An unclassified tibial plateau fracture: Reverse Schatzker type IV.
ABSTRACT: The most commonly accepted system of classification for tibia plateau fractures is that of Schatzker. Increasingly, both high energy injuries and atypical osteoporotic fragility failures have led to more complex, unusual and previously undescribed fracture patterns being recognized. We present a case of a patient with a previously unreported pattern of tibia plateau fracture and knee dislocation. We highlight the challenges confronted and present the management and the outcomes of his injury. A 28-year old male motorcyclist was involved in a head on collision with a truck and was transferred by helicopter to our level 1 major trauma centre emergency department. His injuries were a circumferential degloving injury to his left leg and a right lateral tibial plateau fracture/knee dislocation. The pattern of the lateral tibial plateau fracture was unique and did not fit any recognised classification system. The patient received a spanning external fixator initially and after latency of 12 days for soft tissue resuscitation he underwent definite fixation through an antero-lateral approach to the proximal tibia with two cannulated 6.5 mm partially threaded screws and an additional lateral proximal tibia plate in buttress mode. A hinged knee brace was applied with unrestricted range of motion post-operatively and free weight bearing were permitted post operatively. At the 6 months follow up, the patient walks without aids and with no limp. Examination revealed a stable joint and full range of motion. Plain radiographs revealed that the fracture healed with good alignment and the fixation remained stable. High energy injuries can lead to more complicated fracture patterns, which challenge the orthopaedic surgeons in their management. It is crucial to understand the individual fracture pattern and the possible challenges that may occur. This study reports a lateral tibia plateau fracture/dislocation which perhaps is best described as a reverse Schatzker IV type fracture.
Project description:BACKGROUND:Both tibial plateau fractures and extensor apparatus injuries are serious injuries to the knee joint that generally do not occur in the same patient. We report a rare case of open tibial plateau fracture combined with quadriceps tendon rupture and complete displacement of the patella into the tibial plateau fracture. CASE PRESENTATION:The case involved a male who was 19?years old who had been in a motorcycle accident. The patient was admitted to our department with an open tibial plateau fracture 3?h post-injury. X-ray showed a tibial plateau fracture and complete displacement of the patella into the tibial plateau. CT showed an avulsion fracture in the patella and tibial intercondylar eminence. Concomitant quadriceps tendon injury and both anterior and posterior cruciate ligament tibial insertion avulsion fractures were considered. The operative findings of emergency surgery confirmed our preoperative diagnosis. Single-stage quadriceps tendon repair and ORIF for the tibial plateau fracture were performed. Satisfactory restoration of function was acquired at the last follow up. CONCLUSION:The most difficult aspect of this case was the determination of the cause of the intra-osseous dislocation of the patella into the tibial plateau. The most likely mechanism of the injury may be that the patient experienced transient posterior dislocation of the knee during the injury. Rupture of the quadriceps tendon should be considered with posterior dislocation of the knee, and the patella was pushed into the tibial plateau fracture by force after the rupture of the quadriceps tendon.
Project description:Tibial plateau fracture treatment remains challenging for orthopaedic surgeons around the world, especially in case of type III fractures according to the Schatzker classification, which are a pure depression of the lateral tibial plateau. Whereas open surgical procedures are associated with increased soft-tissue trauma because of the extent of the surgical approach and do not always allow for proper visualization of the fracture site, arthroscopic-assisted surgeries have been proven to have benefits over the former in terms of minimizing soft-tissue trauma, improved visual control of the fracture reduction, and the time of recovery. Most arthroscopic techniques, however, require using fluoroscopy. We present an all-arthroscopic procedure for Schatzker type III lateral tibial plateau fractures with using a trans-septal portal for visualization, which does not demand fluoroscopy.
Project description:BACKGROUND:The objective of this study to evaluate prospectively the effectiveness of Schatzker type IV tibial plateau fractures involving posteromedial plane managed by combined lateral peripatellar and posteromedial approaches. METHODS:We analyzed 18 patients with Schatzker type IV tibial plateau fractures involving posteromedial plane. There were 12 males and 6 females with an average of 38.5?years (range, 25-60?years). The mechanism of injury included traffic accident in 15 patients and falling in 3 patients. The injured lower limbs were right in 11 patients and left in 7 patients. The mean time from injury to surgery was 6.78?days (range, 5-9?days). There were 8 patients with meniscus injuries in our study. RESULTS:The mean operation time was 3.41?h (range, 3-4?h). The mean blood loss was 352.78?ml (range, 300-410?ml). All the injured meniscuses were repaired. All patients were followed up, and the average time of follow up was 16.61?months (range, 14-22?months). Bone union was achieved at a mean of 12?weeks (range, 10-14?weeks). The mean degree of knee extension was 1.11° (range, 0-5°), and the mean degree of knee flexion was 120.56° (range, 110-130°). The mean points of KSS were 83 (range, 74-89 points). According to the criteria of KSS, 14 patients had clinical outcomes rated as excellent and 4 patients were rated as good. CONCLUSION:Our results suggested that Combined lateral peripatellar and posteromedial approaches in the treatment of Schatzker type IV tibial plateau fractures involving posteromedial plane acquired satisfying outcomes. It was good for repairing the injured meniscus through our approaches.
