1. A 42-year-old Thai man presented to the emergency room with right knee pain after falling off his motorcycle when hit by a bicycle. 2. Physical examination revealed swelling, deformity, and limited range of motion of the right knee with intact sensation and good blood flow. X-rays showed a closed fracture of the right tibial plateau. 3. The patient was admitted for pain control, antibiotics, and planned surgery to repair the closed fracture of the right tibial plateau via open reduction and internal fixation.

1. CASE
CONFERENCE
13/5/2559
Ext.Sunatcha Chomsantia

2.  Case ชายไทยอายุ 42 ปี
 ภูมิลาเนา อาเภอเมือง จังหวัดนครราชสีมา

3.  CC: ปวดเข่าขวา 4 hr PTA
 PI: 4 hr PTA ขับ MC ล้มเอง โดนจักรยานตัดหน้า ไม่สลบ จา
เหตุการณ์ได้ เอาขาขวากระแทกพื้น ขาขวาบิด รู้สึกปวดบริเวณเข่าขวา เดิน
ลงน้าหนักไม่ได้ จึงมารพ.

4. Past history
 No U/D
 No allergy

5. Physical Examination
 GA : A Thai man good consiousness,well co-
operative
 HEENT : not pale conjunctivae,anicteric sclera
 Lung : clear,equal breath sound
 Heart : normal S1S2,no murmur
 Abdomen : soft,not tender

6. Physical Examination
 Ortho :
RT.Knee :marked swelling,
tender,deformity,limited ROM,
pin pick sensation intact,capillary refill < 2,
Dorsalis pedis artery2+,Posterior tibial artery 2+
ABI :Rt. 1.3 Lt.1.4

9. Investigation
 Film Knee
AP,Lateral

11. Diagnosis
 Close Fracture Rt. tibial plateau

12. Management
 Admit
 lab pre-op : CBC,Bun,Cr,Electrolyte,anti-HIV
 CXR
 pain control : MO 4 mg IV q 6 hr
 cefazolin 1 g IV q 6 hr
 plan Sx

13. Fracture tibial plateau

14. Anatomy

18. Fracture tibial plateau
 Periarticular injuries of the proximal tibia
frequently associated with soft tissue injuries

19. Fracture tibial plateau
Epidemiology
 demographics
 bimodal distribution
 males in 40s (high-energy trauma)
 females in 70s (falls)
 location
 unicondylar vs. bicondylar
 frequency
 lateral > bicondylar > medial

20. Fracture tibial plateau
Mechanism
 varus/valgus load with or without axial load
 high energy
 frequently associated with soft tissue injuries
 low energy
 usually insufficiency fractures

21. Schatzker Classification

22. Schatzker Classification

23. Schatzker Classification
 Type I Lateral split fracture
 Type II Lateral Split-depressed fracture
 Type III Lateral Pure depression fracture
 Type IV Medial plateau fracture
 Type V Bicondylar fracture
 Type VI
Metaphyseal-diaphyseal disassociation

24. Type I

25. Type II

26. Type III

27. Type IV

28. Type V

29. Type VI

30. Associated conditions
 meniscal tears
 lateral meniscal tear
 more common than medial
 associated with Schatzker II fracture pattern
 medial meniscal tear
 most commonly associated with Schatzker IV
fractures

31.  ACL injuries
 more common in type V and VI fractures (25%)

32.  compartment syndrome
ได้แก่ 5 Ps คือ
a. Pain (markedly increase)
b. Paresthesia
c. Pallor
d. Paralysis
e. Pulseless
Tx. Fasciotomy and decompression

33.  Vascular injury
 commonly associated with Schatzker IV fracture-
dislocations
 Most >>> popliteal artery

34. Management
1. Recognition
2. Reduction
2.1 Closed Reduction
2.2 Continuous traction
2.3 Open Reduction
3. Retention
4. Rehabilitation

35. Treatment
Non-operative
 hinged knee brace, PWB for 8-12 weeks, and
immediate passive ROM
 indications
 minimally displaced split or depressed fractures
 low energy fracture stable to varus/valgus
alignment
 nonambulatory patients

37. Operative
 temporizing bridging external fixation w/ delayed ORIF
 indications
 significant soft tissue injury
 polytrauma
 external fixation with limited open/percutaneous fixation of articular
segment
 indications
 severe open fracture with marked contamination
 highly comminuted fractures where internal fixation not
possible
 outcomes
 similar to open reduction, internal fixation

38.  open reduction, internal fixation
 indications
 articular stepoff > 3mm
 condylar widening > 5mm
 varus/valgus instability
 all medial plateau fxs
 all bicondylar fxs