The impact of proximal fibula fractures in the prognosis of tibial plateau fractures: a novel classification

Fifty-five patients who presented with the complaint of tibia plateau fractures between January 1998 and November 2001 were retrospectively evaluated. The evaluation was based on their treatment modality. Twenty-five conservatively-treated patients (group 1) and 30 surgically-treated patients (group 2) were evaluated. In group 1, seven patients with proximal fibula fractures had lateral hamstring tightness. Five out of these seven patients had concomitant lateral knee pain. Similarly, nine patients with proximal fibula fractures in group 2 had lateral hamstring tightness, and seven patients in the same group suffered from lateral knee pain. The patients with no fibula proximal fracture in both groups had no hamstring tightness or lateral knee pain. The proximal fibula in the knee joint and its anatomical structures are of utmost importance for the anatomical integrity of the knee and its normal functions. The fibula has rich anatomical relations, some of which are important structures of the knee. These anatomical structures and the fibula provide stability of the knee joint and its functions as well as being an important mechanical support to the knee joint. Therefore, the knee joint will receive the negative effects from the pathologies of the bone or soft tissue that may occur in fibula fractures.

Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures

OBJECTIVES

Current data show smoking is associated with a number of complications of the fracture healing process. A concern, however, is the potential confounding effect of covariates associated with smoking. The present study is the first to prospectively examine time to union, as well as major complications of the fracture healing process, while adjusting for potential confounders.

SETTING

Eight Level I trauma centers.

PATIENTS

Patients with unilateral open tibia fractures were divided into 3 baseline smoking categories: never smoked (n = 81), previous smoker (n = 82), and current smoker (n = 105).

OUTCOME MEASURE

Time to fracture healing, diagnosis of infection, and osteomyelitis.

METHODS

Survival and logistic analyses were used to study differences in time to fracture healing and the likelihood of developing complications, respectively. Multivariate models were used to adjust for injury severity, treatment variations, and patient characteristics.

RESULTS

After adjusting for covariates, current and previous smokers were 37% (P = 0.01) and 32% (P = 0.04) less likely to achieve union than nonsmokers, respectively. Current smokers were more than twice as likely to develop an infection (P = 0.05) and 3.7 times as likely to develop osteomyelitis (P = 0.01). Previous smokers were 2.8 times as likely to develop osteomyelitis (P = 0.07), but were at no greater risk for other types of infection.

CONCLUSION

Smoking places the patient at risk for increased time to union and complications. Previous smoking history also appears to increase the risk of osteomyelitis and increased time to union. The results highlight the need for orthopaedic surgeons to encourage their patients to enter a smoking cessation programs.

Open reduction and internal fixation of 117 tibial plateau fractures

This retrospective study evaluated the surgical management of 117 tibial plateau fractures treated between 1990 and 1998. At last patient follow-up, results were rated good to excellent in 94, fair in 13, and poor in 10 cases. Follow-up radiographs showed degenerative changes in the lateral compartment in 29 cases. Other complications included five wound infections, two deep venous thromboses, five delayed unions, and three nonunions. Operative treatment of tibial plateau fractures is recommended as it enables better alignment, meniscal access, and other soft-tissue injury repair.

Tibial plateau fractures: evaluation with multidetector-CT

PURPOSE

To evaluate the role of Multislice CT (MSCT) in classifying tibial plateau fractures and deciding on the appropriate therapeutic treatment compared to conventional radiology.

MATERIALS AND METHODS

Twenty-five patients with a clinical diagnosis of tibial plateau fracture were studied with plain film and MSCT. The CT images were reconstructed with MPR and 3D technique and the fractures classified according to the Swiss AO-ASIF classification. The following radiographic and CT parameters were used: fracture location and size, number of fragments or degree of depression of fracture; plateau area involved; surgical access; degree of osteoporosis and bone tissue loss.

