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Semelhante a Tibia Plateau, Shaft, and Plafond Fractures Review
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Tibia Plateau, Shaft, and Plafond Fractures Review
- 1. TIBIA PLATEU, SHAFT, AND PLAFOND FRACTURES AAOS/ASSH General Review Jul 12, 2012 Matthew L. Jimenez, MD, FACS
- 2. Mandatory Disclosure Ü The 2012 14th Annual Chicago Trauma Symposium received support from 40 industry partners
- 3. Mandatory Disclosure Ü Foundation for Education and Musculoskeletal Research (FEMR) several industry and philanthropic partners
- 5. Surgical Goals Ü Obtain/Secure Articular Reduction Ü Reduce Condylar Width Ü Restore Axial Alignment Ü Neutralize Meta-Diaphysis Ü Secure Tibial Tubercle Ü Early ROM Ü Appropriate Soft Tissue Handling
- 6. Surgical Timing § Stage 1: Temporary Spanning External Fixation ú Soft tissue stabilization ú Fracture stabilization in polytraumatized patient ú Develop surgical tactic - CT scan!!!! § Stage 2: ORIF ú Execute surgical tactic ú Definitive articular & axial reductions and fixations
- 7. Buttress Plating Buttress plate - A plate employed to support the fractured bone in the area of the metaphysis, usually used in conjunction with lag screws Antiglide plate - A plate used to reduce an oblique fracture indirectly through interference between the plate and the undisplaced main fragment
- 8. Buttress Ü Resists shear forces Ü Metaphyseal Fractures
- 11. Resists shear
- 12. Anti-Glide Ü Resists shear forces Ü Create stable axilla
- 15. Lateral Plateau Condylar width Lateral split Depression
- 16. Strategy Open Book? Femoral distractor Submeniscal arthrotomy Containment Meniscus repair Buttress Elevate joint from below
- 17. Containment
- 18. Containment Condylar width Bone graft/support Joint compression Buttress Non locking implant
- 20. Lateral locked vs dual plating Ü Can bicondylar fx s be treated with laterally based locked plating alone? Ü Is dual incision and plating better?
- 21. Lateral locked plating has NOT solved it all
- 22. The Medial Plateau Coronal Fx Sagi%al Fx Posteromedial Fragment Separates En1re Medial Plateau
- 23. Barei et al, JOT 2008
- 24. Posteromedial fragment Ü Subject to shear forces Ü Medial femoral condyle follows Ü Risk of displacement Ü Raises questions about fixation strategies and surgical approach
- 25. Barei et al, JOT 2008
- 29. With Posteromedial Fragment Ü Consider dual approach Ü Will locking screws from the lateral side support that fragment?
- 30. Ipsilateral, Noncontiguous Plateau and Shaft Fractures
- 31. Plateau/Shaft Fractures Ü Unusual injury pattern Ü Difficult to treat with a single implant Ü Goal = treat both injuries optimally
- 32. Barei et al, JOT 2008
- 33. Barei et al, JOT 2008
- 34. Tibia Plateau Summary Ü Buttress Ü Radiographic evaluation Ü Develop a strategic plan Ü Careful consideration - lateral locked vs. dual plating Ü Beware the posteromedial fragment
- 36. Current Surgical Indications - Open Fracture - Vascular Injury - Compartment Syndrome - Multi-trauma - Unstable Fracture
- 37. What is an Unstable Tibial Shaft Fracture? - 1 cm shortening - Tibia + fibula fractured at same level - High-energy fracture - Displaced tibia with intact fibula
- 38. Current Concepts: Reamed Intramedullary Nailing - Proximal (4-7 cm from joint) - Distal (3-4 cm from joint) - Segmental fractures - Closed fractures - Open fractures
- 39. Early Amputation for Mangled Extremity?
- 40. Early Amputation for Mangled Extremity? NO
- 41. Mangled Extremity: LEAP Study - Scoring systems are not helpful. - Initial sensation is not a reliable indicator of future sensation. - Results poor at 2 years, whether amputated or salvaged. - Results even worse at 7 years. - Most risk factors for poor results are beyond surgeon s control. - Poor results related to socioeconomic status
- 42. Damage Control
- 43. IM Nailing after Ex Fix? - Best done early (within 2 weeks) - Pin sites must be clean. - Patient must be stable. - Infection risk higher than in femur.
