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Tibia plateu, shaft, and plafond fractures 2012
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Tibia plateu, shaft, and plafond fractures 2012

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  • 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

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