1. PROXIMAL TIBIAL FRACTURE

2. OVERVIEW
 TIBIAL FRACTURE and TYPES
 MECHANISM OF INJURY
 EVALUATION
 MANAGEMENT
 TIBIAL SPINE INJURIES
 TIBIA TUBERCLE FRACTURE
 TIBIA SHAFT FRACTURE
 PROXIMAL TIBIAL EPIPHYSIS FRACTURE
 COMPLICATIONS OF TIBIAL FRACTURE

3. TIBIAL FRACTURE AND TYPES

4. TIBIAL FRACTURES
 Most common long bone
fracture
 492,000 fractures yearly
 Average 7.4 day hospital
stay
 100,000 nonunions per year
Orthopaedia Trauma Association

5. DEMOGRAPHICS
• 1% of all fractures
• 8% of all fractures in the elderly
• Lateral plateau involved 55-70%
• Medial plateau involved 10-20%
• Both involved 10-30%
Sports medicine consult

6. TYPES :-
1. Articular (Hohl and Moore`s classification )
Plateau fracture
Fracture dislocation
2. Nonarticular

7. PLATEAU FRACTURE
Minimally displaced Local compression Split compression
Total condylar depression Bicondylar fracture

8. FRACTURE DISLOCATIONS
1. Split fracture
2. Entire condyle fracture
3. Rim avulsion fracture ( Involves lateral
condyle, associated with capsular tears and
vascular injuries )
4. Rim compression type (Unstable associated with
avulsion of cruciates)
5. Four part fracture (Unstable with Collateral
avulsed And neurovascular injuries)

9. MECHANISM OF INJURY

10. MECHANISM OF INJURY
 Can have both shear and compressive
forces
 Valgus (or varus) force split
 Axial load depression
 Combined force split/depression
(80%)
 Higher velocity (bumper fracture) leads to
an increase
 Comminution
 Displacement
 Soft tissue injury

11. EVALUATION

12. EVALUATION
 Trauma Evaluation
 ABCs
 Associated Injuries
 Evaluation of Limb
 Gentle exam for knee stability
 Observation of soft tissues
 Neurovascular evaluation
 Evaluate for compartmental syndrome
 Imaging Evaluation
Browner and Jupiter, Skeletal Trauma, 3rd Ed

13. PHYSICAL EXAMINATION
 Neurologic Exam
 Peroneal nerve especially with valgus force
 R/O compartment syndrome with severe injuries
 Vascular Exam
 Palpable pulses do not exclude injury
 popliteal artery and medial plateau injuries
 beware the of the knee dislocation posing as a fracture
 beware of posteriorly displaced fracture fragments
 ABI <0.9 urgent arterial study

14. PHYSICAL EXAMINATION
 Soft Tissue Assessment
 Tscherne & Goetzen (Closed injury)
 Gustillo and Anderson (Open injury)

15. TSCHERNE & GOETZEN
CLOSED FRACTURE CLASSIFICATION
 Grade 0
 Minimal Soft Tissue
Injury
 Simple Fracture Pattern
 Grade 1
 Superficial Abrasion
 Mild to Moderate
Fracture Pattern
 Grade 2
 Deep Abrasion
 Impending Compartment
Syndrome
 Severe Fracture Pattern
 Grade 3
 Extensive Crush
 Severe Fracture Pattern
 +/- Vascular Injury

16. GUSTILLO-ANDERSON
OPEN FRACTURE CLASSIFICATION
 Grade I - Wound < 1cm
 Grade II - Wound 1-10 cm
 Grade III - Wound > 10 cm
 IIIA = Adequate Soft Tissue Coverage
 IIIB = Requires Soft Tissue Coverage
 IIIC = Arterial Injury Requiring Repair

17. CLINICAL FEATURES
 Pain
 Swelling
 Deformity
 Haemarthrosis
 Decrease movement of knee
 Instability in valgus or varus

18. PHYSICAL EXAMINATION
 Hemarthrosis, aspirate for:
 Pain relief
 Fat evaluation
 Assessment of stability after local anesthetic
 Varus/valgus in full extension
 Compartment syndrome
 Pain with passive stretch
 Pain out of proportion