Project description:Tibia plateau fracture (TPF) treatment aims at achieving a stable, aligned, mobile, painless knee and preventing post-traumatic osteoarthritis. To achieve this goal, surgeons consider criteria such as patients' characteristics, severity, risk of complications, fracture displacement/depression, degree of soft tissue injury. However, body mass index (BMI) is not considered as a risk factor in literature. Our study was conducted to find out any possible correlation between BMI and functional scores or radiological score separately.Retrospective analysis of case series between 2011 and 2014 was done on the database of a tertiary hospital in Istanbul. There were 67 TPF patients (54 males, 13 females) in the study. Relationship between BMI and functional knee scores or radiological score was compared statistically. Closed fractures with both high-energy and low-energy injury were included in the study. Patients with open fracture, multi-trauma presence, meniscus and/or ligamentous injury, increased co-morbidity, inadequate records (25 cases in all) were excluded. Surgery type, Schatzker classification, injury side, trauma energy, and gender were considered as possible risk factors. Binary regression analysis was done for possible factors affecting functional knee scores and radiologic score.Model summary calculations were done as Nagelkerke R2 test for Knee Society score, Lysholm knee score, and Ahlback and Rydberg radiologic scores, which were 0.648, 0.831, and 0.327 respectively. Homer-Lemeshow test values were 0.976, 0.998, and 0.362, respectively. There is negative correlation between BMI and both knee function scores. There is no correlation between BMI and radiologic score.An increase in BMI has a negative effect on functional knee scores after surgical treatment of TPFs. Therefore, BMI should be considered as a risk factor for surgical treatment of TPFs.
Project description:<h4>Purpose</h4>The objective of this study was to evaluate the morphological characteristics of lateral tibial plateau split-depression fractures (Schatzker type II).<h4>Methods</h4>A retrospective analysis of radiographic and computed tomographic (CT) data of lateral tibial plateau split-depression fractures from January 2009 to December 2010 was conducted in a level 1 trauma centre. The discontinuity arc, angle of depression centre (ADC), anterior-posterior position of articular depression centre (APDC), surface area percentage (SAP), sagittal angulation and depression depth were measured on CT images using the Picture Archiving and Communication System.<h4>Results</h4>Based on the integrity of posterolateral wall and discontinuity arc, 140 cases of Schatzker type II fracture were divided into two subtypes: intact group (69 cases) and broken group (71 cases). The fracture of the intact group was located in the anterior part of the lateral plateau, the average ADC was 72.13°, APDC was 43.25 % of sagittal diameter, SAP was 22.16 % of total plateau, sagittal angulation was 6.59°and depression depth was 10.80 mm. Of the broken group, the average ADC, APDC, SAP, sagittal angulation and depression depth was 92.45°, 61.84 %, 22.63 %, 9.00° and 10.78 mm, respectively. Forty-seven cases in the broken group had a posterolateral fragment and 15 cases among them had articular depression centered in the posterolateral region. The difference in ADC, APDC and sagittal angulation between the two groups was statistically significant (p?<?0.05), while no significant difference was observed for SAP and depression depth.<h4>Conclusions</h4>Of all the 140 cases in this study, 10.7 % are located in the posterolateral region. An appropriate operative approach and fixation method should be selected based on the individual morphological characteristics of lateral plateau fractures.
Project description:A 66-year-old woman had sustained crush injury 3 hours prior to her presentation to our hospital. The diagnosis was defined as lateral tibial plateau fracture of the right knee (Schatzker III). Supine position was set up and a pad was put under the affected hip. After sterilization of the surgical field the sterilized sheets were placed beneath the leg in order to be higher than the other side. A rolled sheet was put under the knee joint so that the knee joint was flexed around 30° to 40°. After the surgical field was draped the skin was incised. Iliotibial band was incised by blade (not by electrotomy) and sharp dissection was performed in the Gerdy's tubercle. Capsulotomy was made by cutting the tibial meniscal ligament. Then the meniscus was tagged superiorly and the articular surface was clearly visualized. A window was made in the lateral cortex beneath the plateau, so the impacted fragment was elevated through the window. The metaphyseal void was filled by bone allograft. The placement of the raft-screw plate must be ensured that the raft screws passing the plate could purchase the subchondral bone. After perfect placement of the plate was defined, the femoral distractor was removed and the knee joint was relaxed. It was ensured that the alignment of the lower leg was normal, and then the other screws were inserted. Following placing drainage in the wound the iliotibial band was closed and the subcutaneous soft tissue and skin were closed in layer.
