tibial plateau fracture and its management.pptx
- 1. Tibial Plateau Fracture And Its Management Presented by: Dr Sunil Rouniyar PG 1st YR, Orthopaedic Moderator: Dr.Mukesh Kushwaha
- 2. TIBIAL PLATEAU • Tibial plateau is the proximal end of tibia including metaphyseal, epiphyseal regions as well as articular surfaces. • AO defines tibial plateau as metaphysis to a distance equal to the width of the tibia at the joint line.
- 3. EPIDEMIOLOGY • Fractures constitute 1% of all fractures and 8% of all fractures of elderly. • Most of these fractures are associated with 1. Neurological and Vascular injuries 2. Compartment syndrome 3. Contusion and Crush injuries of soft tissue
- 5. Anatomy • Tibial plateau composed of articular surfaces of medial and lateral tibial plateaus, on which cartilagenous menisci are present Medial meniscus Lateral meniscus Larger in size smaller Concave convex inferior 2~3 mm superior Cartilagionus thickening ~ 3mm ~ 4mm
- 6. • Normal tibial plateau has Posterio -inferior slope ~ 10 degrees (Posterior proximal tibial angle)
- 8. Bony prominence near tibial plateau • ANTERIORLY-: TIBIAL TUBERCLE Patellar tendon insertion • ANTEROLATERALLY:- GERDY’S TUBERCLE Insertion of Iliotibial band • ANTEROMEDIALY:- PES ANSERINUS Attachment of Medial Hamstrings Sartorius Gracillis Semitendinosus
- 11. Mechanism of injury 1.Force directed medially (valgus force) or laterally (varus force) or both split # +collateral lig. tear 2. Axial compressive force depression# 3.Both axial force and force from the side split + depression +/- collateral lig. tear
- 12. Classification 1. HOHL AND MOORE CLASSIFICATION 2. AO / OTA CLASSIFICATION 3. THREE COLUMN CLASSIFICATION 4. DUPARC CLASSIFICATION 5. SCHATZKER CLASSIFICATION
- 14. AO/OTA CLASSIFICATION • TYPE A – Extraarticular • TYPE B – Partial articular • TYPE C– Articular
- 16. THREE COLUMN CLASSIFICATION • Zero column # :- Pure articular depression • 1 column # • 2 column # • 3 column # :- Atleast 1 independent articular fragment in each of these 3 columns
- 18. Schatzker classification • Type –1 Pure cleavage -- Wedge shaped uncomminuted fragment is split off and displaced laterally & downward -- Common in young patients -- Lateral meniscal pathology may be present • Type -2 cleavage combined with depression --Split fracture of the lateral tibial condyle with associated impaction or depression of the articular surface ---Commonly in older individuals(osteoporotic bones)
- 19. • Type –3 pure central depression Pure depression of the lateral articular surface only. Common in elderly • Type-4 fracture of medial condyle These may split off as a single wedge or may be comminuted and depressed. Tibial spines often involved.
- 20. • Type-5 Bicondylar fracture Both tibial plateau are split off Metaphysis & diaphysis retain continuity • Type-6 Plateau fracture with dissociation of metaphysis & diaphysis Transverse or oblique fracture of proximal tibia is present, along with fracture of single or both tibial condyles and articular surface
- 21. Associated injuries • 90% of these fractures asssociated with soft tissue injuries • Meniscal tears occurs in 50% of these fractures • Associated ligamentous injuries (cruciate or collateral) occur in 30% of these fractures • Others-: > common Peroneal nerve > Popliteal artery injury
- 22. Management • Evaluation of injury---Clinical Evaluation:- – Neurovascular examination to rule out any neurological or vascular injury (peroneal nerve or popliteal artery injury) – Assessment for any ligament injury – Assessment for compartment syndrome – Assessment for Haemarthrosis
- 23. Radiographic evalution • X-ray • AP view • Lateral view • 40 degree Internal rotation view (lateral plateau) • 40 degree external rotation view (medial plateau) • Caudally tilted plateau view (articular surface) 110
- 24. • CT with 3Dreconstruction- • Better visualisation • Preoperative planning • MRI – • Useful for evaluating injuries of menisci, cruciate & collateral ligaments and soft tissue envelope • Arteriography • for any vascular injury in question
- 25. Treatment • Non-operative – Indicated for non-displaced or minimally displaced fractures, without any ligament injury & in pts with advance osteoporosis – Immoblisation with cast or brace for a wk followed by early range of knee motion in a hinged knee brace along with skeletal traction – Isometric quadriceps exercises and progressive passive, active- assisted, and active range-of-knee motion exercises are indicated – Toe touch wt bearing for 8 to 12 weeks is allowed, with progression to full weight bearing.
- 26. Operative Treatment INDICATION FOR SURGERY :- Fracture associated with instability Ligaments injury Significant articular displacement • Acceptable articular displacement is controversial • Some authors recommended sx–articular stepoff > 2mm other –articular stepoff>5mm • Some studie reported similar clinical result for operative vs non–operative t/t for articular stepoff 8mm • Most of authors agreed articular stepoff > 10mm is an absolute indication for sx •
- 27. If the articular depression is 5 to 8mm , the decision for operative or non operative t/t depends on- age of pt activity demand of the knee • Instability >10 degrees of nearly extended knee compared to the contralateral side is an absolute indication. • Open fractures • Associated compartment syndrome • Associated vascular injury
- 28. Aims of surgery • Restoration of articular congruity, joint stability and original knee axis • Provide fracture stability allowing for early pain free movement of knee & mobilization of the pt • Obtain full functional recovery as a long term goal. • Avoidance of posttraumatic arthritis.
