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Percutaneous Fixation of Type II Frx

- Discussion:
    - note that type II fractures may often not be amenable to percutaneous fixation because an acceptable reduction of the depressed 
         fragment can be difficult to obtain;
         - part of the difficult lies in the fact that the depressed fragment is buried w/ in the plateau and is obsured by the frx lines of the split 
         - hence the patient should be forewarned about the need for open reduction;
    - Reduction:
         - if the split fragment is depressed, it needs to be brought out to length with use of a femoral distraction;
               - the distractor is placed on the same side as the fracture;
         - once the fracture fragment has been elevated w/ ligamentotaxis, then the medial or lateral displacement can be corrected;
         - reduction is achieved w/ percutaneous applied reduction forceps w/ flourscopic assistance;
         - consider applying the reduction forceps eccentrically, and then torque the reduction forceps to achieve reduction;
         - adequate reduction implies less than 1-2 mm step off;
         - depressed fragments:
               - make a small window in the metaphyseal cortex and elevate the depressed fragment with a bone tamp;
    - Fixation Methods:
          - percutaneous screws:
                 - wedge of type I frx of lateral plateau can usually be fixed w/ only cancellous percutaneous lag screws and washers (plates are 
                         usually not necessary);
                 - consider 6.5 mm cancellous screws (over washers) which are placed in a triangular position;
          anti-glide screw:
                 - antiglide screws are typically placed after 1-2 percutaneous lag screws are placed thru the frx fragment;
                 - antigluide screws (over washers) are placed just distal to the frx edge to prevent distal displacement;
                         - 4.5 mm cortical screws over washers are typically used

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