MANAGEMENT

OF

TIBIAL PLATEAU

FRACTURES

RAJESH J. SAWARBANDHE

MANAGEMENT OF

TIBIAL PLATEAU FRACTURES

A

THESIS

FOR

M.Ch. ( ORTHOPAEDICS)

By

RAJESH J. SAWARBANDHE

UNIVERSITY OF SEYCHELLES

&

AMERICAN INSTITUTE OF MEDICINE ( USAIM)

2012

ACKNOWLEDGEMENT

I owe a great debt of gratiute to Dr. Anil Golhar,

M.S. (Ortho) , Hon. Professor & Head of the Department of

Orthopaedics, NKP Salve Medical College, Nagpur for his

valuable guidance & supervision in completing this work. It was

because of his suggestions & constant encouragement that I am

able to overcome my own shortcomings.

I am also thankful to Dr. Sushil Mankar, M.S. (

Ortho), Hon. Professor of Orthopaedics for his timely criticism

& overlasting help during the project.

I am also thankful to Dr. Ravi Bhajani, M.S. (

Ortho), Practicing in Nagpur for his guidance.

Rajesh J. Sawarbandhe

CONTENTS

S. No. Chapter Page No.

1. INTRODUCTION . . 1

2. HISTORICAL REVIEW . . 3

3. ANATOMY . . 6

4. REVIEW OF LITERATURE . . 13

5. MATERIAL AND METHODS . . 35

6. OBSERVATIONS . . 39

7. DISCUSSION . . 46

8. SUMMARY AND CONCLUSIONS . . 54

BIBLIOGRAPHY I to VII

INTRODUCTION

INTRODUCTION

The luxuries of our life in the present time is at the cost of rapidly

increasing industrialization, urbanization and mechanisation – so also the

traumatic cases are on increase. crowed cities, irregular traffic

arrangement, fast moving vehicles are the most important contributory

factors causing bony injuries, particularly polytrauma, comminuted

fractures and also the soft tissue injury. Tibial plateau fracture is one of

them.

Tibial plateau fractures have been studied and reported extensively

and exhaustively but still controversy exists over its management,

whether surgical or conservative. Excellent results have been published

in both groups. On one hand, we have got a group of surgeons who says

that most of the tibial plateau fractures [eighty-five percent] can be

managed by conservative treatment and on the other hand, other group

says conservative treatment means therapeutic nihilism and except for

undisplaced fracture every tibial plateau fracture should be operated upon

to achieve anatomical reduction and rigid internal fixation. Even

undisplaced tibial plateau fractures should be operated, so that early

mobilization of knee it is possible.

Before deciding the line of treatment one must bear in mind the

following facts :

1. Extent of damage in tibial plateau fracture is often greater than

what is seen on x-ray.

2. Malunion is exteremely common where as non-union is

unknown.

3. Painful knee and stiffness are the most serious and common

complications of the tibial plateau fracture.

In this small study, it is intended to outline the various principles of

management of tibial plateau fracture especially rigid fixation and to put

forward fresh clinical material to evaluate the results of surgical and

conservative methods.

HISTORICAL REVIEW

HISTORICAL REVIEW

Fractures of tibial condyles were brought into promience in 1929

by the papers of cotton F.J. Berg R. in Boston, and cubbins W.R., Seiffert

G. and coneley A.H., from chicago – mone calling them as fender

fracture and other as bumper fracture because they were often caused by

“automobile in contact with the jay walking citizens.”

Server J.W. had already reported three cases of fracture tibial

plateau in 1916 and discussed them again in 1922. During this time, most

of the fractures were treated by immobilization.

In 1940 Barr J.S. described the operative treatment of tibial plateau

fracture where depressed plateau is elevated by spike and supported by

cancellous bone grafts. This started a new era of operative intervention in

tibial plateau fractures, where anatomical reduction was thought to be

mandatory, so also support by variety of implants- [Foged J. 1943, palmer

I. 1951, jakobsen A. 1953, slee G. 1955, Turner V.C. 1959, Duparc J. and

ficate P. 1960, Courvoisier E. 1965, Fryjordet A. Jr. 1967].

During the same time, studies were carried out by many surgeons

by conservative approach and early mobilization of knee. In 1956, G.

Apley published the series of patients treated by skeletal traction and

early mobilization with excellent results. by this time, so many methods

of closed reduction and traction were published with excellent results.

[Inclan A. 1937, Dobelle M. 1941, Motz A.R., Householder R and

Depree J.K. 1943, Bagdley C.E. and o’connor S.J. 1952, Fyshe T.G.

1952, Lindholm R.V. 1954, Ilfeld F.W. and Hohl M. 1960 ].

In the meantime, different experimental studies were carried out.

Haldeman K.O. 1939, proved that hyaline cartilage is replaced by

fibrocartilage. Hohl M. 1956 proved that prolonged immobilization

leads to formation of intra-articular adhesions. Martin A.F. 1960 carried

out experimental study on dissected knee joints of cadevera and put

forward the machanism of injury. A.G. Apley, 1956, Hohl M. 1956,

Rasmussen P.S. 1973 put for ward the systeme of grading the results.

Moor T.M. and harvey J.P. [1974] deacribing the tibial plateau

view for measuring the exact depression of plateau. Fagerburg S. 1958,

Schioler G. [1971] and Elstrom j, panko vich Am, Sassoon H. of al

[1976] lauded the use of tomogram for the measurement of depression

and type of fracture. Many varieties of implants have been developed

and used to fix the plateau fracture.

Later AO [ASIF] described that the surgical treatment is mandatory

for tibial plateau fractures. Aim is to achieve anatomical reduction, rigid

internal fixation and early mobilization. They developed their own

contoured Buttress plates and DCP plates. AO PRINCIPLES for the

management of tibial plateau fracture have wide acceptance now a days.

Till the date, controversy still exists between the choice of the

treatment – conservative or surgical. But definitely trend is towards

operative treatment.

ANATOMY

ANATOMY

Anatomy of the upper end or tibia :

It is expanded, especially in its transverse axis, providing an

adequate bearing surface for the femur. It comprises of two prominent

masses, the medial and the lateral condyle and a smaller projection, the

tuberosity of the tibia. The condyles project backwards a little. Superiorly

each is covered with an articular surface, the two being separated by an

irregularly roughened intercondylar area. They form visible and palpable

landmarks at the sides of the ligamentum patellae, the lateral condyle

being mroe prominent.

The medial condyle is the larger, but does not overhang so much as

the lateral condyle. Its upper articular surface-oval in outline, is concave

in all diameters, and its lateral border projects upwards, deepening the

concavity and covering an elevaton, the medial intercondylar tubercle.

The posterior surface of the condyle is marked immediately below the

articular margin by a rough strip asperated from the medial surface of the

shaft by an inconspicuous ridge.

The lateral condyle overhange the shaft, especially at its

posterolateral part, which bears on its inferior surface a small circular

facet for articulation with an upper end of the fibula. The upper surface is

covered with an articular surface for the lateral condyle of the femur,

nearly circular in outline, it is slightly hollowed in its central part, and its

medial border extends upwards to the lateral intecondylar tubercle. The

anterior surfaces of the two condyles become continuous in front with the

tuberosity of the tibia.

The intercondylar area :

This area is a roughened area on the superior surface which

intervenes between the articular surfaces of the two condyles. It is

narrowest at its middle, where it is elevated into the intercondylar

eminence. The lateral and medial parts of the eminence project alightly

upwards, and constitute the lateral and medial intercondylar tubercles.