RESULTS

The plain film and MSCT classification showed agreement in 48% of cases and disagreement in 52%. MSCT better demonstrated disruption of the tibial plateau surface and showed a larger number of fragments. In 60% of patients the CT features led the orthopaedist to modify the treatment. In three patients CT demonstrated bone tissue loss, suggesting for bone graft. In four patients CT showed alteration of the bone architecture and suggested the use of different material for osteosynthesis. Compared to axial CT, the MSCT MPR and 3D reconstructions enabled a more accurate assessment of plateau depression, and of rotation and separation of the fragments. The 3D technique proved better than MPR in evaluating rotation of fractured fragments as it provides an overall view as well as the possibility of rotating the bone segments.

CONCLUSIONS

MSCT and 3D reconstructions are very useful for classifying tibial plateau fractures and for preoperative assessment. Patients with clinical evidence of fracture might benefit from an examination with CT instead of conventional radiology.

Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique

OBJECTIVES

Single incision open reduction and double plate fixation of complex tibial plateau fractures has been associated with high wound complication rates. Minimally invasive methods have been recommended to decrease the wound complication rates as compared with open techniques. Additionally, laterally applied fixed-angle devices appear to minimize late varus deformity without the need for additional medial stabilization. Accurate reduction of comminuted lateral and/or medial articular surfaces, however, often requires visualization through an open reduction. This study reports the complications, infection rate, and radiographic assessment of reduction associated with double plating complex AO/OTA 41-C3 tibial plateau fractures utilizing 2 incisions.

DESIGN

Retrospective clinical review.

SETTING

Urban level 1 university trauma center.

PATIENTS

Over a 77-month period, 83 patients were treated for a complex bicondylar tibial plateau fracture at our institution utilizing a 2-incision technique.

INTERVENTION

Dual plating using anterolateral and posteromedial incisions.

MAIN OUTCOME MEASURE

Type and incidence of septic and non-septic complications and radiographic assessment of articular reduction and axial alignment.

RESULTS

Eleven fractures were open (13.3%) and classified according to Gustilo as type II (1 patient), type III-A (7 patients), type III-B (2 patients), and type III-C (1 patient). Compartment syndrome was diagnosed and treated with fasciotomies in 12 patients (14.5%). The average time interval from injury to definitive surgical treatment was 9 days. Seven patients developed deep wound infections (8.4%). Three of these had an associated septic arthritis (3.6%). Clinical resolution of infection occurred after an average of 3.3 additional procedures. The presence of a dysvascular limb requiring vascular reconstruction was statistically associated with a deep wound infection (P = 0.006). Secondary procedures for complications included 13 patients who required removal of implants secondary to local discomfort, 5 patients who required a knee manipulation, 2 patients that were managed with excision of heterotopic ossification to improve knee motion, 1 patient that required an equinus contracture release, and 1 patient treated for a metadiaphyseal nonunion. Sixteen patients (19.3%) incurred deep venous thromboses. No patient was diagnosed with pulmonary embolism. Sixty-two percent of patients demonstrated satisfactory articular reductions, 91% demonstrated satisfactory coronal alignment, 72% demonstrated satisfactory sagittal alignment, and 98% demonstrated satisfactory condylar width.

CONCLUSIONS

Comminuted bicondylar tibial plateau fractures can be successfully treated with open reduction and medial and lateral plate fixation using 2 incisions. Dysvascular limbs requiring vascular repair are at increased risk for deep sepsis. The use of 2 incisions, temporary spanning external fixation, and proper soft-tissue handling may contribute to a lower wound complication rate than previously reported.

[Clinical research of Schatzker type IV tibial plateau fracture]

OBJECTIVE

To study the characteristic, treatment and prognosis of tibial plateau fracture Schatzker type IV.

