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Surgeon outlines conservative, operative management for proximal tibial fractures
ISTANBUL — Orthopaedic surgeons should treat proximal tibial fractures in patients individually based on fracture classification, intra-articular involvement and various patient factors, according to a presenter.
“Fractures that occur in this area are grossly heterogeneous and their prognosis depends on intra-articular involvement and severity, the degree of fracture comminution and extension, the condition of the soft-tissue envelope, osteoporosis and patient’s age and comorbidities,” Christos Garnavos, MD, PhD, said.
Christos Garnavos
Co-existing problems that accompany proximal tibial fractures include soft tissue, meniscal and ligamentous injuries. Meniscal injuries can occur in as many as 80% of proximal tibial fracture cases, with ACL and PCL injuries occurring in up to 35% and 10% of cases, respectively.
Garnavos said some surgeons prefer an immediate treatment approach for the treatment of meniscal and ligamentous injuries, while other surgeons advocate for “active neglect,” or delaying surgery.
"It is my opinion that it is not totally wrong to defer and delay a treatment for a second time because of the background of an acute bone injury," Garnavos said. “Many of these injuries can be very well dealt with at the second stage where the bony injury will have been healed and some of them many not require anything at all.”
He cited studies noting that conservative treatment of selected minimally displaced proximal tibial shaft and condylar fractures could be undertaken with a knee brace, graduated weight bearing and ambulation. For extra-articular fractures, open reduction and internal fixation (ORIF) or minimally invasive plate osteosynthesis with a locking plate is indicated, as well as external fixation for open or closed fractures.
Garnavos said that in the past it was believed that proximal tibial shaft fractures do not respond well to intramedullary (IM) nailing. However, with improvements of the technique, recent studies have shown that IM nailing performs similarly when compared to plating or external fixation techniques.
Garnavos said 55% to 70% of intraarticular fractures occur on the lateral plateau and 10% to 30% are bicondylar fractures, with open fractures comprising 1% to 3% of total fractures. Tibial plateau fractures require preoperative planning and assessment of articular reduction with arthroscopy, fluoroscopy or direct visualization.
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“The operative treatment of the tibial plateau is a ‘must’ because we must restore the anatomy very well [in the] knee joint,” Garnavos said.
Simple fractures (Schatzker type I) are most popularly treated with cannulated screws, while Schatzker type II, III and IV intermediate intra-articular fractures are treated with a combination of ORIF and buttress plating with or without bone graft, Garnavos said. (Schatzker type V and VI) are treated with ORIF with conventional plates and screws, closed reduction and internal fixation with locking plates and external fixators, but orthopaedic surgeons should pay special attention to meniscal and ligamentous injuries, soft tissue injuries and severe skin contusions. External fixation can be used as a temporary or spanning device in those cases.
Reference:
Garnavos C. Management of proximal tibial fractures. Presented at: EFORT Congress. June 5-8, 2013; Istanbul.
Disclosure: Garnavos has no relevant financial disclosures.