Both behind and in front of the eminence the intercondylar area becomes

wider, as the curved margine of the articular surfaces recede from each

other.

Knee Joint :

This joint occurs between the large, rounded condyles of the femur

and the much flattened condyles of the tibia. It is a midified syunovial

hinge type of joint. The knee joint is held together by a capsule that is

strengthened by the patellar ligament, and tibial and fibular collateral

ligaments; several intracapsular ligaments also aid in maintaining the

joint.

Capsule – The capsule completely surrounds the knee joint. Its

attachments to the femur area as follows. Anteriorly, the capsule is

attached to the arterior surface of the femur. Laterally, the capsule is

attached to the lines between the epicondyles and the condyles.

Posteriorly the superior edges of the rounded condyles serve as the line of

capsular attachment. The capsular attachments of the upper end of tibia is

shown in the diagram.

Patellar Ligament – The quadriceps tendon, the patella, and the patellar

ligament form the anterior wall of the knee joint. Lateral expansions from

the quadriceps tendon (retinaculi) blend with the capsular ligament.

Tibial Collateral Ligament – This thin band of ½ “ in width extends

from the medial epicondyule of the femur to the side of the tibia. It is

attached to the medial meniscus.

Fibular Collateral Ligament – This ligament is cord like and extends

from the lateral epicondyle of the femur to the head of the fibula. Unlike

the tibial collateral ligament, this is not attached to the lateral meniscus.

The intra articular structures are the semiliunar cartilages or

menisci, transverse, and two cruciate ligaments.

Meniaci :

These are two crescent shaped fibrocarilaginous plates that serve to

deepen the shallow fessae on the articular surface of the tibia. They are

firmly attached to the intercondylar region of the tibia but slightly

movable else where. The lateral meniscus is round in its outline, while the

medial appears oval. If a meniscus is cut in cross section, it is seen to be

wedge shaped, with the wide part peripherally located and the sharp edge

inside projecting into the joint cavity. The lateral meniscus is attached to

the intercondylar eminence. A cord of fibers stretch from the posterior

surface of this meniscus to the posterior cruciate ligament.

The medial meniscus is not as complete as the lateral; its

attachments to the intercondylar region are comparatively far apart.

Anteriorly it is atached to the lateral meniscus by a band of fibres

coursing transversely, the transverse ligaments.

Cruciate Ligaments :

These important ligaments are actually hold the femur and tibia

together and the name is derived from the fact that they across one

another. The anterior cruciate ligament arises from the anterior

intercondylar region of the tibia, and courses posteriorly and laterally to

attach to the posterior end of the lateral condyle of the femur on its

medial surface. This ligament become tense in extension of the joint,

prevents overextension, and is thought to induced the medial rotation

needed to lock the knee joint. The posterior cruciate ligament arises from

the psoterior part of the intercondylar region of the tibia, courses

superiorly in an anterior and medial direction to reach the medial condyle

and is atached to its lateral surface. This ligament becomes tense in

flexion of the joint and prevent overflexion, and may be involved in

locking the joint.

The knee joint is strengthened by various muscles that surround it.

They are the quadriceps femoris anteriorly; the biceps femoris laterally,

the sartorius, semitendinosus, and gracilis muscles medially and the

popliteus, gastrocnemius, semimembranosus, and plataris muscles

posteriorly.

The geometrical features of the knee joint cannot be appreciated

from standard anteroposterior and lateral x-ray and has been well studied

from specimens of amputed limb. The combined transverse diameters of

articular surface of femoral condyles is less anterior than posteriorly,

where condyles spread on each side of the intercondyular notch.

Therefore, in flexed position of knee, the posterior flared position of

femoral condyle is directed above tibial plateau and when knee is

extended, the narrower wedge shaped anterior surface of the femoral

condyle is opposed to the upper end of tibia. Viewed from the front , the

flexed knee resembles a flanged wheel rolling on the track. In extension,

femoral condyle comes like a bumper against the anterior margin of both

the menisci and the tibial condyles beneath.

The screwhome phenomena where by femur is internally rotated on

the tibia takes place in the last few degrees of extension. Because of this

internal rotation of femur and the juxtaposition of the narrowed anterior

part of the lateral femoral condyle to lateral tibial condyle when the knee

is extended , a substantial portion of the upper articular surface of the

lateral tibial plateau is left uncovered.

A routine x-ray shows (lateral view) a difference in the contours of

the femoral condyles, one is round from anterior to posterior while other

is flattened in its anterior quadrant. Examination of amputated specimens

reveal that the medial femoral condyle is uniformly semicircular in

contour. The upper surface of the lateral tibial plateau is uniformly

convex upward when seen from lateral aspect. The convexity is not

distinct on lateral x-ray. The tibial plateau is usually considered concave

on the AP x-ray. In reality it is saddle shaped facet, convex in sagital

plane and concave in coronal plane.

Normally the axial weight bearing thrust on the knee passess

thorugh the medial compartment of knee joint. This is reflected by the

trabecular pattern of the cancellous bone in the tibial condyle. In a

coronal section through the upper end of tibia, vertical trabeculations can

be seen extending from the medial cortex of the metaphysis upward to the

medial plateau. Beneath the articular surface here, there are intersecting

transverse trabeculae. The longitudinal trabeculae which extend from the

lateral cortex of the tibial metaphysis upward towards lateral tibial

plateau are less dense. The transverse trabeculae immediately beneath the

articular surface of the lateral tibial plateau are similarly thin. This subtle

but distinct difference is commonly visible on routine AP x-ray of upper

end of tibia and is an indication of the reactive vulnerability of lateral

tibial plateau to injury.

REVIEW OF LITERATURE

REVIEW OF LITERATURE

A] Mechanism of Injury :

Cotton F.J. and Berg R. (1929) considered it to be caused by the

fender of the automobile striking the extended leg of the “Jay Walking

citizens”. This was supported by Klin R. (1934).

According to Graham Apley (1956), when a straight Knee is

subjected to an abduction or valgus strain, the medial ligament may tear

or lateral tibial plateau may fracture. This view was also suggested by

Cubbins W.R., Conley A.H. and Callahan J. (1934). Later on Wilson W.J.

and Jacob J.E. (1952), Goylling U. and Lindholm R. (1953) suggested

that when the abduction force is combined with compression force,

fracture of tibial plateau may occur and this is the common mechanism.

Experimental study of Kennedy J.C. (1968) shows that forced abduction

and compression are necessary for the production of condyle fracture.

Forced abduction may cause external margin of the lateral femoral

condyle to press against the lateral tibial plateau. The levarge of the

femur acts on the plateau against the tensile strength of medial collateral

ligament and anterior cruciate ligament. Should the load on lever exceed

the tensile strength of tissue, the lesion may be a fracture or a ligament

injury or both. Forced vertical compression as in a fall from height

produce characteristic fracture configuration, usually T or T type. Pure

valgus or varus force tend to cause ligament tearing injuries rather than

fracture but when body weight is on the knee (axial compression) various

types of fracture configuration can occur. Twisting type of force can also

cause variety of fractures (Hymbert R. 1939).

According to Hohl M. and Robert Larson (1975) location and to

some extent the amount of depression in a fracture depends upon the

flexion angle of the knee at the moment of injury. With the knee in full

extension, the compression force is exerted anteriorly on the tibial

condyle. However, with knee in flexion, there is no such restrain on the

extent of compression, the medial or posterior part is usually involved.

