Proximal tibia fracture

11,107 views
10,692 views

Published on

Published in: Health & Medicine, Sports
2 Comments
36 Likes
Statistics
Notes
No Downloads
Views
Total views
11,107
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
4
Comments
2
Likes
36
Embeds 0
No embeds

No notes for slide

Proximal tibia fracture

  1. 1. PROXIMAL TIBIAL FRACTURE
  2. 2. OVERVIEW  TIBIAL FRACTURE and TYPES  MECHANISM OF INJURY  EVALUATION  MANAGEMENT  TIBIAL SPINE INJURIES  TIBIA TUBERCLE FRACTURE  TIBIA SHAFT FRACTURE  PROXIMAL TIBIAL EPIPHYSIS FRACTURE  COMPLICATIONS OF TIBIAL FRACTURE
  3. 3. TIBIAL FRACTURE AND TYPES
  4. 4. TIBIAL FRACTURES  Most common long bone fracture  492,000 fractures yearly  Average 7.4 day hospital stay  100,000 nonunions per year Orthopaedia Trauma Association
  5. 5. DEMOGRAPHICS • 1% of all fractures • 8% of all fractures in the elderly • Lateral plateau involved 55-70% • Medial plateau involved 10-20% • Both involved 10-30% Sports medicine consult
  6. 6. TYPES :- 1. Articular (Hohl and Moore`s classification ) Plateau fracture Fracture dislocation 2. Nonarticular
  7. 7. PLATEAU FRACTURE Minimally displaced Local compression Split compression Total condylar depression Bicondylar fracture
  8. 8. FRACTURE DISLOCATIONS 1. Split fracture 2. Entire condyle fracture 3. Rim avulsion fracture ( Involves lateral condyle, associated with capsular tears and vascular injuries ) 4. Rim compression type (Unstable associated with avulsion of cruciates) 5. Four part fracture (Unstable with Collateral avulsed And neurovascular injuries)
  9. 9. MECHANISM OF INJURY
  10. 10. MECHANISM OF INJURY  Can have both shear and compressive forces  Valgus (or varus) force split  Axial load depression  Combined force split/depression (80%)  Higher velocity (bumper fracture) leads to an increase  Comminution  Displacement  Soft tissue injury
  11. 11. EVALUATION
  12. 12. EVALUATION  Trauma Evaluation  ABCs  Associated Injuries  Evaluation of Limb  Gentle exam for knee stability  Observation of soft tissues  Neurovascular evaluation  Evaluate for compartmental syndrome  Imaging Evaluation Browner and Jupiter, Skeletal Trauma, 3rd Ed
  13. 13. PHYSICAL EXAMINATION  Neurologic Exam  Peroneal nerve especially with valgus force  R/O compartment syndrome with severe injuries  Vascular Exam  Palpable pulses do not exclude injury  popliteal artery and medial plateau injuries  beware the of the knee dislocation posing as a fracture  beware of posteriorly displaced fracture fragments  ABI <0.9 urgent arterial study
  14. 14. PHYSICAL EXAMINATION  Soft Tissue Assessment  Tscherne & Goetzen (Closed injury)  Gustillo and Anderson (Open injury)
  15. 15. TSCHERNE & GOETZEN CLOSED FRACTURE CLASSIFICATION  Grade 0  Minimal Soft Tissue Injury  Simple Fracture Pattern  Grade 1  Superficial Abrasion  Mild to Moderate Fracture Pattern  Grade 2  Deep Abrasion  Impending Compartment Syndrome  Severe Fracture Pattern  Grade 3  Extensive Crush  Severe Fracture Pattern  +/- Vascular Injury
  16. 16. GUSTILLO-ANDERSON OPEN FRACTURE CLASSIFICATION  Grade I - Wound < 1cm  Grade II - Wound 1-10 cm  Grade III - Wound > 10 cm  IIIA = Adequate Soft Tissue Coverage  IIIB = Requires Soft Tissue Coverage  IIIC = Arterial Injury Requiring Repair
  17. 17. CLINICAL FEATURES  Pain  Swelling  Deformity  Haemarthrosis  Decrease movement of knee  Instability in valgus or varus
  18. 18. PHYSICAL EXAMINATION  Hemarthrosis, aspirate for:  Pain relief  Fat evaluation  Assessment of stability after local anesthetic  Varus/valgus in full extension  Compartment syndrome  Pain with passive stretch  Pain out of proportion
