Tibia plateu, shaft, and plafond fractures 2012

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Tibia plateu, shaft, and plafond fractures 2012

  1. 1. TIBIA PLATEU, SHAFT, AND PLAFOND FRACTURES AAOS/ASSH General Review Jul 12, 2012Matthew L. Jimenez, MD, FACS
  2. 2. Mandatory DisclosureÜ  The 2012 14th Annual Chicago Trauma Symposium received support from 40 industry partners
  3. 3. Mandatory DisclosureÜ  Foundation for Education and Musculoskeletal Research (FEMR) several industry and philanthropic partners
  4. 4. Tibia Plateau Fractures
  5. 5. Surgical GoalsÜ  Obtain/Secure Articular ReductionÜ  Reduce Condylar WidthÜ  Restore Axial AlignmentÜ  Neutralize Meta-DiaphysisÜ  Secure Tibial TubercleÜ  Early ROMÜ  Appropriate Soft Tissue Handling
  6. 6. Surgical Timing§  Stage 1: Temporary Spanning External Fixation ú  Soft tissue stabilization ú  Fracture stabilization in polytraumatized patient ú  Develop surgical tactic - CT scan!!!!§  Stage 2: ORIF ú  Execute surgical tactic ú  Definitive articular & axial reductions and fixations
  7. 7. Buttress PlatingButtress plate - A plate employed to support the fractured bone in the area of the metaphysis, usually used in conjunction with lag screwsAntiglide plate - A plate used to reduce an oblique fracture indirectly through interference between the plate and the undisplaced main fragment
  8. 8. ButtressÜ  Resists shear forcesÜ  Metaphyseal Fractures
  9. 9. ButtressFunction
  10. 10. ButtressFunction
  11. 11. Resists shear
  12. 12. Anti-GlideÜ  Resists shear forcesÜ  Create stable axilla
  13. 13. Lateral Plateau Condylar width Lateral split Depression
  14. 14. StrategyOpen Book?Femoral distractorSubmeniscal arthrotomy ContainmentMeniscus repair Buttress Elevate joint from below
  15. 15. Containment
  16. 16. ContainmentCondylar widthBone graft/supportJoint compressionButtressNon locking implant
  17. 17. Complex BicondylarsMeta-­‐Diaphyseal  
  18. 18. Lateral locked vs dual platingÜ Can bicondylar fx s be treated with laterally based locked plating alone?Ü Is dual incision and plating better?
  19. 19. Lateral locked plating has NOT solved it all
  20. 20. The Medial Plateau Coronal Fx Sagi%al  Fx    Posteromedial Fragment Separates  En1re  Medial   Plateau  
  21. 21. Barei et al, JOT 2008
  22. 22. Posteromedial fragmentÜ Subject to shear forcesÜ Medial femoral condyle follows Ü Risk of displacementÜ Raises questions about fixation strategies and surgical approach
  23. 23. Barei et al, JOT 2008
  24. 24. With Posteromedial Fragment Ü Consider dual approach Ü Will locking screws from the lateral side support that fragment?
  25. 25. Ipsilateral, NoncontiguousPlateau and Shaft Fractures
  26. 26. Plateau/Shaft FracturesÜ Unusual injury patternÜ Difficult to treat with a single implantÜ Goal = treat both injuries optimally
  27. 27. Barei et al, JOT2008
  28. 28. Barei et al, JOT2008
  29. 29. Tibia Plateau SummaryÜ ButtressÜ Radiographic evaluationÜ Develop a strategic planÜ Careful consideration - lateral locked vs. dual platingÜ Beware the posteromedial fragment
  30. 30. Tibia Shaft Fractures
  31. 31. Current Surgical Indications- Open Fracture- Vascular Injury- Compartment Syndrome- Multi-trauma- Unstable Fracture
  32. 32. What is an Unstable Tibial Shaft Fracture?- 1 cm shortening- Tibia + fibula fractured at samelevel- High-energy fracture- Displaced tibia with intact fibula
  33. 33. Current Concepts: Reamed Intramedullary Nailing- Proximal (4-7 cm fromjoint)- Distal (3-4 cm from joint)- Segmental fractures- Closed fractures- Open fractures
  34. 34. Early Amputation for Mangled Extremity?
  35. 35. Early Amputation for Mangled Extremity? NO
  36. 36. Mangled Extremity: LEAP Study- Scoring systems are not helpful.- Initial sensation is not a reliable indicator offuture sensation.- Results poor at 2 years, whether amputated orsalvaged.- Results even worse at 7 years.- Most risk factors for poor results are beyondsurgeon s control.- Poor results related to socioeconomic status
