Treatment of low-energy tibial plateau fractures: open vs percutaneous techniques

Educational Objectives

The goal of this program is to improve the management of tibial plateau fractures. After hearing and assimilat­ing this program, the clinician will be better able to:

1. Outline the classic fracture patterns, evaluation, and treatment for tibial plateau fractures.

Summary

Treatment of Low-Energy Tibial Plateau Fractures: Open vs Percutaneous Techniques

Evaluation: assess soft tissues; identify open vs closed fractures; look for compartment syndrome; document serial neurovascular examinations; determine knee stability

Imaging: plain films  —  anteroposterior (AP) and lateral of knee; include tibial plateau x-ray with 10° to 15° poste­rior tilt; CT  —coronal and sagittal reconstructions with axial cuts assist with preoperative planning; MRI  —  not commonly used

Fracture classification: Schatzker classification used most commonly; Schatzker I  —  simple split; often amenable to closed reduction with internal fixation; Schatzker II  —  split-depression; consider closed reduction with arthros­copy, or ORIF; Schatzker III  —  pure depression

Examples: 1) Schatzker I with split of lateral plateau; place screws percutaneously; secure proximal aspect (articu­lar fragments); place screw or antiglide plate distally; 2) Schatzker II requires ORIF (especially with significant comminution); reduce articular fragments; evaluate and repair meniscus; stabilize to allow early range of motion (ROM); 3) Schatzker III  —  seen in older patients with softer bones; treat percutaneously with holes punched into lateral cortex or operate through fracture; elevate articular surface; place screws underneath for support; ORIF best for younger healthy patients with pure lateral plateau fracture

Classic fracture pattern: lateral split depression often associated with posteromedial coronal split; place screws an­terior to posterior to fix coronal split

Associated injuries: commonly occur within and around knee; preserve and repair menisci

Treatment: goals  —  reestablish stable knee; restore mechanical axis; restore articular congruity; retain meniscus; achieve early ROM; angular alignment  —  too much valgus or any varus leads to degenerative changes in tibia; articular incongruity  —limit incongruity to 2- to 3-mm range

Nonoperative management: requires stable knee in full extension, <5 mm articular incongruity, normal mechanical axis, and low-demand patient; prevent further displacement; early ROM; limited weightbearing for first 6 mo

Indications for surgery: 1) instability in extension; 2) significant articular incongruity; 3) open fractures; 4) associ­ated vascular injuries; 5) bicondylar fractures; treatment options  —  ORIF, percutaneous fixation after closed re­duction, and arthroscopically assisted reduction; surgical tactics  —  plan surgery from plain films and CT; use care handling soft tissues; perform articular reduction with preservation of menisci; provide stable internal fixa­tion; postoperative care  —  achieve early ROM; full weightbearing at 3 mo

Readings

Suggested Reading

Barei DP et al: Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-inci­sion technique. J Orthop Trauma, 2004 Nov-Dec;18(10):649-57; Canadian Orthopaedic Trauma Society: Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am, 2007 Jan;89(1):1-10; Chaudhary SB et al: Complications of ankle fracture in patients with diabetes. J Am Acad Orthop Surg, 2008 Mar;16(3):159-70; Crichlow RJ et al: Appropriateness of patient transfer with associated orthopaedic injuries to a Level I trauma center. J Orthop Trauma, 2010 Jun;24(6):331-5; Egol KA et al: Staged management of high-energy proximal tibia fractures (OTA Types 41): the results of a prospective, standardized protocol. J Orthop Trauma, 2005 Aug;19(7):448-55; Feng Y et al: The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy. J Vasc Surg, 2009 Sep;50(3):675-82; Ganesh SP et al: The impact of diabetes on patient outcomes after ankle fracture. J Bone Joint Surg Am, 2005 Aug;87(8):1712-8; Gonzalez A et al: Reduction of irreducible Hawkins III talar neck fracture by means of a medial malleolar osteot­omy: a report of three cases with a 4-year mean follow-up. J Orthop Trauma, 2011 May;25(5):e47-50; Hill JM, et al: Closed treat­ment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br, 1997 Jul;79(4):537-9; Kou JX, Fortin PT: Commonly missed peritalar injuries. J Am Acad Orthop Surg, 2009 Dec;17(12):775-86; Thakur NA et al: Inappropriate transfer of patients with orthopaedic injuries to a Level I trauma center: a prospective study. J Orthop Trauma, 2010 Jun;24(6):336-9; Wukich DK, Kline AJ: The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am, 2008 Jul;90(7):1570-8.

 

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Borrelli was recorded at the University of California, San Francisco, School of Medicine’s 6th Annual San Francisco Orthopaedic Trauma Course, held April 28-30, 2011 in San Francisco, CA. Information about next year’s Annual San Francisco Orthopaedic Trauma Course is avail­able at cme.ucsf.edu/cme.The Audio-Digest Foundation thanks the speaker and the University of California, San Francisco, School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR341704

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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