2.6.1 Introduction

More than 100 years ago one of the pioneers of operative fracture treatment—Alb in Lambotte from Belgium—stated that fractures involving a joint should be reduced anatomically and fixed rigidly with screws and plates to allow early motion of the affected joint, as only then could an acceptable return of function be expected. Furthermore, Lambotte also stressed the importance of soft-tissue care and supported his recommendations with many impressive clinical examples and a regular follow-up of his patients.

Unfortunately at that time implant and instrument design was inconsistent, materials were often inadequate, and the high risks of infection prevented most surgeons from following Lambotte’s advice. It was not for another 60 years that Sir John Charnley from England and F. Pawels from Germany again strongly recommended the operative fixation of articular fractures.

Today, throughout the world a displaced articular fracture is considered an absolute indication for anatomical reduction and stable internal fixation, provided the external circumstances are appropriate for a surgical intervention.

2.6.2 Anatomy and basic principles

Joints are an essential part of the human skeleton, allowing the limbs to move. They vary in structure and form but share common features. A synovial joint has two bony ends covered by hyaline cartilage that are bound together by a fibrous capsule. The smooth, elastic hyaline cartilage serves to distribute the forces to the underlying subchondral bone. It is lubricated and nourished by synovial fluid produced by the synovial lining of the joint capsule. Synovial joints have very low friction and are more slippery than a skate on wet ice. Motion and functional loading are necessary for the diffusion of this fluid into the avascular cartilage. Joint stability relies on the passive stabilizers of joint morphology (eg, the ball and socket shape of the hip joint) and strong ligaments as well as active stabilizers in the form of muscles that cross the joint. Disruption of any component of an articulation can result in altered joint function and mechanical loading, which in turn can trigger pathophysiological processes, such as arthrofibrosis or osteoarthritis.

Consider, for example, a displaced malleolar fracture with gaps and steps in the joint surfaces together with subluxation of the joint and malalignment of the whole leg. In Figure 2.6-1 the patient is unable to move the ankle joint, and standing on the leg is painful. With inadequate fracture reduction and particularly prolonged immobilization in a cast, the inflammatory response becomes accentuated, leading to fibrosis of the intraarticular hematoma which will result in joint stiffness, deformity, and functional disability.

If, however, the intraarticular effusion is removed, and the anatomical relationships are restored and fixed by interfragmentary compression that allows for immediate postoperative pain-free joint motion, the probability of a return to full function is significantly higher (Fig 2.6-2).

There is ample experimental and clinical evidence showing that articular cartilage can remain viable after blunt trauma and that it has a limited capacity for repair, mostly with fibrocartilage. It has been demonstrated in animal experiments that anatomical reduction and stable fixation with interfragmentary compression followed by continuous passive motion leads to true hyaline cartilage healing. However, any increase in stress on the articular cartilage secondary to axial malalignment (a step or gap) of the articular surface, or abnormal movements due to joint instability or meniscal tears may lead to cartilage degeneration and osteoarthritis.