Proximal Tibia Fractures and Its Management.pptx
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Objectives: -Recognize the anatomy of the proximal tibia -Describe initial evaluation and management -Identify common fracture patterns -Apply treatment principles and strategies for Partial articular fractures and Complete articular fractures -Discuss rehabilitation and complications -Learn Management in selected tibial plateau case scenarios
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Proximal Tibia Fractures and Its Management.pptx
- 1. Proximal Tibia Fractures Dr. Kota Aditya MS Orthopaedics Fellow in Ilizarov Surgery Fellow in Sports Medicine Fellow in Joint Replacement Member - AO Trauma & Young Surgeon Committee – SICOT Professor Department of Orthopaedics Curriculum Committee Member Medical Education Unit ASRAM Medical College
- 2. • Recognize the anatomy of the proximal tibia • Describe initial evaluation and management • Identify common fracture patterns • Apply treatment principles and strategies • Partial articular fractures • Complete articular fractures • Discuss rehabilitation and complications • Learn Management in selected tibial plateau case scenarios Learning Objectives
- 3. Epidemiology • 1-2% of all fractures • Bimodal distribution • Young adults: high energy mechanism • Highest in 5th decade • Male > Female • Elderly: low energy mechanism • Osteoporotic bone • Female > Male • Lateral Plateau: 70% of fractures • Medial Plateau: 10% of fractures • Bicondylar Plateau: 20% of fractures
- 4. Anatomy Consist of Medial and Lateral Plateau – Medial larger & harder (thus less likely to fracture) – Medial lower & concave – Lateral higher & convex – Lateral cartilage thicker (3 vs 4 mm) Medial Lateral Medial Strong Lateral Weak Medial concave Lateral convex
- 5. Anatomy • Bony prominences • Intercondylar eminence (menisci & cruciate ligaments attachment) • Tibial tubercle (patellar tendon) • Gerdy’s tubercle (Iliotibial band) • Tibia slope: 10 degrees posteroinferior
- 6. Mechanism of Injury • Valgus producing force – Lateral plateau • Varus producing force – Medial plateau • Axial compressive force – Bicondylar plateau • Combination – High energy – Bicondylar plateau – Soft tissue injury
- 7. Mechanism of Injury • Valgus producing force – Lateral plateau • Varus producing force – Medial plateau • Axial compressive force – Bicondylar plateau • Combination – High energy – Bicondylar plateau – Soft tissue injury
- 8. Mechanism of Injury • Valgus producing force – Lateral plateau • Varus producing force – Medial plateau • Axial compressive force – Bicondylar plateau • Combination – High energy – Bicondylar plateau
- 9. Initial presentation – mechanism matters! • Lower energy • Simple falls, struck from side • Remain length stable • Higher energy • Axial load, associated shearing • Risk of Compartment syndrome
- 10. Associated Injuries • Lateral plateau – Tear of meniscus likely if • > 5mm depression • > 6mm condylar widening – MCL / ACL tear • Medial Plateau – Fracture / dislocation variant – Popliteal artery injury – Peroneal nerve injury • Bicondylar – Open injury – Compartment syndrome MCL tear
- 11. Evaluation - History • Mechanism of injury • Injury factors – Soft tissue status – Fracture patterns – Associated injuries • Patient factors – Age – Bone quality – Comorbidities • Previous level of activity – Function demands
- 12. Evaluation – Physical Exam • Initial Inspection – Skin integrity – Soft tissue swelling – Open fracture – Gross deformity – Shortened limb – Neurovascular status • Always Document the Examination findings!
- 13. Evaluation – Physical Exam • Soft tissue assessment • Stability tests – difficult to perform • Avoid missing compartment syndrome • Determine timing of surgery – Skin Wrinkles present or not?
