Tibia plateu, shaft, and plafond fractures 2012

Matthew L. Jimenez, MD, FACS

TIBIA PLATEU, SHAFT, AND PLAFOND FRACTURES AAOS/ASSH General Review

Jul 12, 2012

Mandatory Disclosure

Ü  The 2012 14th Annual Chicago Trauma Symposium received support from 40 industry partners

Mandatory Disclosure

Ü  Foundation for Education and Musculoskeletal Research (FEMR) several industry and philanthropic partners

Tibia Plateau Fractures

Surgical Goals Ü Obtain/Secure Articular

Reduction

Ü  Reduce Condylar Width Ü  Restore Axial Alignment

Ü Neutralize Meta-Diaphysis Ü  Secure Tibial Tubercle Ü  Early ROM

Ü Appropriate Soft Tissue Handling

Surgical Timing §  Stage 1: Temporary Spanning External

Fixation

ú  Soft tissue stabilization ú  Fracture stabilization in polytraumatized patient ú  Develop surgical tactic - CT scan!!!!

§  Stage 2: ORIF

ú  Execute surgical tactic ú  Definitive articular & axial reductions and

fixations

Buttress Plating

“Buttress plate”

- A plate employed to support the fractured bone in the area of the metaphysis, usually used in conjunction with lag screws

“Antiglide plate”

- A plate used to reduce an oblique fracture indirectly through interference between the plate and the undisplaced main fragment

Buttress

Ü  Resists shear forces

Ü  Metaphyseal Fractures

Buttress Function

Buttress Function

Resists shear

Anti-Glide

Ü  Resists shear forces

Ü  Create stable axilla

Lateral Plateau

Condylar width Lateral split

Depression

Strategy

Open Book?

Femoral distractor

Submeniscal arthrotomy

Meniscus repair

Buttress Elevate joint from below

Containment

Containment

Containment

Condylar width

Bone graft/support

Joint compression

Buttress

Non locking implant

Complex Bicondylars

Meta-­‐Diaphyseal  

Lateral locked vs

dual plating

Ü Can bicondylar fx’s be treated with laterally based locked plating alone?

Ü Is dual incision and plating better?

Lateral locked plating has NOT solved it all

Coronal Fx Posteromedial Fragment

The Medial Plateau Sagi%al  Fx    

Separates  En1re  Medial  Plateau  

Barei et al, JOT 2008

Posteromedial fragment

Ü Subject to shear forces Ü Medial femoral condyle follows Ü Risk of displacement

Ü Raises questions about fixation strategies and surgical approach

Barei et al, JOT 2008

With Posteromedial Fragment

Ü Consider dual approach

Ü Will locking screws from the lateral side support that fragment?

Ipsilateral, Noncontiguous Plateau and Shaft Fractures

Plateau/Shaft Fractures

Ü Unusual injury pattern

Ü Difficult to treat with a single implant

Ü Goal = treat both injuries optimally

Barei et al, JOT 2008

Barei et al, JOT 2008

Tibia Plateau Summary

Ü Buttress

Ü Radiographic evaluation

Ü Develop a strategic plan

Ü Careful consideration - lateral locked vs. dual plating

Ü Beware the posteromedial fragment

Tibia Shaft Fractures

- Open Fracture - Vascular Injury - Compartment Syndrome - Multi-trauma - “Unstable Fracture”

Current Surgical Indications

- 1 cm shortening - Tibia + fibula fractured at same level - High-energy fracture - Displaced tibia with intact fibula

What is an Unstable Tibial Shaft Fracture?

- Proximal (4-7 cm from joint) - Distal (3-4 cm from joint) - Segmental fractures - Closed fractures - Open fractures

Current Concepts: Reamed Intramedullary Nailing

Early Amputation for Mangled Extremity?

NO

Early Amputation for Mangled Extremity?

- Scoring systems are not helpful. - Initial sensation is not a reliable indicator of future sensation. - Results poor at 2 years, whether amputated or salvaged. - Results even worse at 7 years. - Most risk factors for poor results are beyond surgeon’s control. - Poor results related to socioeconomic status

Mangled Extremity: LEAP Study

Damage Control

- Best done early (within 2 weeks) - Pin sites must be clean. - Patient must be stable. - Infection risk higher than in femur.

