Proximal Tibia Fracture: Case Discussion

Today, we’re discussing proximal tibia fracture case. Pre-planning is the key! Sometimes for adequate visualisation of the articular surface, surgeons may prefer Arthroscopy, however a few surgeons prefer submeniscal arthrotomy for direct visualisation of fracture reduction.

Clinical History

• 46 year old male
• History of RTA
• Presented on the day of Injury
• Pain and swelling over right leg
• Co-morbidities – nil

What are the issues with this fixation?

• Fracture appears to be Split fracture of lateral tibial condyle (Schatzker Type 1).
• Articular step has not been corrected.
• Compression not achieved at fracture site.
• Hockey plate gives option of placement of only two screws at subchondral region, additional screws (outside plate) could have been used.
• Plate is not positioned properly can lead to implant prominence.
• Stress riser at plate end due to attempted bone drill.

Which factors led to these issues during fixation?

• Adequate exposure and visualization of the articular surface is of prime importance in fixation of such fractures.
• These fractures require pre-surgical planning in terms of approach required for accessing each fracture with adequate visualization of articular surface.
• Some Surgeons advocate use of arthroscopy to visualize the articular continuity/reduction whereas other group prefer submeniscal arthrotomy for direct visualization of fracture reduction.
• These fractures appear simple and one tends to have minimum visualization of lateral fluoroscopy view in a hurry of fracture fixation.

How to troubleshoot these factors?

• Pre-plan the surgery in-terms of fixation system- Internal fixation/ external fixation.(read implant manual for ideal site of placement of plates)
• Plan the necessary approach.
• Plan for bone grafting if articular depression is observed intraoperatively.
• Always temporarily fix the reduction with K wires/ screw to prevent sagging of articular fragment and Visualize the articular congruity.
• Confirm the fracture reduction in two planes.
• Use of magnified fluoroscopy view of articular surface in anteroposterior and lateral view.

Author approach

• Adequate visualization of the fracture with submeniscal arthrotomy.
• Reduction of fracture and compression is temporarily achieved with condylar compression clamps and temporary fixation with K wires.
• Countersunked Lag screw at the apex of the fracture fragment.
• T shaped plate instead of L shaped Plate as fracture line is in anterior one third tibia(lateral view)
• Longer plate for spacing out screws.
• Backup plan:
  • Additional lag screw in condylar region(prior to plate fixation)
  • Window on contralateral cortex for elevating articular surface