- 14. Evaluation – Physical Exam Documentation of NeuroVascular status • Neurologic • Peroneal nerve • Vascular • Ankle-Brachial Index (ABI) > 0.9 is normal
- 15. Evaluation – Physical Exam • Ankle Brachial Index : Ratio of the blood pressure at the ankle to the blood pressure in the upper arm (brachium) • Screening test – Lower Extremity injuries with concerns for vascular injury
- 16. Evaluation–Physical Exam Ankle Brachial Index • ABI < 0.90 – Predictable of arterial injury – Vascular consult – Proceed with arteriogram • ABI > 0.90 – Admit for observation – Followed with serial noninvasive exam
- 17. Evaluation - Radiographic • Plain X-ray knee/tibia • AP • Lateral • Obliques of knee • Internal or external rotation
- 18. Evaluation - Radiographic • Tibial plateau view • Normal tibial slope – 10 degrees posteroinferior 10 degrees Angle for x-ray
- 19. Evaluation - Radiographic • CT scan • Useful for surgical planning • Assessing • Depression • Comminution • Fracture lines • Obtain CT after applying traction (ex fix)
- 20. Evaluation - Radiographic • MRI scan? • Subtle nondisplaced fracture line • Noted high associated soft tissue injuries • Lat. meniscus: 91% • Med. Meniscus 44% • ACL • PCL
- 21. Classification Schatzker • Type I: Split fracture of the lateral plateau • Type II: Split depression fracture of the lateral plateau • Type III: Pure depression fracture of the lateral plateau • Type IV: Medial plateau (possible fracture / dislocation) • Type V: Bicondylar plateau fracture • Type VI: Plateau fracture with metaphyseal / diaphyseal dissociation
- 22. Three Column Concept of Plateau Fractures • Better incorporates fractures involving posterior plateau • Help with determining appropriate fixation strategy Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010 Nov;24(11):683-92. doi: 10.1097/BOT.0b013e3181d436f3. PMID: 20881634
- 23. Treatment Principles • Soft tissue management – Surgical timing is important – Wrinkles in the skin • Temporary Stabilization – Staged protocol for Fixation
- 24. Treatment Principles • Anatomic reduction of articular surface – Obtain and maintain • Reduce condylar width • Address meniscal injuries • Restore mechanical axis – metadiaphysis • Stable fixation • Early ROM
- 25. Treatment Options: Nonsurgical • Patient factors – Elderly – Nonambulatory – Pre-existing arthritis • Injury factors – Articular incongruity – <5 mm, elderly, sedentary activity – Stable Varus / Valgus stress • < 5 -10 degrees instability 71 y/o male, multiple med. comorbidities
- 26. Nonsurgical – Technical Pearls • Immobilize 1-2 weeks • Knee immobilizer or hinge knee brace – Locked in extension • Start Early Range of Motion (In Bed) • Non Weight Bearing for 6-8 weeks Radiographic Follow up - Weekly for first 3 weeks
- 27. Indications for Surgery Absolute indications: • Open tibial plateau • Associated compartment syndrome • Associated vascular injury
- 28. Indications for Surgery Relative indications: • Axial malalignment • Instability in full extension • Articular incongruity • >3mm in young, active • Condyle widening
- 29. Indications for Surgery • Displaced bicondylar fractures • Most of the medial plateau fractures
- 30. Timing of Surgery Low Energy: Fixed electively and early High Energy: Don’t Hurry, Have patience
- 31. Temporary External Fixation • Knee spanning external fixation • Ligamentotaxis • Improve fracture fragment gross alignment – Length and alignment • Minimize further damage to articular surface • Soft tissue assessment and wound care
- 32. Temporary External Fixation Indications: • Unstable tibial plateau fracture – Bicondylar fracture – Schatzker type V and VI • Fracture / Dislocation – Schatzker type IV
- 33. External Fixation • 2 pins in femur – Anterior or lateral • 2 pins in tibia – Antero-medial
- 34. External Fixation - Pearls • Mark knee joint and fracture sites • Schanz pins placement out of zone of future surgical incisions
- 35. Temporary Stabilization-Case Example • Staged protocol • Knee spanning external fixation • Restore length, alignment, rotation • Definitive ORIF in 1 to 3 weeks • Wait for soft tissue • CT scan • Preop plan
- 36. Calcaneum Traction if Ex Fix is Not Applied in Complex cases Using Ilizarov Wire and Half Ring
- 37. ORIF- Equipment • Femoral distractor/ Manual Traction • Osteotomes • Bone tamps / Punch • Fracture reduction instruments • K-wires
- 38. ORIF- Implant options • Unicondylar fracture • Conventional non- locking plate – “L” or “T” plate – Buttress • Pre-contoured periarticular plates • Raft screws alone – 3.5mm or 4.5mm • Locking plate – Osteoporotic bone
- 39. ORIF- Implant Options • Angular stable (Locking) implants • Precontoured for proximal tibia • Bicondylar tibia plateau with metadiaphyseal involvement • Spanning or bridging across fracture zone • Selected fracture, allows stabilization of medial plateau
- 40. External Fixation • Limited internal fixation – Small incisions or percutaneous • Thin-wire ring fixators – Connect to the shaft – Fixation distally with 5mm half-pins • Advantages – Minimize soft tissue injury • Still need to reduce articular surface!!! May need a screw!
