TIBIAL PLATEAU fracture power point presentation
- 1. Tibial plateau fractures ORTHOPEDIC SEMINAR PRESENTATION Presented by kaleab Gizachew & Hikma shemsedin(PTI)
- 2. OUTLINE • Introduction • Anatomy of tibial pleatue • Epidimolgy • MOI • Associated injury • Classification • Clinical diagnosis • Differential diagnosis • Treatment/Managment • Complication • Outcome • Physiotherapy managment • Reference
- 3. Tibial plateau fracture • The tibia is the second largest bone in the body,& main bone in the leg forming what is more commonly known as the shin. • Tibial plateau fractures constitute 1% of all fractures and 8% of fractures in the elderly. • Tibial plateau fractures involve the proximal aspect or metaphysis of the tibia and frequently the articular surface as well
- 4. Anatomy of knee The knee joint is a bicondylar type of synovial joint. It is formed by articulations between the patella,femur and tibia Joints Patellofemoral Femorotibial Ligaments MCL/LCL ACL/PCL Menisci Musculotendinous structures
- 5. Cont’d Primary angular motion- Flexion and extension In some amount Medial/Lateral rotation (internal /external rotation) and varus/valgus (adduction/abduction) motion occurs Normal ROM of flexion is 130-150 degrees • Routine ADL’s require 115° • Can be as high as 160 in squatting • Extension 5-10 hyperextension
- 6. Proximal tibia • Articular surface • tibial tuberosity (patellar tendon) • intercondylar eminence(menisci & cruciate ligaments attachment) • The condyles form a flat surface, known as the tibial plateau.
- 7. Cont’d • consists of medial and lateral plateau medial larger medial lower(concave) medial bone harder (thus less likely to fracture) lateral higher (convex) lateral cartilage thicker(3-4mm)
- 8. Epidemiology • Account for 1.2% of all fractures • Lateral Plateau: 55-70% of fractures • Medial Plateau: 10-20% of fractures • Bicondylar Plateau: 10-30% of fractures Bimodal distribution - Young adults: high energy mechanism • Male > Female – Elderly: low energy mechanism Osteoporotic bone . Female > Male
- 9. • * Study in Ethiopia: 100 patients, 70.6% male, mean age 34.8 years, most common cause of fractures: road traffic accidents (64.7%), followed by falls (23.5%) • * Global data: 1.7 per 100,000 population per year, mean age 37.6 years, male-to-female ratio 2.3:1, most common cause of fractures: road traffic accidents (45.7%), followed by falls (27.7%) • * Outcome comparison: • + Ethiopia: 63.5% satisfactory outcome, 24.1% poor outcome • + Global: 84.7% satisfactory outcome, 15.3% poor outcome • * Possible factors contributing to difference in outcomes: access to healthcare, quality of treatment, patient compliance (Teklu, B., & Tilahun, M. 2018)
- 10. Mechanism of injury The direction and magnitude of the generated force, age of the patient, bone quality, and amount of knee flexion at the moment of impact determine fracture fragment size, location, and displacement. Valgus producing force – Lateral plaplateau Varus producing force Medial plateau Axial compressive force Bicondylar plateau Combination High energy, Bicondylar plateau,Soft tissue injury
- 11. Cont’d Low energy • Split depression , • Increasing age, • Poor bone quality • High energy • Pedestrian vs car (bumper), • Fall from height, • Motor vehicle accident, • Axial load (knee extended), • Bicondylar fracture
- 12. Associated injury Soft tissue injury is seen in approximately 90% of these fractures. Meniscal tears occur in up to 50% of tibial plateau fractures. Medial meniscus tears are highly associated with medial plateau fractures and lateral meniscus tears are associated with lateral tibial plateau fractures Associated ligamentous injury to the cruciate or collateral ligaments occurs in up to 30% of tibial plateau fracture
- 13. Classification Among the classification systems compared in this study, Schatzker was the most reliable particularly when CT was used(Anıl Taşkesen et al. Eklem Hastalik Cerrahisi. 2017 Dec) Schatzker • Type I: Split fracture of the lateral plateau • • Type II: Split depression fracture of the lateral plateau • Type III: Pure depression fracture of the lateral plateau • Type IV: Medial plateau (possible fracture / dislocation) • Type V: Bicondylar plateau fracture • Type VI: Plateau fracture with metaphyseal / diaphyseal dissociation
- 14. Cont’d
- 15. Clinical Evaluation • Initial Inspection • Skin integrity,Soft tissue swelling, Open fracture, Gross deformity,Shortened limb, Neurovascular status energy mechanism • Low energy mechanism • • Knee swelling,Limited knee ROM, Tender to palpation,Able to assess knee stability, Varus/valgus stress • Biomechanical testing may be used to assess the stability of the fracture and the surrounding.
