Articular Fractures: Principles

Introduction
• Disruption of joint component -> Altered function
– Gaps or steps -> Instability, pain, and ROM
– Inflammation -> fibrosis in and outside of joint
• Inappropriate management -> worsening of stiffness,
pain, and instability
– Closed reduction and external fixation usually unsuccessful
– Traction and joint mobilization improved motion but
instability persist
• Chanley proposed open reduction and internal fixation
 Functional Consideration
• Three factors that influence joint function and arthritis risk
– Joint incongruity
• Increase contact stress of joint
• + instability -> abnormal movement
– Malalignment
• Shift loading pattern of joint articular surface -> Progression of arthritis
• New point of contact is maladapted to cartilage loading
– Instability (Fracture, ligament, or meniscal injury)
• Example:
– Posterior acetabulum wall fracture -> Posterior dislocation
– Excision of meniscus in tibial plateau fracture -> Osteoarthritis development

• Restoration of anatomical axis, articular surface, and joint

stability is crucial for joint preservation
• Current philosophy of operative treatment
– Plaster cast immobilization -> Joint stiffness
– Plaster cast immobilization AFTER ORIF -> Worse stiffness
– Depressed and impacted central articular fragment can not be
resolved with traction and closed manipulation
– Anatomical reduction and stable fixation of articular fragment
is necessary
– Metaphyseal defect must be grafted to avoid fragment re-
displacement
– Metaphyseal and diaphyseal displacement must be aligned
– Early motion -> Prevent stiffness and maximize healing
 Mechanism of Injury
• 2 Main mechanisms
– Indirect application of force (Partial articular fracture)
• Bending movement -> articular surface into opposing surface
• Ligament resist eccentric load, convert into axial overload

– Direct application of force

• Axial transmission of force into diaphysis
• Causes complete multifragmentary articular fracture and sever
soft tissue injury
 Clinical Evaluation
• Most commonly caused by high energy trauma
– High risk of polytrauma
– Assess life threatening injuries!
• Systematic joint injury assessment
– Soft tissue surrounding joint
• Open (Laceration, degloving, synovial fluid leakage)
• Closed
– Position of bones (Subluxated / dislocated / normal alignment)
– Ligament injury
• Tenderness
– Vascular status
• Distal pulse, capillary refill time, ankle-brachial index
– Neurological examination
– Sign of compartment syndrome
 Radiologic Evaluation
• Must not delay initial assessment and primary joint
stabilization
• Simple fracture = Rule of two
• Complex fracture + 45o oblique view
– Extensive fragmentation -> Traction view
• Detect
– Displacement and fragmentation
– Impaction and deression
• CT-scan
– Pre-op for better and more detailed view
– Post-op to assess articular alignment
 Indication for Operation
• Free and painless joint function is crucial for limb function restoration
• Absolute indication
– Open fracture
– Irreducible fracture dislocation
– Associated neurological injury (compression)
– Associated vascular injury
– Sign of compartment syndrome
• Relative indication
– Displaced articular surface > 2 mm
– Loose fragment within joint
– Instability of joint
– Displacement of mechanical axis
 Early Mobilization
• Immobilization -> stiffness and cartilage
degeneration
• Continuous passive motion facilitated cartilage
repair
 Nonoperative Treatment
• Indications
– Nondisplaced fracture
– Noncompliant patient
– Significant comorbidities
– Heavy smoker
• Always balance risk – benefit for every surgery
 Principle of Operative Treatment - Timing

• According to patient physiologic response to

resuscitation
• Damage-limitation surgery
– Only if:
• Vascular injury
• Severe contamination
• Compartment syndrome
– Delay complex fracture reconstruction (day 5-10)
– Early fracture fixation for patient who respond well to
resuscitation
• Isolated injury of joint with swelling /
hemorrhage -> Evacuate hemorrhage
immediately
• Open contamination -> Early debridement and
irrigation (< 6 hours)
• Swollen / traumatized soft tissue surrounding
joint -> delay definitive surgery
– Temporary stabilization with external fixator and
maintain alignment
– Definite fixation when patient condition stabilize
and soft tissue is adequately healed
 Principle of Operative Treatment –
Preoperative Planning
• Adequate x-ray analysis
• Decide details on procedure
– Position, approach, reduction tactic, instruments,
implants, need for intra-operative x-ray
• Detailed steps and surgical tactics
Principle of Operative Treatment – Reduction
and Fixation Technique
• Indirect reduction with traction and ligamentotaxis
– Soft tissue attached to fragment
• Direct reduction
– Impacted central articular fragment
– Free fragment within joint
• Fragments should be cleared of hematoma and early callus
• All fracture should be retained
• Osteochondral fragments should be removed
• Impacted osteochondral fragments should initially not yet be
elevated
• Debris should be cleared before traction
• If stability is inadequate, use large distractor /
external fixator to maintain distraction and axial
alignment and allow indirect reduction of fragment
• Use osteotome or elevator to elevate impacted
fragment
• Use intact surface as a template
• Fill remaining defect with bone graft / substitute
– Structural support
– Stimulate reconstruction
• Confirm reduction before fixation
– Intraoperative x-ray
– Direct inspection
• Arthrotomy
• Arthroscopy
• Once reduction is satisfactory -> Fixation
– Lag screw
– Don’t over compress small fragments
• Use fully threaded position screws
• “Rafting technique” with locking head screw and plate
 Principle of Operative Treatment – Articular Fracture
with Metaphyseal/Diaphyseal Extension

• Once articular block has been reduced and

fixated -> correct alignment of diaphysis
• Stable fixation for early mobilization
– Plate
– External fixator
– IM nail with locking bolt
– Bone graft if necessary
• Reduce according to biology. Don’t compromise
soft tissue and fragment vascularization.
Principle of Operative Treatment – Soft-tissue
Repair
• Torn ligament impede reduction and cause
instability
• Torn meniscus of knee cause severe instability
• Treatment of soft tissue according to joint
– Meniscus repair strongly adviced
 Postoperative Treatment
• Isometric muscle exercise started at day 1
• Removable splint to maintain position
– Don’t risk early mobilization
• Limited weight-bearing (10-15 kg) 6-8 weeks after
surgery
• Regular x-ray
– Assess fixation
– Guide rehabilitation
– Guide intervention if needed
 Outcome
• Aim of surgical management
– Anatomical reduction
– Axial alignment Early mobilization
– Stable fixation
• Decide surgery according to patient condition and soft tissue
• Intraarticular fracture management require
– Experience
– Well-designed plan
– Good surgical skill
• Intraarticular surface reduction is important to prevent
osteoarthritis