METHODS

According to the roentgenogram and CT scan in 51 patients, Schatzker type IV injury is divided into 3 types: split, total condylar, depression. In the treatment of split and total condylar injury, if there was no articular depression on CT scan, reduction is done through medial approach; if CT scan demonstrated articular depression, middle approach was used to reduce the depression and bone graft. In split injury, buttress plate was fix on posterior-medial side. In total condylar injury, buttress plate is fix on medial side. In depression injury, fracture was reduced through medial approach, bone graft and buttress plate was fix on medial side. Thirty-three patients were followed up in 41 months averagely. And the statistical analysis was done.

RESULTS

The average Lysholm score of 33 patients was 83.2. Eight patients were excellent, 9 were good, 14 were fair, 2 were poor. The range of motion from 30 degrees to 147 degrees (average 110 degrees ). The factors that caused bad results were: the fracture was not anatomical reduced; tibial plateau is more than 4 mm wider than femoral condylar or lateral subluxation exceed 8 mm; varus deformity of knee. They also caused the increase of osteoarthritis.

CONCLUSIONS

In order to get anatomical reduction and stable fixation, the approach and fix pattern should be chosen on the bases of classification and CT scan of Schatzker IV injury. The factors which influence the prognosis are: (1) tibial plateau is more than 4mm wider than femur condylar, or lateral subluxation more than 8 mm; (2) Varus deformity. Attention should be paid to avoid these during operation.

Treatment of complex tibial plateau fractures using the less invasive stabilization system plate: clinical experience and a laboratory comparison with double plating

BACKGROUND

Bicondylar tibial plateau fractures are complex injuries, historically associated with high complication rates. The purpose of this study was: 1) to evaluate the clinical use L.I.S.S plating system for stabilization of bicondylar tibial plateau fractures. 2) To compare the biomechanics of this plating system with a double plate construct.

METHODS AND MATERIALS

Thirty-eight patients who sustained a complex tibial plateau fracture (OTA type 41C) at one of three level-one trauma centers were stabilized using the Less Invasive Stabilization System (L.I.S.S.). The cohort of patients was evaluated clinically and radiographically for outcomes at a mean 15 months. In phase 2 of this study a model of a bicondylar tibial plateau fractures was made in six matched pairs of embalmed, human tibia and randomized to fixation with either a L.I.S.S plate or a standard double plate construct. The tibias were then subjected to an axial cyclic load of 500N for 10 cycles (3Hz) to approximate 2 months in vivo and displacements measured.

RESULTS

Thirty-six of /38 (95%) patients united at 4 months after surgery with no loss of fixation nor infection. Two patients underwent prophylactic autogenous bone grafting for bone loss and united by 3 months postgrafting. Significant loss of knee range of motion (<90) was seen in five patients.Biomechanically, no differences in permanent inferior displacement of the medial fragment were found in initial axial loading and after 10 cycles between the two plate constructs. However, when loaded to 500N the L.I.S.S plate construct demonstrated almost twice the displacement of the medial fragment compared with the dual plate construct. No specimen lost fixation during cycling.

CONCLUSION

The L.I.S.S plating system provides stable fixation of complex bicondylar tibial plateau fractures allowing early range of knee motion with favorable clinical results.

The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: short-term results

OBJECTIVES

To report on the use of a new plating system in the treatment of high-energy tibial plateau fractures using minimally invasive stabilization techniques.

DESIGN

Prospective, consecutive patient series.

SETTING

University Level I trauma center.

PATIENTS

Thirty-seven patients with 39 fractures of the tibial plateau were treated using specialty plates. All fractures were OTA class 41C. Ten of the fractures were open, including eight Gustilo and Anderson Type IIIA and two Type IIIB. Thirty-three patients with 34 fractures had follow-up of at least 12 months.

INTERVENTION

Internal fixation with the Less Invasive Stabilization System (LISS, Synthes USA, Paoli, PA) using minimally invasive techniques. MAIN OUTCOME MANAGEMENT: To determine clinical outcome, time to union, fracture alignment, articular step-off, incidence of complications, Short Form-36 outcome scores, and Lysholm knee scores in patients with associated ligament injuries.