  37. 37. Damage Control
  38. 38. IM Nailing after Ex Fix?- Best done early (within 2weeks)- Pin sites must be clean.- Patient must be stable.- Infection risk higher than infemur.
  39. 39. ORIF after Ex Fix?- Can be delayed.- Pin sites should be clean.- Skin must be healthy.- Can be minimallyinvasive.
  40. 40. Techniques for Proximal Fractures:- Obtain reduction.- Provisional plating (unicortical).- Blocking screws.- Multiple interlocking screws.- Interest in suprapatellar approach.
  41. 41. Techniques for Distal Fractures:- Plate fibula if fractureddistally.- Steinman pins as joysticks.- Blocking screws.- Multiple interlocking screws
  42. 42. Wire FixatorsBeing replaced by locking plates.
  43. 43. Summary of Current Concepts- Indications have not changed.- Reamed intramedullary nailing is the mainstay oftreatment.- Remember ATLS, Damage Control.- Don t be in a hurry to amputate.- Consider delayed ORIF after Ex Fix.- Obtain and Maintain reduction of proximal anddistal fractures.- New technologies have not yet withstoodscrutiny.
  44. 44. Tibia Plafond Fractures
  45. 45. Evaluation§  Ankle radiographs§  Tibia radiographs§  CT scans
  46. 46. It s not the fractureIt s the Soft Tissues
  47. 47. Poor TimingWagner, Unfallchir, 1986 GuaranteesMast, CORR 1988 Soft tissue must beTrumble, JOT 1992 ready for surgical insultWyrsch, JBJS 1996Helfet, CORR 1994 Poor Outcome
  48. 48. Staged protocols Early LateÜ Trans-articular Ü Definitive external fixation ArticularÜ Fix fibula reconstructionÜ Allow soft tissue stabilization Ü Remove fixator
  49. 49. Stage 1 GoalsÜ  Restoration of skeletal length and alignmentÜ  Span joint and allow soft tissues to stabilizeÜ  Distraction across ankle joint
  50. 50. Plate FibulaFibula must be anatomically reduced
  51. 51. A FibulaMalreductionWill PreventLater Correct Alignment of the Plafond
  52. 52. Sagittal Plane Malalignment
  53. 53. Temporizing FixatorÜ Span joint and allow soft tissues to stabilizeÜ Maintains alignment and length Ü Not articular congruityÜ  Portable tractionÜ Treat soft tissues Ü Flaps, dressing changes, etc
  54. 54. Post ex-fix imagesÜ Use fluoroscopy to look at reductionÜ Look at ankle joint carefully
  55. 55. Look CarefullyÜ Make sure you regain length Ü Articular landmarks Ü Fibula
  56. 56. Look CarefullyÜ Look at articular surface Ü Chaput fragment Ü  Maintains soft tissue connection with fibula
  57. 57. Look Carefully•  Look at fibula length – No overlap – Must be out to length
  58. 58. Stage IÜ External fixatorÜ Fibula platingÜ CT Scan Ü post fixator when possible
  59. 59. CT Scans•  After external fixation•  Guide to fracture fragments•  Plan surgery •  Incisions •  Lag Screws •  Closed vs. open •  Wire Placement Tornetta, CORR 1996
  60. 60. Next Step
  61. 61. Surgical Decision MakingÜ Soft tissueÜ Soft tissueÜ Soft tissue
  62. 62. Surgical Decision MakingÜ  Resolution of EdemaÜ  Wrinkle testÜ  Epithelialized fracture blisters
  63. 63. Surgical TimingÜ  PatienceÜ  Timing criticalÜ  Avoid 1-6 daysÜ  Await soft tissue Inflammatory Phase Reparative Phase envelope Proliferative Phase Ü  (10-21 days)
  64. 64. Staged protocols Early LateÜ Fix fibula Ü DefinitiveÜ Trans-articular Articular external fixation reconstructionÜ Allow soft tissue stabilization Ü Remove fixator
  65. 65. Stage 2 GoalsÜ Avoid complicationsÜ Anatomic restoration of jointÜ Stable fixation to allow motionÜ Healed anatomically aligned limb
  66. 66. Post-op ProtocolÜ Cast until sutures outÜ Cam walker until able to keep foot at neutralÜ NWB for 8-12 weeks
  67. 67. SummaryÜ Difficult fracturesÜ No single treatment methodÜ Staged protocolÜ Patience
  68. 68. SummaryÜ Biological exposure & fixationÜ Accurate reduction of the articular surfaceÜ Rigid fixation to allow early motion
  69. 69. THANK YOU

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