Intra-articular Extensile Approach for Tibial Plateau Fractures

Several types of tibial plateau fractures are a complex management problem. The knee joint may have a significant comminution and depression, and the physician may need to take an extensile approach for reduction and fixation of this fracture. Personally, I use the intra-articular extensile approach for tibial plateau fracture reduction and fixation. In general, fracture of the tibial plateau is a complicated problem.

A vascular evaluation is necessary. The ankle-brachial index (ABI) is needed in some types, such as in medial plateau fractures or in severe types, such as Schatzker Type V or Type VI. The ABI should be more than 0.9. Usually, medial tibial plateau fractures are considered to be a knee dislocation. A fasciotomy may be needed if compartment syndrome occurs. The soft tissue condition may be bad, and an external fixator may be initially used until the soft tissue condition improves.

The association between tibial plateau fractures and meniscal tear is not uncommon. A lateral plateau fracture will create a lateral meniscal tear, while the medial plateau fracture will cause a medial meniscal tear. A tear of the meniscus is usually peripheral. It should be recognized and dealt with. The physician may want to look at the x-ray and see if there is a depression or separation of more than 6mm, as this indicates a high chance of meniscal tear.

The posteromedial fragment is another problem with tibial plateau fractures which needs to be fixed separately. When an extensive comminuted displaced tibial plateau fracture occurs, the physician may need excellent exposure of the articular surface to allow for anatomic reduction of the joint and visualization and repair or debridement of the meniscus if it is torn. This extensile exposure is important, especially if the posterior part of the plateau is involved. The traditional way to see the articular cartilage of the tibial plateau is to use the submeniscal approach by cutting the coronary ligament, but the exposure is limited. Other extensile approaches are also developed; however, we use the extensile intra-articular approach for complex, comminuted tibial plateau fractures. This involves anterior detachment and retraction of the meniscus to improve visualization of the tibial articular surface. This approach can be utilized for lateral or medial tibial plateau fractures and it is especially helpful in diagnosing and repairing the torn meniscus. This allows for inspection of the meniscus pathology in fractures of the articular surface. This improves reduction of the fracture and the torn meniscus is repaired and reattached to the coronary ligament. Incision and reflection of the meniscus allows great exposure and inspection of the joint which is followed by reattachment and suturing of the anterior horn of the meniscus to its normal position which is followed by reattachment of the meniscotibial (coronary) ligament. The sutures are tied to the sides of the patellar tendon on the opposite side of the meniscus.

Pelvic Fractures with Bleeding

Pelvic fractures may cause significant bleeding. The superior gluteal artery is responsible for the majority of bleeding in pelvic fractures with an arterial injury. Most of the bleeding in pelvic fractures is from the veins and the fracture itself. Hemorrhage is the most life-threatening complication associated with pelvic injuries and will typically occur at the Superior Gluteal Artery. Hemorrhage of the Superior Gluteal Artery can be fatal. Approximately 10% of patients will have severe bleeding. Severe bleeding usually occurs in fracture patterns that are highly unstable to both rotational and vertical forces.

APC III (open book like type) is the complete disruption of anterior SI, sacrotuberous, and sacrospinous ligaments; disrupted posterior SI ligaments.

Vertical Shear Fractures are very bad fractures as they cause the complete disruption of the anterior and posterior ligaments; cephaloposterior displacement. Anteroposterior compression or vertical shear injuries are consistently associated with a higher risk of mortality from bleeding. The mortality rate is directly related to the amount of shock the patient is in at the time of presentation.

When treating patients with pelvic fractures and massive bleeding, it is important to remember that the patient will lose approximately 35% of their blood volume with acute hemorrhage before a sustained decrease in systolic blood pressure occurs. Immediate application of a pneumatic anti-shock garment is absolutely contraindicated in patients with a rupture of the diaphragm. Ringer’s lactate is the preferred initial fluid replacement used to resuscitate hypovolemic trauma patients in shock. A hypotensive blunt trauma patient will be given an initial fluid push with 2,000mL of Ringer’s lactate. A patient with bleeding and in shock will probably require O negative blood. If the patient is given 4 units of blood but remains hemodynamically unstable, then angiography and embolization is needed. Immediate application of an external fixator is another method to control bleeding, especially if the pelvis is unstable in external rotation. An abdominal and pelvic CT scan will clearly define the bony injury as well as the extent and source of the bleeding.

The best treatment for pelvic fractures with bleeding is a blood transfusion with correction of hypothermia and coagulopathy.