lecture on proximal tibia fracture and its management

1. fractures of
PROXIMALTIBIA

2. OVERVIEW
 HISTORIALOVERVIEW
 ANATOMY
 CLASIFFICATIONS
 MANAGEMENT
 OPERATIVETECHNIQUES
 LATESTADVANCES

3. HISTORY
 In the past 5 decades treatment and techniques of proximal tibia
fractures have evolved dramatically from predominantly non
operative treatment in early 3 decades to ORIF in past 2 decades
 Early non operative treatment included traction techniques, cast
bracing, and even spica casting.
 In 1825 sir Astley cooper first described fractures of proximal tibia.

4.  Landmark Events in the Development of Treatment Strategies
• In 1825, Sir Astley Cooper recommended treatment by re-alignment,
splintage and early passive motion.
• In 1939, the first classification system was proposed by Marchant.
• In 1972, Sarmiento popularized functional cast bracing of
most tibial condylar fractures.
• In 1973, Rasmussen introduced open reduction and internal
fixation (ORIF) of tibial condylar fractures.
• In 1979, Schatzker described his classification which is still commonly
used today.
• In 1987, AO/OTA came up with its own classification.

5. ANATOMY
 The proximal end of the tibia features several important
landmarks which function as sites of muscle attachment and
articular surfaces: two tibial condyles (medial and lateral)
separated by intercondylar areas (anterior and posterior).
 The superior surface of the medial condyle is round in shape
and somewhat concave, so it fits perfectly into a joint with the
medial condyle of the femur.
 the superior surface of the lateral condyle is pretty much a
mirror image of the medial condyle. It is round in shape,
somewhat convex, and articulates with the lateral condyle of
the femur.
 The articular surfaces are separated by two small
prominences, the medial and lateral intercondylar tubercles.
These tubercles form the intercondylar eminence.

8.  Anterior horn of medial meniscus
 Anterior cruciate ligament
 Anterior horn of lateral meniscus
 Posterior horn of lateral meniscus
 Posterior horn of medial meniscus
 Posterior cruciate ligament

10. JOINT CAPSULE
 Attached to circumference pf tibial plateau except at two places
 Where the tendon of the popliteus crosses the margin of tibia capsule
extends down to the head of the fibula.
 Posteriorly to the ridge below the grove for PCL.

11.  The posterior horn of the medial meniscus is firmly attached
to the posterior aspect of the periphery to the joint capsule. At
its midpoint, the meniscus is firmly attached to the femur and
tibia through a condensation in the joint capsule known as the
deep medial ligament. The medial meniscus has no direct
attachment to any muscle, but indirect capsule connections to
the semimembranosus may provide some retraction of the
posterior horn.
 There is no attachment of the lateral meniscus to the LCL.
Its peripheral attachment is interrupted posterior to where the
popliteal tendon passes. The capsular components attach the
lateral meniscus to the tibia less firmly than the medial
meniscus. The lateral meniscus is more mobile than medial.

13.  the ligaments of Humphrey and Wrisberg are meniscofemoral
ligaments which run from the posterior horn of lateral
meniscus to the lateral aspect of the medial femoral condyle.
 these ligaments are named based on their location in relation
to the PCL
 the anterior meniscofemoral ligament is known as the
ligament of Humphrey where as the posterior meniscofemoral
ligament is known as the ligament of Wrisberg.

15. MEDIAL
ATTACHMENTS

16. LATERAL
ATTCHMENTS

17. ANATOMICAL
ANGLES

18. FRACTUREOF
PROXIMALTIBIA
 Tibial plateau fractures are one of the most common intraarticular
fractures.
 Results from indirect coronal or direct axial compression forces.
 Strong varus and valgus forces along with axial loading. Eg,
bumper fracture
 Comprise of 1% of all fractures.
 Associated with considerable soft tissue and neurovascular
damage.

19. CLINICAL
FEATURES
 Pain
 Swelling
 Fracture blisters
 Compartment syndrome
 Neurovascular injury

20. IMAGING
STUDIES
 Plain x ray AP and lateral view knee
 CT scan
 MRI
 angiography

21. CLASSIFICATION
 SCHATZKAR CLASSFICATION
 AO CLASSIFICATION
 Both have got equal clinical significance
 Also have similar communication and interobserver reliability.

22. SCHATZKAR
CLASSIFICATION

23. AO
CLASSIFICATION

27. PRINCIPLES
OF
TREATMENT
 Goal is to obtain stable aligned mobile and painless limb.
 And to minimise post traumatic OA knee.

28.  Tibial plateau fracture immobilised for 4 weeks leads to stiffness.
 Internal fixation along with immobilization leads to even higher
degree of joint stiffness.
 So regardless of treatment option opted, limb should be
immobilized early.

29.  Impacted articular fragments cannot be dislodged by traction
alone as there is no soft tissue attachment to lever them up.
 They need to be surgically corrected.

