Tibial Plateau Fractures: Depressed Fragment Elevation Technique

Today, we’re going to talk about Tibial plateau fractures & the depressed fragment elevation technique! Anatomic reduction of the fracture & rigid fixation is the key!

CASE 1

Clinical Presentation:

• 60 years female.
• Slip and fall at home.
• Severe pain in right knee with restricted knee ROM and inability to weight bear on right leg.

Radiological Investigation:

• X-Ray Right knee – Anteroposterior and Lateral Views

Diagnosis:

• Split Depression Lateral Tibial Plateau Fractures (Schatzkers Type 2).

• Intraoperatively under image intensifier depressed fragment is identified in both AP & Lateral views.
• Medial cortical window created.
• Using curved bone punch under image guidance defect is elevated while visualizing in both AP and lateral views with gentle taps/ blows to punch.
• Once satisfactory elevation/ reduction of articular surface is attained, the restored surface is stabilised with k-wire.
• The defect thus created in metaphyseal region is grafted thus providing subchondral support.
• Finally plating done using MIPPO technique to provide lateral buttress and raft screws providing subchondral support.

X-Ray shows appropriate reduction / elevation of depressed articular fragment with buttressing of split lateral plateau.

CASE 2

Clinical Presentation:

• 39 years male.
• Motor Vehicle Accident.
• Severe pain in left knee with restricted knee ROM and inability to weight bear on left leg.

Radiological Investigation:

• X-Ray Left knee – Anteroposterior and Lateral Views

Diagnosis:

• Split Depression Fracture Lateral Tibial Plateau with Tibial Eminance (ACL attachment) avulsion and MCL Injury

• Intraoperatively under image intensifier depressed fragment is identified in both AP & Lateral views.
• Fracture split is jacked open allowing direct visualisation of depressed joint surface.
• Using punch (here a curette) under image guidance defect is elevated while visualizing in both AP and lateral views.
• Once satisfactory elevation/ reduction of articular surface is attained, the restored surface is stabilised with k-wire.
• The defect thus created in metaphyseal region is grafted thus providing subchondral support.
• Split repositioned, compressed and stabilised with K-wires.
• Finally plating done using MIPPO technique to provide lateral buttress and raft screws providing subchondral support.

• Aulsed ACL attachment/Tibial eminance stabilised, compressed ACL jig under image intensifier and fixed using Mini Tight Rope
• Split posterolateral fragment reduced, stabilised and fixed with 4mm CCS in compression mode, restoring congurity of lateral tibial plateau.
• MCL was intraoperatively found to be avulsed from its tibial attachment site, reenforced with ethibond and fixed using bone staple.
• Thus, managing fracture with associated multi-ligamentous injury in toto.

Surgical Principles and Lacunae in Management

• Principles
  • Management for Periarticular Fractures is based on concept of Anatomical reduction of fracture.
  • To allow for Primary Bone Healing to happen, Absolute stability and Rigid fixation must be attained.
  • Use reduction technique that respects the biological principles of fixation (closed, minimally invasive or open).

• Lacunae
  • Failure to restore articular surface anatomically may result in long term post traumatic arthritis.