19. RADIOGRAPHIC EVALUATION
 AP, Lateral on Large Cassettes
 Obliques
 Internal rotation view
 Shows postero-lateral fragment
 Traction Films
 Defines fragments
 Bridging Ex-fix can provide traction
 CT scan with reconstruction
 Obtain after ex fix if using
 Coronal
 Sagittal
 Arteriography when necessary
 ? MRI – unsuspected fxs or soft tissue injury

20. RADIOGRAPHS
 Plain films
 Interobserver agreement = 62%
 Unchanged by CT scan
 Addition of CT scan increased agreement for surgery
plan from 58 to 71%
 Treatment plan changed in > 25% FROM CT
 CT shows
 Comminution
 Depression
 FX lines
Chan, JOT,1997

21. CLASSIFICATION
 Type I - Split Lateral Tibial Plateau Fx
 Type II - Split/Depression Lateral Plateau Fx
 Type III - Pure Depression Lateral Plateau Fx
 Type IV - Medial Tibial Plateau Fx
 Type V - Bicondylar Split Fx
 Type VI - Tibial Plateau Fx with Metaphyseal - Diaphyseal
Separation
Schatzker, Clin Orthop, 1979

23. SCHATZKER I:
 Definition:. Lateral split
 Etiology: Often due to valgus stress.
Occurs in younger patients with stronger
bones, which are resistant to depression.
Often due to a bumper injury.
 Common associated injuries: Lateral
meniscal tear. The lateral meniscus may
also become entrapped in the fracture
and require arthroscopy.
 Treatment: Typically, lateral fixation.

24. SCHATZKER II
 Most common tibial plateau fracture.
 Definition: Lateral split with depression.
 Etiology: Often due to valgus or axial
stress. Occurs in older patients with
osteoporosis with bones that do not resist
depression.
 Common associated injuries: Lateral
meniscus, medial meniscus, and medial
collateral ligament.
 Treatment: Typically, lateral fixation. The
depressed fragments are elevated and
supported with bone graft.

25. SCHATZKER III:
 Definition: Pure lateral depression; no
splitting
 Etiology: Older patients with
osteoporosis. Often just due to a fall.
 Common associated injuries: If the
depressed fragments are lateral and
posterior, it is associated with joint
instability.
 Treatment: If there is instability, the
fractured fragments are elevated and
supported with bone graft and lateral
internal fixation.

26. SCHATZKER IV:
 Definition: Medial tibial plateau fracture
that may be a split or split depression
type fracture.
 Etiology: Varus stress. Often severe
trauma.
 Common associated injuries: Associated
with avulsion of the intercondylar
eminence, which may indicate anterior
cruciate ligament injury. Lateral collateral
ligament injury. Peroneal nerve injury.
Popliteal artery injury.
 Treatment: Medial plate and screws.

27. SCHATZKER V:
 Definition: Split medial and lateral
tibial plateau (Bicondylar).
Metaphysis is still in continuity with
the diaphysis.
 Etiology: Often pure axial stress
with severe trauma.
 Common associated injuries:
Neurovascular, ACL, and meniscal
injuries.
 Treatment: Typically, medial and
lateral internal fixation.

28. SCHATZKER VI:
 Definition: Metaphyseal fracture that
separates the articular surface from
the diaphysis.
 Etiology: High-energy trauma.
 Common associated injuries:
Neurovascular injury and
compartment syndrome. Also
meniscal, ACL, and collateral
ligament injuries.
 Treatment: Typically medial and
lateral internal fixation

29. AO/OTA CLASSIFICATION
 Type A - Extraarticular
 Type B - Partial Articular
 Type C - Intra-articular and Metaphyseal
Orthopaedia Trauma Association

30. AO/OTA CLASSIFICATION

31. AO/OTA CLASSIFICATION
Type II
Type III
Type I
Type IV

32. AO/OTA CLASSIFICATION
Type V
Type VI

33. MANAGEMENT

34. TIMING OF SURGERY
 Stable, resuscitated patient
 Define fracture
 Soft tissue envelope
 Swelling
 Ecchymosis
 “Damage Control Orthopaedics”
 Positioning of patient
 Other injuries

