[MUSIC] [MUSIC] In order to have a better understanding of tibial plateau fractures, here once again is an updating on the anatomical basic principles involved: the tibial plateau forms part of the knee joint. This consists of the femororbital articular surface and the femoropatellar articular surface. A series of bursa and ligamentary structures are also to be found, for example the medial and lateral collateral ligament, the anterior and posterior cruciate ligament as well as the patella ligament and the iliotibial tract. A series of vascular tissues run in the vicinity of the knee joint. The popliteal artery and the peroneal nerve are especially to be mentioned in this regard. Tibial plateau fractures either occur following low-energy injuries in usually older patients, with an injury to the lateral plateau being frequently involved. High speed traumas with younger patients frequently lead to a complete articular fracture and concomitant soft tissue injuries being accordingly sustained. High speed traumas also frequently occur as a result of winter sport injuries or road traffic accidents. The incidence of more complex fractures is tending to increase. Yes. >> Dr. Neumaier... The ambulance crew have just delivered a young girl, Ms Hoschka. It's most likely to be a skiing accident. >> OK. I am on my way. What is her name again? Jasmin Hoschka. >> Hello Ms. Hoschka. >> Hello. So you went skiing, I believe? >> Yes, I was coming down the mountain piste and someone cut in front of me and, I don’t know how, but this led to my ski and my leg being rotated and I then fell over and heard a strong cracking sound. And since then, I have had strong pains in my knee. >> Did you fall on your head or lose consciousness as well? >> No, not at all, that is to say... Were you wearing a helmet? >> Yes, I was wearing one as I always do... So everything was OK in terms of my head. >> Apart from your knee, does anything else hurt - arms, legs? >> Just my knee. >> Ok. We now need to have a look at it again, OK? >> I’ll be very careful. >> Let's try. Just like that. Now I’ll just... OK, we can now see it clearly. Yes, it really is thick and blue. You can still move your toes OK? >> Yes. >> Can you feel everything OK down here? >> Mhm. >> Yes. OK? And your ankle, does that hurt at all? The calf is supple. Now, let's check the pulses once again. So where does it hurt most now, inside or outside? >> Inside. >> Ok. Here? >> Mhm. >> Yes. Now, if I take it... >> I see. >> Is that OK? >> Yes. >> May I have another look? Does that hurt? >> Oh, yes! Yes, that does hurt. >> Okay. >> OK, I now want to have a quick look at the cruciate ligaments, so just hang on. >> Yes, yes, yes, yes, yes! >> It certainly is. OK, everything seems stable. We need to take an x-ray of your knee so that we can know what the position really is, as I rather tend to think it is broken. Ok. Do I need to have an operation? >> It is too early for me to say. We need to wait for the x-ray images. >> Ok. >> Everything clear? >> Yes. >> OK? So now we’ll take you away for the x-ray and then we’ll meet up again. See you soon. >> See you soon. In any clinical examination where tibial plateau injuries are suspected, focus must be paid to popliteal neurovascular bundles in addition to any soft tissue damage. The peroneal nerve, in particular, can be endangered in any circumstances involving injuries to the knee joint. Imaging diagnostic investigation provides for x-ray in two planes and computerised tomogram or MRI diagnostic investigation if applicable. Yes, Neumaier, Trauma Surgery, hello. I need another CT for Ms Hoschka, the patient who was just been admitted with the knee joint problem. Thank you. Bye. Tibial plateau fractures are classified either according to the AO scheme or, when English is being used, according to Schatzker. Classifications according to Tscherne or Moore involve a specific accident mechanism or dislocation fractures. This chart shows the AO classification. The proximal tibia is designated with the number 41. Type A fractures are fractures below the joint line. Please note that an A3 fracture with a debris zone can be markedly unstable. Type B fractures are partial fractures of a joint and Type C fractures are fractures in which the articular surface is completely interrupted. Classification according to Moore refers to dislocation fractures. The Schatzker classification, which is widely used in English-speaking circles, makes reference to six different types of fracture. Hello. Here I am again and this time with the x-ray images. As was to be feared, unfortunately something is broken. I’ll show you precisely where the problem is. It is particularly the case down here, where the bone has been completely severed. Several fractures have occurred here, but it is also breaking into the joint here as well. We have taken an x-ray from the side as well. You can see here as well that this completely penetrates and we can see precisely from the CT scan what it looks like inside the joint. Up there, you can see that several pieces are present up here and that the anterior cruciate ligament is also broken here and has been penetrated once as well. >> Ok. >> The breakages are unfortunately so bad that we have no alternative but to operate. >> Now? Today? >> No, in the course of the next few days, when the swelling has gone down. >> And what will you do in the course of the