RESULTS

All 34 of the fractures healed without additional surgical intervention or bone grafting. The mean follow-up in our series was 21 months, with a range of 12 to 38 months. Twenty-nine patients with 30 fractures had follow-up of greater than 1 year. The average time to radiographic callus was 6.1 weeks, and the average time to complete union was 15.6 weeks. The articular step-off average was 0.8 mm, with a range of 0 to 5 mm. The postoperative alignment demonstrated 1 patient with a malalignment of 5 degrees procurvatum and 1 patient with 4 degrees of valgus. There were two superficial wound infections and no cases of deep infection or osteomyelitis.

CONCLUSIONS

The use of LISS plates appears to stabilize complex fractures of the tibial plateau with a low incidence of complications. The LISS system functioned well in maintaining alignment and obtaining union in these high-energy fractures.

Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system

OBJECTIVE

Proximal tibia fractures with metaphyseal comminution present a difficult treatment challenge. The Less Invasive Skeletal Stabilization (LISS) internal fixator system has theoretical advantages (minimally invasive fixed angle construct) for the treatment of these injuries. This report presents clinical results of the LISS system for treatment of complex proximal tibia fractures and illustrates the unique properties of the system.

DESIGN

Prospective clinical trial.

SETTING

Level I trauma center.

PATIENTS

Twenty-eight consecutive patients with comminuted proximal tibia metaphyseal fractures (41A3, 41C2, or 41C3) treated with LISS plates.

OUTCOME MEASUREMENTS

Healing, fracture alignment, infectious and implant-related complications, and functional outcome based on the Lower Extremity Measure (LEM).

RESULTS

Average follow-up was 23 months (range 12-48). Thirty-seven of 38 patients healed their fracture after the index procedure. The other healed after implant removal without the need for further fracture repair. Postoperative fracture alignment was satisfactory in 37 of the 38 cases and was maintained in all patients at union. There were no infectious complications. The average LEM score was 88.

CONCLUSIONS

The LISS internal fixator system can be used successfully to treat complex proximal tibia fractures without the need for additional medial stabilization. Surgeons attempting to use fixed angle internal fixation plating systems should familiarize themselves with the significant technical differences between these and traditional plating systems to assure satisfactory results.

Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures

OBJECTIVE

To summarize the surgical experience and clinical results of the first 89 fractures of the proximal tibia treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA).

DESIGN

Retrospective analysis of prospectively enrolled patients into a database.

SETTING

Academic level I trauma center.

SUBJECTS/PARTICIPANTS

Eighty-seven consecutive patients with 89 proximal tibia fractures (AO/OTA type 41 and proximal type 42 fractures) treated by 2 surgeons. Seventy-five patients with 77 fractures were followed until union. The mean follow-up was 14 months (range: 3-35 months). There were 55 closed fractures and 22 open fractures.

INTERVENTION

Surgical reduction and fixation of fractures, followed by rehabilitation.

MAIN OUTCOME MEASUREMENTS

Perioperative and postoperative complications, postoperative alignment, loss of fixation, time to full weight bearing, radiographic union, and range of motion.

RESULTS

Seventy of 77 fractures healed without major complications (91%). There were 2 early losses of proximal fixation, 2 nonunions, 2 deep delayed infections, and 1 deep peroneal nerve palsy. Other complications included a superficial wound infection and 3 seromas. Postoperative malalignment occurred in 7 patients with 6 degrees to 10 degrees of angular deformity (6 flexion/extension and 1 varus/valgus malalignments), and an eighth patient had a 15 degrees flexion deformity. In 4 patients, the hardware was removed at an average of 13 months because of irritation (5%). The mean time for allowance of full weight bearing was 12.6 weeks (range: 6-21 weeks), and the mean range of final knee motion was 1 degrees to 122 degrees .

