Mechanism of tibial plateau fracture
- 5-10% - bilateral fracture.
- Tibial plateau fractures or intra-articular tibial condyle fractures 1% of all fractures
- In 75-80% of cases it affects the lateral tibial plateau (in 50% of cases it is combined with damage to the lateral meniscus) and in 5-10% - the medial tibial plateau
- 50% of patients are pedestrians in traffic accidents
- Fall with spiral injury
- Often older women (osteoporosis, mainly compression fractures) and young men (sports injuries)
- The most common pathomechanisms of a proximal tibia fracture are valgus stress with or without axial compressive force or, in comminuted fractures, vertical compressive force (in a fall on straightened lower limbs)
- A medial tibial plateau fracture is caused by trauma with significantly greater force than a lateral tibial plateau fracture.
- The lateral tibial plateau has a smaller transverse trabecular surface area than the medial tibial plateau.
Schatzker classification:
Type I: fracture with splitting of the lateral tibial plateau and depression (mainly in young people).
Type II: fracture with splitting of the tibia with displacement (dislocation) of the lateral articular surface (mainly in elderly patients with osteoporosis).
Type III: deepening of the lateral plateau of the tibia without fracture with splitting through the articular surface.
Type IV: fracture with splitting of the medial tibial plateau with or without depression.
Type V: Split fracture through the medial and lateral tibial plateau.
Type VI: separation of the tibial plateau from the underlying metaphysis/diaphysis (massive injury).
Signs and symptoms[edit]
Tibial plateau fractures typically present with patellar effusion, soft tissue swelling of the knee, and inability to bear weight. The knee can become deformed due to displacement and/or fragmentation of the tibia, causing it to lose its normal appearance. Blood in the soft tissue and knee joint (hemarthrosis) can cause bruising and a loose feeling in the knee joint. Because of the proximity of the tibial plateau to important vascular (eg, arteries, veins) and neurological (eg, nerves, e.g., peroneal and tibial) structures, damage to them may occur during fractures. A thorough examination of the neurovascular system is mandatory. A serious complication of tibial plateau fractures is compartment syndrome, in which swelling causes compression of the nerves and blood vessels inside the leg and can ultimately lead to necrosis or cell death of leg tissue. [ citation needed
]
Which method of diagnosing a tibial plateau fracture to choose: MRI, CT, X-ray
Selection Methods
- X-ray examination, CT.
What X-rays will show for a tibial plateau fracture
- X-ray examination in frontal and lateral projections
- Lateral view with horizontal beam direction (projection crossing the tibial plateau)
- Oblique projection
- Repeated x-rays to monitor fracture healing
- Fracture line direction
- Effusion in the joint cavity
- In the presence of lipohemarthrosis on the transverse projection of the tibia, the level of fat-liquid in the effusion is determined due to the separation of fatty bone marrow (radiolucent) from the rising blood components.
What will CT scans of the tibia show for a plateau fracture?
- For accurate diagnosis in case of indeterminate X-ray results, as well as for planning surgical intervention
- Optimal visualization of articular surface depression, split fracture and bone fragment avulsion.
a-c Fracture of the lateral plateau of the tibia with damage to the intercondylar region. X-ray examination of the left knee joint in frontal (a), lateral projections ( b ), as well as CT reconstruction (c). Compression of trabeculae with deepening of the lateral articular surface (a, c) and fracture line in the metaphysis ( b ).
Classification of tibial plateau fractures.
I Fracture without displacement.
II Fracture with depression of the articular surface.
III Compression fracture.
IV Compression/depression fracture.
V Bicondylar fracture.
Fracture of the upper third of the leg
Treatment of fractures of the proximal end of the tibia can be conservative or surgical. Each of these methods has its own advantages and disadvantages.
The decision to undergo surgical treatment should be made jointly by the patient, his family and the attending physician. The preferred treatment method is selected based on the type of fracture and the individual needs of the patient.
When drawing up a treatment plan, the doctor takes into account several issues, including: your expectations, lifestyle and your health.