  19. 19. RADIOGRAPHIC EVALUATION  AP, Lateral on Large Cassettes  Obliques  Internal rotation view  Shows postero-lateral fragment  Traction Films  Defines fragments  Bridging Ex-fix can provide traction  CT scan with reconstruction  Obtain after ex fix if using  Coronal  Sagittal  Arteriography when necessary  ? MRI – unsuspected fxs or soft tissue injury
  20. 20. RADIOGRAPHS  Plain films  Interobserver agreement = 62%  Unchanged by CT scan  Addition of CT scan increased agreement for surgery plan from 58 to 71%  Treatment plan changed in > 25% FROM CT  CT shows  Comminution  Depression  FX lines Chan, JOT,1997
  21. 21. CLASSIFICATION  Type I - Split Lateral Tibial Plateau Fx  Type II - Split/Depression Lateral Plateau Fx  Type III - Pure Depression Lateral Plateau Fx  Type IV - Medial Tibial Plateau Fx  Type V - Bicondylar Split Fx  Type VI - Tibial Plateau Fx with Metaphyseal - Diaphyseal Separation Schatzker, Clin Orthop, 1979
  22. 22. SCHATZKER I:  Definition:. Lateral split  Etiology: Often due to valgus stress. Occurs in younger patients with stronger bones, which are resistant to depression. Often due to a bumper injury.  Common associated injuries: Lateral meniscal tear. The lateral meniscus may also become entrapped in the fracture and require arthroscopy.  Treatment: Typically, lateral fixation.
  23. 23. SCHATZKER II  Most common tibial plateau fracture.  Definition: Lateral split with depression.  Etiology: Often due to valgus or axial stress. Occurs in older patients with osteoporosis with bones that do not resist depression.  Common associated injuries: Lateral meniscus, medial meniscus, and medial collateral ligament.  Treatment: Typically, lateral fixation. The depressed fragments are elevated and supported with bone graft.
  24. 24. SCHATZKER III:  Definition: Pure lateral depression; no splitting  Etiology: Older patients with osteoporosis. Often just due to a fall.  Common associated injuries: If the depressed fragments are lateral and posterior, it is associated with joint instability.  Treatment: If there is instability, the fractured fragments are elevated and supported with bone graft and lateral internal fixation.
  25. 25. SCHATZKER IV:  Definition: Medial tibial plateau fracture that may be a split or split depression type fracture.  Etiology: Varus stress. Often severe trauma.  Common associated injuries: Associated with avulsion of the intercondylar eminence, which may indicate anterior cruciate ligament injury. Lateral collateral ligament injury. Peroneal nerve injury. Popliteal artery injury.  Treatment: Medial plate and screws.
  26. 26. SCHATZKER V:  Definition: Split medial and lateral tibial plateau (Bicondylar). Metaphysis is still in continuity with the diaphysis.  Etiology: Often pure axial stress with severe trauma.  Common associated injuries: Neurovascular, ACL, and meniscal injuries.  Treatment: Typically, medial and lateral internal fixation.
  27. 27. SCHATZKER VI:  Definition: Metaphyseal fracture that separates the articular surface from the diaphysis.  Etiology: High-energy trauma.  Common associated injuries: Neurovascular injury and compartment syndrome. Also meniscal, ACL, and collateral ligament injuries.  Treatment: Typically medial and lateral internal fixation
  28. 28. AO/OTA CLASSIFICATION  Type A - Extraarticular  Type B - Partial Articular  Type C - Intra-articular and Metaphyseal Orthopaedia Trauma Association
  29. 29. AO/OTA CLASSIFICATION
  30. 30. AO/OTA CLASSIFICATION Type II Type III Type I Type IV
  31. 31. AO/OTA CLASSIFICATION Type V Type VI
  32. 32. MANAGEMENT
  33. 33. TIMING OF SURGERY  Stable, resuscitated patient  Define fracture  Soft tissue envelope  Swelling  Ecchymosis  “Damage Control Orthopaedics”  Positioning of patient  Other injuries
