Proximal Tibia Fractures and Its Management.pptx

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

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 s elected 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: 2 0% of fractures

4. Anatomy Consist of M edial and L ateral P lateau Medial larger & harder (thus less likely to fracture) Medial lower & concave Lateral higher & convex Lateral cartilage thicker (3 vs 4 mm) Medial Lateral Media l 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 Exam ination findings !

13. Evaluation – Physical Exam Soft tissue assessment Stability tests – difficult to perform Avoid missing compartment syndrome Determine timing of surgery Skin W rinkles present or not?

14. Evaluation – Physical Exam Document ation of N euro V ascular status Neurologic Peroneal nerve Vascular Ankle- Brachial Index ( ABI ) > 0.9 is normal

15. Evaluation – Physical Exam A nkle B rachial I ndex : R atio of the blood pressure at the ankle to the blood pressure in the upper arm (brachium) Screening test L ower E xtremity 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 rotatio n

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 S chatzker 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 Wrin k les 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 R ange o f Motion (In Bed) N on W eight B earing for 6- 8 weeks Radiographic F ollow 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 th e 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: U nstable 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 Precontour ed 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

53. Elevate depressed fragment

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 N on Weight B earing 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 G rafting

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: P lates +/- interfragmentary screws Beware of M edial 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. J Orthop Trauma 2009;23(7):493- 501. Lansinger O. J Bone Joint Surg Am 1986;68(1):13- 19. Rademakers M.V. J Orthop Trauma 2007;21(1):5- 10). Schatzker J. Clin Orthop Relat Res 1979;138:94- 104. Stevens DG. J Orthop Trauma 2001;15(5):312- 320. Weigel DP. J Bone 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