Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Partial articular fracture, split

back to skeleton

Glossary

General considerations

41-B1

These are intra-articular fractures, usually low velocity in young adults with good bone. Soft tissue damage is usually mild to moderate.

Because these are intraarticular injuries, the articular component demands anatomic reduction and absolutely stable fixation.
 
Intraarticular fractures should not be immobilized except as a temporizing measure prior to definite surgical treatment.

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

Note: Fractures involving the medial plateau have a great potential for displacement, even when initially undisplaced.

Indications

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

Contraindication

  • Severe soft-tissue damage
  • Severe obesity
  • 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
  • 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 patients

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

MIO - Percutaneous lag screws
Indication summary Skill Equipment
Lateral plateau fractures in young adults, displacement, excellent bone quality, meniscus not trapped in fracture Highly experienced and skilled surgeon Simple surgical and imaging resources

Screw fixation alone is contraindicated in all medial fractures and in most lateral fractures. The exception is a B1.1 fracture in a young adult with excellent bone.

Indications

  • Intraarticular fracture
  • Displacement
  • Excellent bone quality
  • Meniscus not trapped in fracture
  • Open fracture
  • Unstable knee

Contraindications

  • Meniscus trapped in fracture
  • Serious soft-tissue complications
  • Several serious medical co-morbidities
  • Extreme osteoporosis

Advantages

  • Minimally invasive
  • Compression osteosynthesis
  • Stable fixation
  • Functional after-treatment

Disadvantage

  • Meniscus could be trapped in the fracture
  • Surgical risks
ORIF - Lag screws
Indication summary Skill Equipment
Failed indirect reduction, good bone stock, displacement, large fragment Some specialized surgical experience Simple surgical and imaging resources

Screw fixation alone is contraindicated in all medial fractures and in most lateral fractures. The exception is a split fracture of the lateral plateau in a young adult with excellent bone.

Indications

  • Failure of closed reduction
  • Good bone stock
  • Displaced fracture
  • Large fragment
  • Unstable knee
  • Displaced and incongruous articular surface
  • Axial deformity
  • Open fractures

Contraindications

  • Serious soft-tissue complications
  • Several serious medical co-morbidities
  • Extreme osteoporosis

Advantages

  • Open reduction of articular surface
  • Compression osteosynthesis
  • Anatomical reconstruction
  • Stable fixation
  • Functional after-treatment

Disadvantages

  • Risks of surgery
ORIF - Plates without angular stability
Indication summary Skill Equipment
Failed indirect reduction, any operable fractures, especially oblique fractures, young patients without severe osteoporosis Highly experienced and skilled surgeon Simple surgical and imaging resources

Indications

  • Displaced/ unstable fracture
  • Good soft-tissue envelope
  • Open fractures
  • Knee instability
  • 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 which will prevent subsequent displacement and angular deformity
  • Stable internal fixation
  • Stable fixation promotes articular cartilage healing
  • Immediate funtional 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