Impaction fractures of the articular surface without a split wedge component. They may be associated with impaction of the cortical rim and instability of the joint. These occur most often in older patients with weaker cancellous bone.
The key to the treatment of these fractures is the stability of the joint. Stability can only be determined under adequate sedation, since pain and muscle splinting make it impossible to determine stability. If the joint is stable, conservative treatment with protective weight bearing and early movement is usually adequate.
Intraarticular fractures should not be immobilized except as a temporizing measure prior to definite surgical treatment.
Joint impaction cannot be reduced by indirect means, because the impacted bone has no soft tissue attachment and ligamentotaxis does not work.
If the impaction involves the cortical containment, stability will not be regained by simple elevation of the depression.
|Undisplaced, minimally impacted and stable|
- Undisplaced or minimally displaced, and stable
- Patient who cannot tolerate surgery
- Elderly patients
- Open injury
- No risks of surgery
Note: An exception
Even if initially undisplaced, a fracture involving the medial plateau has a great potential for displacement.
|Bridging external fixator (temporary)|
|Provisional means of fixation in severely traumatized patients|
The main indication for a bridging external fixation is to provide temporary immobilization of the fracture.
- Open fractures with severe contamination
- Major impaction and joint instability
- Severe soft-tissue compromise
- Serious medical co-morbidity
- Extreme osteoporosis
- Provides temporary immobilization of the fracture
- Soft-tissue friendly
- Fast procedure
- Bridging of the joint
- Risk of pin-track infection
- Risk of muscle scarring
- Risk of knee stiffness
|Ring external fixator (definitive)|
|Severe open fracture|
This is a technically demanding procedure because of the anatomical situation. It should therefore be considered only if no other method is available.
- Severe open fracture, particulary with bone loss
- Fracture with loss of soft tissue cover
- Stable internal fixation is possible
|ORIF - Plates without angular stability|
|All displaced fractures with knee joint instability, open fractures, compartment syndrome|
- Displaced/ unstable fracture
- Good soft-tissue envelope
- Good bone quality
- Compartment syndrome
- Knee joint instability
- Severe soft-tissue damage
- Open fracture with severe contamination
- Several serious medical co-morbidities
- Extreme osteoporosis
- Open direct anatomical reduction of articular surface
- Buttress fixation of the metaphysis which will prevent subsequent displacement and angular deformity
- Stable internal fixation
- Stable fixation promotes articular cartilage healing
- Immediate funtional after-treatment
- Soft-tissue dissection
- Devitalization of bone
- Large skin incision
- Surgical risks
|Basic surgical experience, no specialized skills|
|Some specialized surgical experience|
|Highly experienced and skilled surgeon|
|Basic equipment only|
|Simple surgical and imaging resources|
|Full specialized surgical and imaging resources|