1. Management of Ligament and Meniscal Injuries in Tibia Plateau Fractures
Sohrab Keyhani (Ass. Prof. SBUMS , Knee surgeon)
Presentation: Mehran Soleymanha (Ass. Prof. GUMS , Knee surgery fellowship, SBUMS, Akhtar Hospital)
P.O.T.A Conference April. 15

2. Things to consider in plateau tibial fracture
Articular depression
Plateau widening
Articular anatomic fixation
Articular support and void
Metaphyseal fixation
Soft tissue injury
Garner MJ. 2013

3. Incidence of soft tissue injuries
Direct vision
Ligament injury ……………… 27 %
Meniscal injury ………………. 35 %
Arthroscopy
ACL injury ………… 25 %
PCL injury …………. 5%
MCL injury ………… 3%
LCL injury …………. 3 %
Delamarter R. 2005
Abdel-Hamid MZ. Arthroscopy. 2006

4. Incidence of soft tissue injuries
MRI
ligaments injury …………….…..… 77 %
lateral meniscus tears ………..……. 91 %
medial meniscus tears .…………….. 44 %
Garner MJ. Journal of Orthopaedic Trauma. 2005
ACL injury …………….……....… 57 %
PCL ……………….………..……. 28 %
Complete LCL tears .…………….. 9 %
Complete MCL tears .…………….. 12 %
Mustonen AO. AJR AM J Roentgenol. 2008

5. Meniscus When you should think about in meniscus injury ?
Joint line depression > 5 mm
Joint widening > 6 mm
Schatzker fracture I , II , III , IV
posterior meniscus observation is often difficult by open arthrotomy and arthroscopy is necessary for better vision

6. Meniscal Injury
meniscus injury incidence has been reported in the MRI analysis …… %
Serious injury required to repair …………………………………… %

7. Meniscal Injury lateral meniscus > medial meniscus post > ant
Peripheral > central
longitudinal > radial > root avulsion (ant & post)

8. Meniscal Injury It seams :
untreated associated meniscus injury causes inferior outcome in long-term follow-up
Repair of meniscal lesions during the primary surgery
Repair peripheral longitudinal tear
partial meniscectomy of complex irreparable tears
radial tear and root avulsion should be fixed (if untreated is equal to total meniscotomy)
King , et al. knee surgery sports traumatology arthroscopy. 2015

9. Ligament Injury avulsion fracture Ligament injury
Delamarter R. Clinical Orthopeadic & Related Research. 1990

10. Ligament Injury Incidence : LCL , MCL < PCL < ACL
Arthroscopy % % <25 %
MRI % % %
When to consider ?
High energy ( Schatzker V , VI ) complex fracture
Coincidence with anterolateral avulsion
Coincidence with anteromedial avulsion

11. Approach to avulsion fracture
ACL avulsion
PCL avulsion
Stahl D. J Orthop Trauma. 2015

12. Approach to avulsion fracture
MCL avulsion
Stener’s like lesion
LCL avulsion

13. Approach to avulsion fracture
Anterolateral ligament avulsion
Mechanism of injury :
Varus
flexion
internal rotation
It causes anterolateral instability

14. Ligament avulsion
tibial tubercle avulsion
gerdy's tubercle avulsion

15. midsubstance ligament injury
Diagnosis
MRI
Arthroscopy
Post fixation exam
After adequate fixation in sagittal and coronal plane you should check stability and alignment
ACL lachman test
PCL posterior drawer test
MCL & LCL varus and valgus stress test in 20 ̊flexion
Be careful
Joint depression
Malreduction and translation displacement { can cause instability }

16. Treatment MCL ……………………… conservative treatment with Hinged knee brace
LCL & PLC …………….. consider limb alignment
ACL …………………..…... reconstruction (if needed)
PCL ……………………..... reconstruction (consider fixed post subluxation)*
Soft tissue treatment is based on :
Age
Fracture pattern
Patient demand
instability
Strobel. American Journal of Sport Medicine. 2002

17. Take home massage Think about soft tissue injury
Avulsion fracture fixation
Arthroscopic evaluation
Meniscus preservation
Post- fixation physical exam and stress view
Delayed reconstruction ( if needed )

18. Thank you