Tibial plateau fracture management .pptx

Tibial plateau fracture

1. MANAGEMENT OF TIBIAL PLATEAU FRACTURE Capt Zaw Myo Han

2. Introduction Tibial Plateau fractures make up 1% of all fractures Up to 70%, are isolated to the lateral plateau

3. 3 DR.SITHU

4. anatomy tibial plateau makes up the superior articular surface of the tibia separated medially and laterally by the intercondylar eminence and both surfaces are covered by articular cartilage 4 DR.SITHU

5. anatomy medial plateau is larger, concave and significantly stronger than the lateral plateau. lateral plateau is smaller, relatively convex and weaker than the medial aspect menisci provide some stability and congruence for articulation with the femoral condyles 5 DR.SITHU

6. anatomy M ajor ligamentous attachments (MCL, LCL-PLC, ACL, PCL) N eurovascular structures that important are the peroneal nerve laterally popliteal vessels and tibial nerve posteriorly 14-Dec-23

7. . (1) Force directed either medially ( valgus deformity, the classic ‘‘bumper fracture’’) or laterally ( varus deformity) (2) Axial compressive force, or (3) Combined Mechanism of injury

8. CLASSIFICATION HOHL AND MOORE CLASSIFICATION SCHATZKER CLASSIFICATION AO CLASSIFICATION THREE COLUMN CLASSIFICTION 14-Dec-23

9. FRACTURE-DISLOCATION CLASSIFICATION (HOHL AND MOORE) 14-Dec-23

10. Type I Pure split fracture of lateral tibial plateau Type II Split-depression fracture of lateral tibial plateau Type III Pure central depression fracture of lateral tibial plateau Type IV Medial tibial plateau fracture Type V Bicondylar tibial plateau fracture Type VI Bicondylar tibial plateau fracture with metaphyseal–diaphyseal dissociation Classificaton Schatzker classification 10 DR.SITHU

11. Type I Pure split fracture of lateral tibial plateau

12. Type II Split-depression fracture of lateral tibial plateau

13. Type III Pure central depression fracture of lateral tibial plateau

14. Type IV Medial tibial plateau fracture

15. Type V Bicondylar tibial plateau fracture

16. Type VI Bicondylar tibial plateau fracture with metaphyseal–diaphyseal dissociation

17. AO classification Type A extra-articular metaphyseal and epiphyseal fractures Type B Partial articular fractures, in these injures, part of the articular surface retains its continuity with the diaphysis Type C Complete articular fractures in which the articular surface has lost all connection to the diaphysis divides the fractures not only into types but also into groups and subgroups 18 fracture types classified into six groups

18. Three C olumn C lassification 14-Dec-23

19. Zero-column 14-Dec-23

20. One-column 14-Dec-23

21. Two-column 14-Dec-23

22. Three-column 14-Dec-23

23. 14-Dec-23

24. Hohl and Moore The fracture-dislocation patterns classified by Hohl and Moore associated ligamentous injuries , meniscal injuries, higher incidence of neurovascular injury, DR.SITHU 24

25. DR.SITHU 25

26. increasing from 2% for type I to 50% for type V, with an overall average of 15%, approximately that of classic dislocation of the knee DR.SITHU 26

27. Presentation/ physical examination 27 DR.SITHU

28. DR.SITHU 28 Medial plateau injuries are associated with neurovascular complications more frequently due to the increased force required to cause the injury One must also have a high suspicion for compartment syndrome and ligament injury and have high vigilence for open injuries

29. Imaging STANDARD RADIOGRAPHIC VIEWS standard AP and lateral views two oblique views 29 DR.SITHU

30. Traction Radiographs If surgical intervention is contemplated used in determining the efficacy of distraction techniques Traction films reveal whether a ligamentotaxis reduction is possible and also aid in planning surgical incisions 30 DR.SITHU

31. Stress Radiographs It sometimes aid decision to operate or to proceed with nonoperative management Instability with greater than 7 to 10 degrees of motion in the coronal plane is usually managed with surgery 31 DR.SITHU

32. COMPUTED TOMOGRAPHY SCANNING CT scan provides the surgeon with the cross-sectional anatomy of the fracture and the potential for sagittal or coronal reconstruction at any desired depth 32 DR.SITHU

33. Traction CT scanning gives the surgeon a much better indication of the effectiveness of distraction techniques 33 DR.SITHU

34. MRI superior for assessment of associated soft tissue injuries such as meniscal and ligamentous disruptions 34 DR.SITHU

35. ARTERIOGRAPHY considered whenever there is serious concern about the possibility of an arterial lesion An intimal tear may be present without a clinically detectable deficit During fracture surgery, such a lesion may lead to an occlusive thrombosis that jeopardizes the extremity 35 DR.SITHU