MODE OF INJURY IN G. SLEE SERIES (1955)

Sr.No. Mode of Injury No. of cases

1. Bumper or fender fracture .. 17

2. Motor cyclist or cyclist .. 23

3. Fall from height .. 24

4. Strucki by falling object .. 10

5. Injuries by animals .. 5

6. Sports injuries .. 6

7. Miscellaneous .. 8

Total .. 94

Tibial plateau fractures are common in males. Commonly found in

middle age and old age. In Rasmussen P.S. series (1973) average age was

55 years.

The incidence and significance injuries to the collateral ligament

of the knee in association with condylar fracture have been studied by

Martin A.F. (1960), Forster E., Mole L. & Coblentz J. (1961), Reibel

D.B. and Wade P.A. (1962), Smillie I.S. (1962), Barrigton T.W. and

Dewar F.P. (1965).

Apart from clinical examination, diagnosis of collateral ligament

injury can be made by stress x-ray Martin A.F. (1960), Forster E., Mole

L. and Coblentz J. (1961) and Hohl M. (1967), Diagnosis can also be

made by examining the patient under anaesthesia. Recently arthroscopy is

also used for diagnosis of ligamental injuries in tibial plateau fracture

(Reiner M.J. 1982.)

J.C. Kennedy and W.H. Bailey (1968) in their experimental study

found only two specimens of ligamental injury. Graham Apley (1978)

said – bone gives way before excessive stress is placed upon the

ligament, that is why ligamental injury is less common than what is often

supposed. Angular, torsional and shearing forces which produce

disruption of the tibial condyle may avulse corresponding meniscus from

peripheral attachment or may tear its substance. (Bradford C.H., Kilfoyle

R.M> and Kellener J.J. (1950), Hohl M. and Luck J.V. (1956) and Wolf

M.D. & While E.H. (1963)].

The mechanism of ligamental injury in tibial plateau fracture is

already discussed in previous section and also shown in opposite

diagram. Early diagnosis and treatment of ligamental as well as meniscal

injury should be carried out so as to prevent instability

LICAMENTAL INJURIES IN RASMUSSEN P.S. SERIES (1973)

Sr.No. Ligaments No. of cases Percentage

1. Anterior cruciate ligament .. 14 5.4

2. Medial collateral ligament .. 10 3.8

3. Posterior cruciate ligament .. 1 0.4

4. Lateral collateral ligament .. 1 0.4

Total 26

B] CLASSIFICATION OF FRACTURES :

Many classifications have been put forward from time to time. Aim

of classification should be its practical utility for carrying out treatment

and prognosis.

a) Knight’s classification (1945) :

Type – I Lateral Condyle

a) Depression of the entries condyle is often associated with

a fracture of the neck of fibula. Complete tearing of the

collateral and cruciate ligament or avulsions of the tibial

attachment of the lateral condyle may also occur.

b) Lateral displacement of the rim of the tibial plateau with

depression and comminution of the central part of

condyle. This may be associated with ligamental injury.

Type – II Medial condyle

Depression of medial condyle is usually without

displacement of peripheral rim.

Type-III Inverted `T’ fracture of both condyles

a) Communited crushing fracture of entire plateau.

b) More severe fracture of one condyle than the other.

b) Watson – Jone’s classification (1955)

Type – I Depressed fracture

Without comminution

Without injury to articular surface

With displacement of fragment.

Type-II Comminuted fracture with separation of the margical

fragment. Often, there is severe injury to the articular

surface with displacement of fracture. It may be

associated with ligamental injury.

Gerald C. Slee’s Classification (1955)

Type – I Split fracture

There is a common type of fracture. The lateral edge of the lateral

femoral condyle is driven down into the articular surface of the

lateral tibial condyle causing a wedge shaped fragment of varying

size to become split off and is displaced outward. There is seldom

downward displacement of lateral fragment. Fracture is associated

with sprain of the medial ligament of varying severity. Similarly

the fracture of medial condyle with sprain of lateral ligament may

occur.

Type-II Compression fracture

Displacement caused by this injury ranges from depression of

anterior, posterior, lateral or medial part of the plateau with

comminution of the area to depression of whole condyle. Fracture

line from the non articular region of the tibial spine to the base of

the condyle and may be associated with the fracture of neck of

fibula. It is usually associated with collateral and anterior cruciate

ligament injury.

Type-III T or Y Shaped fracture

a) Both the condyles are fractured and displacement

outward and downward as one fragment. Their

particular surface appear to be undamaged.

b) Both the condyles fracture and displaced outward and

shows the features of compression.

d) Graham Apley’s classification (1956)

Type – I Linear fracture – vertical/ oblique

split or comminution – 1

Type – II Displaced fracture

- Slight displacement With or without

- Severe displacement Comminution

e) Hohl’s classification (1967)

This classification is excellent and provide a guide to optimum

treatment. Each type has got characteristic roetengenographic

features, problems, management and prognosis.

Type-I - Undisplaced fracture .. 24%

Type – II - Displaced fracture .. 76%

1. Local depession – Central depression .. 26%

– Split depression .. 26%

2. Total depression .. 11%

3. Split fracture .. 3%

4. Comminuted upper end of tibia .. 10%

f) John Robert’s classification (1968)

Type – I Non displaced fractures. A linear fracture may involve

the medial or lateral or both condyles. There is little or no

displacement. Fracture may be comminuted but still placed in this

group as the general contour of the surface of the tibial plateau is

undisturbed.. Fibula is usually intant.

Type – II Local depression type – For anatomical reasons this

fracture can occur only in lateral tibial plateau. There is a

circumscribed area of subchondral comminution or depression. The

mosaic like area of involvement lies in the anterior or central

portion of the lateral plateau. The peripheral rim and posterior

portion are intact. Proximal end of fibula is intact. Less commonly,

the depression fragment remains at or near the normal joint level.

Less commonly the depressed portion is confined to the posterior

quadrant of the plateau when knee was fixed at the time of injury

but fracture still classified as Type-II, if the stability of the joint is

maintained by intact or lateral fragment.

Type – III Significant displacement of peripheral fragment and

gross disruption of the articular surfaces are present. The knee joint

is rendered unstable because the peripheral portion is displaced

either literally or distally from its normal relation, to the

corresponding femoral condyle. Associated fracture of the

proximal part part of the fibula is commonly present.

g) John Kennedy & Bailey W.H. (1968) classification

Type – I - Abduction fracture

- Central

- Rim

- Complete Condylar

Type – II - Compression fracture : Central

Lateral

Anterior

Posterior

Type-III - Abduction and compression,

Type – IV - Explosive (T or Y type )

h) AO classification (Muller, M.E. , Allgower M. and

Willenegger H., (1970)]

Type – I - Pure wedge fracture : These are relatively rare and

occur most commonly laterally or posteriorly. If they occur

medially, then they give rise to a corresponding varus

deformity. The fracture plane is either in the frontal or sagittal

plane.

Type - II - Pure depression fracture : The result of valgus

overload. The lateral tibial plateau is pushed in by the lateral

femoral condyle. The plateau itself is not widened.

Type - III - Combination of types I and II with joint

depression and fracture of the lateral cortex. on the AP

projection, the plateau always appears widened. In the lateral

projection the anterior or posterior part of the articular surface is

either intact or depressed.

