2.1 Case history and physical examination

It is essential to review the case history as both the energy level (high or low) and the injury mechanism are important for decision making. This information provides the surgeon with an idea of the associated soft-tissue injuries as well as the fracture pattern, which in turn will help in surgical planning.

Physical examination is important. Inspection of the soft-tissue envelope provides information as to whether the fracture is closed or open. Clinical signs, such as blisters, superficial abrasions, deep contusions, and degloving injuries, indicate a high-energy injury, which precludes an immediate extensile exposure ( Fig 6.8.1-1 ). It is valuable to repeatedly evaluate the neurological and vascular status of the leg to detect severe complications, such as compartment syndrome. In addition to swelling and tenseness in the leg, severe pain exacerbated by passive stretching is a sensitive clinical indicator of a compartment syndrome [2]. The presence of paresthesia and paralysis represent late findings after an acute compartment syndrome. It is critical to maintain a high level of suspicion and close observation if patients with a compartment syndrome are not to be missed [3].

Be aware that a compartment syndrome can occur in a single compartment with atypical presentation, especially in the anterior or lateral compartment. The pedal pulses must always be palpated. The pedal pulses are usually present in a compartment syndrome.

Absent or abnormal pedal pulses indicate arterial injury or occlusion. This sign must never be ignored and the presence of good capillary return in the foot with absent pulses can be profoundly misleading. In this situation, deformity must be corrected immediately and the pulses palpated again. If they fail to return, the patient has a limb-threatening vascular injury until proven otherwise. This is an emergency situation and an immediate vascular surgery consult is essential.

The soft-tissue structures around the knee, which contribute to stability, are frequently injured in tibial plateau fractures [4]. Examination for knee ligament stability before fracture fixation is not helpful but stability of the joint must always be evaluated at the completion of the operative fixation of a tibial plateau fracture to diagnose ligament injury. Residual instability after fixation often warrants further management.

2.2 Imaging

Conventional x-rays in two planes (AP and lateral) are essential and may be supplemented by both 45° oblique views. However, plain x-rays are not considered sufficient to adequately assess the fracture type. The addition of CT scanning improves the interobserver and intraobserver reliability of classification. Preoperative CT scans with coronal, sagittal, and 3-D reconstructions have become a standard tool in the analysis of tibial plateau fractures. If possible, it should be done after initial reduction and splinting in a cast or following a joint bridging external fixator. With advances in CT technology, more and more attention has been paid to the position of the fracture and the columns that are involved ( Fig 6.8.1-2 ). Sometimes the extent of the injury is hard to detect on plain x-rays due to its location [5, 6].

Although magnetic resonance imaging (MRI) has been shown to be more sensitive than other tests for the assessment of associated soft-tissue injuries, such as meniscal and ligament injuries [4], it is not recommended as a routine diagnostic procedure in the acute setting. A high incidence of ligamentous injuries has been observed with MRI of acute tibial plateau fractures and 80% have associated meniscal tears and 40% have ligamentous disruptions [4]. However, MRI can be oversensitive for these injuries as the acute MRI signal in the knee ligaments does not necessarily reflect a functional deficit when knee stability is examined with the patient anesthetized. Thus, management decisions must be based upon intraoperative examination of stability after fracture fixation. Positive results require careful soft-tissue management. Doppler ultrasound, CT angiography, or digital subtraction angiography should be considered whenever there is concern about extremity vascular trauma but must not result in any significant delay in revascularization ( Fig 6.8.1-3 ).

6.1 Timing of surgery

Staged management with urgent closed reduction and temporary, joint-spanning external fixation ahead of definitive fixation surgery is indicated for the following:

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  Open fractures

  
  
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  Acute vascular injury

  
  
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  Severe, closed soft-tissue injury

  
  
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  Damage control in polytrauma

Under stable conditions, the diagnostic workup can be completed to allow for a thorough assessment and understanding of the fracture type and the condition of the soft-tissues. Once soft-tissue swelling has fully recovered (usually 10–14 days), surgery can be performed safely. In patients with compartment syndrome or open fractures, where primary skin closure is a problem, negative-pressure wound therapy, skin grafts, or rotational flaps may be needed.

A good clinical indicator that it is safe to perform open reduction and internal fixation (ORIF) is skin wrinkling indicating regression of edema ( Fig 6.8.1-1b ).

6.2 Implant selection

External fixation with radiolucent rods is selected for staged care or patients with soft-tissue problems. To fix articular fragments, 3.5 or 4.5 mm lag screws are used and can be placed as a raft to support the subchondral bone in complex articular fractures. Plate fixation is with a locking compression plate (LCP) 3.5 or 4.5, which is used for buttressing or bridging. Nonlocking plates (eg, low-contact dynamic compression plate) can be used for B-type fractures with good bone quality when buttress fixation is required. Smaller locking plates 2.4 or 2.7 can be used as reduction plates or tension band plates and occasionally for fragment-specific fixation. Screw fixation alone can be applied (raft technique) in pure depression fractures (Schatzker III). Intramedullary (IM) nails with proximal interlocking screws can be considered in type A fractures.

6.3 Operating room set-up

The patient is placed in the supine position. A thigh tourniquet is applied, which is inflated only if needed. Light manual traction is maintained on the limb during preparation. The exposed area from mid thigh to the foot is disinfected with the appropriate antiseptic. The limb is draped with a single-use U-drape or extremity drape. A stockinette covers the foot and lower leg and is fixed with a tape ( Fig 6.8.1-9 ).

The surgeon and the assistant stand (or sit) on the side of the injury. The operating room personnel stand next to the surgeon. Position the image intensifier on the opposite side of the injury with the screen in full view of the surgical team and the radiographer ( Fig 6.8.1-10 ).

7.1 Approaches

7.1.1 Anterolateral approach

This approach is the most frequently used and includes a lateral arthrotomy through a transverse incision of the meniscotibial attachment: lifting of the meniscus allows inspection of the lateral joint surface. The following landmarks are important: the joint line, Gerdy tubercle, the tip of the fibula, and the lateral femoral epicondyle. With the knee in 30° flexion, a slightly curved incision is made, beginning in the area of the epicondyle and ending between the fibula and Gerdy tubercle ( Fig 6.8.1-11 ). This incision can be extended proximally and distally if more exposure is needed. The deep dissection involves splitting the fibers of the iliotibial tract. Care should be taken not to dissect other structures that may be displaced, such as the meniscus. The meniscus is then palpated and the knee joint may be opened below the meniscus, which is elevated with a stay suture.

Related posts:

6.1.1 Scapula 6.2.1 Humerus, proximal 6.4 Pelvic ring 6.3.3 Distal radius and wrist 6.6.2 Femur, shaft (including subtrochanteric fractures) 6.6.3 Femur, distal

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