CONCLUSIONS

The LISS provides stable fixation (97%), a high rate of union (97%), and a low (4%) rate of infection for proximal tibial fractures. The technique requires the successful use of new and unfamiliar surgical principles to effect an accurate reduction and acceptable rate of malalignment.

Die Anwendung des injizierbaren Knochenzements Norian�SRS bei Tibiakopffrakturen

Reduction of the depressed joint surface in tibial plateau fractures often leaves large cancellous bone defects. These metaphyseal voids are typically filled with autogenous bone grafts that can cause a significant donor site morbidity. The use of injectable bone cement offers the opportunity to support the reduced joint surface without bone grafting. The aim of this study was to evaluate the clinical and radiological outcome as well as the period of partial weight bearing after the use of Norian SRS in tibial plateau fractures. Twenty-one patients with a mean age of 48 years were included in this prospective trial. According to the AO/OTA Classification, there were seven fractures of type B2, ten B3, one C1, one C2, and two fractures of type C3. The period of partial weight bearing was 3.7 weeks. In 18 patients the follow-up was more than 24 months. After a mean follow-up of 30 months, the Lysholm score was 87.9 at mean. The radiological part of the Rasmussen score was excellent and good in eight cases each and fair in four cases. Soft tissue reactions due to the cement were not observed. On all radiographs taken 36 months after the operation the cement bloc was still visible. The results show that Norian SRS can be used to fill metaphyseal bone defects in tibial plateau fractures. Clinical and radiological results are comparable to those of fractures treated with autologous bone graft. The high compression strength allows early full weight bearing without the risk of secondary loss of reduction.

Injury severity assessment in tibial plateau fractures

Assessment of injury severity is an integral component of the care of the patient with a fracture of the tibial plateau. Devising ways to reliably quantify injury severity, and to make predictive links between injury severity and outcome, however, has been difficult. Assessment of patient-related factors, such as age, functional capabilities, and medical comorbidities, are necessarily subjective, but certain of these factors clearly shape the treatment plan for a patient with a tibial plateau fracture. Clinical examination findings, such as extent of soft tissue injury and mediolateral stability of the knee, also play an important role in determining treatment and predicting outcome. Radiographic classification of tibial plateau fractures also is an important determinant of treatment, but current classification systems have suffered from disappointing interobserver reliability. Although the severity of injury to the articular cartilage almost certainly affects outcome, there currently are no validated modalities to measure this important factor. More carefully validated tools are needed in many of these areas if we are to perfect our understanding of injury severity and establish more accurate correlations between injury severity and outcomes.

Vorteile der minimal-invasiven Reposition, Retention und Ilizarov-(Hybrid)Fixation bei Pilon-tibiale-Frakturen unter besonderer Ber�cksichtigung von C2-/C3-Frakturen

Between October 1993 and September 1999 a total of 62 tibial pilon fractures in 59 patients were treated at the Clinic for Trauma and Reconstructive Surgery, University Hospital Carl-Gustav-Carus, Technical University Dresden. In a retrospective study 49 patients with 50 tibial pilon fractures (81%) could be examined an average of 28 months after injury. The purpose of this study was to compare clinically and radiographically the healing results obtained after using the Ilizarov technique in combination with minimally invasive internal fixation (group I) with those after a conventional surgical procedure (internal fixation with a plate, external fixation with or without minimally invasive internal fixation, and screw fixation exclusively, group II) and to evaluate the efficacy of the Ilizarov technique. Data analysis showed a significantly higher incidence of 43 C2/C3 fractures in Ilizarov group I (73%) than in group II (33.3%). Severe soft tissue injuries and particularly open injuries had a significantly higher incidence in Ilizarov group I (100%) than in group II (38%). Despite the high incidence of C2/C3 fractures and severe soft tissue injuries in group I, there was no incidence of pseudarthrosis or osteitis in the further course and there was no need for arthrodesis during the long-term course. After therapy with a conventional surgical technique, the incidence of osteitis was 5% and of delayed union of a fracture 2.5% and arthrodesis was necessary in 8%. A disadvantage of the Ilizarov system was the relatively frequent incidence of pin infection (45%) necessitating surgical debridement in 18%. The efficacy of the treatment of 43 C2/C3 fractures with the Ilizarov technique was obvious by a statistically significantly better Maryland Foot Score in comparison with group II. More than 87% of the patients treated with the Ilizarov technique and only 38% of the patients treated with a conventional surgical procedure obtained a very good or good score. According to these findings, the Ilizarov technique in combination with minimally invasive internal fixation is an effective method to treat complicated tibial pilon fractures with severe soft tissue trauma.