Type - IV – The Y and T fractures or comminuted fractures of

botrh condyles at times associated with fractures of the

intercondylar eminence. The lateral plateau is usually the more

severely damaged.

As far as anatomical distribution of tibial plateau fracture is

concerned lateral condyl is most commonly affected followed by

bicondylar fracture and lastly medial condyle.

Following table shows distribution of freactures in Rasmussen P.S.

Series (1973).

Condyle No. of cases Percentage

Lateral .. 183 70%

Medial .. 29 12%

Bicondylar .. 48 18%

Total .. 260 100%

Investigations :

Roetengenography is the most important investigation for

diagnosis of tibial plateau fracture. Antero posterior, lateral and oblique

views are sufficient to locate the site and type of fracture.

Stress x – rays give adequate clue of ligamental injury. Increase in

joint space more than one mm., when compared to the normal knee is

suggestive of ligamental injury. (Forster E., Mole L. and Coblentz J.

(1961), Hohl M. (1967)] Moor T.M. and Harvey J.P. Jr. (1974) the

method of taking tibial plateau view where AP view is taken with the

central ray directed at an angle of 105o to tibial crest. It permits accurate

measurement of tibial plateau depression.

Fagerburg S. (1958), Schioler G. (1971), Elstrom J. Pancovich Am,

Sasoon H. et. al . (1976) lauded the use of tomogram and showed that

displacement is often grossly underestimated on standard x-ray views and

that depression upon 7.5 mm. may pass unnoticed. Most striking failure

in examining plain x-ray is inability to distinguish clearly between the

mixed fractures. The value of tomogram in classifying fractures of tibial

plateau and in assessing the extent of fracture displacement and

depression is evident, from the following table.

Type of fractures

I II III IV Total

Plain x- ray 1 5 11 4 21

Tomogram 8 3 4 6 21

Verification at surgery 7 2 2 2 13

Recently arthroscopy has been used to examine the ligamental

injuries in tibial plateau fracture. [Reiner M.J. (1982).

TREATMENT :

Historically, the treatment part of tibial plateau fracture can be

divided into 3 phases. In the early days, immobilization was though to the

mandatory along with reduction of fracture. (Severe J.W. 1916, Cotton J.

and Berg R. 1929, Klin R. 1934, Perking G. 1940, Dobelle M. 1941,

Maisel B. and Cornell N.W. 1948, Dikson J. 1937, Fyshe T.G. 1952].

The second phase was of early active knee mobilization. [Badgley

C.E. and O’connor S.J. 1952, Fairbank T.J. 1955, Apley A.G. 1956, Hohl

M. and Luck J.V. 1956, Borrows H. 1956, Ilfeld F.W. and Hohl M. 1960,

Barrigton T.W. and Dewar F.P. 1965).

The last phase which has a wide acceptance nowadays is the

surgical treatment i.e. open reduction, internal fixation and early

mobilization [Foged J. 1943, Palmar I. 1951, Wilson W.J. and Jacob J.E.

1952, Jakobsen A. 1953, Slee G. 1955, Lee H. 1957, Dupare J. and Ficate

P. 1960, Rombold Charles 1960-, Courvoisier E. 1965, Fryjordet A. Jr.

1967, Muller M.E., Allgower M. and Willenegger H. 1970, Kennedy

W.R. 1978, Clyton Perry, Lawerence G. Evans, Semrile et.al. 1984].

Still the treatment of tibial plateau fracture is controversial.

Surgeon must choose that method or combination of methods best suited

to the clinical situation basing the choice on the reasonable demands of

the patient as well as medical condition, age, physical capability, on his

own professional experience and facilities available to him [Heppenstal

R.B. (1979).

The treatment of all types of intra-articular fractures aim at

restoration of normal joint function and preservation of late post-

traumatic osteoparthritis. Permanent or progressive disability in the knee

is caused by instability, angular deformity, restricted movement and pain.

(Hohl M. and Luck J.V. 1956).

The extent of damage in the tibial plateau fracture is often greater

than indicated by roetengenography, yet paradoxically patient frequently

does well than one prognosticate (Rombold Charles 1960).

Haldman K.O. (1939) studied the healing of intra-articular cartilage

and concluded that normal hyaline cartilage is replaced by fibrocartilage.

Healing of osteocarticular fracture was studied by Hohl M. and Luck J.V.

in 1956 on rhesus monkey and concluded that immobilization in

osteoarticular fracture for a long time will result in formation of

intraarticular adhesions and stiff knee.

In the initial days, immobilization was thought to be mandatory

during this time preferred regime was reduction with immobilization in

plaster. The force of manipulation can be augmented by using traction

table and compression claimp. (Watson J. 1955).

Inclan A. (1937) introduced a different method of treatment called

traction, compression and reduction.’ Hereunder anaesthesia heavy

skeletal traction is applied and compression is given at fracture site by

Esmarch bandage. If reduction is not achieved padded mallet is used to

press the displacedd fragment. Fyshe T.G. (1952) treated the patients with

immobilization in stader splint. Metz A.R., Householder R. and Depree

J.F. (1943) used larged pressure tonge maintain the reduction of fragment

with good results.

A.G. Apley 1956 published the results of conservative treatment

i.e. by putting a steinman pin two inch below the fracture, attempt to

reduce the fracture by traction and compression at fracture site. From next

day active knee bending exercises are given. Traction is continued for six

weeks. Excellent results were obtained. According to Hohl M. and Luck

J.V. (1967) tibial plateau fracture having depression less than five mm.

can be manged well by conservative treatment i.e. skeletal traction and

early knee bending exercises. Rusmusson (1973) used to treat most of the

patients conservatively except those having lateral instability (varus or

valgus more than 10o in extended position) y closed reduction and skeletal

traction or only skeletal traction. Recently Dennis Drennam and F.

Locher (1979) published the series of tibial platea fracture where patients

were treated by reduction followed by moulded hip spica with good

results. Eighty five percent of patients had good results.

RESULT OF FEW SERIES OF CONSERVATION TREATMENT

Sr.

No.

Author No. of

Cases

Excellent Good Fair Poor

1. Parey O. (1952) 22 11 - 8 3

2. Goylling and

Lindholm (1953)

47 6 25 13 3

3. Jakobsen A. (1953) 65 35 16 4 10

4. A.G.Apley (1956) 41 22 11 7 1

5. Perkin G. (1940) Excellent results were obtained.

6. Fairbank

T.G.(1955)

Excellent results were obtained.

While controversy over management of tibial plateau fracture

continues, excellent results of surgical treatment were shown by Palmer I.

1939 and 1951, Slee G. 1955, Duparc J. and Ficate P. 1960, Rombold

Charles 1960, Reibel D.B. and wade P.A. 1962, Courvoisier E. 1965,

Fryjordet Arne Jr. 1967, Gottofries A., Hagert G. and Sorensen S.E.

1971.

Palmer I (1952) said if there is any displacement or depression,

surgery should be performed and conservative treatment is the therapeutic

nihilism. Courvoisier E. (1965) stated that if there is any depression or

displacement, open reduction should be carried out. Hohl M. (1967) and

Rombold C. (1940) suggested open reduction and internal fixation when

depression is more than five mm. or when the lateral displacement is

more than one cm. Rasmussen (1973) did open reduction for valgus or

varus instability of 10o or more in extended position.

Moor T.M. and Harvey J.P. Jr. (1974) used the tibial palteau view

to measure the exact degree of depression before planning any surgery.

