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Work Up and PreOp Planning for Tibial Plateau

- Exam:
      - skin abrasion and contussions from direct blows;
      - r/o compartment syndrome;
      - ligamentous instability
      - peroneal nerve function;

- Radiographs:

- Indications for treatment:
    - Open Plateau Frx or Frx w/ compartment syndrome;
    - Articular Surface Depression, which can produce joint incongruity;
    - Axial malalignment, which will incr. stresses across articular surface;
    - Ligamentous instability (frx w/ ACL tear = poor prog)
            - look for widening of joint space (indicates collat. lig disruption);
            - varus or valgus instability > 10 deg w/ knee flexed 20 deg;

- Initial Treatment:
    - PreOp Orders
    - consider distal tibial pin traction if OR is delayed;
    - consider preOp pO2 of skin, noting high incidence of skin necrosis;

- Operataive Treatment:
    - Anesthesia:
         - no epidural anesthesia if compartment syndrome is possible;
         - despite what the anesthesiologists will tell you, an epidural can completely mask an anterior compartment syndrome;
    - Positioning:
         - pt should be positioned on the OR table such that the frx can be broken down during the procedure and  knee can be flexed;
               - tape sandbag on table to support foot when knee is flexed;
               - flexion of the knee improves visualization of the joint;
         - for optimal exposure, consider supine position, w bolster under thigh, & table broken so that the knee is flexed 90 deg;
               - this position allows increased exposure submeniscally;
         - or consider having patient in the supine position with the knee flexed over a roll 50-60 deg;
         - consider prepping for bone grafting;
    - Visualization:
         - flouroscopy is useful for split type frx;
         - arthroscopy can be used for depression type frxs, but be aware of fluid extravasation and compartment syndrome;
    - Equipment:
         - flourotable;
         - large tenaculum clamps are useful for reduction;
         - consider using AO large distractor & relying on ligamentotaxis to maintain reduction and provide exposure;
              - usually is distractor is placed on the same side as the frx;
              - one pin is inserted into the femoral condyle and one in the mide tibia;
    - Surgical Approaches:
         - Lateral Plateau:
         - Medial Plateau:
    - Implants:
         - bone tamps is useful to elevate centrally depressed fragments;
         - T plate: is used for buttressing of the medial tibial plateau;
         - L plate: lateral tibial plateau;
         - both of these plates have oval hole which is used for temporary fixation and allows small up and down adjustments;
         - unicondylar Fracture:
              - two 6.5 mm cancellous bone screws or 7.0 mm cannulated screws with washers (in young people);
              - L or T butress plate, lateral tibial head buttress plate, DCP, or LC-DCP, 4.5 mm (in older people);
         - Bicondylar Fracture:
              - L or T butress plate, DCP, or LC-DCP, 4.5 mm, or lateral tibial head butress plate +/- a 3-4 hole semitubular plate on the medial side as a butress plate;
              - 6.5 mm cancellous bone screws or 7.0 cannulated screws, combined w/ external fixation in complex or open frx

- Post Operative Care and Compications

Evaluation of tibial plateau fractures: efficacy of MR imaging compared with CT.

Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.

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