  34. 34. “DAMAGE CONTROL ORTHOPAEDICS”  Temporary Stabilization  Soft Tissue Rest  Bony Stabilization  Bridging ExFix  Across the Knee  Pins Out of Zone of ORIF in Tibia  Types V & VI Primarily  ORIF
  35. 35. ARTICULAR FRACTURES  A decrease in joint surface area leads to increase stresses with subsequent deformity and post – traumatic osteoarthritis  Alignment and stable fixation of the articular surface results in the formation of hyaline cartilage NOT fibrocartlilage Mitchell and Shepard, JBJS, 1980
  36. 36. SURGICAL INDICATIONS  Open Fracture – I&D, spanning ex-fix  Extensive soft tissue contusion – spanning ex-fix  Closed fracture  Varus/valgus instability of the knee  Varus or valgus tilt of the proximal tibia  Meniscal injury/previous meniscectomy  Articular displacement or gapping Rasmussen P, JBJS 55, 1973 Lansinger O, JBJS 68, 1986
  37. 37. SURGICAL APPROACHES  Straight Midline  Lateral Parapatellar  Medial Parapatellar  Posteromedial  Two approaches for bicondylar fractures  AVOID Mercedes incision or midline with stripping of soft tissues, especially for bicondylars www2.aofoundation.org
  38. 38.  Entry site is critical  Reference is Lateral Tibial Spine
  39. 39. JUST RIGHT
  40. 40. TOO LOW! TOO MEDIAL! Procurvatum Valgus
  41. 41. APPROACH  Lateral parapatellar approach  Leg extended  Incision starts over distal head of vastus lateralis  Continues just lateral to patella and patellar tendon
  42. 42. APPROACH  Complex Fractures  Long, straight anterior midline incision  Two Incisions – Preferred  Bridge knee with distractor or ex-fix  Apply moderate distraction to stabilize soft tissues
  43. 43. POSTEROMEDIAL APPROACH  Useful for bicondylar  Medial injury often  Posteromedial  Coronal
  44. 44. SURGICAL TECHNIQUES  Ligamentotaxis  Helps with Condyle Architecture  Does not reduce Joint Depression  Femoral Distraction  Indirect Reduction  Preserve Meniscus  Bone Graft
  45. 45. TIBIAL SPINE INJURIES
  46. 46. TIBIAL SPINE INJURIES  aka intercondyle eminence  Same mechanism as ACL rupture (hyperextension, rotation, ab/adduction)  In young patients ACL stronger than tibial spine – thus tibial spine injury  Suspect with ACL-like presentation (positive Lachman, etc.) AND inability to weight bear
  47. 47. TIBIAL SPINE INJURIES  Type I  Incomplete avulsion with no displacement  Type II  incomplete avulsion with displacement  Type III  Completely avulsed fragment http://remergs.com/WEBPAGE%20Notes/Trauma/50%20--%20Knee%20and%20Leg.pdf
  48. 48. TIBIAL SPINE INJURY Type II tibial spine avulsion fracture
  49. 49. TIBIAL SPINE INJURIES TREATMENT  Consider arthroscopy for definitive classification  Type I: conservative; cast immobilization in full extension X 6 weeks  Type II: arthroscopic or open reduction; internal fixation with screws and wires Arthroscopic or ORIF: significant displacement, associated ligamentous injury,  Type III fractures, failure of closed reduction Displaced or rotated fractures require ORIF to restore normal ACL function http://remergs.com/WEBPAGE%20Notes/Trauma/50%20--%20Knee%20and%20Leg.pdf
  50. 50. TIBIA TUBERCLE FRACTURE
  51. 51. 52 FRACTURE OF THE TIBIA TUBERCLE  Tibia tubercle: patella tendon insertion, most anterior and distal portion of the proximal tibia epiphysis  Result from jumping or a rapid quadriceps contraction against a flexed knee
  52. 52. 53 OSGOOD-SCHLATTER DISEASE  Active children over the age of 8  Pain in tibia tubercle  Superficial microfracture of the cartilage at the insertion of the tendon
  53. 53. 54 EVALUATION  Pain, swelling, tenderness  Limited displacement: may not be an effusion, capable of limited active extension  Displaced frx: active knee extension is impossible, effusion,
