the tibial plateau mechanism of injury...
TRANSCRIPT
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The Tibial Plateau Fracture
Walter Mak, MD
Department of Medical ImagingSt. Michael’s HospitalUniversity of Toronto
Mechanism of Injury
Acute knee trauma
Knee dislocation Tibial Plateau Fracture
Plain filmMRI+/- CT angiogram
Plain filmCT+/- CT angiogram
Restore ligamentous/soft tissue stability
Restore osseous stability
Where is the fracture?
Where is the fracture?
Lateral plateau fracture
Where is the fracture?
Medial plateau fracture
High energy trauma
High association with cruciate ligament and neurovascular injury
Almost always treated with open reduction and internal fixation (ORIF)
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Where is the fracture?
Medial plateau fracture,ground level fall
Varus malalignmentpoorly tolerated longterm
Usually undergo ORIF
Courtesy Dr. Ivan Diamond
Where is the fracture?
Bicondylar fracture
High energy mechanism
Almost always treated surgically
Where is the fracture?
Posterior shear fracture
Coronal fracture plane on lateral view
Direct posterior surgical approach
Bhattacharyya T. et al. J Orthop Trauma 2005, 19:305-310
Where is the fracture?
Posterior shear fracture
Coronal fracture plane on lateral view
Direct posterior surgical approach
Bhattacharyya T. et al. J Orthop Trauma 2005, 19:305-310
Is there a split and/or depressed component?
Split and/or depression?
Depression Fracture
Impaction of cancellous bone
Low energy, osteoporotic bone
During ORIF, grafting of defect may be required
Markhardt et al. Radiographics 2009; 29:585-597
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Split and/or depression?
Split Fracture
Shearing force splits plateau
Higher energy, normal bone
Usually see with depressed component
Split and/or depression?
Split fracture
No articular surface depression
ORIF without grafting
Split and/or depression?
Split-depression fracture
Very common, often clinically unstable
Split and/or depression?
Depression fracture lateral plateau
No split component
Pure depression fractures of lateral plateau often clinically stable
Is there articular incongruity?
Articular incongruity?
Articular surface depression
Measured using opposite plateau or remaining intact surface
Measure to point of maximal depression
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Condylar widening
Condylar widening
Overhang of tibial plateau in relation to femoral condyles
Sum of overhang medially and laterally if appropriate
Articular Surface Incongruity
How much is ‘too much’?No uniform consensus
Articular surface depression: >4mm at SMHCondylar widening: >4mm at SMH
Depression/widening ≥2 mm should be reported
Is there metadiaphyseal dissociation?
Metadiaphyseal Dissociation
High-energy mechanism, significant soft tissue and neurovascular injury
Tibial articular surface completely dissociated from diaphysis
Comminution of one or both tibial plateaus and articular surface
Metadiaphyseal dissociation?
Always undergo ORIF
Formal ORIF while soft tissue injuries addressed
Temporary external fixation, delayed ORIF
What other fractures are present?
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Associated fractures?
Tibial tuberosity avulsion
May result in extension lag if not fixed
Associated fractures?
Intercondylar eminence fracture, cruciate ligament avulsion
Fixed at time of ORIF if amenable to screw/suture fixation
Addressed in delayed fashion if comminuted and residual instability
Associated fractures?
Fibular head fracture –posterolateral corner injury
Timing of ORIF and/or ligament reconstruction varies
Value of CT
Value of CT: Fracture characterization
Medial plateau fracture?
CT reveals split componentthrough lateral plateau
Bicondylar fracture; surgical approach altered
Value of CT: Fracture characterization
Medial plateau fracture?
CT reveals split componentthrough lateral plateau
Bicondylar fracture; surgical approach altered
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Value of CT: Assessing articular incongruity
Depression may be underestimated on plain film
6 mm depression confirmed on CT
Value of CT: Associated Fractures
Medial plateau fracture
Intercondylar eminence fracture?
Confirmed on CT
Value of CT: Associated Fractures
Medial plateau fracture
Intercondylar eminence fracture?
Confirmed on CT
Value of CT: Fragment characterization
Coronal fracture plane; separate posteromedial fragment
Common pattern in bicondylar fractures
Requires posteromedial plate; may preclude lateral-only fixation
J Orthop Trauma 2008;22:176-182
Value of CT: Fragment characterization
Bicondylar fracture
Posteromedial fragment
Secured with posteromedial plate
Value of CT: Fragment characterization
Bicondylar fracture
Posteromedial fragment
Secured with posteromedial plate
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Value of CT: Fragment characterization
Bicondylar fracture
Posteromedial fragment
Secured with posteromedial plate
Value of CT: Fragment characterization
Comminuted, split lateral plateau
CT reveals bicondylar fracture
Gross comminution of medial plateau, not amenable to fixation
Value of CT: Fragment characterization
Comminuted, split lateral plateau
CT reveals bicondylar fracture
Gross comminution of medial plateau, not amenable to fixation
Summary: Questions toAnswer
1. Where is the fracture? Lateral, medial, bicondylar, posterior
2. Is there a split and/or depressed component?
3. Is there articular incongruity? Articular surface depression, condylar widening
4. Is there metadiaphyseal dissociation?5. What other fractures are present? Tibial
tuberosity, intercondylar eminence, fibular head
Summary: Indications forOperative Fixation
Bicondylar fractures
Medial plateau fractures
Lateral plateau fractures:•>10° varus/valgus instability•>4mm articular surface depression•>4mm condylar widening
Open fractures
Compartment syndrome/arterial injury
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