Bicondylar and Type V Plateau Frx 


 - Discussion: Tibial Plateau Frx Menu
    - consists of wedge frx of medial & lateral plateau;
    - if articular depression is present, it is usually present on the lateral plateau;
    - frx may have an inverted Y appearance, w/ the articular frx originating in the intercondylar region;
    - associated injuries:
          - 50% of plateau fractures will have peripheral meniscal detachment;
          - ACL avulsions may occur in about 1/3 patients; 
          - consider possibility of spontaneously reduced knee dislocation;
                  - ref: Soft tissue injury of the knee after tibial plateau fractures.
          - compartment sydrome
          - popliteal artery injury
    - referernces:
          - Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique.
          - Infection After Spanning External Fixation for High-Energy Tibial Plateau Fractures: Is Pin Site-Plate Overlap a Problem?

- Radiographs:    


- Non Operative Treatment:
    - because of soft tissue attachment to fracture fragments, traction occassionally provides an acceptable reduction & once frx has
              become sticky may be managed in a cast brace;
    - note, however, that loss of frx position & alignment is common when plaster cast is used after bicondylar fractures;


- PreOp Planning
    - consider CT scan to clearly define fracture patterns;
    - soft tissue evaluation:
          - pay attention to abrasions, bruising, and hemarthrosis since these are risk factors for wound breakdown;
          - w/ ORIF w/ extensive periosteal stripping may result in a 20% incidence of wound breakdown & infection (some small series
                    report even higher rate of infection) that often leads to poor clinical results;
    - compartment syndrome:
          - insist on general anesthesia inorder to avoid dips in blood pressure (which occurs with spinal anesthesia) and inorder to allow
                    for immediate neurovascular exams; 
          - reference:
                 - Influence of Prior Fasciotomy on Infection After Open Reduction and Internal Fixation of Tibial Plateau Fractures.  
                 - Timing of internal fixation and effect on Schatzker IV-VI tibial plateau fractures.
                 - Timing of definitive fixation of severe tibial plateau fractures with compartment syndrome does not have an effect on the rate of infection.

- Spanning fixators and surgical timing:
     - Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.
     - Compartment syndrome in Schatzker type VI plateau fractures and medial condylar fracture-dislocations treated with temporary external fixation.
     - Timing of internal fixation and effect on Schatzker IV-VI tibial plateau fractures.
     - Infection after spanning external fixation for high-energy tibial plateau fractures: is pin site-plate overlap a problem?
     - The effect of knee-spanning external fixation on compartment pressures in the leg.
     - External Fixation and Temporary Stabilization of Femoral and Tibial Trauma
     - Staged Management of High-Energy Proximal Tibia Fractures




- Operative Technique
    - indirect reduction stratedgy:
          - consider using universal femoral distractor for assistance of reduction thru ligamentotaxis;
          - condylar reduction can be improved w/ percutaneously applied reduction forceps; 
    - external fixation: (see external fixation for tibia fractures /  circular wire fixators)
          - CT scan is important for preoperative planning;
          - femoral distractor should be considered;
          - fracture reduction: need reduction before fixator placement;
                 - percutaneous incision allows for insertion of periosteal elevator to elevate depressed fragments;
                 - fracture clamps allows percutaneous fracture stabilization;
          - pin placement: (see safe zone)
                 - transfixing olive wires are placed in the proximal fragments with use of orientation of main fracture lines as seen on the
                          preop CT scan;
                 - 1st wire: inserted through fibular head from lateral to medial
                 - 2nd wire: olive wire is inserted from posteromedial to anterolateral;
          - pitfalls: 
                 - prevent the leg from "sagging" posteriorly and coming into contact with the rings by padding the rings posteriorly;
                 - proximal wires need to be 1 cm from the joint line to avoid transgressing the reflections of the joint capsule
          - references:
                 - Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Results of a multicenter, prospective, randomized clinical trial.
                 - Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Surgical technique.
                 - Indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures 
                 - External Fixation and Limited Internal Fixation for Complex Fractures of the Tibial Plateau
                 - Internal versus External Fixation of Bicondylar Tibial Plateau Fractures
                 - Treatment of bicondylar tibia plateau fractures using locked plating versus external fixation

