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Tibial Plateau Fractures

  - Discussion:
     - 60% of plataue frxs involve lateral plateau.
          - this probably is result of valgus alignment of lower extremity and fact that most injuring forces are
                    directed laterally to medially;
     - frxs of medial plateau make up 15% & bicondylar lesions 25% of plateau frx;
     - bicondylar frxs combine any of unicondylar lesions w/ frx of metaphysis;
     - expected frx patterns:
             - lateral split fragment - found in 75%;
             - posteromedial fragment - seen in 43%;
             - tibial tubercle fragment - seen in 16%;
             - zone of comminution that including the tibial spine - frequently extends to the lateral
                    condyle - seen in 28%
             - references: 
                    - Tibial Plateau Fracture Characteristics: Computed Tomography Mapping of Lateral, Medial, and Bicondylar Fractures
     - partial or complete ligamentous ruptures occur in about 15% to 45% & meniscal lesions in about 5-37% of all tibial plateau frx;
     - AO Classification:
          - Type I Fracture / Minimally Displaced Fractures
          - Type II Fracture: / Split Compression Fractures
          - Type III Fracture: / Local Compression Fracture
          - Type IV Fractures: / Medial Tibial Plateua Fractures
          - Type V Fractures: / Bicondylar Fractures
          - Type VI Fractures:
          - ref: Classifications in Brief: Schatzker Classification of Tibial Plateau Fractures
     - Misc Tibial Plateau 
          - Fracture Dislocations
          - Frx of the Fibula and Tibial Plateua fractures
          - Ligamentous Injuries in Tibial Plateau Fractures
          - Rim Fractures
          - Split Fractures
          - Total Depression Fracture
     - reference:
          - Classification of fractures of the tibial condyles.

- Exam:
       - skin abrasion and contussions from direct blows;
       - compartment syndrome: occurs in 11%
               - ref: Radiographic Predictors of Compartment Syndrome in Tibial Plateau Fractures
       - ligamentous instability
       - peroneal nerve function;

- Radiographic Studies
        - How much articular displacement can be detected using fluoroscopy for tibial plateau fractures?

- Non Operative Treatment
    - references:
            Closed reduction of tibial plateau fractures. A comparison of functional and roentgenographic end results.
            The cast brace and tibial plateau fractures.
            Cast brace treatment of proximal tibia fractures. A ten-year follow-up study.
            Fractures of the tibial plateau. Treatment by closed reduction and spica cast.
            Tibial plateau fractures. A comparison of conservative and surgical treatment.

- Operative Management:
    - Work Up and PreOp Planning:
           - references:
                   - Acute compartment syndrome in tibial plateau fractures--beware!
                   - Influence of prior fasciotomy on infection after open reduction and internal fixation of tibial plateau fractures.
                   - Does Early versus Delayed Spanning External Fixation Impact Complication Rates for High-energy Tibial Plateau and Plafond Fractures?
Surgical Approaches:
           - Lateral Plateau
           - Medial Plateau
    - Percutaneous Fixation:
           - references:
                  - Percutaneous Screw Fixation of Tibial Plateau Fractures.
                  - Closed reduction and percutaneous screw fixation for tibial plateau fractures
                  - Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures.
                  - How much articular displacement can be detected using fluoroscopy for tibial plateau fractures?
Elective removal of implants after open reduction and internal fixation of Tibial Plateau fractures improves clinical outcomes.
    - IM Nailing:

           - A comparative study for complex tibial plateau fractures: nailing and compression bolts versus modern and traditional plating.
           - The management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts.

    - Adjunctive Procedures:
           - Bone Grafting:
                  - references:
                          - Interporous hydroxyapatite as a bone graft substitute in tibial plateau fractures.
                          - Factors influencing the results of open reduction and internal fixation of tibial plateau fractures.
                          - Comparison of autogenous bone graft and endothermic Ca phos cement for defect augmentation in tibial plateau frx.
                          - Outcomes of Schatzker II tibial plateau fracture open reduction internal fixation using structural bone allograft.
                          - Impaction bone grafting has potential as an adjunct to the surgical stabilisation of osteoporotic tibial plateau fractures:

           - Role of Arthroscopy: (see arthroscopy of the knee)
                - advantages:
                        - reduced postoperative pain and swelling;
                        - early recovery of knee motion, and less postoperative knee stiffness;
                        - reduced risk of infection
                        - minimal fragment devascularization
                        - direct visualization of the articular surface: meniscal lesions (20% of the patients) and osteochondral detachments(25%
                                 of the patients)
                        - disadvantages:
                                 -  lack of rigid fixation and the need for delayed weight-bearing.
                  - references:
                          - Arthroscopy of meniscal injuries with tibial plateau fractures.
                          - The Role of Arthroscopy in the Management of Tibial Plateau Fractures
                          - Arthroscopic Restoration of Depressed Tibial Plateau Fractures Using Bone and Hydroxyapatite Grafts.
                          - Arthroscopic Management of Tibial Plateau Fractures.
                          - Arthroscopically assisted treatment of lateral tibial plateau fractures in skiers: use of a cannulated reduction system.
                          - Arthroscopic Management of Tibial Plateau Fractures
                          - Arthroscopic Management of Tibial Plateau Fractures.  
                          - The Role of Arthroscopy in the Assessment and Treatment of Tibial Plateau Fractures
                          - Combined arthroscopic treatment of tibial plateau and intercondylar eminence avulsion fractures.
                          - [Comparison study on effectiveness between arthroscopy assisted percutaneous internal fixation and open reduction and internal fixation for Schatzker types II and III tibial plateau fractures].
                          - Operatively Treated Meniscal Tears Associated with Tibial Plateau Fractures: A Report on 661 Patients.

- Post Operative Care and Complications
        - references:
               - Effect of tibial plateau fracture on lubrication function and composition of synovial fluid

Tibial plateau fractures. Management and expected results.

Fractures of the tibial plateau: a review of ninety-five patients and comparison of treatment methods.

Indications for surgical treatment of tibial condyle fractures.

Immediate internal fixation of open, complex tibial plateau fractures: treatment by a standard protocol.

Tibial Plateau Fractures.  

Limited Internal Fixation of Tibial Plateau Fractures. Rangitsch MR , et al. J Orthop Trauma. 1993;7:168.