Transcript The principles of intra-articular fracture care

The principles of intraarticular
fracture care
Joseph Schatzker
M.D., B.Sc.,(med.), F.R.C.S.(C )
There is a great deal of
strong clinical evidence in
support of operative treatment
of intra-articular fractures
Must examine experimental and
basic scientific facts in support of
operative treatment of
intra-articular fractures
Friedrich Pauwels: joint homeostasis
Articular
Cartilage
regenerations
Articular
Cartilage
destruction
Stress = Force/Area
• Anatomic reduction
• Correction of axial deformity
Pathophysiology
of
joint cartilage
Continuous passive motion
• Brief plaster immobilization potentiates
articular damage
• Prolonged immobilization can result
on cartilage necrosis and or obliterative
arthritis
• Continuous passive motion is a
powerful stimulus to cartilage
regenerations
Nelson Mitchell
The influence of :
•Accuracy of reduction
•Stability of fixation
Articular cartilage
regeneration
osteotomy
No reduction
and no fixation
Anatomic reduction but
no fixation
Anatomic reduction and
stable fixation
The healing of step of defects associated with
Different degrees of displacement
•Negative and positive step off
•Twice the thickness of articular cartilage
(Llinas and Sarmiento)
Step-off deformit
Llinas JBJS 1993 75A
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No more than 2x the thickness of articular
cartilage. Damaging effect of CPM on opposing
joint surface in positive step off defects
Factors important in joint
preservation
• Congruence
• Axial alignment
• stability
Lessons learned from clinical
practice
• Plaster immobilization……….stiffness
• ORIF and immobilization……greater
stiffness
• Traction and early motion……preserves
joint mobility
Lessons learned from clinical
practice
• Intraarticular fractures which are
not treated by open reduction and
stable fixation should be treated by
traction and early motion
Lessons learned from clinical
practice
• Impacted
intraarticular
fractures will not
reduce with
manipulation and
traction and can
be reduced only by
open reduction
The value of clinical
examination
• State of the soft tissue envelope and
timing of surgery
• Integrity of ligaments
• Vascular status
• Neurological status
• Presence of compartment syndrome
Imaging
• Articular
fractures must
have an AP, a
lateral and two
obligue
projections
Imaging
• Complex articular
fractures require CT
in order to determine
joint depression,
comminution,
direction of fracture
lines, intraarticular
fragments
Imaging
• Complex articular
fractures require CT
in order to determine
joint depression,
comminution,
direction of fracture
lines, intraarticular
fragments
Timing of surgery- the indications
for immediate intervention
•
•
•
•
•
Open fracture
Vascular injury
Compartment syndrome
Irreducible fracture dislocation
Nerve injury with dislocation
Timing of surgery- the indications
for delayed intervention
• High energy
axial loading or
crush injuries
Timing of surgery- the indications
for delayed intervention
• Complex intraarticular fractures
requiring
supplemental
imaging and
specialized surgical
expertise such as :
• Acetabular fractures
• Pilon fractures
• Tibial plateau
fractures
• Supracondylar
fractures
Operative detail
• Preoperative plan
• Surgical exposure
• Reduction of
articular surface direct or indirect
( arthroscopy, Carm ), the impacted
fracture and
elevation of
fragments
Operative detail
• Anatomic reduction
of joint surface
• Correction of axial
deformity
• Bone grafting of
metaphyseal defects
• Stable fixation
Operative detail
• Repair torn menisci and collateral
ligaments
• Delay cruciate repair
• In open fractures preserve portions
of articulation essential for stability
• Secure cover for articular cartilage
• Avoid tight closures
Operative detailpostoperative care
•
•
•
•
Splinting and elevation
CPM
Active range of motion
Cast-bracing if ligament damage or
unstable fixation
• Delay weight-bearing
• Recognize complications and intervene
Conclusion - factors
beyond surgical control
• Degree of articular cartilage damage
• Degree of comminution and displacement
• Associated injuries:
- skin and muscle
- artery and nerve
- ligament
- associated system injuries
- CNS injury
Conclusion - factors
under surgical control
• Atraumatic handling of soft tissue and
bone
• Anatomic reduction of the joint, bone
grafting of the metaphysis and correction
of axial deformity
• Stable fixation
• Correct post-operative care