الفهرس 
AnatomyOnly 14 pages are availabe for public view
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Abstract
Summary
The knee joint is one of three major weight-bearing joints in the lower extremity. Fractures that involve the proximal tibia affect knee function and stability. These fractures can either be intra-articular (tibial plateau) or extra-articular (proximal fourth). Generally, these injuries fall into two broad categories: low-energy and high-energy fractures.
Proximal tibial fractures account for 1.2% of all fractures in adults; Tibial plateau fractures constitute 1% of all fractures and 8% of fractures in the elderly. from 1% to 3% of these fractures are open injuries.
The mechanism of injury provides clues to the fracture pattern and should direct the necessary degree of vigilance for associated injuries
The physical examination of the knee and leg is critically important to diagnose associated injuries and complications, to plan for surgical treatment, and to decide on optimal timing of interventions.
Standard radiographic imaging includes AP and lateral views. Suspicion of distal extension of the fracture mandates that full-length tibia and fibula x-rays should be obtained. The CT scan is becoming more and more useful in the evaluation of the size, comminution and orientation of the articular fragments, allowing proper classification and preoperative planning, thus facilitating reduction, especially for the less invasive techniques of treatment.
Classifying tibial plateau fractures is important for physician- to-physician communication (for clinical and research purposes), for estimation of prognosis, and for planning surgery. Many classification systems have been developed for proximal tibial fractures
Tibial plateau fractures are commonly classified using the Schatzker classification, which subdivides these injuries into six types. The OTA/AO classification can be used to classify these injuries, both intra- and extra-articular ones. The Gustillo-Anderson and the Tscherne classifications are used for open and closed injuries respectively.
Recent studies conclude that the three-column classification is more easily reproducible than Schatzker classification system.
The aims of treatment are anatomical reduction and stabilization of the articular surface, restoration and maintenance of the mechanical axis of the leg, preservation of the soft tissue envelope of the proximal tibia, followed by restoration of a functional range of motion. Inadequate treatment of these fractures may result in long term pain, instability, deformity, stiffness and ultimately post-traumatic arthritis.
A universally accepted mode of treatment for complex high-energy tibial plateau fractures remains controversial, with many authors reporting high complication rates and less than satisfactory outcomes. Conservative treatment is reserved for very simple undisplaced fractures that represent a small minority of the overall tibial plateau fracture population or for very low demand patients with severe comorbidities. The general consensus for the young patients with such an injury is to undergo operative treatment, aiming for anatomical reduction, rigid fixation, and early movement. These operative indications and goals are currently expanding further in patients even over 55 years with good results, despite the presence of osteoporosis/osteopenia, coexisting medical problems, or of degenerative joint disease. Traditional methods of open reduction and internal fixation require the use of single or double buttress plates and this involves extensive stripping of the tenuous soft tissue envelope of the proximal tibia. This compromises the viability of the overlying soft tissue and devitalizes underlying bone, resulting in an unacceptable incidence of soft tissue necrosis, wound dehiscence and deep infection. Conventional external fixators are frequently unsuitable for fixation on the proximal side of the fracture and have been reported to have a high incidence of pin site infection and malunion. In addition, conventional external fixators often span the knee joint and do not allow for early range of motion in the post-operative period, leading to permanent joint stiffness.
These concerns have led to the increased use of tensioned fine-wire external fixators which minimizes iatrogenic soft tissue damage and its associated risks, provides adequate fixation of the fracture, and permits early range of motion.
Currently, ORIF with plates and screws is considered the gold standard method of treatment .Modern locking plating systems, providing increased angular stability, low implant profile, improved design matching the peri-articular bone surface, as well as compatible with the minimal invasive techniques (Minimally Invasive Percutaneous Osteosynthesis – MIPO) are nowadays the mainstay of clinical practice. Arthroscopic assisted reduction and internal fixation is recommended by some authors for selected cases (pure depression fractures).The use of circular ring fixators offer a reliable alternative method of treatment for high energy fractures with gross intra-articular comminution (AO/OTA type C3) associated with severe soft-tissue damage. ‘‘Balloon tibioplasty’’ is a novel minimally invasive technique for the reduction of depressed tibial plateau fractures. This technique allowed for reduction of the depressed tibial plateau fragment without classic fenestration of the tibia, thereby minimizing surgical trauma. Although proximal third tibial shaft fractures have historically produced suboptimal results with IMN treatment, recent research has led to the development of several techniques and pearls resulting in more promising results in achieving stable well-aligned reconstruction. The combined use of condylar bolt(s) and intramedullary nailing can offer a reliable treatment option in the management of selected intra-articular fragility fractures of the proximal tibia with specific and significant advantages
A meticulous assessment of the severity of the sustained local injury is essential in the care of patients with a fracture of the tibial plateau. The treatment strategy and the outcome are strongly related to the condition of the soft-tissue envelope. Often, temporary stabilization is required via a spanning the knee external fixator, to allow for soft-tissue resuscitation, pain relief, gain of more information related to the fracture configuration (usually with a CT-scan) and definitive treatment at the optimal time. Other important factors in terms of prediction of immediate as well as long-term results are age, concurrent health problems, smoking history, occupation, functional ability and personal expectations.