Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Complete articular fracture, simple articular, simple metaphyseal

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Glossary

General considerations

41-C1

These are complex articular fractures of the proximal tibia, articular simple and metaphyseal simple. These are almost always high velocity injuries with significant damage to the soft tissue envelope. The state of the soft tissue envelope will dictate the timing and the type of the definitive intervention. These fractures are fracture dislocations of the knee and the joint is always unstable.
Intraarticular fractures should not be immobilized except as a temporizing measure prior to definite surgical treatment. 

Nonoperative treatment
Indication summary Skill Equipment
Undisplaced, minimally displaced and stable fractures Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Undisplaced or minimally displaced, and stable
  • Patient who cannot tolerate surgery
  • Elderly patients

Contraindication

  • Open injury

Advantage

  • No risks of surgery
Bridging external fixation (temporary)
Indication summary Skill Equipment
Provisional means of fixation in severely traumatized patients Some specialized surgical experience Simple surgical and imaging resources

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 fixation (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 fixation (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

MIO - Angular stable plate (LISS)
Indication summary Skill Equipment
Articular, unstable fractures, open fractures, osteoporosis, soft-tissue compromise Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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
  • Allows fixation in some fractures without second plate
  • 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

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
ORIF - Plates without angular stability
Indication summary Skill Equipment
All displaced fractures with knee joint instability, open fractures, compartment syndrome Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Open fractures
  • 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
*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