Chapter 8

Early Complications following Proximal Tibia Fractures

● Disturbed healing of soft-tissue envelope 00

● Postoperative hematoma 00

● Compartment syndrome 00

● Wound infection 00

● DVT/TE 00

● Postoperative damage of peroneal nerve 00

● Postoperatively recognized defi cits of osteosynthesis 00

Chapter 1

Introduction, Classifi cation, Assessment, Planning of Proximal Tibia FracturesSushrut Babhulkar

● Introduction 3

● Forces and Mechanism of Injury 6

● Classifi cation 7

● AO Classifi cation 10

● Evaluation 10

● Indications for Surgical Treatment 14

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Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

3

and Lobenhoff er emphasized the importance of distinguish-ing between the “pure” plateau-fracture pattern and the fracture-dislocation pattern. In their review of 190 proximal tibial articular fractures, 67% of meniscal injuries occurred in plateau-fracture patterns, whereas 96% of cruciate injuries and 85% of medial collateral ligament (MCL) injuries occurred in fracture-dislocation patterns. Peroneal nerve injury was twice as common in fracture-dislocation patterns. These authors also introduced the term complex knee trauma to describe inju-ries associated with signifi cant damage to two or more of the following compartments: the soft-tissue envelope of the knee, the ligamentous stabilizers, and the bony structures of the distal femur and proximal tibia. Complex fractures involving the femoral and tibial articular surfaces had a 25% incidence of vascular injury and 25% incidence of compartment syndrome. In 19 complex fractures with severe soft-tissue injury, vascu-lar injury occurred in 31%, compartment syndrome in 31%, and peroneal nerve injury in 23% of fractures. Accurate determina-tion of fracture pattern and soft-tissue injury is necessary when developing a treatment plan. Schulak and Gunn related the fre-quency of the type of fracture produced and the frequency of collateral ligament injury to the type and mechanism of forces applied to the knee. Considering the “pure” fracture patterns, ligamentous injuries occur more frequently in minimally dis-placed, local compression, and split compression fractures and it is wise to obtain stress radiographs of the knee to evaluate these structures.

1 Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

Introduction

Proximal tibia fractures contribute to and are counted among the major skeletal injuries. Highest incidence occurs between the third and fi fth decades in young, active individuals. If treated inadequately, they cause long-term disability and pain. These fractures occur as a result of high-velocity trauma, and increas-ing severity of impact is directly proportional to the degree of resultant comminution. This type of fracture is frequently asso-ciated with concomitant injuries, including overlying skin injury, ligamentous injuries, and meniscal injuries, adding to the mor-bidity of the resultant outcome. The aim of surgical treatment of proximal tibia and fi bula fractures is to restore and preserve nor-mal knee functions. These goals are accomplished by anatomi-cally restoring the articular surfaces of the tibial condyles, main-taining the mechanical axis, restoring ligamentous stability, and preserving a functional, pain-free range of motion in the knee.

Proximal tibial articular fractures caused by high-energy mechanisms may be associated with neurological and vascular injury, compartment syndrome, deep vein throm-bosis, contusion or crush injury to the soft tissues, or open wounds. The condition of surrounding soft tissue is the most important parameter which provides an appropriate time win-dow to commence surgery. Compartment syndrome adversely aff ects the functional results of this injury. High-energy inju-ries with soft-tissue involvement treated by extensile surgical approaches have yielded poor long-term outcomes. Tscherne

Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

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Chapter 1

An appropriate classifi cation following an eff ective investi-gation and then a good planning can usually render an excellent outcome. Thus, articular fractures and their pattern assessment are of paramount importance in a good result.

Various treatment modalities have been under considera-tion for these fractures, starting from nonoperative option to arthroscopic-assisted reduction of articular fragments. Recent advances for treating such injuries have included newer approaches, understanding the importance of posteromedial fragment, use of raft screws and injectable bone grafting mate-

all the possible treatment options you may want to consider to off er your patient the best possible result from this diffi cult injury.

Conservative, nonoperative treatments using traction and cast bracing have yielded satisfactory outcomes, as reported by some investigators. Currently, with the advent of understanding about the articular fracture patterns and their responses to the

nonoperative management, this type of treatment has become limited to those fractures where there is articular disturbance and comminution. A precise restoration of anatomy will look at a better functional outcome and lessen deformity and secondary arthritic pain. Although tibial articular surface is tolerant to a great extent to the deforming forces, it is important to achieve precise anatomical restoration to gain better functional outcome employing newer techniques, newer implants, and better understanding of injury pattern and its behavior. The surgical treatment with good articular reconstruction and stable fi xation off ers precise limb alignment, articular restoration, and thus a more predictable pattern of healing allowing early weight bearing.

