Tibial Plateau Fractures

1
Tibial Plateau Fractures

• Mechanism of injury
• Varus or valgus force combined with axial loading
  as in
• Car striking a pedestrian (bumper fracture).
• FFH with varus or valgus bending.
• The tibial condyle split by the opposing femoral
  condyle.

2

• FRACTURE CLASSIFICATION (SCHATZKER)
• Type I (Pure cleavage)
• A typical wedge-shaped uncomminuted fragment is
  split off the lateral condyle and displaced
  laterally and downward. This fracture is common
  in younger patients without osteoporotic bone.
• Type II (cleavage combined with depression)
• A lateral wedge is split off, but in addition the
  articular surface is depressed down into the
  metaphysis. This tends to occur in older people.

3

• Type III (pure central depression)
• The articular surface is driven into the plateau,
  the lateral cortex is intact. These tend to occur
  in
• osteoporotic bone.
• Type IV (fractures of medial condyle)
• These may be split off as a single wedge or may
  be comminuted and depressed. The tibial spines
  often are involved.

4

• Type V (bicondylar fractures)
• Both tibial plateaus are split off. The
  distinguishing feature is that the metaphysis and
  diaphyses retain
• continuity.
• Type VI (plateau fracture with dissociation of
  metaphysis and diaphyses)
• A transverse or oblique fracture of the proximal
  tibia is present in addition to a fracture of one
  or both tibial condyles and articular surfaces.

5
Clinical Features

• Swelling, deformity, extensive bruising and
  doughy feeling of the joint due to hemarthroses.
• Neurovascular examination is a must (traction N.
  injury) TYPE IV may cause neuropraxia of common
  peroneal nerve.
• Examination under anesthesia may reveal medial or
  lateral collateral ligament injuries.

6

• Plain X-ray AP, lateral, oblique views.
• CT-scan with reconstructions visualize the exact
  comminution and articular depression.

7
Treatment

• Type I
• Non displaced aspirate the hemarthroses then
  plaster immobilization, partial wt bearing after
  3weeks, plaster removal after 4weeks, full wt
  bearing after 8weeks.
• Displaced can be fixed with two transverse
  cancellous screws.

8

• Type II
• If the depression is less than 5mm or if
  instability cannot be demonstrated on stress,
  treatment is conservative.
• If the depression is severe or if instability can
  be demonstrated on stress, the articular
  fragments should be elevated and bone-grafted,
  and the lateral cortex is supported with a
  buttress plate.

9

• Type III
• The same as type II.
• Type IV
• These fractures tend to angulate into varus and
  should be treated by open reduction and fixation
  with a medial buttress plate and cancellous
  screws.

10

• Type V
• Both condyles can be fixed with buttress plates
  and cancellous screws. It is best to avoid
  stabilizing condyles with large bulky implants.

11

• Type VI
• Should be treated with buttress plates and
  cancellous screws, one on either side if both
  condyles are fractured.
• More recently, pin and wire fixators also have
  been advocated for fixation of these difficult
  fractures (illizarof).

12
Complications

• Early compartment syndrome, neurovascular
  injuries, fracture blisters.
• Late stiffness, deformity, osteoarthrits.

13
Fracture Tibia and Fibula

• Subcutaneous position, commonly fractured and
  commonly sustain compound fracture.
• Mechanism of injury
• Twisting force (spiral fracture of
• both at different level), usually low
• force injury and the bone may penetrate
• the skin from within.

14

• 2. Angulatory direct force (transverse or short
  oblique fracture of both at the same level), high
  energy lesion and crushes the skin over the bone.

15
Clinical Features

• Pain, swelling, bruises, crushing the skin, open
  fracture, circulatory changes, check always for
  impending compartment syndrome.
• Plain X-ray site, type, comminution,
  displacement, angulations, rotation,
• state of nearby joints, old or new,
• pathological or not..

16
Managements

• Depend on certain factors
• State of the soft tissue.
• Severity of bony injury( spiral or transverse,
  comminuted).
• Stability of the fracture( oblique, butterfly,
  comminuted) are unstable.

17

• Conservative treatments
• For low energy fractures, minimally displaced,
  gustillow type I.
• Reduction if needed (MUA) immobilization in a
  full POP cast from midthigh to metatarsal necks.
• If skin in doubt open a window for daily
  observation.
• Elevation and observation for72 hours, after 2
  weeks check x-ray, then partial wt. bearing till
  union(8-16weeks).

18

• Operative treatments
• Unstable high energy fractures, low energy
  fractures cannot be hold satisfactorily by
  conservative way.
• Closed locked intramedullary nailing the
  standard method for most fractures.

19

• Plate and screw metaphyseal fractures (grate
  risk of exposure, periosteal striping,
  infection..).

20
3. External fixation compound fractures,
comminuted fractures, infected fractures, non
union with bone gaps (bone transport).
21
Complications

• Early
• Vascular injury rare, occur with proximal
  fractures.
• Compartment syndrome happen especially if (young
  patient, severe injury, delay treatment, shock,
  excessive manipulation with long operation).
• Infection open fractures, after plate and screw
  fixation.

22

• Malunion.
• Delay union and non union common( poor soft
  tissue, comminuted, segmental, compound,
  infected).
• Ankle and foot stiffness.