IM Nailing after Ex Fix?

- Can be delayed. - Pin sites should be clean. - Skin must be healthy. - Can be minimally invasive.

ORIF after Ex Fix?

- Obtain reduction. - Provisional plating (unicortical). - Blocking screws. - Multiple interlocking screws. - Interest in suprapatellar approach.

Techniques for Proximal Fractures:

- Plate fibula if fractured distally. - Steinman pins as joysticks. - Blocking screws. - Multiple interlocking screws

Techniques for Distal Fractures:

Being replaced by locking plates.

Wire Fixators

- Indications have not changed. - Reamed intramedullary nailing is the mainstay of treatment. - Remember ATLS, Damage Control. - Don’t be in a hurry to amputate. - Consider delayed ORIF after Ex Fix. - Obtain and Maintain reduction of proximal and distal fractures. - New technologies have not yet withstood scrutiny.

Summary of Current Concepts

Tibia Plafond Fractures

Evaluation

§ Ankle radiographs § Tibia radiographs § CT scans

It’s not the fracture It’s the Soft Tissues

Poor Timing

Poor Outcome

Soft tissue must be ready for surgical insult

Guarantees Wagner, Unfallchir, 1986 Mast, CORR 1988 Trumble, JOT 1992 Wyrsch, JBJS 1996 Helfet, CORR 1994

Staged protocols

Early Ü Trans-articular

external fixation

Ü Fix fibula

Ü Allow soft tissue stabilization

Late Ü Definitive

Articular reconstruction

Ü Remove fixator

Stage 1 Goals

Ü Restoration of skeletal length and alignment

Ü Span joint and allow soft tissues to stabilize

Ü Distraction across ankle joint

Fibula must be anatomically reduced

Plate Fibula

A Fibula Malreduction Will Prevent Later Correct

Alignment of the

Plafond

Sagittal Plane Malalignment

Temporizing Fixator

Ü Span joint and allow soft tissues to stabilize

Ü Maintains alignment and length Ü Not articular congruity

Ü “Portable traction”

Ü Treat soft tissues Ü Flaps, dressing changes,

etc

Post ex-fix images

Ü Use fluoroscopy to look at reduction

Ü Look at ankle joint carefully

Look Carefully

Ü Make sure you regain length Ü Articular

landmarks Ü Fibula

Look Carefully

Ü Look at articular surface Ü Chaput fragment

Ü Maintains soft tissue connection with fibula

Look Carefully

• Look at fibula length – No overlap – Must be out to

length

Stage I

Ü External fixator

Ü Fibula plating

Ü CT Scan Ü post fixator when possible

CT Scans •  After external fixation •  Guide to fracture fragments •  Plan surgery

•  Incisions •  Lag Screws • Closed vs. open • Wire Placement

Tornetta, CORR 1996

Next Step

Surgical Decision Making

Ü Soft tissue

Ü Soft tissue

Ü Soft tissue

Surgical Decision Making

Ü Resolution of Edema

Ü “Wrinkle” test

Ü Epithelialized fracture blisters

Surgical Timing

Ü Patience

Ü Timing critical

Ü Avoid 1-6 days

Ü Await soft tissue envelope Ü  (10-21 days)

Reparative Phase Inflammatory Phase

Proliferative Phase

Staged protocols

Early Ü Fix fibula

Ü Trans-articular external fixation

Ü Allow soft tissue stabilization

Late Ü Definitive

Articular reconstruction

Ü Remove fixator

Stage 2 Goals

Ü Avoid complications

Ü Anatomic restoration of joint

Ü Stable fixation to allow motion

Ü Healed anatomically aligned limb

Post-op Protocol

Ü Cast until sutures out

Ü Cam walker until able to keep foot at neutral

Ü NWB for 8-12 weeks

Summary

Ü Difficult fractures

Ü No single treatment method

Ü Staged protocol

Ü Patience

Summary

Ü Biological exposure & fixation

Ü Accurate reduction of the articular surface

Ü Rigid fixation to allow early motion

THANK YOU