Some of the newer things that have happened concerning proximal tibia fractures include soft tissue-friendly approaches, delayed internal fi xation, and minimally invasive techniques, which have all recently improved outcomes following these injuries (Fig. 1.1A, B).

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Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

Fig. 1.1 (A, B) 41-C3.1 fracture in a 44-year-old female after a skiing accident. In bicondylar fractures, the medial plateau is usually sheared off “en bloc” without major damage to the articular surface.

A

B

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Chapter 1

Forces and Mechanism of Injury

Why do we need to know the force vector resulting into the injury we are dealing with? Is it because that is the way we are going to “undo” the pattern while reconstructing the fracture and putting our implant on? The magnitude, type, and directions of forces that injure the knee dictate the fracture pattern. The greater the energy absorbed by the proximal tibia, the more severe is the fracture and more displaced and comminuted are the fragments. Generally, axial-loading forces are more rapid and release greater energy than angular forces. In cadavers, it is possible to produce typical split frac-tures with pure valgus forces, local compression fractures with axial forces, and split depression fractures with combination of both forces. The MCL acts like a hinge for the lateral femo-ral condyle, and in this cadaver study it should be present for the lateral plateau to fracture which means that clinically the MCL should not be torn in these lateral patterns. The proxi-mal tibia is most likely to be subject to a valgus force because of the normal 5 to 7 degrees of valgus alignment of the knee besides the propensity to be struck from the lateral side. A valgus force loads the lateral tibial plateau to failure from direct impact with the lateral femoral condyle. A combination

of valgus and axial compressions produces lateral side depres-sion, split depression, or less commonly, lateral split or total lateral condyle fractures. Younger patients with good bone tend to have split fractures with less depression while elderly patients with osteopenic bone have a greater component of compres-sion with a less prominent split fragment. Most commonly in lateral fracture patterns, there is at least a small component of both a split fracture and depression at the peripheral margin of the fracture, less commonly than in lateral side fractures, varus injuries lead to failure of the medial plateau. A posteromedial fracture of the medial plateau is a common medial pattern and can occur as an isolated split fracture or in as many as one-third of bicondylar fractures and it is a part of the bicondylar fracture pattern. The mechanism has been described as knee fl exion varus and internal rotation of the medial femoral condyle. This fragment has gained a lot of importance as improper fi xation of this fragment leads to early failure. Tibial plateau fractures most often occur with leg in a weight-bearing position, hence load is typically some component of the injuring force. Gener-ally, greater the axial load component, the more severe is the fracture pattern. Bicondylar fracture patterns result when axial load predominates with the severity varying based on the mag-nitude of the axial forces.

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Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

Classifi cation

Classifi cation of the fractures is a must that leads us to plan an eff ective way of executing a perfect articular and frac-ture reconstruction.8 It should be a protocol to classify each fracture using a plain X-ray and wherever needed, accompa-nied by three-dimensional computed tomography (3D CT) reconstruction. Magnetic resonance imaging (MRI) is used in suspected soft-tissue trauma and ligamentous injuries.

Schatzker classifi cation continues to be the mainstay for these fractures facilitating in planning the surgery and place-ment of implants. Currently, AO classifi cation is the worldwide

standard in documenting fractures and exchanging thoughts. We have discussed various classifi cations in this chapter to help you apply these in your clinical practice (Table 1.1).

Honkonen and Jarvinen have recently modifi ed Schatzker classifi cation to take residual limb alignment into account. They have divided Type VI fractures into two types: those that are medially and laterally tilted to take into account functional results in treated fractures with residual angulation (Fig. 1.2).

In the Orthopaedic Trauma Association (OTA) classifi cation, which is based on the Association for the Study of Internal Fixation (AO/ASIF) classifi cation, proximal tibia is denoted as segment 43 and is divided into three main categories:

Type A Fractures are extra-articular.

Type B Fractures are partially articular and are subdivided into three main categories: B1 are pure splits, B2 are pure depression, and B3 are split depression.

Type C Fractures are complete articular fractures and are also subdivided into three subtypes: Type 1 is articular and metaphyseal simple, Type 2 is articular simple and metaphyseal multifragmentary, and Type 3 is articular multi-fragmentary.

