CASE CONFERENCE

13/5/2559Ext.Sunatcha Chomsantia

Case ชายไทยอายุ 42 ปี ภมูลิำาเนา อำาเภอเมอืง จงัหวดันครราชสมีา

CC: ปวดเขา่ขวา 4 hr PTA PI: 4 hr PTA ขบั MC ล้มเอง โดนจกัรยานตัดหน้า

ไมส่ลบ จำาเหตกุารณ์ได้ เอาขาขวากระแทกพื้น ขาขวา บดิ รูส้กึปวดบรเิวณเขา่ขวา เดินลงนำ้าหนักไมไ่ด้ จงึมา

รพ.

Past history No U/D No allergy

Physical Examination GA : A Thai man good consiousness,well

co-operative HEENT : not pale conjunctivae,anicteric

sclera Lung : clear,equal breath sound Heart : normal S1S2,no murmur Abdomen : soft,not tender

Physical Examination Ortho :RT.Knee :marked swelling,tender,deformity,limited ROM,pin pick sensation intact,capillary refill < 2,Dorsalis pedis artery2+,Posterior tibial artery 2+ABI :Rt. 1.3 Lt.1.4

Investigation Film KneeAP,Lateral

Diagnosis Close Fracture Rt. tibial plateau

Management Admit lab pre-op : CBC,Bun,Cr,Electrolyte,anti-

HIV CXR pain control : MO 4 mg IV q 6 hr cefazolin 1 g IV q 6 hr plan Sx

Fracture tibial plateau

Anatomy

Fracture tibial plateau

Periarticular injuries of the proximal tibia frequently associated with soft tissue injuries

Fracture tibial plateauEpidemiology demographics

bimodal distribution males in 40s (high-energy trauma) females in 70s (falls)

location unicondylar vs. bicondylar 

frequency lateral > bicondylar > medial

Fracture tibial plateauMechanism varus/valgus load with or without axial

load high energy

frequently associated with soft tissue injuries

low energy usually insufficiency fractures

Schatzker Classification

Schatzker Classification

Schatzker Classification Type I Lateral split fracture Type II Lateral Split-depressed fracture Type III Lateral Pure depression fracture Type IV Medial plateau fracture Type V Bicondylar fracture Type VI Metaphyseal-diaphyseal disassociation 

Type I

Type II

Type III

Type IV

Type V

Type VI

Associated conditions meniscal tears

lateral meniscal tear more common than medial associated with Schatzker II fracture pattern 

medial meniscal tear most commonly associated with Schatzker IV

fractures  

ACL injuries more common in type V and VI fractures

(25%)

compartment syndrome   ได้แก่ 5 Ps คือ a. Pain (markedly increase)b. Paresthesia c. Pallord. Paralysise. Pulseless

Tx. Fasciotomy and decompression

Vascular injury commonly associated with Schatzker IV

fracture-dislocations

Most >>>  popliteal artery

Management1. Recognition 2. Reduction

2.1 Closed Reduction 2.2 Continuous traction 2.3 Open Reduction

3. Retention 4. Rehabilitation

TreatmentNon-operative hinged knee brace, PWB for 8-12 weeks,

and immediate passive ROM indications

minimally displaced split or depressed fractures

low energy fracture stable to varus/valgus alignment

nonambulatory patients

Operative temporizing bridging external fixation w/ delayed ORIF  

indications significant soft tissue injury polytrauma

external fixation with limited open/percutaneous fixation of articular segment indications

severe open fracture with marked contamination highly comminuted fractures where internal fixation not

possible outcomes

similar to open reduction, internal fixation

open reduction, internal fixation   indications

articular stepoff > 3mm condylar widening > 5mm varus/valgus instability all medial plateau fxs  all bicondylar fxs