    - open reduction stratedgy:
          - single anterior incision (which is compatible with a TKR incision for the future) vs lateral and posteromedial incisions (better
                    for wound healing); 
          - references:
                 - Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique.
                 - Treatment of complicated tibial plateau fractures with dual plating via a 2-incision technique.
                 - The use of an anterior incision of the meniscus for exposure of tibial plateau fractures requiring open reduction and internal fixation.
                 - Anterior Approach to the Knee with Osteotomy of the Tibial Tubercle for Bicondylar Tibial Fractures.
                 - Combined Anterior and Posterior Approaches for Complex Tibial Plateau Fractures
                 - Early wound complications after operative treatment of high energy tibial plateau fractures through two incisions.
                 - Treatment of bicondylar tibia plateau fractures using locked plating versus external fixation
          - consider performing complete fasciotomy;
          - fixation stratedgy
                  - k wire fixation:
                           - k wires are inserted to maintain provisional fixation;
                           - take care that k wire position does not interfere with plate application;
                  - ultimate goal is to have a synthese lateral locking plate with medial washer to provide fixation for both plateau frx; 
                  - medial plateau:
                           - usually fixation of the medial plateau is easier than the lateral plateau;
                           - consider temporary fixation of the medial w/ a simple medial butress plate;
                           - even if there is a coronal split into the medial plateau, the butress plate will allow a near anatomic reduction which
                                     then allows fixation of the lateral plateau using the medial joint line as a reference; 
                  - posteromedial incision (for secondary coronal plane fracture);
                           - plane between the semitendinosis and gastrocnemius
                           - ref: Posterior coronal plating of bicondylar tibial plateau fractures through posteromedial and anterolateral approaches in a healthy floating supine position.
                           - references:
                                      - Frequency and Fracture Morphology of the Posteromedial Fragment in Bicondylar Tibial Plateau Fracture Patterns.
                                      - Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods.
                                      - Posteromedial second incision to reduce and stabilize a displaced posterior fragment that can occur in Schatzker Type V bicondylar tibial plateau fractures. 

                  - lateral plateau: (see synthes plates)
                           - lateral locking plate is applied in the usual manner;
                           - once the lateral plate proximal anterior and posterior locking screws are applied, the medial buttress plate is removed,
                                    allowing a medial washer to be inserted over the central proximal screw; 
                           - be cafeful of use of isolated lateral locking plate with posteromedial frx with a predominantly coronal fracture line;
                           - references:
                                  - Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures.
                                  - Single lateral locked screw plating of bicondylar tibial plateau fractures. 

          - wound closure:
                 - expect that anterior compartment swelling will interefere with wound closure;
                 - consider proximal wound closure and leaving the distal half of the wound open to prevent compartment syndrome;
                 - "pie crust" technique is a simple technique to facilitate delayed wound closure; 
                 - consider wound vac +/- bead pouch
                 - ref: Multiple relaxing skin incisions in orthopaedic lower extremity trauma. 

- IM Nailing:
      - Retropatellar nailing and condylar bolts for complex fractures of the tibial plateau: Technique, pilot study and rationale.
      - A comparative study for complex tibial plateau fractures: nailing and compression bolts versus modern and traditional plating
      - Biomechanical comparison of intramedullar versus extramedullar stabilization of intra-articular tibial plateau fractures.
      - Patella osteotomy: a new approach for complex trauma around the knee.

- Post Operative Care and Compications:
      - Complications of High-Energy Bicondylar Tibial Plateau Fractures Treated with Dual Plating Through Two Incisions.
      - varus deformity is common w/ type V frx;
      - references: 
             - Complications after tibia plateau fracture surgery.
             - [Nicotine in plastic surgery: a review]
             - Recovery of knee function following fracture of the tibial plateau. 
      - vascular complications:
             - Evaluation of Popliteal Artery Injury Risk With Locked Lateral Plating of the Tibial Plateau
             - Injury to the Anterior Tibial System During Percutaneous Plating of a Proximal Tibial Fracture
  



Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.

Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Surgical technique.

Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates.

Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures.

Treatment of Complicated Tibial Plateau Fractures With Dual Plating Via a 2-incision Technique

Surgical management of tibial tubercle fractures in association with tibial plateau fractures fixed by direct wiring to a locking plate.

Patella Osteotomy: a new approach for complex trauma around the knee



    - case example:
          - 40-year-old female involved in MVA, sustaining bicondylar tibial plateau frx, but no other injuries;
                - interesting points about this case:
                1) the initial AP of the knee did not adequately show the lateral plateau frx, since the knee immobilizer had been left in place; 

                       

                2) because the medial plateau was more comminuted and displaced than the lateral plateau, the surgeon decided to apply a "T" butress plate to the medial side w/ two proximal 6.5 mm cannulated screws angled slightly posteriorly to engage the lateral plateau frx; 

                       
    - case example: 

               



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, August 16, 2016 4:37 pm