Type AA

Type B

Type C

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Chapter 1

Table 1.1 Schatzker classifi cation of tibial plateau fractures

Type Name Features

Schatzker I Lateral split A pure cleavage fracture of the lateral tibial plateau that results in a wedge-shaped frac-ture segment.

Schatzker II Split with depression A cleavage fracture of the lateral tibial plateau in which the remaining articular surface is depressed into the metaphysis.

Schatzker III Pure lateral depression A pure central depression fracture of the lat-eral tibial with an intact osseous rim.

Schatzker IV Pure medial depression This is a medial tibial plateau fracture with a split or depressed component. It is usually the result of a high-energy injury and involves a varus force with axial loading at the knee. There is high risk of damage to the popliteal artery and peroneal nerve and therefore carry a worse prognosis.

Schatzker V Bicondylar A bicondylar fracture in which the fracture line often forms an inverted the metaphysis and diaphysis remain intact.

Schatzker VI Split extends to metadiaphysis A tibial plateau fracture in which there is dissociation between the metaphysis and the diaphysis; these fractures may have varying degrees of comminution of one or both tibial condyles and the articular surface.

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Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

Fig. 1.2 Schatzker classifi cation.

Type I

Type IV

Type II

Type V

Type III

Type VI

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Chapter 1

AO Classifi cation

The AO/OTA classifi cation employs the designation of number 4 for the tibia and number 1 for the proximal portion of the bone. Consequently, all the tibial plateau fractures have the designation of 41. A letter is then added to classify the frac-tures. The letter A indicates a proximal fracture that does not enter the knee joint. A B-type fracture is a unicondylar injury and correlates to Schatzker Type I through IV patterns. Although many fractures in the 41B group are low-energy injuries, medial plateau fractures are important. A 41C fracture is a bicondylar injury and correlates to Schatzker Types V and VI injuries. These are normally high-energy injuries. Each of the major patterns (41A, 41B, and 41C) is further subdivided into nine additional patterns. A major advantage of the AO/OTA classifi cation is precision and detail, with 27 subclassifi cations. This provides a major advantage for research and clinical out-come analysis, and allows a comparison of identical fracture types. The classifi cation becomes cumbersome and diffi cult to use clinically if taken beyond the major patterns (Fig. 1.3).

Evaluation

A detailed history including determination of the mecha-nism of injury and the patient’s overall medical status, age, and functional and economic demands must be obtained. A detailed physical examination is necessary to detect concomi-tant ligamentous injuries, neurovascular injuries, compartment syndrome, additional fractures, and other injuries. Compart-mental pressures should be measured with an accurate method if compartment syndrome is suspected. An arteriogram should be obtained in fractures with suspected vascular injury or in patients with fracture dislocations. Patients with obvious vas-cular injuries should be taken promptly to the operating room for vascular exploration and revascularization (Fig. 1.4A–D).

Anteroposterior, lateral, and oblique X-rays and CT are necessary to evaluate these fractures. Whatever the injury, the damage to the joint usually is more extensive than the X-rays indicate. The bony attachments of one or both cruciate ligaments may be avulsed and lie as free fragments in the

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Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

Fig. 1.3 Müller AO classifi cation.

41–A1

41–B1

41–C1 41–C2 41–C3

41–B2 41–B3

41–A2 41–A3

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Chapter 1

Fig. 1.4 The rare case of an isolated fracture of the medial plateau, 41-B3.2 (or Schatzker IV) fracture, which may be associated with an injury to the popliteal vessels.

Fig. 1.4 (A) Standard anteroposterior view. Fig. 1.4 (B) 3D reconstruction as seen from behind.

A B

Fig. 1.4 (C) Lateral view.

C

Fig. 1.4 (D) Lateral 3D reconstruction.

D

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Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

joint. Comminuted fragments of the articular surface often lie at angles to their normal plane and may be upside down. The meniscus often is torn at its periphery and a part or all of it may lie between the comminuted fragments. Assessment of the degree and the size of depressed articular fragments may be possible only with conventional tomography or CT. 3D CT reconstruction is very helpful in looking at displacement of various articular fragments and their possible reconstruction. Often the classifi cation of the fracture made from standard X-rays is changed to another type after CT tomograms are eval-uated. The upper tibial articular surface is normally inclined posteriorly 10 to 15 degrees, and an anteroposterior radiograph with the beam angled caudally 10 to 15 degrees provides bet-ter views of the tibial plateaus. Stress radiographs for collateral ligament injury have been mentioned earlier. Any widening of the femoral–tibial articulation greater than 10 degrees upon stress examination indicates ligamentous insuffi ciency. Split fractures of the lateral plateau have a relatively high incidence

of associated ligamentous injury, because the dense cancellous bone associated with split fractures does not compress. Energy is therefore not dissipated, and the force is imparted to the MCL.

