In the elderly osteoporotic fractures although the principles are the same but some special considerations in management of the soft tissues and the bony injuries are considered.

1. Dr Smarajit Patnaik DNB
Senior Consultant Orthopaedic Surgeon
Apollo Hospitals
Bhubaneswar
Proximal Tibial Fractures in
the elderly: Surgical
considerations

2. Objectives
• Understand complexity
• Appreciate mechanics
• Classify
• Achieve a rational treatment plan
–Articular
–Metaphyseal
–Soft tissues

3. Tibial plateau
• Articular fracture by definition
• Aim for:
–Perfect reduction of articular surface
–Absolute stability (compression)

4. Caused by a variety of forces:
•Valgus/varus deformation
•Torsional forces due to slip and fall
•Axial compression
•Flexion/extension
•Direct trauma
Fracture mechanisms

5. Fracture mechanisms
• 1% of all fractures:
– Lateral plateau: 60%
– Medial plateau: 25%
– Bi-condylar: 15%
• Two subgroups exist
• Young patients with good bone stock—high-
energy
• Elderly patients with osteoporosis—low-
energy

6. Classification of
proximal tibial fractures (41-A)• A: extraarticular
– A1: avulsion
– A2: metaphyseal simple
– A3: metaphyseal multifragmentary
•

7. Classification of
proximal tibial fractures (41-B)
• B: partial articular
– B1: pure split
– B2: pure depression
– B3: split-depression

8. Classification of
proximal tibial fractures (41-C)• C: complete articular
– C1: articular simple, metaphyseal simple
– C2: articular simple, metaphyseal multifragmentary
– C3: articular multifragmentary

9. Schatzker Classification
• Schatzker I
– Split of the lateral tibial
plateau without
depression

10. Schatzker Classification
• Schatzker II
– Split and depressed
fracture of the lateral
tibial condyle

11. Schatzker Classification
• Schatzker III
– Isolated depression of
the lateral tibial
plateau

12. Schatzker Classification
• Schatzker IV
– Fractured medial
plateau

13. Schatzker Classification
• Schatzker V
– Bicondylar fracture

14. Schatzker Classification
• Schatzker VI
– Bicondylar fracture and
diaphyseal/metaphyseal
dissociation

15. Posterior shear fracture
• Pure posterior
fracture fragments
• Does not fit into
Schatzker’s
classification, may
be bicondylar, or a
knee dislocation
variant.
• Needs posterior
approach

16. • Usually cruciate
ligament avulsions.
Intercondylar eminence fracture

17. Etiology: high-energy trauma
Extensive damage to the soft tissues:
• Contusions
• Open injuries
• Compartment syndrome
• Peroneal and tibial nerve injury
• Popliteal artery injury

18. Etiology: low-energy trauma
• Axial trauma
• No contusions
• Closed injuries
• Less soft-tissue problems
• Axis deviation
• Fixation problem (osteoporosis)

19. Etiology
• In low-energy trauma the problem is:
– Mechanical—fixation in osteoporotic bone
• In high-energy trauma the problem is:
– Biological and associated with damage to the
soft tissues

20. Investigations
• X-ray
– AP and lateral views
– 45°oblique views
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Angiography

21. • Plain X-Ray:
• Supine AP and lateral view for all patients
• Internal and external oblique view
• Obtain contralateral AP and Lateral (compare)
• Tibial plateau view: AP with knee extended and beam
directed 15 degrees caudally
• CT scan:
• increases the diagnostic accuracy
• indicated in cases of articular depression
• shown to increase the interobserver and intraobserver
agreement on classification in tibial plateau fractures
• excellent adjuncts in the preoperative planning
Radiology

22. • MRI:
• alternative to CT scan or arthroscopy
• osseous as well as the soft tissue
components of the injury
• cost prohibitive for use in standard situations
• Duplex US and Arteriography:
– To evaluate associated arterial injury.
Radiology

23. THREE-COLUMN CONCEPT

25. Personality of the fracture
• Soft-tissue damage
• Degree of fracture displacement
• Degree of comminution
• Degree of joint involvement
• Osteoporosis
• Neurovascular injury
• Complex ipsilateral injuries and polytrauma

26. Goals of treatment
• Decompression and preservation of soft-tissues
• Reconstruction of joint surfaces
• Reconstruction of normal mechanical axis
• Early motion

