Tibial Plateau FracturesTibial Plateau FracturesMechanism of injury:Mechanism of injury: Varus or valgusVarus or valgus force combined with force combined with

axial loadingaxial loading as in: as in:

1.1. Car striking a pedestrian (Car striking a pedestrian (bumper bumper fracturefracture).).

2.2. FFHFFH with varus or valgus bending. with varus or valgus bending.

The tibial condyle split by the opposing The tibial condyle split by the opposing femoral condyle.femoral condyle.

FRACTURE CLASSIFICATION FRACTURE CLASSIFICATION (SCHATZKER)(SCHATZKER)

Type IType I (Pure cleavage) :(Pure cleavage) : A typical wedge-shaped uncomminuted fragment A typical wedge-shaped uncomminuted fragment

is split off the lateral condyle and displaced is split off the lateral condyle and displaced laterally and downward. This fracture is laterally and downward. This fracture is common in younger patients without common in younger patients without

osteoporotic bone.osteoporotic bone. Type IIType II (cleavage combined with (cleavage combined with

depression)depression) : :A lateral wedge is split off, but in addition the A lateral wedge is split off, but in addition the

articular surface is depressed down into the articular surface is depressed down into the metaphysis. This tends to occur in older people.metaphysis. This tends to occur in older people.

Type IIIType III ((pure central depressionpure central depression):):

The articular surface is driven into the The articular surface is driven into the plateau, the lateral cortex is intact. plateau, the lateral cortex is intact. These tend to occur inThese tend to occur in

osteoporotic bone. osteoporotic bone. Type IVType IV (fractures of medial (fractures of medial

condyle)condyle): :

These may be split off as a single wedge These may be split off as a single wedge or may be comminuted and depressed. or may be comminuted and depressed. The tibial spines often are involved. The tibial spines often are involved.

Type VType V (bicondylar fractures):(bicondylar fractures): Both tibial plateaus are split off. The Both tibial plateaus are split off. The

distinguishing feature is that the metaphysis distinguishing feature is that the metaphysis and diaphyses retainand diaphyses retain

continuity.continuity. Type VIType VI (plateau fracture with (plateau fracture with

dissociation of metaphysis and dissociation of metaphysis and diaphyses):diaphyses):

A transverse or oblique fracture of the A transverse or oblique fracture of the proximal tibia is present in addition to a proximal tibia is present in addition to a fracture of one or both tibial condyles and fracture of one or both tibial condyles and articular surfaces. articular surfaces.

Clinical FeaturesClinical Features

SwellingSwelling, , deformitydeformity, , extensive bruisingextensive bruising and and doughy feelingdoughy feeling of the joint due to of the joint due to hemarthroseshemarthroses..

Neurovascular examination is a must Neurovascular examination is a must (traction N. injury) (traction N. injury) TYPE IVTYPE IV may cause may cause neuropraxia of common peroneal nerve.neuropraxia of common peroneal nerve.

Examination under anesthesia may reveal Examination under anesthesia may reveal medial or lateral collateral ligament medial or lateral collateral ligament injuries.injuries.

Plain X-ray:Plain X-ray: AP, lateral, oblique AP, lateral, oblique views.views.

CT-scan with reconstructionsCT-scan with reconstructions:: visualize the exact comminution and visualize the exact comminution and articular depression.articular depression.

TreatmentTreatment Type I:Type I:

Non displaced:Non displaced: aspirate the aspirate the hemarthroses then plaster hemarthroses then plaster immobilization, partial wt bearing immobilization, partial wt bearing after 3weeks, plaster removal after after 3weeks, plaster removal after 4weeks, full wt bearing after 8weeks.4weeks, full wt bearing after 8weeks.

Displaced:Displaced: can be fixed with two can be fixed with two transverse cancellous screws.transverse cancellous screws.

Type II:Type II:

1.1. If If the depression is less than 5mm or the depression is less than 5mm or if instability cannot be demonstrated if instability cannot be demonstrated on stress, treatment is conservative.on stress, treatment is conservative.

2.2. IfIf the depression is severe or if the depression is severe or if instability can be demonstrated on instability can be demonstrated on stress, the articular fragments should stress, the articular fragments should be elevated and bone-grafted, and be elevated and bone-grafted, and the lateral cortex is supported with a the lateral cortex is supported with a buttress plate. buttress plate.

