- The patient is a 38-year-old Thai man who was in a motorcycle accident after drinking alcohol. He complains of left knee pain for 3 hours. - Radiographs show a fracture of the left tibial plateau and left fibula. Physical examination reveals tenderness over the left knee with limited range of motion due to pain. - The diagnoses are a fracture of the left tibial plateau, a fracture of the left fibula, and a mild head injury. The patient is placed in a long leg splint and advised to remain non-weightbearing on the left leg. Close monitoring is needed for compartment syndrome or neurological changes.

1. Extern conference
Extern Sakulrat Chujai
Extern Phatsasi Pholcharoen

2. PATIENT PROFILE
ชายไทยคู่ อายุ 38 ปี
อาชีพ ค้าขาย
ภูมิลาเนา อาเภอโนนแดง
สิทธิการรักษา บัตรประกันสุขภาพถ้วนหน้า

3. Chief complaint : เจ็บที่เข่าซ้าย 3 hr. PTA
Cause of trauma : ดื่มสุราขับ MCชนราวกั้นถนน
Present illness : 3 hr. PTA ดื่มสุราขับMC ชน
รานกั้นถนน ศีรษะ ลาตัว และขาทั้งสองข้างกระแทก
พื้น มีแผลถลอกที่ใบหน้าและขาทั้งสองข้าง ไม่สลบ
จาเหตุการณ์ได้ ไม่ปวดศีรษะ ไม่มีแขนขาอ่อนแรง
ปวดที่เข่าซ้าย ขยับได้ไม่สุด ปวดไหล่ขวา ไม่ชาปลาย
มือปลายเท้า กู้ภัยนาส่งรพช.ก่อนส่งตัวมารักษาต่อ

4. Primary survay
A : can talk ,not tender along c-spine
B : normal breath sound ,equal breath sound ,CCT negative
C : BP 108/58 ,P 90, no active bleeding
D : E4M6V5 pupil 2 mm RTLBE
E : at picture

5. Adjunct to Primary survey

6. Adjunct to Primary survey

7. Adjunct to Primary survey

8. Adjunct to Primary survey

9. Diagnosis
• Cfx left tibial plateau
• AC ligament injury
• Mild head injury ( moderate risk)

10. Secondary survey
A ปฏิเสธแพ้ยาแพ้อาหาร
M no
P ปฏิเสธโรคประจาตัว
เคยประสบอุบัติเหตุMCล้มแขนซ้ายหักประมาณ1ปีก่อน
ได้รับการผ่าตัดซ่อมเส้นประสาทมือซ้ายอ่อนแรงอยู่เดิม
Chronic alcohol drinking
No smoking
L ประมาณ 18.00 น. ( 4 ชั่วโมงก่อนมารพ)
E ดื่มสุราขับMC ชนราวกั้นถนน

11. PHYSICAL EXAMINATION
Vital sign : BT 37.0, PR 90 bpm, RR20 /min, BP108/58
HEENT : not pale ,no jaundice , abrasion wound at lower lip 3 cm
Heart : normal S1 S2 , no murmur
Lung : Clear , equal breath sound ,CCT negative
Abdomen : soft ,not tender
Neuro : E4M6V5 pupil 2 mm RTLBE motor power gr 5 all escape
left hand gr 4 left leg limit due to pain , sensory intact
Extremity : tender at Right shoulder full ROM
left ulnar claw hand with old surgical scar
tender at left knee , Valgus and Varus Stress Test negative
mild swelling of left knee and leg
limit ROM due to pain ,DPA 2 + both leg
contusion at right leg ,mild tender

13. Adjunct to Secondary survey
t

14. Diagnosis
• Cfx left tibial plateau
• Cfx left fibular
• Cfx Right distal clavicle
• Mild head injury ( moderate risk)

15. Management
• Ortho
On long leg slab left
Observe compartment syndrome
• Neuro Sx.
Observe neuro sign
• Trauma Sx.
ABI 1.1
observe R/O vascular injury

18. Tibial Plateau
Fracture

19. 19

20. Overview
20
- Fractures of tibial plateau involve the articular surface
of the proximal tibia.
- Assessing associated soft tissue injuries around the
knee is critically important.
- Treatment conceps based on restoring or preserving
limb alignment
- Represent approximately 1% in adults.
- Fractures in men occur at a younger age and tend to be
the result of high energy trauma; women have
increasing incidence with advancing age.
THO Ch - of Tib#
Instable type Groans
Tmnt.
-
=
-
-
-

21. Assessment
21
- Mechanism of injury :
- In middle aged or elderly patients, simple falls
lead most commonly to lateral side.
- Higher speed injuries in younger patients from
sports can cause split fractures or rim avulsion fractures
associated with knee ligament injury.
- The energy of fracture results from a combination
of axially loading forces and angular forces
- Associated Injuries :
- Ligament and meniscal injury
- Soft Tissue Envelope

22. Assessment
22
- Physical examination:
- Knee Physical examination,
- special test can examine only in stable type.
- Neurovascular examination
- Communicating open wounds
- Compartment syndrome evaluation
- Radiograph
- Film knee AP/Lat
- CT
- MRI
joslignmeut
,
attenderpointt.ba/otterut
→ Distal pulses
-
-
'
b
Ttgligtsotltissuinjyyig

23. Radiograph
23
684
sub chant
¥k¥hH .

24. Classification
24

25. split
ft
Split dean
g- Ifm
.

27. Outcome
25
- The factors that most predictably lead to favorable
outcome include patient factors, injury factors, and
factors involved with treatment.
- In general, tibial plateau fractures have favorable
outcomes if knee alignment is maintained and
complications are avoided.
- In comparing outcomes and arthrosis rates, the
articular surface of the proximal tibia appears to be
more tolerant to fractures than the ankle or hip

28. Treatment Options
26
- Nonoperative Treatment
- Cast immobilization up to 6 wks.
- Non weight bearing during the
initial weeks after injury, typically 4-8 wks.
- Operative Treatment
- Plates and Screw Fixation
- External Fixation IT
a

29. 27
- Operative Treatments indicated for displaced unstable
tibial plateau fractures.
- In young healthy patients, this will include almost all
bicondylar and shaft dissociated patterns, and all but
minimally displaced medial plateau fractures and lateral
plateau fracture patterns where valgus alignment will
occur.
- For the lateral patterns, the presence of a split fragment,
a depression affecting over half of the lateral articular
surface, a fibular head fracture, valgus alignment on
injury radiographs, and clinical valgus alignment on
exam are all strong indications for surgery.
Treatment Options

31. Post Operative Care
28
- Non weight bearing or minimal weight bearing 6-12 wks.
- Early mobilizing the knee postoperatively.
- The early motion was much more important after operative
treatment, because knees immobilized for longer than 2 wks
tended to be stiff
he