- 44. ORIF after Ex Fix? - Can be delayed. - Pin sites should be clean. - Skin must be healthy. - Can be minimally invasive.
- 46. Techniques for Proximal Fractures: - Obtain reduction. - Provisional plating (unicortical). - Blocking screws. - Multiple interlocking screws. - Interest in suprapatellar approach.
- 48. Techniques for Distal Fractures: - Plate fibula if fractured distally. - Steinman pins as joysticks. - Blocking screws. - Multiple interlocking screws
- 49. Wire Fixators Being replaced by locking plates.
- 50. Summary of Current Concepts - Indications have not changed. - Reamed intramedullary nailing is the mainstay of treatment. - Remember ATLS, Damage Control. - Don t be in a hurry to amputate. - Consider delayed ORIF after Ex Fix. - Obtain and Maintain reduction of proximal and distal fractures. - New technologies have not yet withstood scrutiny.
- 52. Evaluation § Ankle radiographs § Tibia radiographs § CT scans
- 53. It s not the fracture It s the Soft Tissues
- 55. Poor Timing Wagner, Unfallchir, 1986 Guarantees Mast, CORR 1988 Soft tissue must be Trumble, JOT 1992 ready for surgical insult Wyrsch, JBJS 1996 Helfet, CORR 1994 Poor Outcome
- 56. Staged protocols Early Late Ü Trans-articular Ü Definitive external fixation Articular Ü Fix fibula reconstruction Ü Allow soft tissue stabilization Ü Remove fixator
- 57. Stage 1 Goals Ü Restoration of skeletal length and alignment Ü Span joint and allow soft tissues to stabilize Ü Distraction across ankle joint
- 59. Plate Fibula Fibula must be anatomically reduced
- 60. A Fibula Malreduction Will Prevent Later Correct Alignment of the Plafond
- 62. Temporizing Fixator Ü Span joint and allow soft tissues to stabilize Ü Maintains alignment and length Ü Not articular congruity Ü Portable traction Ü Treat soft tissues Ü Flaps, dressing changes, etc
- 63. Post ex-fix images Ü Use fluoroscopy to look at reduction Ü Look at ankle joint carefully
- 64. Look Carefully Ü Make sure you regain length Ü Articular landmarks Ü Fibula
- 65. Look Carefully Ü Look at articular surface Ü Chaput fragment Ü Maintains soft tissue connection with fibula
- 66. Look Carefully • Look at fibula length – No overlap – Must be out to length
- 67. Stage I Ü External fixator Ü Fibula plating Ü CT Scan Ü post fixator when possible
- 68. CT Scans • After external fixation • Guide to fracture fragments • Plan surgery • Incisions • Lag Screws • Closed vs. open • Wire Placement Tornetta, CORR 1996
- 69. Next Step
- 70. Surgical Decision Making Ü Soft tissue Ü Soft tissue Ü Soft tissue
- 71. Surgical Decision Making Ü Resolution of Edema Ü Wrinkle test Ü Epithelialized fracture blisters
- 72. Surgical Timing Ü Patience Ü Timing critical Ü Avoid 1-6 days Ü Await soft tissue Inflammatory Phase Reparative Phase envelope Proliferative Phase Ü (10-21 days)
- 73. Staged protocols Early Late Ü Fix fibula Ü Definitive Ü Trans-articular Articular external fixation reconstruction Ü Allow soft tissue stabilization Ü Remove fixator
- 74. Stage 2 Goals Ü Avoid complications Ü Anatomic restoration of joint Ü Stable fixation to allow motion Ü Healed anatomically aligned limb
- 77. Post-op Protocol Ü Cast until sutures out Ü Cam walker until able to keep foot at neutral Ü NWB for 8-12 weeks
- 78. Summary Ü Difficult fractures Ü No single treatment method Ü Staged protocol Ü Patience
- 79. Summary Ü Biological exposure & fixation Ü Accurate reduction of the articular surface Ü Rigid fixation to allow early motion
- 80. THANK YOU