tibial plateau lecture - orthopaedic trauma association (ota)pattern and soft tissue envelope •...
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Orthopaedic Trauma Association
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Resident Comprehensive Fracture Course
Tibial Plateau Fractures
Objectives
• Identify and Classify the fractures
• Treatment Algorithm• Why, How, When to treat…
• Understand predictors of treatment success / failure
Classification
Primarily Low Energy Fractures
Schatzker I
• Solitary lateral condyle fracture line
• Lateral articular surface depression
Schatzker I
• Coronal plane stability– ~10 degrees of
instability is significant• Strong relative surgical
indication
• Articular Depression• 3 – 10mm
Schatzker II
CT Scan• Condylar fracture
orientation / location
• Depth of articular impaction
• Condylar Widening• 5mm
• Meniscal entrapment
Split and Depressed lateral unicondylar fracture
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Articular Fracture AssessmentDepression depth Fracture location / orientation
Schatzker III
• Metaphyseal void
• Intact cortical rim• Arthroscopic reduction
assistance
• Balloon-aided metaphyseal augmentation
Isolated depression of the lateral plateau articular surface
Operative Tactic - Unicondylar
• Restore joint stability / mechanical alignment
• Visualize and reduce articular surface
• Support the articular reduction– Fill metaphyseal defect (autograft, allograft, bone void fillers)– Buttress support of cortical surface – Rafting screws for articular surface
Set Up in OR
• C arm opposite side
• Bump under knee
• Traction via external fixator/distractor
Incision
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Use of Distraction Articular Reduction
INDIRECT
Fluoroscopic assessment, percutaneous tamps
DIRECT
Submeniscal arthrotomy, arthroscopic assistance
Metaphyseal Reduction Fixation
O R I F:
reduction needs to come before fixation
Rafting Screws Bone Void ManagementAutograft, Allograft, Bone void fillers
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Classification
Primarily High Energy Fractures
Treatment Algorithm
Compartment Syndrome? Vascular Injury?
Schatzker IV
• Never underestimate this injury• High energy pattern• Never just a “medial
condyle fracture”
• Association with dislocation and vascular injury
• Never just “lag screw” fixation
Bicondylar Fracture Evaluation
• Lateral fracture– Articular impaction
– Metaphyseal comminution
– Meta-diaphyseal extension
• Tubercle Integrity
• Cortical Rim Continuity
Schatzker V and VI
Bicondylar Fracture Evaluation
• Medial Metaphyseal Medial Component– Apex location, comminution,
displacement
– CT Scan (after distraction)
BEWARE: Coronal Plane Fracture Lines
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Treatment Considerations
Screws: uni or bi cortical
Locking?
One or two plates?
Soft tissue management? Surgical
timing?
High Energy Fracture Considerations
• Fasciotomies?
• Spanning External Fixator
• Distraction CT scan
• Surgical Planning• Must wait until soft
tissues stable
Spanning Fixation
• Length and alignment restored No hurry to fix• 10-20 day delay for soft
tissue stabilization
• Consider transfer to traumatologist
1 Plate or 2
• Apex reductions with medial fracture with – Direct cortical contact
– Minimal comminution
• Lateral locking plate only is OK
Distraction CTHigh Energy Fracture Considerations
• Surgical approach and fixation dictated by:
– Fracture Pattern
– Soft tissue envelope
• Anterolateral• Posteromedial• Posterior
• Midline?
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Medial Surgical Fixation
• Posterior medial
• Direct posterior
GOAL: Place plate at apex of medial condyle fracture
Posterior Medial Approach
Direct Posterior
Plate Selection and Screw Position
• Orientation of Fracture Line
• Comminution of base
• Size of fragment
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Understand the Fracture in All Planes
Will This Plate Hold This Fracture
Locking Plate Indications
• Poor bone quality
• Extensive articular comminution
• Meta-diaphyseal extension
• Bicondylar fracture pattern with undisplaced medial cortex
ClosureOften this is the time to repair meniscus
Careful Soft Tissue Handling MRI?
Assess Meniscus and ACL (ACL disrupted in ~25% of Shatzker VI fractures)
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Summary
Make A Plan• Timing
• Approach(es)• Considering fracture
pattern and soft tissue envelope
• Reduction• Joint alignment #1• Articular #2
• Only hardware reps benefit from O_I F management
• Hardware• Bone void management
Predictors of Poor Outcomes
• Altered Joint line– 5 degree alteration of
joint mechanical axis
• Ligamentous instability
• Meniscectomy
Restoration of joint stability is greatest predicator of long term
outcome