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Proximal Tibia Fractures and Its Management.pptx
The document discusses proximal tibia fractures, covering their anatomy, mechanisms of injury, evaluation methods, and treatment principles. It emphasizes the importance of recognizing fracture patterns like partial and complete articular fractures and outlines surgical approaches, including external fixation and open reduction internal fixation techniques. The document also highlights rehabilitation, potential complications, and includes case studies for practical understanding.
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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 theanatomy 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% ofall 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 andLateral 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 – mechanismmatters! • Lower energy • Simple falls, struck from side • Remain length stable • Higher energy • Axial load, associated shearing • Risk of Compartment syndrome
- 10. Associated Injuries • Lateralplateau – 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 – PhysicalExam • Initial Inspection – Skin integrity – Soft tissue swelling – Open fracture – Gross deformity – Shortened limb – Neurovascular status • Always Document the Examination findings!
- 13. Evaluation – PhysicalExam • Soft tissue assessment • Stability tests – difficult to perform • Avoid missing compartment syndrome • Determine timing of surgery – Skin Wrinkles present or not?
- 14. Evaluation – PhysicalExam Documentation of NeuroVascular status • Neurologic • Peroneal nerve • Vascular • Ankle-Brachial Index (ABI) > 0.9 is normal
- 15. Evaluation – PhysicalExam • 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 BrachialIndex • 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 Conceptof 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 • Softtissue management – Surgical timing is important – Wrinkles in the skin • Temporary Stabilization – Staged protocol for Fixation
- 24. Treatment Principles • Anatomicreduction of articular surface – Obtain and maintain • Reduce condylar width • Address meniscal injuries • Restore mechanical axis – metadiaphysis • Stable fixation • Early ROM
- 25. Treatment Options: Nonsurgical • Patientfactors – 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 – TechnicalPearls • 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 Absoluteindications: • Open tibial plateau • Associated compartment syndrome • Associated vascular injury
- 28. Indications for Surgery Relativeindications: • 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 LowEnergy: 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 • 2pins 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 ifEx Fix is Not Applied in Complex cases Using Ilizarov Wire and Half Ring
- 37. ORIF- Equipment • Femoral distractor/ ManualTraction • 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 • Limitedinternal 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 • Othersurgical 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 SchatzkerFractures Types
- 44. Schatzker Type ISplit Split
- 45. • Goals: • Restorearticular congruity • Articular step off • Condylar widening • Open vs.. percutaneous • Fixation • Lag screws • Buttress plate Schatzker Type I Split
- 46. Schatzker Type IISplit- Depression Split-depression
- 47. Schatzker Type IISplit- 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 IISplit-Depression • Fill defect • Allograft • Autograft • Bone substitutes • Buttress plate • Nonlocking: Most • Locked: osteoporotic bone • Subchondral raft screws
- 50. Schatzker Type IIIPure 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 IIIPure Depression • Surgical technique • Submeniscal arthrotomy • Arthroscopic • Elevate depressed fragment • Fill defect • Stabilization • Subchondral screws
- 53.
- 54. Schatzker Type IVMedial plateau CT post ext. fix Split fracture, Medial plateau
- 55. Schatzker Type IVMedial plateau • Surgical approach • Posteromedial • Interval between • Pes anserine tendons and Medial head gastrocnemius Copyright by AO Foundation, Switzerland
- 56. Schatzker Type IVMedial plateau • Don’t forget about possible lateral plateau depression • May need anterolateral incision to reduce depression
- 57. Schatzker Type IVMedial 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, VIBicondylar • 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 • Kneebrace • 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.
- 70. Case 1 • SchatzkerII • ORIF after elevation of fragment • Buttress plate • Raft screws
- 71. Case 2 Bicondylar withmetadiaphyseal fracture
- 72. Case 2 Bicondylar withmetadiaphyseal fracture • Ext Fix
- 73. Case 2 Bicondylar withmetadiaphyseal 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 tibialtuberosity fracture CT scan Case 3
- 76. Case 3 Bicondylar withtibial 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 withtibial tuberosity fracture CT scan
- 79. Case 4 Bicondylar withtibial tuberosity fracture • ORIF • Posteromedial approach – 3.5mm recon plate – Buttress • Anterolateral approach – Precontour plate • ORIF tuberosity – 1/3 tubular plate
- 80. • Undisplaced Type 1Split Lateral Condyle Fracture • Percutaneous CC Screws in Anti Glide Method Case 5
- 81. Case 5 Bicondylar TibialPlateau Fracture Fixed using MIPPO Technique dual locking plate
- 82. Case 6 • Minimallydisplaced Bicondylar Fracture • Fixed with Posteromedial Buttress using Semi tubular Plate and percutaneous CC screws for Lateral Condyle split fracture
- 83. Case 7 • Type6 Scahtzker with Poor Soft Tissue Condition (skin Bleps and Blisters) • Ilizarov Externeral Fixator after Interfragmentary screw to maintain intra articular congruity
- 84. Case 8 • Type6 Scahtzker with Poor Soft Tissue Condition (skin Bleps and Blisters) • Ilizarov Externeral Fixator after Interfragmentary screw to maintain intra articular congruity
- 85. Summary • Understand thefracture 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 PPTEducation 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.
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