  54. 54. 55 CLASSIFICATION
  55. 55. 56 TREATMENT  Non-displaced type I: long leg cast in extension for 4~6 wks  Others: ORIF with screws and washers, post-op immobilization for 4~6 wks Complication:  Genu recurvatum
  56. 56. TIBIA SHAFT FRACTURE
  57. 57. TIBIAL SHAFT FRACTURE  Most commonly fractured long bone  Commonly open (1/3 of surface area just subcutaneous)  Precarious blood supply  Hinge joints at knee and ankle are unforgiving of post-reduction deformity emedicine.medscape.com/article/1249984-overview
  58. 58. TIBIAL SHAFT FRACTURES CLASSIFICATION  No universally accepted classification scheme. Describe the following  Location (prox, middle, distal third)  Configuration (transverse, spiral, comminuted)  Displacement  Angulation  Length  rotation
  59. 59. TIBIAL SHAFT FRACTURE Closed distal third comminuted fracture of left tibia Nondisplaced as <5% angulation, no rotation
  60. 60. TIBIAL SHAFT FRACTURE ED TREATMENT  Manage neurovascular status  Carefully inspect any soft tissue defect for open fracture  Splint in long-leg, padded, posterior splint  Beware of compartment syndrome
  61. 61. TIBIAL SHAFT FRACTURE DEFINITIVE MANAGEMENT  No consensus exists re: definitive treatment  Multifactorial decision  Possible management  ORIF  Intramedullary rod  Cast immobilization  Early progressive weight bearing after two weeks
  62. 62. PROXIMAL TIBIAL EPIPHYSIS FRACTURE
  63. 63. 64 FRACTURE OF THE PROXIMAL TIBIAL EPIPHYSIS  Uncommon, 3% of epiphyseal injuries of lower extremity  Proximal tibial epiphysis:  55% of the length of the tibia  25% of the entire length of the limb  0.6 cm per year  Popliteal artery: lies close to the epiphysis in the popliteal fossa, at risk of injury with displaced fracture www.ncbi.nlm.nih.gov/pubmed/1405569
  64. 64. 65 EVALUATION  Pain, swelling, decreased ROM of knee  Neurovascular assessment  Vascular injury is suspected  arteriogram Classification:  Salter-Harris classification Associated injury:  Popliteal artery and peroneal nerve injury
  65. 65. 66 TREATMENT  Salter-Harris type I, II: close reduction + immobilization 4~6 weeks  Salter-Harris type III, IV: CRIF with percutaneous pins or cannulated screws  Displaced frx with vascular injury: urgent reduction and vascular status reassess  Irreducible or vascular injury present: open reduction  After reduction, splint in 10 ~20 degree flexion  Cast when risk of compartment has decreased
  66. 66. COMPLICATIONS OF TIBIAL FRACTURE
  67. 67. COMPLICATIONS  Knee stiffness  Infection  Compartment syndrome  Malunion or nonunion  Posttraumatic osteoarthritis  Peroneal nerve injury  Popliteal artery laceration.  Avascular necrosis
  68. 68. 69 COMPLICATION – COMPARTMENT SYNDROME  Potential devastating complication  Poorly controlled pain is the earliest sign  Discomfort during passive stretch of the muscle  Partial fibulectomy: lead to valgus deformity in child, should not be performed
  69. 69. 70 COMPLICATION – DELAY UNION OR NONUNION  Fail to heal within 6 months  Unusual  Mean healing time  10 weeks in close frx  5 months in open frx  Iliac crest bone grafting: usually successful in healing the nonunion
  70. 70. 71 COMPLICATION – ANGULAR DEFORMITY  Result from poor alignment or over-growth  Valgus deformity from frx of proximal tibia metaphyseal  Frequently correct spontaneously over several years  Observation is recommended
  71. 71. 72 COMPLICATION – ROTATIONAL DEFORMITY  Result from inadequate reduction  Does not spontaneously correct  >20 degree  rotational osteotomy
  72. 72. COMPLICATION – PROXIMAL TIBIAL PHYSEAL CLOSURE  Rare complication  Cause a genu recurvatum deformity  Corrected with an opening wedge osteotomy
  73. 73. THANK YOU

×