36. meniscal tears and ligament injuries neurovascular injury Differential Diagnosis/Associated Injuries 36 DR.SITHU

37. management 37 DR.SITHU

38. 38 DR.SITHU

39. Principle of treatment 39 DR.SITHU

40. DR.SITHU 40

41. Goal of Treatment Restoration of articular congruity Axial alignment Joint stability Functional motion of knee joint 14-Dec-23

42. Non-operative Treatment Absolute indication Fractures that occur after a low-energy injury which are usually incomplete or non-displaced a displaced lateral plateau fracture without articular instability and some unstable lateral plateau fractures in osteoporotic patients Relative indication presence of significant cardiovascular, pulmonary, neurologic, or metabolic compromise 42 DR.SITHU

43. Operative Treatment 43 DR.SITHU

44. Timing of Surgery urgently irrigated & debrided repeated debridement Antibiotics Fasciotomy Immediate internal fixation & delayed closure Open fracture 44 DR.SITHU

45. Temporary spanning external fixator Initial treatment modality of choice Stabilizes the soft tissue Pain relief Fracture reduction via ligmentotaxis Visualizations of soft tissue Mobilization 45 DR.SITHU

46. In polytrauma patient and in those with soft tissue compromise, reduction of the joint is advocated as soon as possible Percutaneous or limited incision approaches with temporary spanning external fixation across the joint allows mobilization of the polytrauma patient 46 DR.SITHU

47. Preoperative Planning Routine and traction X-rays CT Scan and MRI Confirm that appropriate implants and reduction instruments. Use of preoperative drawings to make a detailed plan of all the steps in the surgical tactic. Surgery is performed on paper before being carried out in the operating room. 14-Dec-23

48. Anterior midline --- avascular necrosis dural plating infection 50-80% Anterolateral Medial Posteromedial Lazy-S incision, the L-shaped incision, and the ‘‘Mercedes star’’ incision are contraindicated Surgical Approaches 48 DR.SITHU

49. Special situations Posteromedial Posteromedial plateau # Medial # d/l Wedge like post: metaphyseal # Fibular osteotomy Posterolateral depression/dislocation 49 DR.SITHU

50. Two-Incision Technique with Dual plating using anterolateral and posteromedial incisions or anterior and posterior incisions Surgical Approaches 50 DR.SITHU

51. used in open reduction and medial and lateral plate fixation for High-Energy Bicondylar Tibial Plateau Fractures Surgical Approaches 51 DR.SITHU

52. Fracture Types ( Schatzker ) Type I 52 DR.SITHU

53. Type II 53 DR.SITHU

54. Type III 54 DR.SITHU

55. Type IV 55 DR.SITHU

56. Type V 56 DR.SITHU

57. Type VI 57 DR.SITHU

58. Articular surface 3mm to 10mm Controversy of joint depression Stability of joint is essential Anatomic reduction of articular surface 58 DR.SITHU

59. Bone graft allograft autograft synthetic graft DR.SITHU 59

60. extramedullary internal fixation system developed by AO minimally invasive implantation technique , anatomically pre-contoured plates with minimal bone contact, and unicortical screws with threaded screw holes and screw head minimallly invasive submuscular & extraperiosteal technique Less Invasive Stabilization System(LISS) 60 DR.SITHU

61. Functional outcome Articular reduction Stability Mechanical axis 61 DR.SITHU

62. Complications 62 DR.SITHU

63. Complications 63 DR.SITHU

64. Four primary factors determine the prognosis 64 DR.SITHU

65. Post-operative Care To minimize complications and loss of reduction of the fracture and maximize knee motion A period of non-weight bearing or minimal weight bearing is necessary to minimize the chances of displacing the reduced fracture. Duration depends on the fracture pattern and the strength of the fixation Probably takes 6 to 12 weeks Early motion was much more important after operative treatment Immobilized for longer than 2 weeks tended to be stiff 14-Dec-23

66. Practice points All high- energy tibial plateau fractures have concomitant soft- tissue injury Temporary spanning external fixation is often the initial treatment of choice A biologic approach, mindful of the vascularity of soft tissue and bone, can prevent many adverse outcomes 66 DR.SITHU

67. Summary With more complex fractures, it is essential to consider not only the bone injury but also the associated soft tissue damage Use of limited open approaches ligamentotaxis , indirect reduction aids wire-guided cannulated screws minimally invasive plating techniques allows the surgeon to treat higher energy injuries effectively with internal fixation 67 DR.SITHU

68. Take home massage ORIF of tibial plateau # is challenging 68 DR.SITHU

69. DR.SITHU 69 Thank You