30. CONSERVATIVE
TRETMENT
 CLOSED REDUCTIONAND POP CAST APPLICATION
 SKELETALTRACTIONAND MOBILIZATION
 FUNCTIONAL BRACE

31. SURGICAL
TREATMENT
 PERCUTANEOUSCANCELLOUS SCREW FIXATION
 ORIFWITH CANCELLOUS SCREWAND BONEGRAFTING
 ORIFWITH BUTTRESS PLATE AND SCREWS
 ORIFWITH BUTTRESS PLATE AND SCREWSAND BONE
GRAFTING
 EXTERNAL FIXATOR
 HYBRID EXTERNAL FIXATOR
 ILLIZAROV EXTERNAL FIXATOR
 ARTHROSCOPICALLYASSISTED INTERNAL FIXATION
 MIPPO

32. POST
OPERATIVE
CARE
 Limb elevation and early mobilization
 Non weight bearing for 4-8 weeks
 Partial weight bearing for another 4-6 weeks
 Full weight bearing after 3 months only.

33. TIBIAL
EMINENCE
FRACTURE
 A Tibial Eminence Fracture, also known as a tibial spine
fracture, is an intra-articular fracture of the bony attachment of
the ACL on the tibia that is most commonly seen in children
from age 8 to 14 years during athletic activity.

34. • Pathophysiology
• traumatic mechanism
• rapid deceleration or hyperextension/rotation of the knee, as in
sports
• same mechanism that would cause ACL tear in adults
• fall from bike or motorcycle (typically resulting in
hyperextension)
• Associated conditions
• occur in 40% of eminence fractures
• meniscal injury
• collateral ligament injury
• capsular damage
• osteochondral fracture

35. • tibial eminence is non-articular portion of the tibia between
the medial and lateral tibial plateau
• Consists of two spines: ACL attaches to medial spine
• ACL insertion is 9mm posterior to the intermeniscal ligament
and adjacent to anterior horns of meniscus
• PCL does not attach to tibia spines

36. • Symptoms
• severe swelling and pain in the knee
• inability to bear weight
• Physical exam
• inspection
• immediate knee effusion due to hemarthrosis
• Knee usually in flexed position
• ROM
• often limited secondary to pain
• once pain is controlled, lack of motion may indicate meniscal
pathology
• displaced/entrapped fracture fragment
• positive anterior drawer

38. TREATMENT
• Nonoperative
• closed reduction, aspiration of hemarthrosis, immobilization in
full extension
• indications
• non-displaced type I and reducible type II fractures
• immobilization
• cast in extension for 3-4 weeks
• patients get extremely stiff with prolonged immobilization
• allow for gradual rehab program

39.  Arthroscopic fixation is the gold standard treatment of type III and
unreducible type II fractures.

40. THREE
COLUMN
CONCEPTOF
TIBIAL
PLATEAU
FRACTURE
 This three-column classification system published in 2010
relies on preoperative CT images to depict injuries to the
medial, lateral, and posterior columns of the tibial plateau.
 Traditionally, lateral and medial buttress plating has been the
standard approach for ORIF of complex tibial plateau
fractures. However, complex tibial plateau fractures that have
separate posterior column fragments cannot be adequately
stabilized with this traditional method.
 Updated surgical approaches have been developed to allow
dorsal plating of these separate posterior fragments.

41. The landmarks that are used to divide the columns include the center of
the intercondylar eminence, anterior tibial tuberosity, posteromedial ridge
of the proximal tibia, the most anterior point of the fibular head, and
posterior sulcus of the tibial plateau

43.  In contrast to one-, two-, and three-column fractures, zero-column
fractures do not result in a cortical break of the column wall.

45. APPROACHES

46. ANTERO-
LATERAL
APPROACH

47.  Incise and elevate the proximal medial tibialis anterior to
expose the lateral tibia
 For visualization of the lateral plateau, incise the
capsule/retinaculum below the proximal border of the plateau.
Partially detach the lateral meniscus from the plateau, while
maintaining anterior attachment and using stay sutures for
reattachment upon closure.

49. MINIMAL
INVASIVE
ANTEROLATE
RAL
APPROACH

50.  Incision
 Two incisions are made. Proximally, begin the incision just
proximal and lateral to Gerdy’s tubercle and extend it
distally in a curvilinear fashion for approximately 5 cm to 6
cm.
 Distally make a 5- to 6-cm longitudinal incision
approximately 2 cm lateral to the tibial crest and parallel
with it. The size and length of the distal window depends on
the pathology to be treated and the implants to be used.
The position of the incision often can only be assessed using
the image intensifier control

51. POSTERO-
MEDIAL
APPROACH

52.  Internervous Plane
no internervous plane. The plane between the bone and
the gastrocnemius muscle is utilized.
 Superficial Surgical Dissection
 Deepen the incision through the subcutaneous fat. The long
saphenous vein and the saphenous nerve will be just anterior to
your surgical approach; these structures should be identified and
preserved. Identify the pes anserinus expansion overlying the
tibia.
 To approach the tibia, either divide the pes anserinus
longitudinally in the line of the skin incision or identify the
anterior border of the pes and partially resect it from its
insertion into the tibia, reflecting it posteriorly.
 Deep Surgical Dissection
 Develop an epi-periosteal plane between the pes anserinus and
the medial head of the gastrocnemius at the posteromedial
border of the tibia. The muscle can be gently freed from the bone
by blunt dissection.

54. THANKYOU.