35. “DAMAGE CONTROL ORTHOPAEDICS”
 Temporary Stabilization
 Soft Tissue Rest
 Bony Stabilization
 Bridging ExFix
 Across the Knee
 Pins Out of Zone of ORIF in Tibia
 Types V & VI Primarily
 ORIF

36. ARTICULAR FRACTURES
 A decrease in joint surface area leads to increase
stresses with subsequent deformity and post –
traumatic osteoarthritis
 Alignment and stable fixation of the articular surface
results in the formation of hyaline cartilage NOT
fibrocartlilage
Mitchell and Shepard, JBJS, 1980

37. SURGICAL INDICATIONS
 Open Fracture – I&D, spanning ex-fix
 Extensive soft tissue contusion – spanning ex-fix
 Closed fracture
 Varus/valgus instability of the knee
 Varus or valgus tilt of the proximal tibia
 Meniscal injury/previous meniscectomy
 Articular displacement or gapping
Rasmussen P, JBJS 55, 1973
Lansinger O, JBJS 68, 1986

38. SURGICAL APPROACHES
 Straight Midline
 Lateral Parapatellar
 Medial Parapatellar
 Posteromedial
 Two approaches for bicondylar fractures
 AVOID Mercedes incision or midline with stripping
of soft tissues, especially for bicondylars
www2.aofoundation.org

39.  Entry site is critical
 Reference is
Lateral Tibial Spine

40. JUST RIGHT

41. TOO LOW! TOO MEDIAL!
Procurvatum Valgus

42. APPROACH
 Lateral parapatellar
approach
 Leg extended
 Incision starts over
distal head of vastus
lateralis
 Continues just lateral
to patella and patellar
tendon

43. APPROACH
 Complex Fractures
 Long, straight anterior
midline incision
 Two Incisions – Preferred
 Bridge knee with
distractor or ex-fix
 Apply moderate
distraction to stabilize soft
tissues

44. POSTEROMEDIAL APPROACH
 Useful for bicondylar
 Medial injury often
 Posteromedial
 Coronal

45. SURGICAL TECHNIQUES
 Ligamentotaxis
 Helps with Condyle Architecture
 Does not reduce Joint Depression
 Femoral Distraction
 Indirect Reduction
 Preserve Meniscus
 Bone Graft

46. TIBIAL SPINE INJURIES

47. TIBIAL SPINE INJURIES
 aka intercondyle eminence
 Same mechanism as ACL rupture
(hyperextension, rotation, ab/adduction)
 In young patients ACL stronger than tibial spine – thus
tibial spine injury
 Suspect with ACL-like presentation (positive
Lachman, etc.) AND inability to weight bear

48. TIBIAL SPINE INJURIES
 Type I
 Incomplete avulsion with no displacement
 Type II
 incomplete avulsion with displacement
 Type III
 Completely avulsed fragment
http://remergs.com/WEBPAGE%20Notes/Trauma/50%20--%20Knee%20and%20Leg.pdf

49. TIBIAL SPINE INJURY
Type II tibial spine avulsion fracture

50. TIBIAL SPINE INJURIES TREATMENT
 Consider arthroscopy for definitive classification
 Type I: conservative; cast immobilization in full
extension X 6 weeks
 Type II: arthroscopic or open reduction; internal
fixation with screws and wires
Arthroscopic or ORIF: significant
displacement, associated ligamentous injury,
 Type III fractures, failure of closed reduction
Displaced or rotated fractures require ORIF to
restore normal ACL function
http://remergs.com/WEBPAGE%20Notes/Trauma/50%20--%20Knee%20and%20Leg.pdf

51. TIBIA TUBERCLE FRACTURE

52. 52
FRACTURE OF THE TIBIA TUBERCLE
 Tibia tubercle: patella tendon insertion, most anterior and
distal portion of the proximal tibia epiphysis
 Result from jumping or a rapid quadriceps contraction
against a flexed knee

53. 53
OSGOOD-SCHLATTER DISEASE
 Active children over the age of 8
 Pain in tibia tubercle
 Superficial microfracture of the cartilage at the insertion of
the tendon

54. 54
EVALUATION
 Pain, swelling, tenderness
 Limited displacement: may not be an effusion, capable of
limited active extension
 Displaced frx: active knee extension is
impossible, effusion,