According to Elstrom J., Pankovich AM, Sasson H. et. al. (1976) before

planing any surgery tomography should be done to know the exact

depression, separation of fragment and type of fracture.

According to A.O. ASIF principles except for undisplaced

fractures, every plateau fracture should be operated to achieve anatomical

reduction and internal fixation.

Barr JS (1940) suggested the method of elevation of depressed

plateau, bone grafting and internal fixation. Autogenous bone grafts can

be augmented with bank bone. Methylmethocrylate has also been used

for fixation of fragment. (Kenney W.R. 1978).

Recently Clyton perry and Lawerence G. Evans and samrile

(1984) described a new approach where anterior horn of lateral meniscus

is incised and detached so that the split fragment can be opened like book.

Incision of the anterior horn minimizes the need to free the lateral

meniscus from its attachment.

Variety of implants have been used for internal fixation like Dowel

bone grafts, K wires (Turner V.C. 1959), wire loops (Rasmussen P.S.

1973), Gottfries A. Hagert CG and Sorensen S.E. 1971) Bolts and

washers (Barr J.S. and McAusland W.R. Jr. (1958), Hohl M. and Luck

J.V. 1956) Knowel pins (Robert J.M. 1968) Buttress plates T or L type

(Hohl M. 1967), Muller M.E., Allgower M. Wilengger H. 1970),

Cancellous screws : Charnely’s clamp (Black Burn J.W. 1977)].

Nowdays internal fixation with butress plate and cancellous screws

has been widely accepted.

Principle of Buttress plate : (Muller M.E., Allgower M. Wilenegger H.

1970) – a plate may be used to buttress or to support a thin cortical wall

and maintains its length. A buttress plate functions in a manner opposite

to tension band plate in that it is always under compression. Buttress

plates are used where cortices are thin, medullary bone is cancellous and

often compressed. They prevent the recurrence of slowly progressive

deformity with settling or bone absorption. Once the plate has been

applied, the fixation should be supported by packing cancellous bone

grafts into the defect to prevent the loss of height. A plate used as a

buttress is never under tension. Regular round hole ASIA – A.O. plate,

D.C.P. or contoured T or L plate can be used as a buttress plate.

Wilson and Jacob JS (1952) independently described an original

method of treating severely depressed comminuted fracture of lateral

tibial plateau where patella is removed and is used to replace the articular

surface of condyle. Lee H. (1957) used pear shaped graft from anterior

superior iliac spine to fill, the defect of articular surface of lateral

condyle.

Percutaneous bolting of minimally displaced fracture was

described by D’ Aubigne, R and Mazar F. (1960). Miller T.S. (1965)

published the report on closed reduction and traction followed by

percutaneous introduction of wire or pins under roentgenographic control.

Internal fixation recommended by A.O. ASIF is shown in diagram.

Ligamental repair – It has been a common practice over the years to

repair the bone damage and to expect theligamental injury to heal with

immobilization. Analyusis of results have shown that this does not occur

always. (Bick E.M. 1941, Knight R.A. 1945, Maisel B. and Cornell N.W.

1948, Bradford C.H., Kilfoyle, R.M. Kellecher J.J. 1950, Badgley C.E.

and O’Connor S.J. 1952, Hohl M., Luck J.V. 1956, O’Donoghue D.H.

1962, Solomen K.A. 1963). Maximum integrity of both soft tissue and

bone structure about knee joint will result in best possible function.

However, only few ligament in presence of condylar fracture have been

reported [Eliason E.L. and Eberling W.W. 1933, Naviaser J.S. and

Eisenberg S.H. 1956, Rombold Charles, 1960].

According to Muller, M.E., Allgower M. and Willenegger H.,

twenty percent of compression fracture of the lateral plateau are

associated with injuries of the medial collateraal ligament, which is either

avulsed out of bone or torn through its substance together with a tear of

the posterior capsule. Therefore, once the lateral plateau is reconstructed,

it is necessary to test the stability of the medial collateral ligament and

capsule by applying a valgus force with the knee first in full extension

and then in 30o of flexion. One must also test for meniscal injuries and for

injuries to the cruciate liagments.

When meniscus is torn, removal is indicated but when peripheral

attachment is torn, it can be sutured in place with little risk of subsequent

derangement (Hohl M. and Luck J.V., 1956).

RESULT OF FEW SERIES OF SURGICAL TREATMENT

OF TIBIAL PLATEAU

Sr.

No.

Name Year No.of

patients

Implants used Acceptable

results

1. Palmar I. 1952 37 Cancellous

screws and

bolts

80%

2. Dupare J. and

Ficat P.

1960 144 Bolts and

buttress

plates

62%

3. Barrington T.W.

and Dewar F.P.

1965 28 Bolts and

screws

50%

4. D’Aubigne R. and

Mazar F.

1960 28 Bolts and

screws

83%

5. Fry Jordet A. Jr. 1967 62% Bolts and

screws

62%

6. Hohl M. 1967 44 Bolts,

buttress

plates and

screws

72%

7. Rasmussen P.S. 1973 44 Circlase wire

bone grafts

87%

MATERIAL AND METHODS

MATERIAL AND METHODS

First 30 cases of tibial plateau fractures admitted in Indira Gandhi

Medical College and Mayo Hospital were studied from the date 1.3.1984

to 31.5.1985. All the cases were diagnosed, treated and followed

according to prescribed proforma.

Once the patient was admitted, x-rays were taken (AP and lateral),

posterior cast was given for support and analgesics and anti-inflammatory

drugs were given. All the associated injuries were treated accordingly.

Type of fracture was decided according to AO classification. Line of

treatment was decided according to the type of fracture, degree of

displacement and depression, and general condition of the patient. Out of

30 patients 15 were treated surgically and 15 were by conservative

method.

All displaced, depressed fractures were operated upon to achieve

anatomical reduction, rigid internal fixation and early mobilization.

Out of 15 patients treated conservatively i.e. by skeletal traction

and early mobilization, six were advised primarily conservative treatment

because of linear and undisplaced fracture, and nine were either those

who refused surgery or medically unfit patients.

Whenever conservative treatment was decided, patient was taken to

operation theatre. Under all stertile precautions, Steinman pin was

passedthrough the lower one-third of tibia. Haemarthrosis, if present was

aspirated and Jones bandage was given. No attempt was made to reduce

the fracture. The patient was shifted to the ward, where affected limb was

kept on Bohler’s splint and traction of 2 ½ kg. was applied. Quadricepa

exercises were begun from the next day. Guarded knee bending exercises

were started from 7th

day. Average duration of skeletal traction was 4-6

weeks. Before discharge range of movement, angular deformity were

measured and check x-ray was also done. Patient was discharged with the

instruction of knee bending exercise, quadriceps exercisee and non

weight bearing. Patient was followed every month, at each visit check x-

ray was done, range of movement angular deformity, were measured.

Patients’ complaints were noted and data was filled in the proforma.

Partial weight bearing was started between 10-12 weeks while complete

weight bearing was started approximately between 12-16 weeks.

Whenever surgery was decided, patient was thoroughly

investigated, affected knee and iliac crest was prepared. All patients were

operated under spinal anaesthesia and tourniquent. In all patients,

parapatellar approach (medial or lateral) was preferred. Once fracture site

was exposed, depression and displacement was noted by elevating the

meniscus.

In type-I fracture when wedge was small, it was fixed by

cancellous screws while when wedge was large, buttress plate was used.

