Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tiba Complete articular fracture, fragmentary articular

back to skeleton

Glossary

General considerations

41-C3

These are intraarticular fractures, articular complex and metaphyseal complex.

They are all high energy fracture dislocations of the tibial plateaus with both medial and lateral columns involved and are usually associated with moderate to marked degree of injury to the soft tissue envelope.
Intraarticular fractures should not be immobilized except as a temporizing measure prior to definite surgical treatment.

Nonoperative treatment
Indication summary Skill Equipment
Stable, medical compromise, initial temporary splintage, marked osteoporosis Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Patient who cannot tolerate surgery
  • Elderly patients
Bridging external fixator (temporary)
Indication summary Skill Equipment
Provisional means of fixation in severely traumatized patients Basic surgical experience, no specialized skills Basic equipment only

The main indication for a bridging external fixation is to provide temporary immobilization of the fracture.

Indications

  • Open fractures with severe contamination
  • Joint instability
  • Polytrauma
  • Severe soft-tissue compromise
  • Serious medical co-morbidity

Contraindication

  • Extreme osteoporosis

Advantages

  • Provides temporary immobilization of the fracture
  • Soft-tissue friendly
  • Fast procedure

Disadvantages

  • Bridging of the joint
  • Risk of pin-track infection
  • Risk of muscle scarring
  • Risk of knee stiffness

Hybrid external fixator (definitive)
Indication summary Skill Equipment
Severe open fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Open fractures
  • Major joint instability
  • Severe soft-tissue compromise, not permitting definitive internal fixation
  • Non compliant patient

Note: If the soft tissue envelope prevents conversion to stable internal fixation, the fracture can be treated by changing the hybrid to a double ring fixator until union.


 

Ring external fixator (definitive)
Indication summary Skill Equipment
Severe open fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

This is a technically demanding procedure because of the anatomical situation. It should therefore be considered only if no other method is available.

Indications

  • Severe open fracture, particulary with bone loss
  • Fracture with loss of soft tissue cover

Contraindication

  • Stable internal fixation is possible

ORIF - Conventional plates
Indication summary Skill Equipment
All operable fractures; knee instability, open fractures, compartment syndrome Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Conventional plating of the major diaphyseal component of these fractures is contraindicated because it requires open direct reduction. Minimally invasive plate osteosynthesis with the aid of plates with locking screws is much less traumatizing to the soft tissue envelope and is therefore the method of choice.

Indications

  • Open fracture
  • Displaced/ unstable fracture
  • Unstable knee
  • Good soft-tissue envelope
  • Good bone quality
  • Compartment syndrome

Contraindications

  • Severe soft-tissue damage
  • Open fracture with severe contamination
  • Several serious medical co-morbidities
  • Extreme osteoporosis

Advantages

  • Open direct anatomical reduction of articular surface
  • Buttress fixation of the metaphysis and bridge plating of the diaphyseal extension which will prevent subsequent displacement and angular deformity
  • Stable internal fixation
  • Stable fixation promotes articular cartilage healing
  • Immediate functional after-treatment
  • Compression osteosynthesis

Disadvantages

  • Soft-tissue dissection
  • Devitalization of bone
  • Large skin incision
  • Surgical risks
MIO - Less invasive stabilization system
Indication summary Skill Equipment
Osteoporosis, minimal soft-tissue compromise, less traumatic than conventional plating, surgeon's preference, knee instability, compartment syndrome Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Conventional plating of the major diaphyseal component of these fractures is contraindicated because it requires open direct reduction. Minimally invasive plate osteosynthesis with the aid of plates with locking screws is much less traumatizing to the soft tissue envelope and is therefore the method of choice.
The LISS cannot stabilize a posteromedial fragment and therefore a second posteromedial plate must be used to buttress the medial column.

Indications

  • Open fractures
  • Articular, displaced/ unstable fracture
  • Closed fractures with compromised soft- tissue envelope
  • Osteoporosis
  • Compartment syndrome


Contraindications

  • Severe open and contaminated wound
  • Medical co-morbidities

Advantages

  • Less traumatic to soft-tissue
  • Buttress fixation of the metaphysis and bridge plating of the diaphyseal extension which will prevent subsequent displacement and angular deformity

Stable

  • Does not require anatomic reduction
  • Minimally invasive surgery
  • Restoration of the correct mechanical axis

Disadvantages

  • Risk of neural  trauma with plating
  • Technically demanding
  • Cost
  • Requires intraoperative imaging
  • Use of complex equipment
  • Difficult to obtain and maintain the reduction
  • Surgical risks
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2010-05-15