Tibia and fibula, proximal: intraarticular bicondylar fracture, no metadiaphyseal involvement—41-C3

10.1055/b-0034-87653

Tibia and fibula, proximal: intraarticular bicondylar fracture, no metadiaphyseal involvement—41-C3

Jong-Keon Oh

Case description

A 44-year-old man injured his right leg in a car accident sustaining a closed fracture of the proximal tibia ( Fig 19.4-1, Fig 19.4-2 ). There were no associated injuries and the neurovascular status was normal. Significant swelling around the knee joint and proximal tibia was evident (see Fig 19.4-3 ). Initial management was with a bridging external fixator. It took 2 weeks until the soft tissue settled down which was verified by the presence of a wrinkle sign.

Indication for MIPO

Operative treatment was mandatory to restore the anatomy of the articular surface and intramedullary nailing was excluded due to the fracture anatomy.

A MIPO procedure was indicated using a small plate on the medial side to restore the medial column which could then be used as a reference for reconstructing the comminuted lateral condyle.

a–b Preoperative x-rays show a 41-C3 fracture with no metadiaphyseal extension along the medial column. Significant articular depression on the lateral plateau is visible. c The axial CT scan shows the extent of articular involvement on the lateral plateau. Attention should be paid to the large amount of soft-tissue damage that can be seen under the skin (arrows).

A bridging external fixator was applied because of the high-energy fracture pattern and the swelling was present both on physical examination and CT scan.

A simple one-plane monofixator was placed in the sagittal plane. Because two incisions would be needed to carry out medial plating and a tension band plating for the tuberosity fragment, the sites of pin insertion were carefully planned to avoid violating the sites of definitive fixation. The knee joint was kept in almost full extension to avoid flexion contracture ( Fig 19.4-4 ).

a–d Three-dimensional CT scans show a medial plateau fracture consisting of a single bone block and significant articular and metaphyseal comminution of the lateral plateau.

A clinical image taken in the operating room shows the swelling and fracture blisters formed on the medial side of the proximal tibia.

a–b X-rays taken after bridging external fixation show the restoration of length.

Usually swelling reaches its peak 2–3 days after injury. The location and nature of the fracture blisters were carefully assessed and documented. The skin under the blisters filled with dark fluid is more likely to be necrotic than those containing clear fluid ( Fig 19.1-5 ). The blisters were aspirated and the collapsed epithelium was used as a biological dressing.

a–b Two days after bridging external fixation more fracture blisters have formed around the proximal tibia. a Medial side of left leg. Asterisks indicate the fracture blisters filled with dark fluid with a higher risk of associated skin necrosis than with blisters filled with clear fluid (arrows). b Lateral side of left leg.

Preoperative planning

Medial plateau reduction: direct exposure and reduction of the medial plateau fragment through a straight incision along the posteromedial aspect of the proximal tibia using a one-third tubular plate or T-plate 3.5.
Tension band plating of the tuberosity fragment to enhance stability of the construct.
Lateral plateau reconstruction: submeniscal approach via standard anterolateral incision for access to allow elevation of the depressed articular fragments. The elevated fragments are supported with a raft of subchondral K-wires.
Buttressing of the split fragment with precontoured locking plate 3.5 with multiple articular supporting screws.