Injury to the collateral ligaments has been reported to occur in 7 to 43% of tibial plateau fractures, and rupture of the ante-rior cruciate has been reported in up to 23% of high-energy injuries. Meniscal injuries have been reported in up to 50% of tibial plateau fractures. In split-type fractures, the meniscus may be incarcerated within the fracture site. Colletti, Green-berg, and Terk analyzed MRI fi ndings in 29 tibial plateau frac-tures and found tibial collateral injuries in 55%, lateral meniscal tears in 45%, fi bular collateral ligament injuries in 34%, anterior cruciate ligament injuries in 41%, posterior cruciate ligament injuries in 28%, and medial meniscal tears in 21% of fractures. This study showed the spectrum of soft-tissue injuries associ-ated with tibial plateau fractures; however, MRI scans are not routinely indicated.

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Chapter 1

Indications for Surgical Treatment

Nonoperative management utilizing cast brace is appropriate for some fractures of the tibial plateau. Indications for closed management may include the following fractures:

1. Nondisplaced or minimally displaced (< 3 mm)2. Stable to varus and valgus stress3. Peripheral submeniscal fractures4. Low-energy fractures with minimal comminution, and5. Low demand patients with medical contraindications to

surgery.Outcome results reported with cast bracing have been variable and often depend on the pattern and stability of the injury. A key to obtaining a successful outcome is to allow adequate early motion. Both bicondylar and split depression fractures have been noted to be associated with less favorable outcome when treated with closed reduction and cast bracing compared with open reduction, internal fi xation (ORIF). Poor results have been reported in 10 to 32% of fractures.

The decision to treat a tibial plateau fracture with surgery is multifactorial, involving patients, fracture, and surgeon. Issues to consider regarding the patient include their age, activity, type of employment, associated injuries, and medical problems.

Important factors associated with the fracture include the pat-tern, degree of comminution, displacement, joint impaction, mechanism of injury or energy imparted to the tissues at the time of injury, condition of the soft tissue around the fracture, and stability of the knee. Factors a surgeon should consider include the surgical team’s experience and the operating-room environment and equipment.

The most important factor to consider prior to embarking on surgical management of tibial plateau fractures is the condi-tion of the local soft tissues. Severe damage to the soft-tissue envelope is the most common contraindication to early surgical treatment of tibial plateau fractures. It is important to grade the soft-tissue condition and carefully consider this factor follow-ing both open and closed fractures. Delaying defi nitive surgical treatment until optimal soft-tissue conditions exist minimizes complications.

Absolute indications for surgery include open fractures, frac-tures associated with a compartment syndrome, and fractures associated with a vascular injury. Relative indications for surgi-cal stabilization include most displaced bicondylar and medial condyle fractures, lateral plateau fractures that result in joint instability, condylar widening that exceeds 5 mm, fracture dislocations of the knee, and fractures in the polytraumatized patient that will prevent early mobilization of the patient if the knee is treated nonoperatively.Thie

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Introduction, Classifi cation, Assessment, Planning of Proximal Tibia Fractures

Tips and Pearls● Tibial plateau fractures have high incidence of concomitant injuries, such as meniscus injury, cruciate

injury, and collateral ligament injury. They need identifi cation and appropriate treatment for good long-term outcome.

● Conservative treatment has a very limited role in articular fractures.● With newer approaches and fi xation techniques, improved outcome is achievable.● The proximal tibia is most likely to be subject to a valgus force because of the anatomy of the knee.

A combination of valgus and increasing axial compression produces lateral side depression, split depression, or, less commonly, lateral split or total lateral condyle fractures.

● Bicondylar patterns result when axial load is high.● A posteromedial fracture of the medial plateau is a common medial pattern and can occur as an

isolated split fracture or in as many as one-third of bicondylar fractures. It needs identifi cation and a dedicated treatment.

● CT scan has a crucial role to play in identifying comminution, displacement of fragments, and planning.

● MRI is seldom required except in situation of suspected soft-tissue injuries.● Articular surface involving fracture should be surgically reconstructed to recreate the normal articular

anatomy and supporting diaphyseal axis.

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