Tibial plateau fractures and compartment syndrome

Question 1

Mx of tibial plateau fracture

Answer 1

1. ATLS
2. Examination
3. Analgesia
4. Abx and tetanus for open fractures + picture
5. Admit
6. Splint
7. Reduction
8. Fixation
9. Rehab - - hinged knee brace non weight bearing for 8 - 12 weeks

Question 2

Open reduction

Answer 2

If intra-articular fracture

If already open fracture can do open

Question 3

Fixation methods and indications

Answer 3

Plaster - children as heals quicker 
External fixation - extensive soft tissue injury 
Internal fixation - 1st line 
- plates and screws 
- intramedullary nail 
- flexible nail - children

Question 4

Benefits of internal fixation

Answer 4

Less time immobilised
More stable
Can rehabilitate quicker

Question 5

Time taken for union

Answer 5

20 weeks

Question 6

Factors affecting bone healing

Answer 6

Age 
Frailty 
DM 
Smoking 
Immunocompromised 
RA

Question 7

Compartment syndrome definition

Answer 7

Elevated interstitial pressure in closed osseofascial compartment causing microvascular compromise

• pressure increase compresses veins, increasing hydrostatic pressure so venous blood moves out of veins to tissue
• less venous return
• eventually decreased arterial flow - ischaemia
• compresses nerves - paraesthesia

Question 8

Signs of compartment syndrome

Answer 8

Pain
Pain on stretching affected compartment
Woody hard compartment
Paraesthesia

Question 9

Ischaemic leg signs

Answer 9

Pain 
Pulselessness 
Pallor 
Paraesthesia
Perishing with cold 
Paralysed

Question 10

Causes of compartment syndrome

Answer 10

Trauma 
Constricting plaster or dressing 
Circumferential burns 
Extra - venous infusions
Revascularisation

Question 11

Mx of compartment syndrome

Answer 11

Maintain BP - fluids
Oxygen if required
Keep limb neutral

Remove cast 
NBM, Group + save 
Emergency fasciotomy
Analgeasia
Skin incisions are left open for 24 - 48 hours - relook

Question 12

Which nerve is commonly affected in tibial plateau fracture

Answer 12

Common peroneal nerve due to injury of neck of fibula

- foot drop

Question 13

Osgood-Shlatter’s

Answer 13

Tibial tuberosity apophysitis + patellar tendonitis - inflammation of growth plates
• Children 10-14yrs
• M>F=3:1
• Associated with physical activity
• Symptoms: pain below knee, especially with quads contraction
• X-ray: tuberosity enlargement ± fragmentation
• Tx: rest, consider POP

Question 14

Plaster of Paris

Answer 14

First 2 weeks - plasters are not circumferential to allow swelling

Question 15

Complications of compartment syndrome

Answer 15

Acute limb ischaemia

Question 16

Investigations of compartment syndrome

Answer 16

Clinical diagnosis mainly
Intra compartmental pressure monitor - if clinical uncertainty
Bloods - CK, U+Es (due to rhabdomyolysis)

Question 17

Mechanism of injury for tibial plateau fracture

Answer 17

High energy trauma

• Fall from height
• Road traffic accident
• Impaction of the femoral condyle
• Varus deforming force

Question 18

Clinical features of tibial plateau fractures

Answer 18

Sudden onset pain 
Unable to weight bear 
Swelling of the knee 
Tenderness of proximal tibia 
Potential ligament instability

Question 19

Ix of tibial plateau fractures

Answer 19

Xray - AP and lateral

CT

Question 20

Classification of tibial plateau fractures

Answer 20

Type I - Lateral split fracture
Type II - Lateral split – depressed fracture
Type III - Lateral pure depression fracture (rare)
Type IV - Medial plateau fracture
Type V - Bicondylar fracture (rare)
Type VI - Metaphyseal – diaphyseal disassociation

Question 21

Iliotibial Band Syndrome

Answer 21

Lateral knee pain due to inflammation of the iliotibial band

Question 22

Mx of Iliotibial Band Syndrome

Answer 22

Diagnoses clinically

Mx:

• modify activity
• simple analgesics
• local steroid injections
• physio

Question 23

When is surgery indicated for liotibial Band Syndrome

Answer 23

If pain persist for 6 months dispite conservative management

• release iliotibial band