1. The principles of intra- articular fracture care Joseph Schatzker M.D., B.Sc.,(med.), F.R.C.S.(C )

2. There is a great deal of strong clinical evidence in support of operative treatment of intra-articular fractures

3. Must examine experimental and basic scientific facts in support of operative treatment of intra-articular fractures

4. Friedrich Pauwels: joint homeostasis Articular Cartilage regenerations Articular Cartilage destruction

5. Stress = Force/Area Anatomic reduction Correction of axial deformity

6. Pathophysiology of joint cartilage

7. Continuous passive motion

8. 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

9. Nelson Mitchell The influence of : Accuracy of reduction Stability of fixation Articular cartilage regeneration

10. osteotomy No reduction and no fixation

11. Anatomic reduction but no fixation Anatomic reduction and stable fixation

13. 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)

14. Step-off deformit Llinas JBJS 1993 75A 1x 2x No more than 2x the thickness of articular cartilage. Damaging effect of CPM on opposing joint surface in positive step off defects

15. Factors important in joint preservation Congruence Axial alignment stability

16. Lessons learned from clinical practice Plaster immobilization……….stiffness ORIF and immobilization……greater stiffness Traction and early motion……preserves joint mobility

17. 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

18. Lessons learned from clinical practice Impacted intraarticular fractures will not reduce with manipulation and traction and can be reduced only by open reduction

19. 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

20. Imaging Articular fractures must have an AP, a lateral and two obligue projections

21. Imaging Complex articular fractures require CT in order to determine joint depression, comminution, direction of fracture lines, intraarticular fragments

22. Imaging Complex articular fractures require CT in order to determine joint depression, comminution, direction of fracture lines, intraarticular fragments

23. Timing of surgery- the indications for immediate intervention Open fracture Vascular injury Compartment syndrome Irreducible fracture dislocation Nerve injury with dislocation

24. Timing of surgery- the indications for delayed intervention High energy axial loading or crush injuries

25. Timing of surgery- the indications for delayed intervention Complex intra- articular fractures requiring supplemental imaging and specialized surgical expertise such as : Acetabular fractures Pilon fractures Tibial plateau fractures Supracondylar fractures

26. Operative detail Preoperative plan Surgical exposure Reduction of articular surface - direct or indirect ( arthroscopy, C- arm ), the impacted fracture and elevation of fragments

27. Operative detail Anatomic reduction of joint surface Correction of axial deformity Bone grafting of metaphyseal defects Stable fixation

28. 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

29. Operative detail- postoperative care Splinting and elevation CPM Active range of motion Cast-bracing if ligament damage or unstable fixation Delay weight-bearing Recognize complications and intervene

30. 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

31. 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