Type III:Type III:

The same as type II.The same as type II. Type IV:Type IV:

These fractures tend to angulate into These fractures tend to angulate into varus and should be treated by open varus and should be treated by open reduction and fixation with a medial reduction and fixation with a medial buttress plate and cancellous screws. buttress plate and cancellous screws.

Type V:Type V:

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

Type VI:Type VI:

Should be treated with buttress plates Should be treated with buttress plates and cancellous screws, one on either and cancellous screws, one on either side if both condyles are fractured.side if both condyles are fractured.

More recently, pin and wire fixators More recently, pin and wire fixators also have been advocated for fixation also have been advocated for fixation of these difficult fractures (illizarof). of these difficult fractures (illizarof).

ComplicationsComplications::

Early:Early: compartment syndrome, compartment syndrome, neurovascular injuries, fracture neurovascular injuries, fracture blisters.blisters.

Late:Late: stiffness, deformity, stiffness, deformity, osteoarthrits.osteoarthrits.

Fracture Tibia and FibulaFracture Tibia and FibulaSubcutaneous position, commonly Subcutaneous position, commonly

fractured and commonly sustain fractured and commonly sustain compound fracture.compound fracture.

Mechanism of injury:Mechanism of injury:

1.1. Twisting forceTwisting force (spiral fracture of (spiral fracture of

both at different level), usually low both at different level), usually low

force injury and the bone may penetrate force injury and the bone may penetrate

the skin from within.the skin from within.

2. Angulatory direct force2. Angulatory direct force (transverse or short oblique (transverse or short oblique fracture of both at the same level), fracture of both at the same level), high energy lesion and crushes the high energy lesion and crushes the skin over the bone.skin over the bone.

Clinical FeaturesClinical FeaturesPainPain, , swellingswelling, , bruisesbruises, , crushing the crushing the

skinskin, , open fractureopen fracture, , circulatory circulatory changeschanges, , check always for check always for impending compartment syndromeimpending compartment syndrome..

Plain X-ray:Plain X-ray: site, type, comminution, site, type, comminution, displacement, angulations, rotation, displacement, angulations, rotation,

state of nearby joints, old or new,state of nearby joints, old or new,

pathological or not…..pathological or not…..

ManagementsManagementsDepend on certain factors:Depend on certain factors: State of the soft tissue.State of the soft tissue. Severity of bony injury( spiral or Severity of bony injury( spiral or

transverse, comminuted).transverse, comminuted). Stability of the fracture( oblique, Stability of the fracture( oblique,

butterfly, comminuted) are unstable.butterfly, comminuted) are unstable.

Conservative treatments:Conservative treatments:For low energy fractures, minimally For low energy fractures, minimally

displaced, gustillow type I.displaced, gustillow type I. Reduction if neededReduction if needed (MUA); (MUA);

immobilization in a full POP cast from immobilization in a full POP cast from midthigh to metatarsal necksmidthigh to metatarsal necks..

If skin in doubt open a window for daily If skin in doubt open a window for daily observation.observation.

Elevation and observation for72 hours, after Elevation and observation for72 hours, after 2 weeks check x-ray, then partial wt. 2 weeks check x-ray, then partial wt. bearing till union(8-16weeks).bearing till union(8-16weeks).

Operative treatments:Operative treatments:Unstable high energy fractures, low Unstable high energy fractures, low

energy fractures cannot be hold energy fractures cannot be hold satisfactorily by conservative way.satisfactorily by conservative way.

1.1. Closed locked intramedullary Closed locked intramedullary nailing:nailing: the standard method for the standard method for most fractures.most fractures.

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

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

ComplicationsComplicationsEarly:Early:

1.1. Vascular injuryVascular injury:: rare, occur rare, occur with proximal fractures.with proximal fractures.

2.2. Compartment syndromeCompartment syndrome:: happen especially if (happen especially if (young patientyoung patient, , severe injurysevere injury, , delay treatmentdelay treatment, , shockshock, , excessive manipulation with excessive manipulation with long operationlong operation).).

3.3. InfectionInfection:: open fractures, after open fractures, after plate and screw fixation.plate and screw fixation.

4.4. MalunionMalunion..

5.5. Delay union and non unionDelay union and non union:: common( poor soft tissue, common( poor soft tissue, comminuted, segmental, compound, comminuted, segmental, compound, infected……).infected……).

6.6. Ankle and foot stiffnessAnkle and foot stiffness. .