Type VI Plateau Frx 

  - Discussion:  Tibial Plateau Frx Menu
    - bicondylar frx w/ distal oblique shaft frx;
    - these frx have bicondylar frx along w/ dissociation of diaphysis from metaphysis;
    - if the medial plateau fragment is intact, this frx can be treated with placement of a lateral plate and
            and Ex Fix to prevent displacement;
    - 35% of type VI fractures are open and 86% has extensive soft tissue injuries; 
    - look for compartment syndrome (approximately 30% of cases)
    - consider possibility of spontaneously reduced knee dislocation;
            - ref: Soft tissue injury of the knee after tibial plateau 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 GEA anesthesia inorder to avoid dips in blood pressure (which occurs with spinal anesthesia) and inorder to allow for
                     immediate N/V 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.

- Management: 
    - 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 
            -
Does Early versus Delayed Spanning External Fixation Impact Complication Rates for High-energy Tibial Plateau and Plafond Fractures?

    - circular wire fixators: (safe zones)
            - can be used to stabilize the diaphyseal-metaphyseal segment;
            - circular wire fixators are unable to reliably stabilize the articular surface;
            - articular fixation requires either lateral plating or insertion of cancellous lag screws inserted over washers;
                    - this fixation should precede application of the fixator;
                    - if possible screws should be inserted from lateral to medial or from anterior to posterior;
    - complications:
            - pin tract infections can lead to devastating knee sepsis and therefore pins needs to be inserted at least 2 cm from the joint line;
                    - in the study by Reid JS, et al, the authors determined in a cadaver study that proximal tibial transfixation wires away from
                            tib-fib joint are likely to be extra-articular if kept greater than 14 mm away from the subchondral bone.
                            - in the region of tib-fib joint, safe distance is difficult to determine since it cannot be known preop which knees have
                                    torn septum; 
                    - loss of fixation following frame removal; 
                            - note that in complex fractures, the frame may have to be left in place for up to 3 months to ensure maturation of
                                      fracture healing (gradual loss of reduction may occur with premature frame removal);
          - references:
                 - Bicondylar Tibial Plateau Fractures Treated with a Hybrid Ring External Fixator: A Preliminary Study.
                 - Safe placement of proximal tibial transfixation wires with respect to intracapsular penetration.  
                 - Internal versus External Fixation of Bicondylar Tibial Plateau Fractures.  
                 - Hybrid external fixation of comminuted tibial plateau fractures.   
                 - External fixation and limited internal fixation for complex fractures of the tibial plateau.
                 - The small pin circular fixator for proximal tibial fractures with soft tissue compromise.  
                 - Treatment of bicondylar tibia plateau fractures using locked plating versus external fixation


- Indirect Reduction Strategy

- Open Reduction Strategy 
        - consider performing complete fasciotomy;
        - 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 frx requiring ORIF.
              - 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.
              - The use of an anterior incision of the meniscus for exposure of tibial plateau fractures requiring ORIF.
              - 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
              - Patella Osteotomy: a new approach for complex trauma around the knee.

        - fixation strategy:
              - 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
              - references:
                    - Posterior coronal plating of bicondylar tibial plateau fractures through posteromedial and anterolateral approaches in a healthy floating supine position.
                    - Posteromedial second incision to reduce and stabilize a displaced posterior fragment that can occur in Type V fractures.
                    - Postero-medial approach for complex tibial plateau injuries with a postero-medial or postero-lateral shear fragment.

        - 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.

       - 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 fractures 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.

- Post Operative Care and Complications 
      - 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 

- 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.





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Treatment of Complex Tibial Plateau Fractures with the Ilizarov External Fixator. Buckle R, et al. J Orthop Trauma 1993;7:167.

Early Results of a New Technique for Treatment of High Grade Tibial Plateau Fractures. Christensen K, et al. J Orthop Trauma 1990;4:226. 

Less Invasive Stabilization System (LISS) for fractures of the proximal tibia: indications, surgical technique and preliminary results of the UMC Clinical Trial. 

Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury.
Retropatellar nailing and condylar bolts for complex fractures of the tibial plateau: technique, pilot study and rationale.
The management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts.
A comparative biomechanical 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.



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

Last updated by Data Trace Staff on Monday, August 15, 2016 4:27 am