Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Partial articular fracture, split-depression

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Glossary

General considerations

41-B3

Intraarticular fractures should not be immobilized except as a temporizing measure prior to definite surgical treatment.
A split depression fracture of the lateral plateau is usually a low velocity injury.
Fractures involving the medial plateau or the tibial spine are high velocity injures with great risk of soft tissue complications. Even when undisplaced there is a great risk of deformity. The split depression is often split also in the coronal plane which leads to posteromedial subluxation of the joint. Beware of popliteal artery injuries and traction lesions of the peroneal nerve.

Nonoperative treatment
Indication summary Skill Equipment
Undisplaced/stable, medical compromise, initial temporary splintage, marked osteoporosis 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 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 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 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
  • Open fractures
  • 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

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