- 29. Operative treatment principle • Reduction and buttressing of elevated articular segments with bone graft or bone graft substitute. • Soft tissue reconstruction including menisci and ligaments . • Use of Spanning external fixator as a temporizing measure in patients with high-energy injuries or significant soft tissue injury.
- 30. Surgical approaches • Antero-lateral • Minimal access Antero-lateral • Postero-medial • Anterior
- 31. Antero-lateral approach • Used for ORIF of lateral plateau • S shaped incision starting approximately 3-5 cm proximal to joint line • Staying just lateral to patellar tendon • incision is curved anteriorly over Gerdy’s tubercle and it is extended distally ,1cm lateral to anterior border of tibia.
- 32. Minimal acsess antero-lateral approach • 2 incisions are made • Proximal incision start just proximal and lateral to Gerdy’s tubercle and extended distally in a curvilinear fashion for 5-6 cm • Distal incision is 5-6 cm longitudinal incision, 2 cm lateral to tibial crest • Then an epi-periosteal plane is developed to connect the two incisions running along the lateral border of tibia
- 33. Posterior medial approach • For ORIF of # Medial tibial plateau • A 6 cm longitudnal incision over the postero – medial border of proximal tibia is made and then subcutaneous fat is incised and Pes Anserinus is divided and retracted
- 34. Anteroir approach • longitudnal incision on anterior surface of leg parallel to anterior border of tibia and 1 cm lateral to it is made
- 35. Implant option • The choice of implant is related to the fracture pattern, degree of displacement and the familiarity of surgeon • Plate and screw – Buttressing against shear forces or neutralizing rotational forces • Screw alone – Simple split – Depressed fracture elevated percutaneously • External fixator • Thinner plates
- 36. External fixator 1. BRIDGING EXTERNAL FIXATOR 2. HYBRID EXTERNAL FIXATOR 3. RING EXTERNAL FIXATOR
- 37. SCHAZTKER TYPE I • Closed reduction with 6.5mm cancellous lag screw with washer to gain compression • In young patient screw fixation is adequate • In elderly buttress plate is required
- 38. SCHATZKER TYPE II • Via anterolateral approach , open reduction and elevation of the depress fragment • Bone graft is placed to support the elevated fragment • Temporarily held with k- wire • Fixed with lateral buttress plate & cancellous scews
- 39. SCHATZKER TYPE III • Elevation of depressed articular fragment through a metaphyseal window • Bone grafting to support the fragment • Fixation Subchondral plate/ screws
- 40. SCHATZKER TYPE IV • These fracture tend to angulate in varus, these are fixed with medial butress plate and cancellous screws .
- 41. Schatzker V and VI • In these type of complex fracutres traditional method of open reduction and plate fixation require extensive exposure, which may compromise soft tissue further and devascularise bone fragments and this leads to infection. • To reduce these complications – less extensile exposure – indirect reduction techniques by supplementing lateral buttress plate with medial two pin external fixator or small antiglide plate in place of bulky medial plate are being used.
- 42. Arthoscopically assisted reduction and fixation of tibial plateau fracture • Arthroscopically assisted reduction and fixation techniques are being used with increased frequency, for treatment of schatzker type I,II,III Tibial plateau fractures • Arthroscopic techniques require minimal soft tissue dissection ,afford excellent exposure of articular surface and can be used to diagnose and treat concomitant meniscal and ligament injury.
- 43. • Phase I – Maximum Protection (0 to 1 weeks): • Ice and modalities to reduce pain and inflammation • Use crutches non-weight bearing for 6 weeks • Elevate the knee above the heart for the first 3 to 5 days • Initiate patella mobility drills • Begin full passive/active knee range of motion exercises • Quadriceps setting focusing on VMO restoration • Multi-plane open kinetic chain straight leg raising • Gait training with crutches (NWB)
- 44. Phase II – Progressive Stretching and Early Strengthening (Weeks 1 to 6): • Maintain program as outlined in week 0 to 1 • Continue with modalities to control inflammation • Initiate global lower extremity stretching program • Begin stationary bike and pool exercise program (when incisions healed) • Implement reintegration exercises emphasizing core stability • Closed kinetic chain multi-plane hip strengthening on uninvolved side • Manual lower extremity PNF patterns • Proprioception drill emphasizing neuromuscular control • Multi-plane ankle strengthening
- 45. Phase III – Strengthening and Proprioceptive Phase (Weeks 6 to 10): • Weeks 6 to 8: • • Modalities as needed • • Continue with Phase II exercises as indicated • • Begin partial weight bearing at 25% of body weight and increase by 25% approximately every 3 days. May progress to one crutch at 71/2 weeks as tolerated, gradually wean off of crutches by week 8 – 9 • Weeks 9 to 10: • • Normalize gait pattern
- 46. Post operative
- 47. complication • Early commonly is infection (3 – 38 %) Superficial Deep Thromboembolic complication (DVT, PE) • Late: Painful hardware Loss of fixation Posttraumatic arthritis malunion
- 48. reference
- 49. Thank you