TIBIAL PLATEAU FRACTURES WITH MULTI-LIGAMENT INJURIES - DR. MITEN SHETH

Summary

This video discusses the complex management of tibial plateau fractures accompanied by ligament injuries. It emphasizes the importance of both bony and soft tissue repair, including ACL, PCL, and MCL injuries. The speaker highlights classification systems for fractures, the importance of timely intervention, and surgical strategies like percutaneous screw fixation, arthroscopy, and ligament reconstruction. Key principles include ensuring alignment, articular congruity, and joint stability while managing soft tissue injuries based on the timing of intervention. The video provides valuable insights for managing these challenging cases in trauma and sports medicine.

Takeaways

• 😀 Early management of tibial plateau fractures involves both bony fixation and soft tissue stabilization to ensure optimal outcomes.
• 😀 Always assess ligament stability using a varus-valgus stress test to compare the injured side with the uninjured side for joint stability.
• 😀 In cases of MCL injury, if instability is noted, a hinge knee brace should be used during rehabilitation for at least the first 6 weeks.
• 😀 For posterior medial fractures and ACL avulsions, a primary knee arthroscopy is recommended to address both the fracture and ligament injuries if performed early.
• 😀 When presenting late (e.g., 3 months post-injury), focus on achieving bony union first before addressing ligament and meniscal injuries.
• 😀 The goal of surgical fixation for tibial plateau fractures is to restore joint alignment and articular congruity, followed by ligament stabilization.
• 😀 Tibial plateau fractures are often associated with multi-ligament injuries; always evaluate for common peroneal nerve damage and vascular compromise.
• 😀 In cases of KD4 or KD5 (severe ligament injury or knee dislocation), early surgical intervention is crucial to prevent instability and further damage.
• 😀 For ACL injuries associated with tibial plateau fractures, consider suture bridge techniques for ACL reconstruction, particularly in cases of femoral avulsion.
• 😀 Post-operative rehabilitation should be guided by the type of fracture and soft tissue injury, with gradual weight-bearing and strengthening exercises integrated as healing progresses.

Q & A

What is the importance of assessing the MCL during the treatment of tibial plateau fractures?

The MCL (medial collateral ligament) plays a crucial role in knee stability. If a significant difference (5-10mm) is found between the affected leg and the normal leg during a varus-valgus stress test, it may indicate a need for surgical repair of the MCL to prevent joint instability.

Why is it necessary to use a hinge knee brace for patients with MCL injuries?

A hinge knee brace helps stabilize the knee and prevent further damage during the first six weeks of rehabilitation, particularly in patients with grade 2 MCL injuries, ensuring the knee remains stable while the ligament heals.

What role does arthroscopy play in the treatment of tibial plateau fractures?

Arthroscopy allows for a minimally invasive evaluation and treatment of the fracture site, particularly for visualizing and repairing meniscus tears and assessing soft tissue damage, such as ligament tears or joint instability.

How do you manage a posterior medial tibial plateau fracture with associated ACL injury?

A posterior medial tibial plateau fracture with ACL involvement is often treated with a posterior medial plate for fracture fixation. The ACL can be repaired later, typically using a suture bridge technique, after the fracture has begun healing.

What is the key principle when treating tibial plateau fractures early versus late?

For early intervention, the focus should be on bone alignment, congruity, and stability. For late-stage presentations (e.g., 3 months post-injury), bone union becomes the priority, and soft tissue concerns like the meniscus and ligaments are addressed once the bone has healed sufficiently.

What is the significance of checking for ligament injuries in tibial plateau fractures?

Ligament injuries, particularly of the MCL and ACL, can lead to knee instability. Early identification and repair of these ligaments, if necessary, are critical to restoring knee function and preventing long-term complications.

Why is alignment considered the most important factor in treating tibial plateau fractures?

Alignment is critical for proper weight distribution and joint function. Misalignment can lead to chronic pain, joint instability, and early degenerative changes. Ensuring proper alignment early in treatment is key to achieving a successful long-term outcome.

What should be done if a tibial plateau fracture results in a significant meniscus tear?

If a meniscus tear is identified, it should be treated surgically (if needed) to restore knee function. However, treatment for meniscal damage is considered after addressing the more critical concerns of bone union and ligament stability.

How do you assess the need for ACL reconstruction in tibial plateau fractures?

The need for ACL reconstruction is assessed based on imaging (CT and MRI) and clinical tests like the varus-valgus stress test. If there is significant ACL damage or an ACL avulsion, surgical repair should be performed to restore knee stability.

What are the primary considerations when treating a Shatzker type 4 or 5 fracture?

For Shatzker type 4 or 5 fractures, particular attention should be paid to associated ACL injuries, which often require reconstruction. These fractures are typically more complex and may require both fracture fixation and ligament repair to ensure the knee is stable and functional.