Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Partial articular fracture, depression

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Glossary

General considerations

41-B2

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.

Nonoperative treatment
Indication summary Skill Equipment
Undisplaced, minimally impacted and stable 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

Note: An exception

Even if initially undisplaced, a fracture involving the medial plateau has a great potential for displacement.

Bridging external fixation (temporary)
Indication summary Skill Equipment
Provisional means of fixation in severely traumatized patients Some specialized surgical experience 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
  • Major impaction and 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

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

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 Simple surgical and imaging resources

Indications

  • Displaced/ unstable fracture
  • Good soft-tissue envelope
  • Good bone quality
  • Compartment syndrome
  • Knee joint instability

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 which will prevent subsequent displacement and angular deformity
  • Stable internal fixation
  • Stable fixation promotes articular cartilage healing
  • Immediate funtional after-treatment

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