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Local Compression Frx: (Type III frx)

- Discussion:
    - involves central or peripheral depression of frx of lateral plateau w/o associated lateral wedge fracture;
    - it usually occurs from minimal impact on weak osteoporotic bone;
    - commonly affects older age groups (55-60 yrs) w/ marked osteoporosis;
    - stability of joint is rarely affected & excellent function is expected if there is minimal joint incongruity;
    - look for a localized depression in the articular surface;
    - flexion angle of the knee at injury determines depth of depression
           - if knee is extended, depression is limited to about 6 mm.
           - if knee is flexed > 30 deg, depression may be as much as 30 mm;
    - usually central depression frx are stable due to intact peripheral ligaments;

- Radiographs:
    - location & depth of depression should be determined by CT (as either anterior, middle, or posterior);
    - degree of joint involvement may vary, from small central plateau depression to fracture depression involving the whole plateau;

- Non Operative Management:
    - most low energy type III frx in elderly pts w/ poor bone stock should be  treated non-operatively;
    - if no valgus instability is found, it is safe to treat such a frx, w/ early motion but no wt bearing;
    - need to restore knee movement & strength early and disregarding articular depressions;
    - local compression fractures of the lateral plateau with depression of up to 8-10 mm do well with non operative treatment;
          - usually mild valgus deformity and a few degrees of instability will develop;
    - wt bearing is not allowed for 8 weeks;
    - duing its application the cast brace is stressed into varus to prevent  femoral condylar pressure on the elevated plateau;

- Operative Management:
    - PreOp Planning
    - indications:
            - w/ valgus instability, ORIF is considered;
            - > 8 mm of depression, esp. if knee is unstable;
    - if depression is severe, articular fragments should be elevated bone grafted, and the lateral cortex supported with a butress plate;
    - w/ central depression frx, lateral cortex is intact circumferentially, & theoretically, there is no need for butress plate;
    - arthroscopic assisted reduction is most useful w/ depressions of  <12 mm;
            - elevate fragments, pack bone grafts under articular surface;
            - tibial tunnel ACL guide can be useful for creating a cortical window and allowing accurate elevation of bone fragments;
    - internal fixation:
                  - Percutaneous Screw Fixation of Tibial Plateau Fractures.
                  - Closed reduction and percutaneous screw fixation for tibial plateau fractures
                  - Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures.

    - post op:
            - protect the knee in a cast brace, & begin ROM during first 8 weeks;
            - then light wt bearing is used until 12 weeks;
            - note: possibility of fluid extravasation and compartment syndrome;
     - w/ > 12 mm depression, consider need for open reduction, elevation of frx depression and bone grafting to support the surface;
            - 6.5 cancellous screws can be inserted below the bone graft to provide support and prevent subsidence;
     - consider use of an interference screw thru the anteromedial window, which allows a slow driving force to raise the depression; (see milagro)

- Post Operative Care and Compications:
    - elevated articular surface must be protected against pressure from femoral condyle to prevent redepression;
    - Loss of Reduction:
              - loss of reduction of more than 4 mm occurs in 14% of pts;
              - results from inadequate support under elevated fragments;
    - AVN

- Misc:
    - Cast Bracing:

          - reliable external support is required in the post op period to counteract femoral condylar pressure;
          - redepression will frequently occurr w/ long leg cast;
          - instead pt's require well fitted varus cast brace;
          - cast bracing minimizes pressure against elevated articular surface;
          - to be effective, brace is placed in genu varus stress as hinges are affixed;
          - this is maintained for 8-10 weeks, at which time, elevated fragments will have revascularized & will have developed bony healing;
                  - wt bearing is delayed until bony healing is advanced;
          - watch for redepression, AVN of frx fragments, & valgus instability;
          - most frequent of these problems is redepression;
                  - occurs from inadequate postoperative protection of elevated articular surface from the femoral condylar pressure;
                  - more than 3 mm of redepression usually results in noticeable valgus deformity and instability

Interference screw technique for arthroscopic reduction and internal fixation of compression fractures of the tibial plateau.

Arthroscopic treatment of lateral tibial plateau fractures: a simple technique.

Arthroscopically assisted treatment of tibial plateau fractures.

Part I: Arthroscopic management of tibial plateau fractures.

Combined Arthroscopic Treatment of Tibial Plateau and Intercondylar Eminence Avulsion Fractures

Balloon Tibioplasty: A Useful Tool for Reduction of Tibial Plateau Depression Fractures

[Comparison study on effectiveness between arthroscopy assisted percutaneous IF and  ORIF for Schatzker types II and III tibial plateau frxs].

Percutaneous Inflation Osteoplasty for Indirect Reduction of Depressed Tibial Plateau Fractures