In physically active patients, surgical joint reconstruction is usually the optimal treatment method to restore maximum stability and mobility of the joint and minimize the risk of developing post-traumatic osteoarthritis.
In other patients, however, the benefits of surgery may not be as obvious. Some comorbidities or underlying problems with the lower extremity may negate the possible benefits of surgery. In such cases, surgery only increases possible risks for the patient (risks of anesthesia or infection, for example).
Emergency help
Open fractures . If the skin in the area of the fracture is damaged, the fracture may become contaminated with bacterial flora and the development of infection. In such cases, the earliest possible surgical treatment is indicated, including: to cleanse contaminated soft tissue and reduce the risk of infection.
External fixation . If there is significant damage to the soft tissue (skin and muscle) in the area of the fracture, or if your health makes you concerned about how you will cope with major surgery, your doctor may temporarily apply an external fixator. During this operation, metal needles or rods are inserted into the bones above and below the level of the fracture, which are fixed to an external fixation device. The latter is a frame that holds the bones in the correct position until you are ready for surgery.
Early after injury, the already damaged skin and soft tissue at the fracture site may be subject to even greater damage as a result of surgery. In such cases, an external fixator may be applied to temporarily stabilize the fracture and allow the soft tissue to heal.
Compartment syndrome . In a small number of cases, swelling of the soft tissues of the leg can be so severe that it begins to threaten the blood supply to the muscles and nerves of the leg and foot. This condition is called compartment syndrome and requires immediate surgical treatment. During an operation called fasciotomy, vertical incisions are made in the walls of the muscle sheaths of the lower leg. These incisions are left open and closed only a few days or weeks after surgery when the swelling has subsided. In some cases, skin grafting is necessary to close these incisions.
Conservative treatment
Conservative treatment includes immobilization with a cast or brace, as well as restriction of movement and weight bearing on the leg. During this treatment, your doctor will periodically order follow-up x-rays to evaluate bone healing. Movement in the knee joint and the load on the leg will depend on the type of fracture and the characteristics of the chosen treatment method.
Surgery
There are several methods that allow the surgeon to restore the correct position of bone fragments and keep them in this position until fusion occurs.
Internal fixation . During this operation, the bone fragments are first returned to their normal position. In this position they are held by special fixators - intramedullary rods or plates and screws.
( Left ) Fracture of the proximal end of the tibia. ( Right ) The same type of fracture fixed with an intramedullary nail.
For fractures of the proximal quarter of the tibia, if the fracture line does not penetrate the joint, fixation with both a rod and a plate is possible. The rod is inserted into the medullary canal in the center of the bone, and the plate is fixed with screws to the outer surface of the bone.
Fractures penetrating a joint usually require plate stabilization. The plate is fixed to the outer surface of the bone.
Plates and screws are commonly used for fractures that penetrate the joint. If the fracture is accompanied by depression of the articular surface, it is necessary to restore this articular surface to restore normal anatomy and function of the joint. After this, a bone defect usually forms in the area of the fracture. Such defects are filled with bone material taken from the patient himself or from a bone bank. It is also possible to use synthetic or natural products that stimulate bone regeneration.
In case of depressed fractures, in order to restore the joint, it is necessary to return the depressed fragment to its place. This reduces the risk of developing osteoarthritis and instability. After this, a defect usually forms in the area of the fracture (left), which is filled with bone, synthetic or natural materials (right).
External fixators . In some cases, the soft tissue in the area of the fracture may be so damaged that the use of internal fixation methods is not possible. In such cases, the external fixator described above can be used as a definitive treatment and is removed only after the fracture has healed.
Treatment methods
- The goal of treatment is to create joint congruence, mechanical axis and joint stability, and promote early mobilization.
Conservative treatment: in the presence of a stable split fracture without displacement
- Plaster splint for 3-4 weeks.
- Sequential physical therapy
- Full load on the joint after 2-3 months.
Surgical treatment: for unstable displaced fractures
- Open reduction
- Reconstruction of the articular surface
- Fixation with screw or plate
- The larger (metaphyseal) fragment is considered as a key fragment, towards which the smaller fragment is oriented
- The goal is to intervene with minimal soft tissue trauma:
- Single fracture: screw fixation.