27. Nonoperative treatment
• No joint step > 2 mm
• No axial instability
• Severe osteoporosis
• General and local contraindications (eg, medical
illness)

28. • Non-operative management:
– Indicated for non-displaced or minimally
displaced fractures
• Method:
– Protected weight bearing and early range-of-knee
motion in a hinged fracture brace.
– Isometric quadriceps exercises and progressive
passive, active-assisted, and active range-of-
knee motion exercises.
– Partial-weight bearing (30-40 Ib) for 8 to 12
weeks with progression to full weight bearing.
Management

29. Schatzker’s principles of treatment
• Immobilization > 4 weeks: residual stiffness
• ORIF and immobilization: even more residual
stiffness
• Regardless of treatment: mobilize early
• As long as mobility is preserved a secondary
reconstructive procedure is possible

30. • Impacted fractures cannot be dislodged by
traction or manipulation
• Depressed articular surfaces remain permanent
defects
Schatzker’s principles of treatment

31. Operative treatment
?

32. Emergency operative
treatment
• Vascular injury
• Compartment syndrome
• Open fractures
• Gross dislocation
• Floating knee
• Polytrauma

33. What if a proximal tibia comes on
day 2 of injury ?
• 1) Take up immediately for
surgery
• 2) Wait for investigations and
operate on second
• 3) Wait for 8-10 days and
operate later
• 4) Would operate after 1
month

34. Delayed surgery (damage control surgery)
• Use of a temporary spanning external fixator
will allow:
– Optimal recovery of soft tissues, appearance
of wrinkle sign.
– Preserve length and axis
• Further imaging and preoperative planning
• SCAN,SPAN,PLAN

36. Surgical approach
• Minimally invasive versus ORIF
– ORIF: anterior, antero lateral, (postero)medial,
(postero)lateral
• Prepare for bone grafting
• Knee flexed position, floating position and
combined approach
• Tourniquet
• Fluoroscopy

37. Surgical approach

38. Intraoperative procedure
• Expose ligamentous and meniscal structures
• Reconstruct the joint surface!
• Support the joint surface with bone or substitute
• Buttress with a plate (conventional)
• Repair the ligaments and menisci to achieve joint
stability

39. • Type I:
– Closed reduction then stabilized cancellous
lag screws with washers to gain compression.
• Type II:
– OR and elevation of depressed fragment
– Bone graft is placed to support the elevated
fragments
– Screws are placed across the reduced split
fracture fragments in lag mode
Operative treatment

40. • Type III:
– elevation through cortical fenestrations
– supported with subchondral screws and bone
graft
• Type IV:
– requires a medial buttress plate to counteract
the shear forces acting on the medial plateau
– lag screws alone are not sufficient to stabilize
these fractures
Operative treatment

41. Percutaneous screw and washer fixation its importance
42

43. Preoperative
Postoperative

45. Locked internal fixators
• Tibial locked internal fixators are available
• Locking head screws provide better
support than conventional screws in a
short metaphyseal fragment
• Percutaneous insertion preserves soft
tissues

48. • Anatomical
reduction
• Lag screw fixation
• Locking head
screws for angular
stability
• Improved pull-out
resistance

56. Fine wire fixator for severe soft-tissue injuries
• Reconstruction of the
joint surface
• Reconstruction of
stable axes
• Early motion
• Excellent results
- (Schatzker IV, V, and
VI)

58. Fine wire/Hybrid
• Exoskeleton allows:
– Attention to soft tissues
– Application of relative stability to
the metaphyseal/diaphyseal
component
• Problems:
– Fine wire irritation
– Intracapsular portals
– Must get articular reduction first!
– Patients unhappy!

59. Results of ORIF on tibial plateau in general
• Depends on the fracture type
• Depends on soft-tissue management
• Depends on realization of goals
• Can be excellent even in high-energy
trauma:
– Average range of motion 0–120°(87%)
– No deterioration in the 2nd 5 years
– Good prognosis

61. Take-home messages
• Anatomical reduction and rigid fixation of
joint surface—absolute stability
• Functional reduction and stable fixation of
metaphysis—relative stability
• Restoration of joint stability by appropriate
soft-tissue reconstruction
• Early active movement
• Non operative treatment has a role in
severe osteoporosis in elderly
• Respect the soft tissues!!!