In type-II fracture, elevation of depression was carried out by

introducing a spike through the window in the cortex. Subarticular space

was filled by cancellous bone grafts. Elevated articular surface was

supported by placing single or double cancellous screws.

In type-III, reduction, elevation, bone grafting followed by fixation

by cancellous screws and buttress plate was done.

In type-IV fracture, reduction, elevation, bone grafting and

followed by fixation by double T plates and cancellous screws was

carried out.

Check x-rays were taken in the operation table before closing the

wound. Post-operative treatments consists of antibiotics, analgesics,

quadriceps exercises.

Gentle knee bending exercise was started after 72 hours while

vigorous knee bending exercise and crutch walking with non weight

bearing was allowed after removal of stitches. Patient was discharged

with the instruction of knee bending exercise, quadriceps exercise and

non weight bearing. Range of movement was noted. Patient was followed

every fifteen days. Every month angular deformity, loss of extension,

pain, and range of knee movement was measured so also check x-ray was

done. All the data obtained were filled in the proforma. Non weight

bearing continued for approximately 10-12 weeks, complete weight

bearing was started aftter 12 weeks.

OBSERVATIONS

OBSERVATIONS

Total 30 patients were studied in this series. Observations made are

given below :

A] Age and Sex Distribution ;

In this study most of the patients belong to the middle age. Mean

age was aproximately 45 years. As far as the sex ratio is concerned, out of

30, 25 were males and only 5 were females. Male to female ratio was 5:1.

Graph of opposite page gives the details of age and sex distribution.

B] Mode of Injury :

In this study, vehicle accidents and fall from height were the

common modes of injury. Minor fall or slip was also an important mode

of injury particularly in the old age.

Following table shows mode of injury in our study.

Sr.

No.

Mode of trauma No. of cases Percentage

1. Minor fall 11 36.66%

2. Fall from height 7 23.33%

3. Struck by vehicle 6 20.00%

4. Fall from vehicle 4 13.33%

5. Unknown 2 6.60%

C] Anatomical Distribution :

As far as the involvement of knee joint is concerned, table shows

that it is approximtely equal in both the knees.

Sr.

No.

Side No. of patients

1. Right knee 16

2. Left knee 14

Distribution of fracture among the medial condyle, lateral condyle

or bicondylar fracture is shown in the following table.

Sr.

No.

Condyle/ Condyles No. of cases Percentage

1. Lateral Condyle 25 83.33%

2. Medial Condyle 1 3.33%

3. Bicondylar 4 13.33%

Total 30 100.00%

D] Associated Injuries :

Although majority of fractures of tibial plateau in the series were

caused by vehicle accident and fall from height, only few patients had

other significant associated injury.

Sr.

No.

Associated Injury No. of cases

1. Head injury 1

2. Fracture spine

compression type – L1

1

3. Fracture calcaneum – Rt 1

4. Fracture nasal bone 1

5. Fracture right radius, ulna and fracture shaft of

humerus right

1

6. Visceral injury 0

7. Contusions 8

E] Classification of fractures :

In all cases, after admission AP and lateral x-rays were taken to

classify the type of fracture. Fractures were classified according to AO

classification.

Sr.

No.

Type of fracture No. of cases Percentage

1. Type – I 4 13.33%

2. Type – II 12 40.00%

3. Type – III 10 33.33%

4. Type – IV 4 13.33%

When type of fracture was compared with the age group, was

found that type-II and type-III were more common in old age so also

minimal trauma was required. Pure wedge fractures and bicondylar

fractures were common in younger age group and also violent trauma was

required.

F] Ligamental injury :

In our study, only two patients had medial collateral ligament

injury. In one case it was partially avulsed from its femoral attachment. In

other case, it was accompanied by anterior cruciate ligament injury, repair

was carried out. This patient had type – IV undisplaced fracture. Overall

incidence of ligamental injury was ten percent. One patient who was

operated for type – II fracture had detached lateral meniscus which was

removed at surgery.

Sr.

No.

Ligament No. of cases

1. Medial collateral ligament 2

2. Anerior cruciate ligament 1

3. Posterior cruciate ligament 0

4. Lateral collateral ligament 0

5. Meniscal injury – lateral 1

G] Treatment :

Out of 30 patients, 15 patients were operated to achieve anatomical

reduction and rigid internal fixation, 15 other patients were treated

conservatively i.e. by skeletal traction and early knee mobilization.

Average duration of hospitalization of these patients shown in the

following table :

Sr.

No.

Duration Surgically

treated patients

Conservatively

treated patients

1. 1-2 Week 4 0

2. 2-3 Week 5 0

3. 3-4 Week 5 6

4. 4-6 Week 1 9

Common complications noted during hospitalization are infection

or pintract infection, chest infection and bed sores. In all the 12 cases who

had infection, with the course of routine antibiotics it was subsided. No

case of deep seated infection or chronic osteomyelitis was noted.

Mortality rate was nil.

Sr.

No.

Complication Surgically

treated

patients

Percentage Conservatively

treated

patients

Percentage

1. Infection 5 33.33% 7 46.66%

2. Chest Infection 2 13.33% 5 33.33%

3. Bed sores 0 - 2 13.33%

4. Other

complications

0 - 0 -

Patients were discharged once the wound was dry, and has

understood the necessary instructions and after discharge, patients were

followed regularly to know the range of movement and residual

disabilities. Average knee flexion in surgically and conservatively treated

patients at the end of 1st, IInd and IIIrd month is given in the graph on

opposite page.

Brief account of residual disabilities is given in the following table.

Sr.

No.

Method of

treatment

Angular

deformity

Pain Instability Loss of

muscle

Lower

Loss of

extension

-10o More

than

20 o

+ ++ +++ Less

than

10

More

than

10

1. Surgery 2 Val. 1

Val.

4 - 1 - 2 2 1

2. Conser- 3 Val. 2

Val.

6 2 1 1 3 3 2

Out of three surgically treated patients, two had valgus deformity

and one had varus deformity. All the five conservatively treated patients

had valgus deformity of varying degree.

Residual pain was classified in to three; + means occasional ache,

++ means pain after walking a distance and +++ means pain at rest.

Details are given in the chart.

Instability was found in only one patient who had anterior cruciate

ligament injury with type-IV undisplaced fracture. Patient was operated

later on.

Loss of muscle power was found in 5 patients. It was

approximately grade-IV power. In all case, it was a symptomatic. Loss of

extension was found in 8 patients – 3 surgically treated patients and five

conservatively treated patients, details of which are given in the chart.

One patient who was operated for type-IV fracture had loosening

of fixation with poor result.

ANALYSIS OF THE RESULT

Sr.

No.

Result Criteria Surgicallly treated patients Conservatively treated patients

Type I Type

II

Type

III

Type IV Total % Type

I

Type II Type

III

Type IV Total %

1. Excellent - Knee is normal

- No interference in patients

work.

- No ache and no swelling.

- Full range of movement

1 3 4 0 8 53.33 1 3 0 1 5 33.33

2. Good - Knee barometric

- Slight limitation to full

flexion otherwise normal

- Does not interfere with day-

to-day work

0 2 1 1 4 26.66 0 2 2 1 5 33.33

3. Fair - Knee hampered the patients

slightly

- Ache after exercise

- Swelling sometime.

- Little limitation to the

movement.