- 41. Surgical Approaches • Anterolateral – Lateral plateau involvement – Combination with medial for complex plateau • Posteromedial – Medial plateau – Coronal split • Posterior • Dual approaches – Anterolateral – Posteromedial Copyright by AO Foundation, Switzerland
- 42. Surgical Approaches • Other surgical approaches • Direct medial or midline parapatellar anterior – Isolated medial tibia fractures • Direct posterior approach – Posterior shear fractures – Prone – Inability to treat anterolateral fracture
- 43. Treatment of Specific Schatzker Fractures Types
- 44. Schatzker Type I Split Split
- 45. • Goals: • Restore articular congruity • Articular step off • Condylar widening • Open vs.. percutaneous • Fixation • Lag screws • Buttress plate Schatzker Type I Split
- 46. Schatzker Type II Split- Depression Split-depression
- 47. Schatzker Type II Split- Depression
- 48. • Submeniscal arthrotomy • Full visualization of articular surface • Repair lateral meniscus • Femoral distractor/ Traction • Elevate articular depression • Reduce condylar widening • Large pelvic reduction clamp • Temporary K-wires Schatzker Type II Split-Depression: Surgical Tactics
- 49. Schatzker Type II Split-Depression • Fill defect • Allograft • Autograft • Bone substitutes • Buttress plate • Nonlocking: Most • Locked: osteoporotic bone • Subchondral raft screws
- 50. Schatzker Type III Pure Depression Central depression
- 51. • Surgical technique • Open approach • Submeniscal • Arthroscopic • Elevate depressed fragment • Fill defect • Stabilization • Subchondral raft screws Schatzker Type III Pure Depression
- 52. Schatzker Type III Pure Depression • Surgical technique • Submeniscal arthrotomy • Arthroscopic • Elevate depressed fragment • Fill defect • Stabilization • Subchondral screws
- 54. Schatzker Type IV Medial plateau CT post ext. fix Split fracture, Medial plateau
- 55. Schatzker Type IV Medial plateau • Surgical approach • Posteromedial • Interval between • Pes anserine tendons and Medial head gastrocnemius Copyright by AO Foundation, Switzerland
- 56. Schatzker Type IV Medial plateau • Don’t forget about possible lateral plateau depression • May need anterolateral incision to reduce depression
- 57. Schatzker Type IV Medial plateau • Fixation • Straight medial plating • Posteromedial plating • Combination
- 58. Schatzker Type V, VI Bicondylar Bicondylar fracture Metadiaphyseal dissociation
- 59. Classic Fracture Pattern • Bicondylar Fxs – 2 classic components: • Lateral split depression • Posteromedial / coronal split
- 60. Schatzker Type V, VI Bicondylar • Preop plan is important • Review x-rays and CT scan • Identify all fractures
- 61. Schatzker Type V, VI Bicondylar • Preop plan is important • Review x-rays and CT scan • Identify all fractures
- 62. Schatzker Type V, VI Bicondylar • Dual incisions • Reduce medial plateau • Antiglide plate • Reduce lateral plateau Elevate the depressed fragment • Restore condylar width • Large reduction clamp • Connect articular block to diaphysis
- 63. Schatzker Type V, VI Bicondylar • Maintain reduction • Dual plating
- 64. Schatzker V, VI Bicondylar • Single lateral fixed angle implant • Ability to capture medial condyle with laterally based implant • Medial apex cortical contact with minimal comminution