- condylar fracture: fixation with a support plate.
- Impacted fracture: external fixation, possibly with mixed external fixation.
- Compression/depression fracture: lifting and placing the implant at the site of depression (if there is a step of 2 mm or more) and fixation with a T-plate.
- Postoperative early functional mobilization, physical therapy and use of rehabilitation devices.
Treatment[edit]
Tibial plateau fracture repair
Pain can be controlled with NSAIDs, opioids, and splinting. [1] [2] For those who are otherwise healthy, treatment is usually done with surgery. [1] Sometimes, if the bones are well aligned and the knee ligaments are intact, people can be treated without surgery. [2]Surgery usually involves restoring the fractured tibial plateau fragments to their anatomical position and fixing them in place only with screws or fixed-angle anatomical plates that provide absolute stability. The choice of implant depends on the type of injury. Typically, simple or incomplete fractures (Schatzker type 1) plateaus are compressed with 6.5 mm partial thread cancellous screws. For complex fractures, a plate will be required to increase stability. Since the tibial condyles connect to the femur (thigh bone) to form the knee joint, any discrepancy in the articular surface is unacceptable as it leads to early arthritis. Prolonged immobilization of the knee joint is also not recommended, as it leads to stiffness of the joint and difficulty in recovery. [ citation needed
]
How is the operation performed?
When it comes to a tibia fracture, specialists most often use the technique of intramedullary osteosynthesis, which involves drilling the bone marrow canal or without drilling. The latter method helps to minimize tissue trauma during surgery, which is important against the background of severe injuries or the threat of shock. But osteosynthesis with reaming helps to ensure a tight fit of all fixed fragments, which is especially important in the presence of a pseudarthrosis.
For open fractures, the technique of compression-distraction transosseous intervention is used. But subsequently it is necessary to walk with the device for a certain time. After healing, the device is removed and intramedullary osteosynthesis is performed. For complicated fractures, a periosteal osteosynthesis procedure is performed.
Contraindications
It is impossible to perform osteosynthesis of the hand and other joints:
- If the area of damage with an open fracture is too large;
- If the open fracture wound is dirty or infected.
- If the patient has a history of epileptic seizures.
- If there are vascular pathologies of the extremities.
To make sure there are no hidden contraindications, as well as to choose the most effective method for reconstructing the bones of the hand, the doctor may prescribe additional examinations: ultrasound, x-ray, three-dimensional tomography.
Links[edit]
- ^ abcdefghijklmno "Fractures of the proximal tibia (shinbone)". OrthoInfo - AAOS
. Archived from the original on June 17, 2021. Retrieved October 15, 2017. - ^ B s d e g h i J k l m p o r Bracker, Mark D. (2012). 5-minute sports medicine consultation. Lippincott Williams and Wilkins. item 242. ISBN. 9781451148121. Archived October 15, 2017.
- Karadsheh, Mark. "Tibial plateau fractures". www.orthobullets.com
. Archived from the original on June 28, 2021. Retrieved October 15, 2017. - Clifford R. Wheeless III, MD. Wheeless' Textbook of Orthopedics. Department of Orthopedic Surgery, Duke University Medical Center. Data Trace Internet Publishing, LLC. Archived March 29, 2008.CS1 maint: uses the authors parameter (link)
- "TO. Markhardt, MD. Schatkzker classification of tibial plateau fractures: use of CT and MRI improves assessment. Radiography 2009.” Quote journal requires |journal=(help)
- ^ ab Scuderi G, Tria A (2010). The knee: a comprehensive review. 1st edition
. Worldwide scientific publishing company. pp. 209–301. - Jump up
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↑ Zeltser D, Leopold S (2013).
"Brief classification: Schatzker classification of tibial plateau fractures". Clinical Orthopedics and Related Research
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(2):371–374. doi:10.1007/s11999-012-2451-Z. PMC 3549155. PMID 22744206. - Pires R (2013). "Epidemiological Study of Tibial Plateau Fractures in a Level I Trauma Center". Acta Ortop bras
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