1 0 1 0 2 13.33 0 2 0 0 2 13.33

4. Poor - Knee was worse than fair 0 1 0 0 1 6.66 0 1 1 1 3 20.00

Total 2 6 6 1 15 100.00 1 8 3 3 15 100.00

DISCUSSION

DISCUSSION

Osteoarticular fractures particularly tibial plateau fractures still

possess the problem of stiff knee and early osteoarthritis. It’s

management still remains controversial, whether surgical or conservative.

Both the schools have divergent thoughts and have published excellent

results. Keeping in mind the controversity of management this study of

30 cases was carried out. Out of 30, 15 patients were treated surgically

and 15 conservatively. All the patients were admitted, treated and

followed regularly.

Common modes of injury in this study were minor fall (36.6%),

vehicle accidents (33.3%) and fall from height (23.33%). This fracture

usually occurs in middle and old age probably due to reduced strength of

subarticular calcellous bone. In Rasmussen P.S. (1973) series average age

was 55 years. In our study, average age was 45 years. Male of female

ratio was 5:1 which corresponds to most of the series.

Antero-posterior, lateral and oblique x-rays are sufficient to

diagnose the extent of depression, displacement and type of fracture.

Tibial plateau view suggested by Moor T.M., Harvey J.P. (1974) is useful

to evaluate the extent of depression. Stress x-rays (Forster E., Mole L.,

Coblentz J. 1961, Martin A.F. 1960) are useful in diagnosis of ligamental

injury.

In our study we preferred AO Classification because it is simple,

uncomplicated and no special x-rays are required. Its practical utility to

carry out treatment and prognosis has got an upper hand. Although

Hohl’s classification is detailed and excellent, it is complicated.

From the observation tables, it is clear that type II and III i.e.

depression type of fractures are more common followed by type IV and I.

In Hohl M. and Luck J.V. (1956) series depressed type of fractures were

63.3%. In our study, it was 72.6%. According to Muller M.E., Allgower

M. and Willengger H. type I is uncommon, but in our study it was

13.33%. Type IV fracture is usually found in pure compression type of

injuries. Type II and III are commonly found in old persons while type I

and IV are commonly found in young patients – this is shown in the

graph.

Frequency of involvement of right and left knee is same. In our

study it was 16:14. Lateral condyle is most commonly affected followed

by medical condyle and finally bicondylar. (Hohl M. 1967). But in our

study following lateral condyle (83.33%) next in frequency was

bicondylar fracture (13.33%) and finally medial condyle (3.33%).

Diagnosis of ligamental injuries should be made at the earliest to

prevent residual disabilities. In Rasmussen P.S. series (1973) overall

incidence of ligamental injury was 2.5%. According to Schulak D.J. and

Gunn D.R. (1975) wedge and bicondylar fractures are commonly

associated with ligamental injury. According to Muller M.E. , Algower

and Willengger depressed type of fractures are very commonly associated

with ligamental injury (20%). In our study incidence of ligamental injury

is 10% (2 Medial Collateral ligaments and 1 anterior cruciate ligament).

In our study 15 patients were treated surgically. Indication of

surgery was either depression or displacement Aim of Surgery was to

achieve anatomical reduction, rigid internal fixation and early

mobilization. Indication of surgery varies in different series.

We have followed AO Technique which is given in diagram. DCP

plates, Buttress plates and cancellous screws were used. For type II, III

and IV bone grafts were used. Surgery requires skill, proper technique

and instrumentation. Check x-rays were done before closing the wound,

stability of the joint was tested. Associated ligamental injury should be

repaired at the time of Surgery. Knee bending was started after 72 hours,

while mobilization with crutches was allowed after removal of stitches.

Average duration of hospitalization was 21 days. It is because of high rate

of post-operative wound infection (33.3%).

As far as conservative treatment is concerned, we employed

Apley’s method of skeletal traction and early mobilization. No attempt

was made to reduce the fracture. Average duration of hospitablization

ranges from 4 to 6 weeks. Two patients had bed sores, while incidence of

chest infection is higher in conservatively treated patients. Incidence of

pin tract infection was 46.66 (7 patients).

Awareness of the factors producing permanent disability after tibial

condylar fractures permits critical appraisal of current methods of

treatment. These factors are limited motion, instability, angular

deformitym, lack of full extension, pain and post-traumatic arthritis and

muscle weakness.

A decided trend towards earlier mobilization of the knee after tibial

condylar fractures have reduced the incidence of stiff knee by preventing

the formation of intra articular adhesions. In our study average range of

flexion at the end of 3rd

month was almost same (105o) in both the

surgically and conservatively treated patients.

The early recognition and surgical repair of ruptures of the

collateral ligaments result in restoration of knee stability when no

fractures is present. The same treatment of ligament injuries when they

are combined with bone injuries that require open reduction should

minimise the residual instability (Hohl M. 1956). In our study instability

was present in only one patient had anterior cruciate ligament and medial

collateral ligament injury with type IV fracture which was repaired.

Late valgus or varus deformities result from incomplete fracture

reduction, collapse of soft cancellous bone beneath the articular surface

during healing, or thinning of articular cartilage. Many patients with these

deformities complain of pain in the medial side of the knee and required

support at times. The long term effect of such deformities is post-

traumatic arthritis. Genu valgus is observed commonly after central

depression fractures which are treated conservatively. Stable tibial

condyles, properly aligned on the femoral condyles are essential to

prevent angular deformity of the knees. In our study angular deformity

was present in 3 surgically treated patients (2 valgus and 1 vargus) and

five (5) conservatively treated patients (valgus).

Lessening the duration of rigid immobilization and insisting upon

early movement, always starting and ending movement with the knee in

full extension prevent limited extension. This principle applies to traction

treatment. 3 operated and 5 conservatively treated patients had loss of

extension of variable degrees.

Disabling pain years after a tibial condylar fracture is uncommon,

although discomfort is noted frequently. Often the discomfort is on the

medial side over the collateral ligament and is the result of chronic strain.

Less often the pain is localized in the previously injured compartment of

the knee and is caused by the traumatic arthritis that results from irregular

surfaces, angular deformity , or degeneration of the articular surface.

Prevention of late valgus or varus deformity seems essential to minimize

the later development of knee pain from strain or traumatic arthritis. In

our study, occasional acheme which is insignificant and was more

common in conservatively treated patient. Pain at rest was present in one

surgically treated patient and three conservatively treated patients.

Muscle Weakness was present in five patients (16.6%). It was

almost grade IV. But in all cases, it was asymptomic.

On an average incidence of residual disabilities was more in

conservatively treated than surgically.

Partial weight bearing was started between 12 to 16 weeks. This

corresponds to most of the series.

Results of treatment depends upon final outcome of the patients.

Hohl M. and Luck J.V., 1956, Rasmussen P.S. (1971) put forward

excellent methods of grading the anatomical and functional results. But

both the systems are complicated. In 1956 G. Apley put forward the

simple method of grading the results, which is utilized in our study.

In surgically treated patient, acceptable results were obtained in

80% of patient (excellent 53.33% and good 26.66%) which corresponds

to series of Palmer I. (1959), Rasmussen P.S. (1973). Poor result was

obtained in one patient who had tyupe IV fracture with varus deformity of

20o

, loss of extension of 10o

, pain at rest and loosening of fixation.

About 93.33% patients were satisfied with the final result, and resumed

their duties. Only drawback of our treatment was high rate of infection

(33.33%) and long duration of hospitalization (25 days).