- 65. Rehabilitation Postoperative Care • Knee brace • Elevate leg • Non Weight Bearing for 10-12 weeks Physical therapy • Early ROM • Quadriceps Strengthening • Gait training – Crutches for non weight bearing in young patients who are compliant
- 66. Complications • Infection • Nonunion – Aseptic • Metadiaphyseal junction – Septic Aseptic Nonunion Revised with Iliac Crest Bone Grafting
- 67. Complications • Contractures • Arthrofibrosis – May require knee manipulation – Arthroscopic lysis of adhesion • Post Traumatic Osteoarthritis 4 yr.. F/U
- 68. Selected Cases – Case 1 • Schatzker II
- 69. Case 1 • Schatzker II
- 70. Case 1 • Schatzker II • ORIF after elevation of fragment • Buttress plate • Raft screws
- 71. Case 2 Bicondylar with metadiaphyseal fracture
- 72. Case 2 Bicondylar with metadiaphyseal fracture • Ext Fix
- 73. Case 2 Bicondylar with metadiaphyseal fracture • ORIF
- 74. Selected Cases – Case 3 Bicondylar with tibial tuberosity fracture • Must address tuberosity – Allow early ROM • Options for tuberosity fixation – Lag screws – Plates/screws
- 75. Bicondylar with tibial tuberosity fracture CT scan Case 3
- 76. Case 3 Bicondylar with tibial tuberosity fracture • ORIF • Posteromedial approach – 3.5mm recon plate – Buttress • Anterolateral approach – Precontour plate • ORIF tuberosity – Percutaneous – Lag screws
- 77. Selected Cases - Case 4 Bicondylar with tibial tuberosity fracture Temporary Ext. Fix
- 78. Case 4 Bicondylar with tibial tuberosity fracture CT scan
- 79. Case 4 Bicondylar with tibial tuberosity fracture • ORIF • Posteromedial approach – 3.5mm recon plate – Buttress • Anterolateral approach – Precontour plate • ORIF tuberosity – 1/3 tubular plate
- 80. • Undisplaced Type 1 Split Lateral Condyle Fracture • Percutaneous CC Screws in Anti Glide Method Case 5
- 81. Case 5 Bicondylar Tibial Plateau Fracture Fixed using MIPPO Technique dual locking plate
- 82. Case 6 • Minimally displaced Bicondylar Fracture • Fixed with Posteromedial Buttress using Semi tubular Plate and percutaneous CC screws for Lateral Condyle split fracture
- 83. Case 7 • Type 6 Scahtzker with Poor Soft Tissue Condition (skin Bleps and Blisters) • Ilizarov Externeral Fixator after Interfragmentary screw to maintain intra articular congruity
- 84. Case 8 • Type 6 Scahtzker with Poor Soft Tissue Condition (skin Bleps and Blisters) • Ilizarov Externeral Fixator after Interfragmentary screw to maintain intra articular congruity
- 85. Summary • Understand the fracture pattern • Respect the soft tissues • Partial articular (Schatzker 1-3) • Buttress: Plates +/- interfragmentary screws • Beware of Medial plateau (Schatzker 4) • Posteromedial approach • Complete articular (Schatzker 5,6) • External fixation is beneficial • Plan, ORIF Dual Approach may be necessary
- 86. References • OTA PPT Education Resources • Rockwood and Green’s Fractures in Adults Philadelphia: Lippincott Williams & Wilkins, 2014. • Katsenis D. JOrthop Trauma 2009;23(7):493-501. • Lansinger O. JBone Joint Surg Am 1986;68(1):13-19. • Rademakers M.V. JOrthop Trauma 2007;21(1):5-10). • Schatzker J. Clin Orthop Relat Res 1979;138:94-104. • Stevens DG. JOrthop Trauma 2001;15(5):312-320. • Weigel DP. JBone Joint Surg Am 2002;84(9):1541-1551. • The Schatzker Classification Figure 55-9. Court-Brown C, Heckman JD, McKee M, et al. Rockwood and Green’s Fractures in Adults Philadelphia: Lippincott Williams & Wilkins, 2014. • Hansen, Matthias; Pesantez, Rodrigo. AO Surgery Reference.
- 87. Thank You