operation? We will stabilise the situation with a plate inserted from outside. Then we can fix it to the shaft using screws. >> But will I be able to practise sport again afterwards? >> Yes, although that will take some time to begin with. The skiing season, however, is definitely over for you for this year. >> Ok. >> But you’ll be able to pick it up again next year. >> Ok. >> It will take four to six months until your knee is fully healed again. >> Ok. >> Now just hang on a moment and I’ll show you the plate. Right, here we are. This is a shinbone, one made of plastic, and it is completely broken, cleanly in your case, and we usually fix this in place by using such plates. They are inserted from outside, that comes here, just a moment, yes, precisely so, meaning it is at such an angle that the block of the joint is nicely reconstructed to begin with and that stands here smoothly again, where the fractures have occurred and we would then insert screws here and bridge the fracture here. >> Ok. >> The plate can sometimes cause problems. In that case, we remove it again after a year once everything has healed well. >> Is the injury a very bad one? >> No, but we have to operate on the fracture and it takes time to heal again. Really essential treatment objectives are the repair of the articular surfaces, the repair of the axial ratios and avoidance of the patient being immobilised. The primary therapeutic decision as to whether non-operative or surgical treatment can take place depends on the type of fracture or any accompanying soft tissue damage there may be. Attention is particularly to be paid to compartment syndrome in this regard. The indication for non-operative treatment is given in the case of closed, non-displaced fractures, edge fragments with a maximum terrace of 3 mm. Non-operative treatment procedures are a splint and relief being provided on crutches. Fixateur externe is available as the simplest procedure in terms of surgical treatment. This can be applied with all forms of soft tissue damage. Attention should be paid in this process to injuries of the extensor system. Minimally invasive procedures have been developed so as to avoid any access morbidities. This means that the repositioning of small fragments can be checked by means of arthroscopy and these fragments can then be fixed with screws or wires via small skin incisions. These minimally invasive procedures are appropriate for use with Schatzker II or III injuries as well as with injuries classified as A3, B2 or B3 according to AO. This publication shows the procedure to be adopted when treating a fracture with arthroscopic support. The top left image is the initial one taken of the fracture. The image converter image can be seen in the centre at the top. The fracture is elevated by means of a bone tamp in this. At the top right side, the direct postoperative treatment can then be seen. The postoperative healing image can be seen bottom right. Open operative procedures have been developed for more complex injuries. These consist, for example, of a plate and screw osteosynthesis or internal fixation with a locking-compression plate. A fixateur externe can be fitted in a situation of polytrauma. If any unstable joint fractures are present, then the indication is given for internal fixation with a locking-compression plate. This slide, for example, shows a standard lateral access. The transient repositioning by means of Kirschner wire can be seen on the right side. This photograph shows the intraoperative situation. The head is shown on the right side and the foot on the left. The articular surface and the looping of the meniscus can be clearly recognised. These postoperative x-ray images show the treatment of an unstable tibial fracture by means of polyaxial fixed-angle plate systems. OK. You will spend about a week with us, five to seven days, and, remember this; you will not be able to stand on the leg for six to ten weeks. >> Ok. Yes. >> Look here, I have already brought along a patient information sheet for you. You can read through this to begin with to see exactly what will happen. The course of the operation is described exactly once again, with a precise explanation as to where the operation will be carried out and how we will deal with any complications which might occur. I’ll leave this here for you to read through. You can learn all you need at your leisure and we will then discuss the operation again later. >> Is everything clear otherwise? >> Yes, everything is OK otherwise. Okay. Then we’ll get everything ready. You will now be taken to the ward and we’ll see each other again up there. >> OK? I see. See you later. >> Bye. The follow-up treatment of tibial plateau fractures is carried out according to this scheme. The limb should be cooled and elevated immediately postoperatively. After that, a knee joint orthesis can be fitted for six weeks. The movement pattern shown here is recommended in this regard. Overall partial weight-bearing of no more than 15 kg should be undertaken for at least eight weeks. An x-ray check-up should then be made and weight-bearing can then be carried out, adapted according to the level of pain which can be endured. thrombosis prophylaxis should be undertaken with low-molecular heparin sollte die Thromboseprophylaxe mit niedermolekularem Heparin until such time as full weight-bearing has been achieved. [MUSIC]