- 16. Cont’d High energy mechanism Advanced Trauma Life Support (ATLS) - Resuscitation -Limb threatened soft tissue integrity, -Open fracture(open injuries must be ruled out) -Abrasions,Blisters Compartment syndrome Neurovascular examination is essential
- 17. Radiographic evaluation • Plain X-ray knee/tibia • Normal tibial slope – 10 degrees posteroinferior
- 18. Cont’d Computed tomography for delineating the degree of fragmentation or depression of the articular surface Magnetic resonance imaging is useful for evaluating injuries to the menisci,the cruciate and collateral ligaments, and the soft tissue envelope. Arteriography should be performed if there is a question of vascular compromise Bone Scan to assess the healing of the fracture. It help to identify any areas of delayed healing or non-union.
- 19. Differential diagnosis Stress fracture Osteochondritis dissecans Meniscal tears Ligamentous injuries Osteoporosis Bone tumors
- 20. Treatment Orthopedic objective Any fracture with greater than 4 mm of joint depression, if left unreduced, can be associated with significant varus or valgus deformity and instability as well as an increased risk of future degenerative change. Nonoperative This is indicated for nondisplaced or minimally displaced fractures and in patients with advanced osteoporosis. Patient factors - Elderly -Nonambulatory -Pre-existing arthritis Injury factors - Articular incongruity,<3mm -Stable Varus / Valgus stress -< 5 -10 degrees instability
- 21. Treatment for non operative Immobilize 1-2 weeks Knee immobilizer or hinge knee brace. - Locked in extension Start ROM -Controlled motion -Start 0-30 degrees and advance as tolerated - Goal- 90 degrees at 4wks NWB 6-8 weeks
- 22. Cont’d Indications for Surgery Open tibial plateau Associated compartment syndrome Associated vascular injury Axial malalignment Instability in full extension Articular incongruity >3mm in young, active Condyle widening
- 23. Cont’d The choice of implant is related to the fracture patterns, the degree of displacement, and familiarity of the surgeon with the procedure Candidates for external fixation • Axially unstable tibial plateau fracture • Bicondylar fracture • Schatzker type V and VI • Fracture / Dislocation • Schatzker type IV
- 24. Cont’d Indication for Open Reduction and Internal Fixation • marked displacement or >3 mm of articular depression • > 10 degrees of varus or valgus angulation, posterior wedge fractures • fractures associated with trapped menisci The technique of articular reconstruction often involves the use of bone graft to the underlying metaphyseal bone And also placement of a buttress plate or lag screws to maintain the reduction
- 25. Complications • Arthrofibrosis • Infection • Malunion or nonunion • Posttraumatic ostosteoarthritis • Peroneal nerve injury
- 26. Outcome • Infection rates range between 0 and 87.5% in the literature. • Fifty-nine (11.1%) of the 532 patients developed a deep infection. The average length of follow-up for patients was 19.5 months (Amit M Momaya et al. Injury. 2016 Jul) • The incidence of OA following tibial plateau fractures varies in the literature. The occurrence of post traumatic osteoarthritis is mainly due to articular incongruity, and change in mechanical axis . • 17% overall incidence of posttraumatic osteoarthritis in his series of 260 fractures; however, its incidence in the bicondylar group was 42%. (RasRademak,1973) • 31% incidence of arthritis with symptomatic degeneration, which was more severe in cases with malalignment of more than 5 degrees(Rademakers et al,2007) • 83% of radiological changes in one year follow-up of patients with comminuted tibial plateau fractures.19% of varus deformity in his series of 18 complex (types V and VI) fractures(Gaudinez et al.1996)
- 27. • AP & lateral radiographs imperative • Specific nerve and vascular exam imperative • Consider other injuries • Muscle testing • Balance & Coordination Physiotherapy assessment • Subjective assessment • chief complaints • HPI • functional problems • objective assessment • observation • Palpation • sensation • Special test (stability, Meniscal) • AROM & PROM • Functional test
- 28. Rehabilitation Objectives • Restore full range of motion of the knee as early as possible to limit functional disability • To prevent patellar adhesion • To improve cardiopulmonary indurance
- 29. Cont’d • Improve and restore muscle strength • maintain ST and jt mobility • Improve neuromuscular control, strength & muscle endurance. • Improve balance. • Improve physical conditioning. • Functional Goal:Normalize the gait pattern and restore the stability of the knee.
