PLATEAUFRACTURE DR.KHADIJAH NORDIN
- 2. Introduction • one ofthe most critical loadbearing areas in the human body. • Goal of management: – Restore joint congruity – Preserved normal mechanical axis – Stable joint – Restore knee motion
- 3. • Issues – Severecomminution – Variable bone quality – Overlying soft tissue injury associated injury to • Cartilage • Meniscus • Stabilizing ligament – Underlying medical condition – Financial background
- 6. Low n highenergy trauma • 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 tissue
- 7. Clinical presentation • History –High energy trauma in young – Low energy trauma in elderly • Assessment – Open or closed fracture – Compartment syndrome – Instability – Neurovascular – ATLS
- 8. Imaging • Radiographs – KneeAP/LAT – Oblique ( subtle plateau depression) – Plateau view ( 10 caudal tilt) • Knee CT – Articular involvement comminution – Schatzker IV V VI – Pre op planning • Knee MRI – Schatzker I II III – Assesment meniscus n ligament • Angiography
- 9. Personality of fracture •Soft tissue damage • Degree of dislocation • Degree of comminution • Degree of join involvement • Osteoporosis • Nerve / blood vessel injury
- 10. Classification • Schatzker classification •AO/OTA • Three column classification
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- 13. The three columnclassification
- 14. • Zero column= schatzker type III • One column = schatzker type I and II – Articular depression in the posterior column with a break of the posterior wall is also defined as a one- column (posterior column) fracture (this type of fracture is not included in any type of the Schatzker classification) • Two column = schatzker type IV – the concurrence of an anterolateral fracture and a separate posterior-lateral articular depression with a break of the posterior wall • Three column = schatzker type V and IV – is defined as at least one independent articular fragment in each column
- 16. Management • Non operative •Operative
- 17. Non operative • Nojoint step >2mm • No axial instability • Severe osteoporosis • General and local contraindication
- 18. • Method: – Protectedweight bearing and early knee ROM with hinged knee brace – Isometric quadriceps exercise and progressive passive active assisted and active knee ROM exercise – PWB for 8-12 weeks with progression to full weight bearing
- 19. Emergency operative treatment •Vascular injury • Compartment injury • Open fracture injury • Gross dislocation • Floating knee • Polytrauma
- 20. Indication for surgery •Depression of the joint equal to the depth of the cartilage – 4mm lateral plateau – 2.5mm for medial plateau – > articular step – off > 3mm • Condylar widening >5mm • valgus/ varus instability • Medial plateau fracture • Bicondylar fracture • Open fracture • Extensive soft tissue contusion/ compartment syndrome • Vascular injury
- 23. Timing for surgery •General principles: – Understanding the configuration of the fracture – Suitable implant and instrument – Skilled surgical team – Pre op plan • Closed schatzker I – III – Axial stable, minimal soft tissue compromise ideally timing on day 5 -7 ( skin wrinkling) • Closed schatzker IV – VI – Axial unstable will shorten, soft tissue compromise, if delay in definative op – joint spanning external fixation / traction within 24h
- 24. Principle of surgicalmanagement • Goals of treatment • Reconstruction of articular surface • Re-establisment of tibial alignment • Stable construct • Early ROM
- 25. • Reducing andbuttressing elevated articular segment with bone graft and implant • Spanning external fixators as temporary measure in patients with high energy injury, severe soft tissue injury and polytrauma • Arthroscopy assisted surgery • Soft tissue reconstruction (meniscuss/ ligament) Principle of surgical management
- 26. Surgical approach • Straightmidline • Anterolateral • Posteromedial • Two approaches for bicondylar fracture • MIPO
- 27. • lateral incision(most common) – straight or hockey stick incision anterolaterally from just proximal to joint line to just lateral to the tibial tubercle • midline incision (if planning TKA in future) – can lead to significant soft tissue stripping and should be avoided • posteromedial incision – interval between semimembranosus and medial head of gastrocnemius • dual surgical incisions with dual plate fixation – indications • bicondylar tibial plateau fractures • posterior – can be used for posterior shearing fracture
- 28. • Skin incision •With the knee in slight flexion make a straight or slightly curved incision running from the medial epicondyle towards the postero-medial edge of the tibia. The incision can be extended as needed both proximally and distally as indicated by the dashed line. • Anterolateral approach • Make a straight incision lateral to the patella. Then, open the deep fascia anterior to the ilio-tibial tract.
- 29. • Skin incision •Identify Gerdy’s tubercle. Make a straight incision about 5cm in length starting posteriorly to Gerdy’s tubercle and running distally and anteriorly.
- 31. Implant option • Choiceof implant if related to the fracture pattern, degree of displacement and the familiarity of surgeon – Plate and screw • Buttressing against shear forces or neutralizing rotational forces • Thinner plate • MIPO • Double plating – Screw alone • Simple split • Depressed fracture elevated percutaneusly – External fixation
- 32. Bridging external fixators •Indication: – Open fracture with severe soft tissue injury – Joint instability – Polytrauma – Severe soft tissue compromised – Serious medical co-morbidity • Contra indication in osteoporosis • Advantages – Provide temporary immobilization of fracture – Soft tissue friendly – Fast procedure – Restore n maintain length – Restore axial alignment – Improves position of bone fragment by ligamentosis • Disadvantages: – Bridging the joint – Risk of pin tract infection – Risk of knee stiffness • Technique – two 5-mm half-pins in distal femur, two in distal tibia – axial traction applied to fixator – fixator is locked in slight flexion
- 33. Hybrid external fixation •Indication – Severe open fracture – Major joint instability – Severe soft tissue compromise, not permitting definitive internal fixation • post-operative care – begin weight bearing when callus is visible on radiographs – usually remain in place 2-4 months • technique – reduce articular surface either percutaneously or with small incisions – stabilize reduction with lag screws or wires – must keep wires >14mm from joint – apply external fixator or hybrid ring fixation
- 34. Ring external fixation •Indication – Severe open fracture with bone loss – Fracture with loss of soft tissue cover
- 35. Plate osteosynthesis • Minimalinvasive plate osteosynthesis (MIPO) with the aids of plate with locking screws • Less traumatizing to soft tissue • Indication – Osteoporosis bone – Articular, displaces, unstable fracture – Open fracture
- 36. Schatzker I • Closedreduction then stabilized with 6.5mm cancellous screw lag screw with washer to gain compression • Anterolateral approach • In young patient screw fixation is adequate • ± antiglide screw /plate • In elderly buttress plate is required
- 37. Schatzker II • Openreduction and elevation of the depress fragment • Anterolateral approach • Bone graft is placed to support the elevation fragment • Temporarily held with k-wire • Position of plate is determine by location of the fracture – Buttress plate – Lag screw • Compression of the articular fragment and of large metaphyseal fragment
- 38. Schatzker III • Openreduction/ arthroscopic assisted • Anterolateral approached • Elevation through a metaphyseal window • Temporary k-wire • Bone grafted • Subchondral plate/ screws
- 39. • Medial buttressplate – Counteract the shear forces acting on the medial plateau – Lag screw alone not sufficient to stabilize the fracture Schatzker IV
- 40. • Required lateraland medial stabilization of fracture • Stabilization – Double plating – Locking plate – External fixators Schatzker V
- 41. Double plating completearticular fracture • Two incision: – Anterolateral and posteromedial • Indication: – Displaced posteromedial fragment need to be buttressed with posterior plate – Medial articular involvement – Displacement of medial column
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