TIBIAL PLATEAU FRACTURE

These are the radiographs for a patient involved in a high-energy road traffic accident.

Describe the appearance in these radiographs.

These are AP and lateral radiographs of the right knee. There is an obvious fracture of the tibial plateau affecting both the medial and lateral compartments.

How would you manage and investigate this patient initially?

This represents a high-energy injury and this patient would be received and treated in the emergency department along ATLS principles.

With respect to this specific injury I would ensure that the patient is given ade- quate analgesia. I would perform a full circumferential examination of the limb paying attention to the state of the soft tissues to identify the degree of soft tissue swelling, any open wounds, blistering or degloving. I would make an assessment of the neurovascular status.

Assuming this is a closed injury without neurovascular deficit, I would then splint the limb using plaster of Paris in an above knee backslab. I would be careful to look for associated injuries to the knee, ankle and foot. It may be difficult to assess for ligamentous injuries of the knee at this time, but I would remain suspicious.

I suspect that this patient may require operative treatment and a CT scan of the knee would help with preoperative planning. I would also make an assessment for and request continued clinical assessments of the potential for development of com- partment syndrome.

What are the treatment options for this patient?

This is a highly comminuted and displaced fracture with disruption of a weight bearing joint. Non-operative treatment is an option depending on the overall con- dition of the patient but in a fit and healthy patient I would recommend operative fixation should the condition of the patient and the soft tissues permit this.

I would expect that this fracture pattern would be amenable to fixation with locked peri articular plates but this would need to be confirmed by the CT scan. Should this not be the case, Ilizarov or Taylor Spatial Frame fixation may be alterna- tives. There is also some evidence for primary arthroplasty as a treatment for elderly patients with tibial plateau fractures and pre-existing knee arthritis.

Can you describe your patient positioning and surgical approach for operative fixation?

In an appropriately marked and consented patient under general anaesthesia, I would request that intravenous antibiotics are administered before a thigh tourniquet is applied and inflated. I would position the patient supine on an operating table that is broken so that the knees are flexed to 90 degrees. A small sterile or wrapped bolster under the knee would assist in obtaining unobstructed lateral radiographs.

I would make a straight midline skin incision passing posteriorly and laterally just proximal to the joint line in a gentle hockey stick curvilinear fashion. This allows the origin of the muscles in the anterior compartment to be released. The approach raises thick flaps down to the joint capsule. The joint capsule is opened through a sub-meniscal arthrotomy. The meniscus is then lifted out of the field of view using a stay stitch to allow the articular surface to be visualised. Alternatively, the anterior horn of the meniscus may be divided, tagged and subsequently repaired to allow access.

This approach allows good access to lateral plateau fractures. Depressed articular portions of the plateau can be reduced by raising the joint through a metaphyseal window using a punch.

I would use a separate posteromedial incision to allow access and reduction of the medial plateau fracture. I would fix this using an additional plate. The skin incision for this approach is based on a line along the posteromedial border of the tibia extending just proximal to the joint line. This leaves a suitable skin bridge. The