Case presentation and discussion on Management of intra-articular Fractures

1. MANAGEMENT OF ARTICULAR
FRACTURES - CASE PRESENTATION
DR. BIJAY MEHTA
2ND YEAR RESIDENT
NAMS

2. Case 1
•32y/Male with a/h/o twisting of left lower limb while carrying heavy load
• Presented to our center 12 hrs after injury with c/o
• Pain and swelling of left knee and
• Inability to bear weight

3. Examination
L/E of Left Knee:
• Overlying Skin: Intact
• Swelling ++
• Tenderness + over anterior aspect of left knee and leg
• DNVS : Intact
• ROM : Couldn’t be elicited

4. Investigations
•X-RAY
•CT Scan

6. Diagnosis
•32/Male with Closed Left Tibial Plateau # (Schatker Type V) with Intact DNVS

7. Management
In ER ,
◦ Limb was immobilized
◦ Elevation done
◦ Ice compression done
◦ Close monitoring of neurovascular status/ development of compartment syndrome
•Baseline blood investigations were sent and patient was planned for surgery

8. Surgery
•Operated on 6th day after swelling subsided
•ORIF with Bicolumnar plating was done via
Anterolateral and Posteromedial approach
•Articular congruency was maintained and
corticocancellous bone graft was placed.
•Knee Immobilizer was applied to allow soft
tissue healing

9. Post-op Rehabilitation
•Active and Passive Knee ROM was started from 2nd post op day
•Partial weight bearing and crutch mobilization was begun as soon as patient tolerated
•Patient was advised to avoid full wt bearing for 10-12 weeks

10. Case 2
•20y/Male, Dang
•A/h/o RTA
•Presented to our center on the day of trauma
•C/o : Pain, Swelling and Deformity of Rt Hip

11. Examination
•Vitals: Stable
•L/E of Rt hip:
• Skin : Intact
• Attitude: FADIR
• Shortening +
• DNVS : Intact

12. Investigation
•X ray Pelvis – AP view
•Diagnosed as Closed posterior dislocation
of RT Hip with Intact DNVS

13. Emergency Management
•Under Sedation, Closed reduction was
done
•Post Reduction Xray- Fracture of femoral
head identified
•CT pelvis sent

14. CT Scan
(Post Reduction)

15. Diagnosis
Closed # Rt Femoral Head (PIPKIN Type I) S/P Reduction of Posterior Dislocation
of Rt hip with Intact DNVS

16. Management
•Open Reduction and Internal Fixation
with Herbert Screw
•Approach: Direct Anterior Approach
(Smith Peterson Approach)

17. Post-op Rehabilitation
•ROM was initiated from 2nd post op day
•Partial Wt bearing was initiated at discharge

18. Case 3
•23y/Male
•A/h/o Fall From bike
•Presented to our center with C/o
• Pain and swelling of Rt Elbow
• Inability to move Rt elbow

19. Examination
•Vitals: Stable
•L/E of Rt Elbow:
• Skin : Intact
• Swelling +
• Tenderness +
• ROM-Restricted and painful
• DNVS : Intact

20. Investigations
X RAY

21. CT

22. Diagnosis
•Closed Intercondylar # Left Humerus(M/M Medial Lambda type,AO C3) with Intact DNVS

23. Emergency Management
•Immobilized in A/E slab
•Limb Elevation
•Close monitoring of DNVS

24. Surgery
•ORIF with Bicolumnar
orthogonal plating
•Posterior splint was applied
to ensure soft tissue healing

25. Post-op Rehabilitation
•ROM was started from 4th post op day after 1st dressing
•Posterior splint was removed after 1 week.

26. Discussions: How to manage
articular fractures ?

27. Articular Cartilage: Histology
•Composition
• Chondrocytes
• Proteoglycans
• Type II Collagen
• Water
•Properties:
• Resilient
• Elastic
• Avascular

28. Articular Cartilage : Functions
•Distributes forces evenly
•Frictionless motion
•Shock absorber

29. Articular Cartilage: Nutrition
•Avascular
•Nutrition comes from synovial fluid
•Flow of synovial fluid requires motion and load
•To preserve articular cartilage one needs:
• Early motion
• Some Load

30. Intra-articular Fractures: Problems
•Immobilization results in joint stiffness
•Immobilization after surgery results in more stiffness
•Loss of articular congruency leads to shift in loading patterns – progression to
osteoarthritis
•Depressed articular fragments will not be reduced by closed manipulation
•Metaphyseal defects beneath reduced articular segments need to be filled
with bone grafts or substitutes to prevent articular fragment redisplacement/
settling

31. Articular Fractures: Treatment
•Anatomic Reduction
• No step-up and gaps, no depressions
•Maintenance of articular congruency
• So that load is evenly distributed
•Stable Internal Fixation (Absolute Stability)
• So that early mobilization is possible
•Early Mobilization
• Prevents joint stiffness and ensures healing

32. Concept of Absolute Stability
Definition: No micromotion between the fracture fragments
under normal physiological loading
◦ Open Reduction is required
◦ Anatomic Reduction is required
•Healing by Primary Intention
•No Callus Formation

33. Concept of Absolute Stability
•Methods :
• Lag Screw Fixation
• Axial Compression with Compression
Plating
• Tension Band Wiring
• Buttress plating

34. Articular Fracture : Principles
•Understanding the mechanism of Injury
•Evaluation of soft tissues
•Adequate imaging
•Timing of surgery
•Appropriate surgical approach
•Articular Reduction
•Buttressing of the metaphysis
•Post Operative Care

35. Postoperative Treatment
•Splinting for short duration to allow healing of soft tissues
•Active assisted exercises as soon as possible
•Regular X ray surveillance at follow-up

36. What’s New ?
•Concept of Absolutive Fixation
•Properties between Absolute and relative stability

37. Take Home Message
•Articular cartilage has a poor healing capacity.
•It is avascular and derives its nutrition from synovial fluid
•Proper flow of synovial fluid requires-
• Motion
• Load
•Early mobilization improves healing of articular cartilage

38. Take Home Message
•Anatomic Reduction-Often direct
•Stability –Absolute – Stable Fixation
•Early mobilization
•Anatomic Reduction + Stable Fixation + Early Mobilization Healing with Hyaline
Cartilage

39. References:
1. AO Principles of Fracture Management, Third Edition
2. Campbell’s Operative Orthopaedics, 13th Edition
3. Rockwood and Green’s Fractures in Adults , 8th Edition

40. Thank You