Articular fractures:

principles of management

Cleber AJ Paccola

V1
Juni 3, 2004

Articular fractures: principles of management

 Articular fractures: principles of management

Articular fractures: principles of management

1. Title slide

2. Aims and objectives

3. Articular cartilage has a unique structure designed to

distribute forces evenly and provide a frictionless surface to
the joint. It is a shock absorber

4. The nutrition of articular cartilage comes from synovial fluid

and the flow of synovial fluid requires both joint motion and
some load

5. Articular cartilage has poor healing potential and will only

heal perfectly with anatomical reduction, inter-fragmental
compression and early joint movement

6. Quote from Sir John Charnley

A O In te rn at io nal J un 3 , 2 00 4 Ar ticu lar fr actu re s: p rincip le s of 2 /9

m an agem en t
 Articular fractures: principles of management

7. Over 100 years ago Alvin Lambotte laid down the principles
for the treatment of articular fractures

8. There is considerable experimental evidence to show that

immobilization of joint injuries results in stiffness and this
stiffness is made worse if you immobilize an articular
fracture that has been treated by open reduction and
internal fixation

9. Joint depressions do not fill in with fibrocartilage and

instability results. With conventional implants it is often
necessary to bone graft metaphyseal defects to prevent
articular redisplacement

10. The metaphysis and diaphysis must be reduced to achieve

correct length, axis and rotation. This need not be
anatomical but any alterations in the mechanical axis will
create joint overload. Immediate motion is necessary for
cartilage healing

11. Traction and early motion is preferable to ORIF plus

immobilization, but ORIF plus early mobilization gives the
best results

12. If you cannot reduce the fixed intra-articular fracture so as to

allow early movement, surgery should not be performed

A O In te rn at io nal J un 3 , 2 00 4 Ar ticu lar fr actu re s: p rincip le s of 3 /9

m an agem en t
 Articular fractures: principles of management

13. The outcome after articular fractures depends on many

factors

14. Treatment decisions depends not only on the fracture but

many other factors

15. List of decision factors

16. The principles of treatment involve a clear understanding of

the injury, meticulous pre-op planning, carrying out the
operation at the right time, through the right approach,
surgery involves anatomical reduction and rigid fixation of
the articular surface and functional reduction and
appropriate stabilization of the metaphysis

17. Timing of surgery maybe influenced by soft tissue

considerations. Delaying surgery will allow better imaging,
CT/MRI

18. CT imaging is essential for complex intra-articular injury,

especially the os calcis, the acetabulum, the proximal tibia
and distal femur

A O In te rn at io nal J un 3 , 2 00 4 Ar ticu lar fr actu re s: p rincip le s of 4 /9

m an agem en t
 Articular fractures: principles of management

19. Pre-op planning must include a full surgical tactic

20. Surgery maybe carried out immediately or be deferred,

usually for soft tissue reasons. Treatment can also be
carried out sequentially with immediate fixation of the
articular surface and delayed bridging of the metaphysis

21. Pilon fracture treated by sequential fixation, immediate

fixation of fibula with bridging ex-fix, delayed internal
fixation

22. Fracture dislocation of ankle. Severe soft tissue problems

treated by immediate fixation of the medial malleolus and
spanning ex-fix followed by delayed internal fixation

23. Pilon fracture treated by immediate fixation of joint surface

and bridging ex-fix, followed by delayed application of
hybrid fixator

24. The surgical approaches should be the least traumatic

possible

A O In te rn at io nal J un 3 , 2 00 4 Ar ticu lar fr actu re s: p rincip le s of 5 /9

m an agem en t
 Articular fractures: principles of management

25. Indirect reduction and percutaneous fixation of intra-

articular fracture of proximal tibia

26. The articular surface is anatomically reduced. K wires are

useful in multi-fragmentary fractures. Bone graft is used to
fill defects. Good function can be obtained in the presence
of small gaps, but not in the presence of step offs

27. Following fixation of the articular surface, the metaphysis is

buttress or bridged

28. Post op care with early movements is critical for restoration

of normal function

29. Many different fixations are available – example of

percutaneous lag screws for simple split fracture of a
proximal tibia

30. Use of hybrid fixator for management of proximal tibial

fractures and use of spanning ex-fix as temporary treatment

A O In te rn at io nal J un 3 , 2 00 4 Ar ticu lar fr actu re s: p rincip le s of 6 /9

m an agem en t
 Articular fractures: principles of management

31. Split depression fracture of lateral tibial plateau

32. Intra-operative view showing depressed fragment

33. Post op radiograph

34. Bone substitutes can also be used including Norian

35. Clinical results of internal fixation

36. Complex intra-articular fracture of knee

A O In te rn at io nal J un 3 , 2 00 4 Ar ticu lar fr actu re s: p rincip le s of 7 /9

m an agem en t
 Articular fractures: principles of management

37. Intra-operative view showing destruction of articular surface

38. Open reduction. Anatomical reduction of joint surface.

Application of lag screws (absolute stability)

39. Bridging plate applied to lateral femoral surface – functional

reduction and relative stability

40. Post op X-ray

41. Fracture union

42. Multi-fragmentary split depression fracture of lateral tibial

plateau

A O In te rn at io nal J un 3 , 2 00 4 Ar ticu lar fr actu re s: p rincip le s of 8 /9

m an agem en t
 Articular fractures: principles of management

43. Anatomical reconstruction of joint surface with hybrid ex-fix

used to bridge the metaphysis

44. Fracture union with four year post op film

45. Over view of lecture

A O In te rn at io nal J un 3 , 2 00 4 Ar ticu lar fr actu re s: p rincip le s of 9 /9

m an agem en t