55. 55
CLASSIFICATION

56. 56
TREATMENT
 Non-displaced type I: long leg cast in extension for 4~6
wks
 Others: ORIF with screws and washers, post-op
immobilization for 4~6 wks
Complication:
 Genu recurvatum

57. TIBIA SHAFT FRACTURE

58. TIBIAL SHAFT FRACTURE
 Most commonly fractured long bone
 Commonly open (1/3 of surface area just
subcutaneous)
 Precarious blood supply
 Hinge joints at knee and ankle are unforgiving of
post-reduction deformity
emedicine.medscape.com/article/1249984-overview

59. TIBIAL SHAFT FRACTURES
CLASSIFICATION
 No universally accepted classification
scheme. Describe the following
 Location (prox, middle, distal third)
 Configuration (transverse, spiral, comminuted)
 Displacement
 Angulation
 Length
 rotation

60. TIBIAL SHAFT FRACTURE
Closed distal third comminuted
fracture of left tibia
Nondisplaced as <5%
angulation, no rotation

61. TIBIAL SHAFT FRACTURE
ED TREATMENT
 Manage neurovascular status
 Carefully inspect any soft tissue defect for open
fracture
 Splint in long-leg, padded, posterior splint
 Beware of compartment syndrome

62. TIBIAL SHAFT FRACTURE
DEFINITIVE MANAGEMENT
 No consensus exists re: definitive treatment
 Multifactorial decision
 Possible management
 ORIF
 Intramedullary rod
 Cast immobilization
 Early progressive weight bearing after two weeks

63. PROXIMAL TIBIAL EPIPHYSIS
FRACTURE

64. 64
FRACTURE OF THE PROXIMAL TIBIAL EPIPHYSIS
 Uncommon, 3% of epiphyseal injuries of lower extremity
 Proximal tibial epiphysis:
 55% of the length of the tibia
 25% of the entire length of the limb
 0.6 cm per year
 Popliteal artery: lies close to the epiphysis in the popliteal
fossa, at risk of injury with displaced fracture
www.ncbi.nlm.nih.gov/pubmed/1405569

65. 65
EVALUATION
 Pain, swelling, decreased ROM of knee
 Neurovascular assessment
 Vascular injury is suspected  arteriogram
Classification:
 Salter-Harris classification
Associated injury:
 Popliteal artery and peroneal nerve injury

66. 66
TREATMENT
 Salter-Harris type I, II: close reduction + immobilization
4~6 weeks
 Salter-Harris type III, IV: CRIF with percutaneous pins or
cannulated screws
 Displaced frx with vascular injury: urgent reduction and
vascular status reassess
 Irreducible or vascular injury present: open reduction
 After reduction, splint in 10 ~20 degree flexion
 Cast when risk of compartment has decreased

67. COMPLICATIONS OF TIBIAL
FRACTURE

68. COMPLICATIONS
 Knee stiffness
 Infection
 Compartment syndrome
 Malunion or nonunion
 Posttraumatic osteoarthritis
 Peroneal nerve injury
 Popliteal artery laceration.
 Avascular necrosis

69. 69
COMPLICATION – COMPARTMENT SYNDROME
 Potential devastating complication
 Poorly controlled pain is the
earliest sign
 Discomfort during passive stretch
of the muscle
 Partial fibulectomy: lead to valgus
deformity in child, should not be
performed

70. 70
COMPLICATION – DELAY UNION OR NONUNION
 Fail to heal within 6 months
 Unusual
 Mean healing time
 10 weeks in close frx
 5 months in open frx
 Iliac crest bone grafting: usually successful in healing the
nonunion

71. 71
COMPLICATION – ANGULAR DEFORMITY
 Result from poor alignment or over-growth
 Valgus deformity from frx of proximal tibia metaphyseal
 Frequently correct spontaneously over several years
 Observation is recommended

72. 72
COMPLICATION – ROTATIONAL DEFORMITY
 Result from inadequate reduction
 Does not spontaneously correct
 >20 degree  rotational osteotomy

73. COMPLICATION – PROXIMAL TIBIAL PHYSEAL CLOSURE
 Rare complication
 Cause a genu recurvatum deformity
 Corrected with an opening wedge osteotomy

74. THANK YOU