MANAGEMENT OF TIBIAL PLATEAU FRACTURE

DR.KHADIJAH NORDIN

Introduction

• one of the most critical loadbearing areas in the human body.

• Goal of management:– Restore joint congruity– Preserved normal mechanical axis– Stable joint– Restore knee motion

• Issues – Severe comminution– Variable bone quality– Overlying soft tissue injury associated injury to• Cartilage• Meniscus• Stabilizing ligament

– Underlying medical condition– Financial background

Low n high energy 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

Clinical presentation

• History– High energy trauma in young– Low energy trauma in elderly

• Assessment– Open or closed fracture– Compartment syndrome– Instability– Neurovascular– ATLS

Imaging • Radiographs

– Knee AP/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

Personality of fracture

• Soft tissue damage• Degree of dislocation• Degree of comminution• Degree of join involvement• Osteoporosis• Nerve / blood vessel injury

Classification

• Schatzker classification• AO/OTA• Three column classification

Schatzker classification

AO/OTA classification

The three column classification

• 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

Management

• Non operative• Operative

Non operative

• No joint step >2mm• No axial instability• Severe osteoporosis• General and local contraindication

• Method:– Protected weight 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

Emergency operative treatment

• Vascular injury• Compartment injury• Open fracture injury• Gross dislocation• Floating knee• Polytrauma

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

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

Principle of surgical management

• Goals of treatment• Reconstruction of articular surface• Re-establisment of tibial alignment• Stable construct• Early ROM

• Reducing and buttressing 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

Surgical approach

• Straight midline• Anterolateral• Posteromedial• Two approaches for bicondylar fracture• MIPO

• 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

• 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.

• 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.

Implant option

• Choice of 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

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

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

Ring external fixation

• Indication– Severe open fracture

with bone loss– Fracture with loss of soft

tissue cover

Plate osteosynthesis• Minimal invasive 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

Schatzker I• Closed reduction 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

Schatzker II• Open reduction 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

Schatzker III

• Open reduction/ arthroscopic assisted

• Anterolateral approached

• Elevation through a metaphyseal window

• Temporary k-wire• Bone grafted• Subchondral plate/

screws

• Medial buttress plate– Counteract the shear

forces acting on the medial plateau

– Lag screw alone not sufficient to stabilize the fracture

Schatzker IV

• Required lateral and medial stabilization of fracture

• Stabilization– Double plating– Locking plate– External fixators

Schatzker V

Double plating complete articular fracture

• Two incision:– Anterolateral and

posteromedial• Indication:

– Displaced posteromedial fragment need to be buttressed with posterior plate

– Medial articular involvement

– Displacement of medial column

Thank you