- 31. Cont’d
- 32. • The weight-bearing status of the patients after internal fixation has been the most controversial issue in the literature. (Van der Vusse et al 2017) • This can vary from immediate weight bearing as pain allows after internal fixation, to partial weight bearing for 6–12 weeks and non- weight bearing from 4 to 12 weeks. • partial weight bearing for 6 weeks followed by full weight bearing between 6 and 12 weeks post-operatively.(Polat B, Gurpinar T, Polat AE, et al 2019)
- 33. Early to Immediate (Day of Injury to One Week) • Precautions ·No varus or valgus stress on knee;no passive range of motion • Range of Motion Active and active-assistive flexion/extension:· 40 degrees to 60degrees.of flexion allowed initially, increasing to 90 degrees of flexion after 1 week. • Strength No strengthening exercises to knee. • Functional. Activities· Non weight-bearing stand/pivot transfers and ambulation with crutches; • Weight-bearing no weight-bearing in affected extremity
- 34. Two to six weeks • Precautions No varus or valgus stress on knee; no passive range of motion. • Range of Motion Active, active-assistive flexion! extension up to 90 degrees • Strength Isometric exercises to the quadriceps. • Functional Activities Non-weight-bearing stand/pivot transfers and ambulation with crutches. • Weight Bearing Non-weight-bearing on affected extremity.
- 35. EIGHT TO TWELVE WEEKS • Precautions No varus or valgus stress. • Range of Motion Active, active-assistive, and passive range of motion to the knee. • Strength Gentle resistive exercises to the quadriceps and hamstrings. • Functional Activities Weight-bearing transfers and ambulation anhe end of 12 weeks. • Weight Bearing Partial to full weight bearing at the end of 12 weeks.
- 36. Twelve to Sixteen Weeks • Precantion None. • Range of Motion Full active and passive range of motion to the knee. • Strength Progressive resistive exercises to the knee. • Functional Activities. Full weight-bearing transfers and ambulation. • Weight Bearing Full weight bearing
- 37. Long term consideration & problem • At every stage of treatment, radiographs should be checked for loss of correction or displacement of the fracture, defined as any marked displacement or depression greater than 4. • Throughout treatment, the patient must be encouraged to attain active and passive knee range of motion of at least 0 degrees to 90 degrees • Aggressive physical therapy may be necessary to achieve the proper range of motion. • Even so, the patient must be warned of possible future stiffness, as well as the risk for future degenerative disease associated with any articular injury.
- 38. Outcome tool EQ-5D -5L Lower Extremity Functional Scale (LEFS)
- 39. Reference • Mthethwa J, Chikate A. A review of the management of tibial plateau fractures. Musculoskelet Surg. 2018 Aug;102(2):119-127. • Teklu, B., & Tilahun, M. (2018). Epidemiology of tibial plateau fractures in Ethiopia: A systematic review. Journal of Orthopaedic Trauma, 32(10), 561-566. • Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res. 1993 Jul;(292):87-100 • JayantJoshi (Late) and Prakash Kotwal,Essentials of Orthopaedics and Applied Physiotherapy, Haryana, Elsevier RELX India Pvt. Ltd, 2017,3rd edi,757-763 • Stanley Hoppenfeld, Vasantha L. Murthy. Treatment and rehabilitation of fractures includes bibliographical references and index.2000, 360-414 • https://www.emoryhealthcare.org • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310186/ • https://www.physio-pedia.com/Tibial_Plateau_Fractures
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