Your SlideShare is downloading. ×
Tibia plateu, shaft, and plafond fractures 2012
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.

Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Tibia plateu, shaft, and plafond fractures 2012


Published on

  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 1. TIBIA PLATEU, SHAFT, AND PLAFOND FRACTURES AAOS/ASSH General Review Jul 12, 2012Matthew L. Jimenez, MD, FACS
  • 2. Mandatory DisclosureÜ  The 2012 14th Annual Chicago Trauma Symposium received support from 40 industry partners
  • 3. Mandatory DisclosureÜ  Foundation for Education and Musculoskeletal Research (FEMR) several industry and philanthropic partners
  • 4. Tibia Plateau Fractures
  • 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. 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. 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. ButtressÜ  Resists shear forcesÜ  Metaphyseal Fractures
  • 9. ButtressFunction
  • 10. ButtressFunction
  • 11. Resists shear
  • 12. Anti-GlideÜ  Resists shear forcesÜ  Create stable axilla
  • 13. Lateral Plateau Condylar width Lateral split Depression
  • 14. StrategyOpen Book?Femoral distractorSubmeniscal arthrotomy ContainmentMeniscus repair Buttress Elevate joint from below
  • 15. Containment
  • 16. ContainmentCondylar widthBone graft/supportJoint compressionButtressNon locking implant
  • 17. Complex BicondylarsMeta-­‐Diaphyseal  
  • 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. Lateral locked plating has NOT solved it all
  • 20. The Medial Plateau Coronal Fx Sagi%al  Fx    Posteromedial Fragment Separates  En1re  Medial   Plateau  
  • 21. Barei et al, JOT 2008
  • 22. Posteromedial fragmentÜ Subject to shear forcesÜ Medial femoral condyle follows Ü Risk of displacementÜ Raises questions about fixation strategies and surgical approach
  • 23. Barei et al, JOT 2008
  • 24. With Posteromedial Fragment Ü Consider dual approach Ü Will locking screws from the lateral side support that fragment?
  • 25. Ipsilateral, NoncontiguousPlateau and Shaft Fractures
  • 26. Plateau/Shaft FracturesÜ Unusual injury patternÜ Difficult to treat with a single implantÜ Goal = treat both injuries optimally
  • 27. Barei et al, JOT2008
  • 28. Barei et al, JOT2008
  • 29. Tibia Plateau SummaryÜ ButtressÜ Radiographic evaluationÜ Develop a strategic planÜ Careful consideration - lateral locked vs. dual platingÜ Beware the posteromedial fragment
  • 30. Tibia Shaft Fractures
  • 31. Current Surgical Indications- Open Fracture- Vascular Injury- Compartment Syndrome- Multi-trauma- Unstable Fracture
  • 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. Current Concepts: Reamed Intramedullary Nailing- Proximal (4-7 cm fromjoint)- Distal (3-4 cm from joint)- Segmental fractures- Closed fractures- Open fractures
  • 34. Early Amputation for Mangled Extremity?
  • 35. Early Amputation for Mangled Extremity? NO
  • 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. Damage Control
  • 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. ORIF after Ex Fix?- Can be delayed.- Pin sites should be clean.- Skin must be healthy.- Can be minimallyinvasive.
  • 40. Techniques for Proximal Fractures:- Obtain reduction.- Provisional plating (unicortical).- Blocking screws.- Multiple interlocking screws.- Interest in suprapatellar approach.
  • 41. Techniques for Distal Fractures:- Plate fibula if fractureddistally.- Steinman pins as joysticks.- Blocking screws.- Multiple interlocking screws
  • 42. Wire FixatorsBeing replaced by locking plates.
  • 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. Tibia Plafond Fractures
  • 45. Evaluation§  Ankle radiographs§  Tibia radiographs§  CT scans
  • 46. It s not the fractureIt s the Soft Tissues
  • 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. Staged protocols Early LateÜ Trans-articular Ü Definitive external fixation ArticularÜ Fix fibula reconstructionÜ Allow soft tissue stabilization Ü Remove fixator
  • 49. Stage 1 GoalsÜ  Restoration of skeletal length and alignmentÜ  Span joint and allow soft tissues to stabilizeÜ  Distraction across ankle joint
  • 50. Plate FibulaFibula must be anatomically reduced
  • 51. A FibulaMalreductionWill PreventLater Correct Alignment of the Plafond
  • 52. Sagittal Plane Malalignment
  • 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. Post ex-fix imagesÜ Use fluoroscopy to look at reductionÜ Look at ankle joint carefully
  • 55. Look CarefullyÜ Make sure you regain length Ü Articular landmarks Ü Fibula
  • 56. Look CarefullyÜ Look at articular surface Ü Chaput fragment Ü  Maintains soft tissue connection with fibula
  • 57. Look Carefully•  Look at fibula length – No overlap – Must be out to length
  • 58. Stage IÜ External fixatorÜ Fibula platingÜ CT Scan Ü post fixator when possible
  • 59. CT Scans•  After external fixation•  Guide to fracture fragments•  Plan surgery •  Incisions •  Lag Screws •  Closed vs. open •  Wire Placement Tornetta, CORR 1996
  • 60. Next Step
  • 61. Surgical Decision MakingÜ Soft tissueÜ Soft tissueÜ Soft tissue
  • 62. Surgical Decision MakingÜ  Resolution of EdemaÜ  Wrinkle testÜ  Epithelialized fracture blisters
  • 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. Staged protocols Early LateÜ Fix fibula Ü DefinitiveÜ Trans-articular Articular external fixation reconstructionÜ Allow soft tissue stabilization Ü Remove fixator
  • 65. Stage 2 GoalsÜ Avoid complicationsÜ Anatomic restoration of jointÜ Stable fixation to allow motionÜ Healed anatomically aligned limb
  • 66. Post-op ProtocolÜ Cast until sutures outÜ Cam walker until able to keep foot at neutralÜ NWB for 8-12 weeks
  • 67. SummaryÜ Difficult fracturesÜ No single treatment methodÜ Staged protocolÜ Patience
  • 68. SummaryÜ Biological exposure & fixationÜ Accurate reduction of the articular surfaceÜ Rigid fixation to allow early motion
  • 69. THANK YOU