Those who were treated conservatively excellent results were

obtained in 33.33% (5 patients), good in 33.33% (5 patients) fair in 2

patients (13.33%) and poor in 3 patients (20%). Overall results

corresponds to series of Jakobsen A. (1953), Parey O. (1952) and A.G.

Apley (1956). Drawbacks of conservative treatment were pintract

infection (46.66%) chest infection (33.33%) bed sores in 2 patients

(13.33%) and high rate of residual disabilities.

SUMMARY AND CONCLUSION

SUMMARY & CONCLUSIONS

30 cases of tibial plateau fracture were treated and studied in Indira

Gandhi Medical College and Mayo Hospital. Fractures were classified

according to AO classification. 15 patients treated surgically i.e.

anatomical reduction, rigid internal fixation and early mobilization. 15

patients were treated conserevatively i.e. skeletal traction and early

mobilization. All the patients were following regularly.

Following conclusions were drawn :

1. Tibial plateau fractures are common in middle and old age (average

age is 45 years). More common in Males (Male to female ratio is

4:1) because of more outdoor activities.

2. Vehicle accidents, fall from height and minor fall are the common

modes of injury.

3. Type II and III (Depression type) fractures are more common than

type I and IV.

4. Incidence of ligamental injury is 10%.

5. Duration of hospitalization is more in conservatively treated

patients.

6. Incidence of post-operative infection is 33.33% while pin tract

infection is conservatively treated patients was 46.66%.

7. Chest infection and bed sores are common problems of

conservative treatment since the patients are bed ridden.

8. Overall incidence of residual disabilities is high in conservatively

treated patients.

9. Acceptable results were obtained in 80% of surgically treated

patients, and 66.66% of conservatively treated patients. Poor

results are frequently seen in conservatively treated patients.

10. Overall surgical treatment is useful in ostechondral fractures of

tibial plateau particularly depressedand displaced. It is associated

with very few complications provided it is carried out properly.

11. Conservative treatment is useful in undisplaced and minimally

displaced fractures but incidence of residual disabilities is high.

BIBLIOGRAPHY

BIBLIOGRAPHY

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MASTER CHART

Sr.

No.

Name Age Sex Mode

of

Injury

Type of # Associated

Injury

Ligt.

Status

T/t Post

operative

complication

Duratio

n of

hospitalizn.

Range of movement Wt. bearing Angular

Deform.

Residu

al pain

Loss

of

Extension

Muscle

Power

Instability Result

I II III Pa C

1 AB 38 M Un II,R,Lt Head Inj. Nil C Nil 30 90 110 120 10 14 Nil + Nil V Nil E

2 AKL 49 F Mf III,R,Lt Nil Nil C PTI,

Chest, inf.

30 100 110 110 12 16 20 Val. +++ 20o IV Nil P

3 AVP 25 M Fh I,L,Lt. Contusion Nil C Chest Inf. 45 90 110 120 12 16 10o Val. ++ 10o V Nil F

4 BDT 49 M Fv II,L,Lt. Nil Nil C PTI 45 100 110 110 10 14 Nil Nil Nil V Nil E

5 BH 50 M Mf IV, R Nil Nil C PTI 40 70 90 110 12 16 Nil Nil Nil V Nil G

6 BM 58 M Mf II, R,Lt. Nil Nil C Bed Sore 39 70 90 100 10 14 Nil + Nil V Nil G

7 CHK 40 M Mf III,R,Lt Nil Nil S Sup. inf. 21 60 80 90 12 16 Nil Nil 10o V Nil F

8 CHRT 34 M Sv II,R,Lt. Nil Nil S Suf.inf. 27 90 100 120 12 16 Nil + Nil V Nil E

9 DAD 35 M Un I,R,Me Contusion Nil S Chest inf. 20 90 100 120 10 14 Nil NIl Nil V Nil E

10 BDS 65 M Fj III, L, Lt Contusion Nil S Nil 10 90 100 110 10 14 Nil NIl Nil V Nil E

11 GLT 50 M Mf II, R, Lt Nil Nil S Nil 20 90 110 110 12 16 Nil NIl Nil V Nil E

12 GML 54 M Sv III, R, Lt Nil Nil S Chest inf. 15 60 90 110 10 14 Nil + Nil V Nil G

13 KGJ 50 M Mf IV, R Nil Nil S Sup. inf. 48 60 90 110 12 16 Nil + Nil V Nil G

14 KKP 58 F Fh III, R, Lt Nil Nil C PTI, chest

inf.

30 70 90 100 12 16 Nil + Nil V Nil G

15 KRP 39 M Mf IV, L Nil ACL, MCL

C PTI 30 90 110 120 12 16 Nil + Nil V + E

16 MCG 40 M Fv II, L, Lt Contusion Nil C Nil 30 90 110 120 12 15 Nil + 10o IV Nil F

17 MGK 58 M Mf II, L, Lt Nil Nil C Nil 15 70 90 110 10 14 Nil Nil Nil V Nil E

18 MOK 49 M Sv I, R, Lt. Multifractur Nil C Chest Inf. 45 70 90 110 10 14 Nil + NIl V Nil E

19 MTK 60 F Fh III, L, Lt #Contusion Nil S Nil 30 90 110 110 12 16 20o Val. +++ 16o IV Nil P

20 MW 28 M Fh II, L, Lt Contusion Nil C Nil 45 70 80 100 12 16 Nil + NIl V Nil G

21 NZK 47 M Mf II, L, Lt Nil Nil S Nil 20 70 90 110 10 15 Nil NIl NIl V Nil E

22 RP 48 M Fv I, L, Lt Nasal b. # Nil S Sup. Inf. 21 90 110 110 12 16 10o Val. Nil 10o IV Nil F

23 SDK 26 M Fh III, L, Lt Nil Nil S Sup. Inf. 21 100 120 120 12 16 Nil Nil NIl V Nil E

24 SMN 27 F Mf II, R, Lt Contusion LM S Nil 16 80 100 100 12 16 Nil + NIl V Nil G

25 SSB 40 F Fh II, L, Lt # Spine MCL C PTI 40 90 110 120 14 16 Nil Nil NIl V Nil E

26 SSG 42 M Mf III, L, Lt Contusion Nil S Nil 11 90 100 120 12 16 Nil + NIl V Nil E

27 TK 60 M Sv II, R, Lt Nil Nil C Bed sore 30 70 100 110 10 14 10o Val. ++ 10o V Nil P

28 PKD 40 M Sv III, R, Lt Contusion Nil S Nil 18 70 90 100 14 16 10o Val. + NIl V Nil G

29 VWG 30 M Fv IV, R Nil Nil C Chest Inf. 40 70 90 110 12 16 20o Val. +++ 20o IV Nil P

30 WVT 40 M Sv III, L, Lt Nil Nil C PTI 45 80 90 100 12 16 10o Val. + Nil V Nil G

ABBREVIATIONS

1. Acl : Anterior Cruciate ligament

2. C : Complete

3. E : Excellent

4. F : Fair

5. Fh : Fall from height

6. Fv : Fall from vehicle

7. G : Good

8. Inf : Infection

9. Lm : Lateral meniscus

10. Lt : Lateral

11. Mcl : Medial collateral ligament

12. Me : Medial

13, Mf : Minor fall

14. P : Poor

15. Pa : Partial

16. Sv : Struck by vehicle

17. Un : Unknown

18. Val : Valgus

19. Var : Varus