The Tibial Plateau Fractures: Diagnosis and Treatment

Francesco Atzori, Luigi Sabatini, Francesco Atzori, Luigi Sabatini

• Publisher: Bentham Science Publishers
• Year: 2016
• Print ISBN: 9781681082424
• eBook ISBN: 9781681082417
• Topic: Medicina
• Subtopic: Ortopedia

A break in the proximal part of the tibia or shinbone region results in a Tibial plateau fracture. This type of bone damage results in the impaired motion and stability of the leg and the knee joint. Since this is a critical load-bearing region of the body, patients affected by these fractures have difficulty in carrying their body weight, which can cause major disability. Tibial plateau fractures commonly occur as a result of motor vehicle accidents in younger individuals and as a result of osteoporosis in elderly women. With appropriate medical guidance, patient rehabilitation is possible. This book is a concise handbook on key information about the diagnosis and treatment of Tibial plateau fractures. Chapters in this book cover the epidemiology of these types of bone fractures, diagnostic imaging, surgical treatment options and patient rehabilitation. The book is intended as a primer on Tibial plateau fractures for medical students and novice surgeons who aim to specialize in orthopaedic surgery. Readers will be able to understand how to manage relevant bone fracture cases which they encounter and will learn how to improve patient recovery after surgical procedures.

Conservative Treatment of Tibial Plateau Fractures: Indications and Results

Jaswinder Singh^{1, *}, Vivek Trikha²

¹ Department of Orthopaedics, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi 110070, India

² Department of Orthopaedics, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi 110029, India

Abstract

A force over tibial plateau with axial loading and valgus or varus vector can be responsible of tibial plateau fracture. The principles of management include joint congruity, joint stability, and axial alignment and the “personality” of the fracture. It is crucial to recognize, assess and monitor soft tissue swelling. In the present era, the indications for conservative management in form of traction or cast bracing are very few. Anatomical reduction is best achieved with operative modalities, either with closed or open techniques. However, non-operative modalities do hold their importance in certain situations like incomplete or undisplaced fractures, stable injuries, those with osteoporosis, and in patients who are not fit for surgery due to their medical comorbidities. Secondary articular cartilage injuries can be managed depending upon lesion size and activity demands, with simultaneous correction of malalignment and ligament instability wherever needed.

Keywords: Cartilage, Cast, Conservative, Injuries, Management, Nonoperative, Tibial plateau fractures.

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^* Correspondence author Jaswinder Singh: Department of Orthopaedics, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi 110070, India; Tel: [phone]; E-mail: [email protected]

INTRODUCTION

Bone fractures with articular involvement have been an important problem since past. Impairment was seen up to varying degrees. According to Charnley [1] in

1961, anatomic reduction along with early mobilization were the preferred treatment for intra-articular fractures. These objectives were difficult to obtain because of the surgical and fixation techniques available in those times.

Pain, instability, malunion or nonunion were often result of surgery treatment. Greater stiffness was seen with surgery along with plaster immobilization, than plaster immobilization alone. Added surgical trauma and the periarticular location of the fixation device [2^-4] was thought to be the cause of stiffness after surgery. Conservative treatment was so generally indicated for treatment of articular fractures and surgery was considered the last resort. Conservative treatment strategy included accurate evaluation, than fracture reduction and immobilization and finally rehabilitation. Joint stiffness was seen invariably during rehabilitation after fracture union. Apley encouraged early joint rehabilitation by “successful methods of traction to permit early motion of joints, while providing sufficient immobilization for the fracture union” [5, 6]. First results in tibial plateau fractures management with this technique were satisfactory, but not reproducible because tibial plateau fractures were not classified [6]. The new concepts by the AO group of atraumatic techniques of open reduction and internal fixation (ORIF) brought about a revolution in fracture surgery [4, 7^-9]. However, with the increase in trauma energy (car accident, sport trauma), soft tissue injuries also increases. High-energy fracture types (Schatzker IV, V, and VI) were often treated with large surgical approaches and internal osteosynthesis through a tenuous soft tissue envelope. This led to high complication rates, with reported 50 percent in some studies [4, 10^-15]. The time tested conservative treatment is now mainly indicated for stable and undisplaced tibial plateau fractures, or with fractures with excessive comminution, or advanced osteoporosis. It might be also the only treatment option available for a patient who is medically unfit for surgery. When chosen, near anatomical articular congruity should be attained along with normal alignment and early mobilization, to prevent compartment overload and future osteoarthrosis [16^-19]. The concept of staged fixation is now favourable. With significant soft tissues compromise, immediate open surgical treatment can be dangerous. An external fixator initially can span through the zone of injury and overall limb realignment and stabilization is achieved. When the soft tissues have recovered sufficiently, “delayed fixation can be accomplished through a safe operative corridor of healthy tissues” [6].

INDICATIONS FOR CONSERVATIVE TREATMENT

Prognosis of proximal plateau injuries depend upon: (1) depth cartilage depression, (2) fracture fragmentation (3) fracture comminution and dissociation [3, 10, 20^-25], and (4) extent of the soft tissue damage [21, 26^-28]. Conservative treatment is indicated for low-energy undisplaced tibial plateu fracture or for stable lateral plateau fractures, and for some osteoporotic patients. Severe comorbidity of the patient can be a good indication for conservative treatment [6].

Instead, some authors state that articular cartilage depression from 4 to 10 mm is tolerable; depression over 10 mm is cause of instability and early osteoarthritis [5, 10, 13, 17, 22, 23, 29^-40, 42]. Closed reduction (manipulation and traction) is not able to correct impacted articular fragments. Pauwels [41] demonstrated that “an incongruence of less than 1.5 mm appears to result in no significant increase in contact pressures”. However, weight bearing increases stress rise in case of axial malalignment [42]. Mitchell and Shepard [43] showed that “malreduction and instability result in rapid articular cartilage degeneration”. A correct reduction without contact over-pressure between femoral condyles and tibial plateau is an important factor for long term prognosis [22, 36]. Rasmussen [4] showed a “high correlatio...

Table of contents

• Welcome
• Table of Contents
• Title Page
• BENTHAM SCIENCE PUBLISHERS LTD.
• DEDICATION
• PREFACE
• FOREWORD
• Pathogenesis and Epidemiology of Tibial Plateau Fractures
• Tibial Plateau Fractures: Applied Anatomy and Classification
• Evaluation of Tibial Plateau Fractures: The Role of Imaging
• Conservative Treatment of Tibial Plateau Fractures: Indications and Results
• Knee Arthroscopy and Tibial Plateau Fractures
• Balloon Tibioplasty
• Open Reduction and Internal Fixation of Tibial Plateau Fractures
• Damage Control Orthopaedics and the Role of External Fixation in Tibial Plateau Fractures
• Diagnosis and Treatment Strategy in Associated Lesions of Tibial Plateau Fractures
• The Role of Primary Total Knee Arthroplasty (TKA) in Tibial Plateau Fractures
• Rehabilitation After Tibial Plateau Fractures
• Appendix