Tibial Plateau Fractures Mechanism of injury: Varus or valgus force combined with axial loading as in: Car striking a pedestrian (bumper fracture). FFH with varus or valgus bending. The tibial condyle split by the opposing femoral condyle.

FRACTURE CLASSIFICATION (SCHATZKER) Type I (Pure cleavage) : A typical wedge-shaped uncomminuted fragment is split off the lateral condyle and displaced laterally and downward. This fracture is common in younger patients without osteoporotic bone. Type II (cleavage combined with depression) : A lateral wedge is split off, but in addition the articular surface is depressed down into the metaphysis. This tends to occur in older people.

Type III (pure central depression): The articular surface is driven into the plateau, the lateral cortex is intact. These tend to occur in osteoporotic bone. Type IV (fractures of medial condyle): These may be split off as a single wedge or may be comminuted and depressed. The tibial spines often are involved.

Type V (bicondylar fractures): Both tibial plateaus are split off. The distinguishing feature is that the metaphysis and diaphyses retain continuity. Type VI (plateau fracture with dissociation of metaphysis and diaphyses): A transverse or oblique fracture of the proximal tibia is present in addition to a fracture of one or both tibial condyles and articular surfaces.

Clinical Features Swelling, deformity, extensive bruising and doughy feeling of the joint due to hemarthroses. Neurovascular examination is a must (traction N. injury) TYPE IV may cause neuropraxia of common peroneal nerve. Examination under anesthesia may reveal medial or lateral collateral ligament injuries.

Plain X-ray: AP, lateral, oblique views. CT-scan with reconstructions: visualize the exact comminution and articular depression.

Treatment Type I: Non displaced: aspirate the hemarthroses then plaster immobilization, partial wt bearing after 3weeks, plaster removal after 4weeks, full wt bearing after 8weeks. Displaced: can be fixed with two transverse cancellous screws.

Type II: If the depression is less than 5mm or if instability cannot be demonstrated on stress, treatment is conservative. If the depression is severe or if instability can be demonstrated on stress, the articular fragments should be elevated and bone-grafted, and the lateral cortex is supported with a buttress plate.

Type III: The same as type II. Type IV: These fractures tend to angulate into varus and should be treated by open reduction and fixation with a medial buttress plate and cancellous screws.

Type V: Both condyles can be fixed with buttress plates and cancellous screws. It is best to avoid stabilizing condyles with large bulky implants.

Type VI: Should be treated with buttress plates and cancellous screws, one on either side if both condyles are fractured. More recently, pin and wire fixators also have been advocated for fixation of these difficult fractures (illizarof).

Complications: Early: compartment syndrome, neurovascular injuries, fracture blisters. Late: stiffness, deformity, osteoarthrits.

Fracture Tibia and Fibula Subcutaneous position, commonly fractured and commonly sustain compound fracture. Mechanism of injury: Twisting force (spiral fracture of both at different level), usually low force injury and the bone may penetrate the skin from within.

2. Angulatory direct force (transverse or short oblique fracture of both at the same level), high energy lesion and crushes the skin over the bone.

Clinical Features Pain, swelling, bruises, crushing the skin, open fracture, circulatory changes, check always for impending compartment syndrome. Plain X-ray: site, type, comminution, displacement, angulations, rotation, state of nearby joints, old or new, pathological or not…..

Managements Depend on certain factors: State of the soft tissue. Severity of bony injury( spiral or transverse, comminuted). Stability of the fracture( oblique, butterfly, comminuted) are unstable.

Conservative treatments: For low energy fractures, minimally displaced, gustillow type I. Reduction if needed (MUA); immobilization in a full POP cast from midthigh to metatarsal necks. If skin in doubt open a window for daily observation. Elevation and observation for72 hours, after 2 weeks check x-ray, then partial wt. bearing till union(8-16weeks).

Operative treatments: Unstable high energy fractures, low energy fractures cannot be hold satisfactorily by conservative way. Closed locked intramedullary nailing: the standard method for most fractures.

Plate and screw: metaphyseal fractures (grate risk of exposure, periosteal striping, infection…..).

3. External fixation: compound fractures, comminuted fractures, infected fractures, non union with bone gaps (bone transport).

Complications Vascular injury: rare, occur with proximal fractures. Early: Vascular injury: rare, occur with proximal fractures. Compartment syndrome: happen especially if (young patient, severe injury, delay treatment, shock, excessive manipulation with long operation). Infection: open fractures, after plate and screw fixation.

Malunion. Delay union and non union: common( poor soft tissue, comminuted, segmental, compound, infected……). Ankle and foot stiffness.