Project description:Injury to the posterolateral corner (PLC) is difficult to diagnose; most lesions of this type are included within the context of complex knee injuries. Study of the posterolateral complex is growing in importance because of the complex instability generated by these injuries. Although various physical examination tests are described for the diagnosis of PLC lesions, in 72% of cases these lesions are not identified at their initial presentation, which shows the difficulty in both performing these tests and interpreting the results. The maneuver described in this report is performed by executing external rotation of the leg. With the thumb of the proximally positioned hand, the examiner evaluates the positioning of the lateral tibial plateau in relation to the femoral condyle. With this maneuver, in lesions of the PLC and particularly lesions of its external rotation-restricting structures, we observe external rotation of the tibia and posterior subluxation of the lateral tibial plateau that cause the anterior edge of the tibial plateau to be posteriorized in relation to the anterior edge of the lateral femoral condyle. The idea behind this maneuver is not to eliminate the use of other tests but, rather, to add it to a diagnostic arsenal that still has interpretation flaws.
Project description:Ellis-van Creveld is a dwarfing syndrome transmitted as an autosomal recessive trait. The constant features of the condition include acromelic-micromelic dwarfism, ectodermal dysplasia involving the nails, teeth and gums, postaxial polydactyly of the hands and congenital heart disease. Congenital heart disease affects 50-60 % of all patients and nearly 50 % of patients die by 18 months of age from cardiopulmonary complications. This study is intended to characterise the orthopaedic manifestations of Ellis-van Creveld based on the authors' unique opportunity to interview and examine the largest group of patients to date in the literature.Detailed interviews, physical examinations and/or radiographs were available on 71 cases of Ellis-van Creveld syndrome. Data were collected from physical examinations, radiographs, computed tomography (CT) reconstruction and magnetic resonance imaging (MRI) of the knee. Pathoanatomy of the knee was reinforced by the direct surgical observation of 25 limbs surgically managed during adolescence and puberty.A number of interesting clinical and radiographic abnormalities were noted in the upper extremities and lower extremities, but by far the most significant orthopaedic finding was a severe and relentlessly progressive valgus deformity of the knee. Although many patients had difficulties making a "fist" with the hand, no patient reported any functional disability. The severe valgus deformity of the knee is the result of a combination of profound contractures of the iliotibial band, lateral quadriceps, lateral hamstrings and lateral collateral ligament, leading to lateral patellar subluxation and dislocation. The lateral portion of the upper tibial plateau presents with cupping and progressive depression of the lateral plateau, along with severe valgus angulation of the proximal tibia and fibula. A proximal medial tibial exostosis is seen in nearly all cases.This is the largest group of Ellis-van Creveld syndrome patients identified in the literature. An understanding of the orthopaedic pathoanatomy of the knee deformity is critical to determining the appropriate surgical management. This paper characterises the orthopaedic manifestations of Ellis-van Creveld syndrome and especially identifies the pathoanatomy of the severe and progressive valgus knee deformity.Level II.
Project description:Open-wedge high tibial osteotomy for medial unicompartmental arthritis of the knee joint is a successful treatment option but is associated with potential intraoperative complications such as tibial plateau fracture, dislocation of the osteotomy hinge, under- or over-correction of the posterior slope, and neurovascular injury. Therefore we devised a protective cutting system and describe our method for the prevention of these complications. The potential advantages of this system are protection of the posterior neurovascular structures using a curved protector, bone cutting along the natural tibial slope using a superior surface aligning with the natural tibial slope, and complete 1-plane sawing of the posterior wall before the lateral hinge.
Project description:To our knowledge, proximal tibiofibular joint instability has never been reported in a patient with a total knee arthroplasty (TKA). We present the case of a patient with anterolateral proximal tibiofibular joint instability associated with a complex primary TKA. In 2010, a male patient of 47 years was referred for TKA after posttraumatic osteoarthritis. The patient's history includes a fracture of the left lateral tibial plateau in 2008 and removal of osteosynthesis material in 2009. TKA with a lateral metal augment and intramedullary stem was performed in 2010. After TKA, instability of the left proximal tibiofibular joint (PTFJ) was diagnosed. The patient underwent PTFJ arthrodesis and, at 5 years' follow-up, had no residual pain, with full range of motion. In this case, arthrodesis was the only possible surgical option because reconstruction surgeries require the establishment of bone tunnels in the tibia and fibula for the passage of a graft. Low bone quality and the use of an intramedullary stem with a metal augment in the tibia made any reconstruction technique unfeasible because the proximal tibia was obliterated. Although several PTFJ reconstruction techniques are available, they are difficult to apply to patients with a complex TKA.