- Exam:
- skin abrasion and contussions from direct blows;
- r/o
compartment syndrome;
-
ligamentous instability
-
peroneal nerve function;
- Radiographs:
- Indications for treatment:
- Open Plateau Frx or Frx w/ compartment syndrome;
- Articular Surface Depression, which can produce joint incongruity;
- Axial malalignment, which will incr. stresses across articular surface;
-
Ligamentous instability (frx w/ ACL tear = poor prog)
- look for widening of joint space (indicates collat. lig disruption);
- varus or valgus instability > 10 deg w/ knee flexed 20 deg;
- Initial Treatment:
-
PreOp Orders
- consider distal tibial pin traction if OR is delayed;
- consider preOp pO2 of skin, noting high incidence of skin necrosis;
- Operataive Treatment:
-
Anesthesia:
- no epidural anesthesia if compartment syndrome is possible;
- despite what the anesthesiologists will tell you, an epidural can completely mask an anterior compartment syndrome;
-
Positioning:
- pt should be positioned on the OR table such that the frx can be broken down during the procedure and
knee can be flexed;
- tape sandbag on table to support foot when knee is flexed;
- flexion of the knee improves visualization of the joint;
- for optimal exposure, consider supine position, w bolster under thigh, & table broken so that the knee is flexed 90 deg;
- this position allows increased exposure submeniscally;
- or consider having patient in the supine position with the knee flexed over a roll 50-60 deg;
- consider prepping for bone grafting;
-
Visualization:
- flouroscopy is useful for split type frx;
- arthroscopy can be used for depression type frxs, but be aware of fluid extravasation and compartment syndrome;
-
Equipment:
- flourotable;
- large tenaculum clamps are useful for reduction;
- consider using
AO large distractor & relying on ligamentotaxis
to maintain reduction and provide exposure;
- usually is distractor is placed on the same side as the frx;
- one pin is inserted into the femoral condyle and one in the mide tibia;
-
Surgical Approaches:
-
Lateral Plateau:
-
Medial Plateau:
-
Implants:
- bone tamps is useful to elevate centrally depressed fragments;
-
T plate: is used for buttressing of the
medial tibial plateau;
- L plate: lateral tibial plateau;
- both of these plates have oval hole which is used for temporary fixation and allows small up and down adjustments;
- unicondylar Fracture:
- two 6.5 mm cancellous bone screws or 7.0 mm cannulated screws with washers (in young people);
- L or T butress plate, lateral tibial head buttress plate, DCP, or LC-DCP, 4.5 mm (in older people);
-
Bicondylar Fracture:
- L or T butress plate, DCP, or LC-DCP, 4.5 mm, or lateral tibial head butress plate +/- a 3-4 hole semitubular plate on the medial side as a butress plate;
- 6.5 mm cancellous bone screws or 7.0 cannulated screws, combined w/ external fixation in complex or open frx;
-
Post Operative Care and Compications:
Evaluation of tibial plateau fractures: efficacy of MR imaging compared with CT.
Staged Management of High-Energy Proximal Tibia Fractures (OTA Types 41): The Results of a Prospective, Standardized Protocol.