Long-Term Results of Multiple-Stage Treatment for Posttraumatic Osteomyelitis of the Tibia

BACKGROUND

The treatment of posttraumatic osteomyelitis of the tibia requires meticulous debridement and adequate soft tissue coverage. At our institution, we perform a staged procedure consisting of surgical debridement followed by muscle coverage. If necessary, implantation of a cancellous iliac bone graft was always performed as a three-stage treatment.

METHODS

We performed a retrospective analysis of 47 patients treated for posttraumatic osteomyelitis of the tibia between 1987 and 1998.

RESULTS

Twenty-two patients originally had a Gustilo grade III fracture, 21 patients had a Gustilo grade I or II or closed fracture, the Gustilo grade was not known for 2 patients, and 2 patients had no fracture. Using the Cierny-Mader classification, most patients had a localized osteomyelitis. To cover the debrided area, 20 pedicled muscle transfers and 28 microvascular free flaps were used; one patient had two localizations of osteomyelitis (both proximal and distal) and received two muscle flaps. Flap failure was 8% and was successfully treated by additional flap coverage in two cases; one was closed by a split skin graft and one was closed by secundum. Twenty-six patients received a cancellous bone graft. During an average follow-up of 94 months, 9% had a recurrence of osteomyelitis for which additional surgical interventions were necessary. Finally, all the infections were eventually cured.

CONCLUSION

Our staged surgery proved to be an excellent method of treating osteomyelitis after open or closed fractures of the tibia.

The nomenclature for intra-articular vertical impact fractures of the tibial plafond: pilon versus pylon

Although most of the controversy surrounding the treatment of intra-articular, vertical impact fractures of the lower tibia is due to the difficult clinical problems they pose, there is a minor, ongoing dispute regarding nomenclature. In the last several decades, these fractures have been called either pilon or pylon fractures. This study traces the etymology of both terms and relates them to their usage in the orthopaedic literature. Based on the origins of each word, and how they were introduced into the orthopaedic literature, it is concluded that the correct term for an intra-articular, vertical impact fracture of the lower tibia is pilon fracture.

Pilon-tibiale-Frakturen

In the AO classification, the distal tibia is 43 and A type injuries are extra-articular, B type partial articular and C type involve the whole of the articular surface with complete separation of the joint from the diaphysis. The term pilon fracture should be confined to B(3) and C type fractures. The injury mechanism of pilon fractures will vary from a simple fall to a high energy road traffic accident, leading to increasing fracture comminution and greater soft tissue injury with more open fractures. Plain radiographs and CT-scans are diagnostic prerequisites. A spanning external fixator, with or without fixing the fibula, is the initial method of choice. The goal is to span the zone of injury with the fixator, to align the limb, to reduce the articular surface through very limited approaches, and to minimize complications related to treatment to maintain length and provisionally align the fracture. When soft tissue swelling has subsided definitive stabilization is performed. Bone grafting of defects is rarely necessary.

Elevated intramuscular compartment pressures do not influence outcome after tibial fracture

BACKGROUND

Although the importance of monitoring differential compartment pressures (Delta P) after tibial fractures has been established, many surgeons continue to use intramuscular pressures in diagnosing compartment syndrome, despite the limitations of this strategy. The cited reason for this is concern over leaving high intramuscular pressures untreated.

METHODS

One hundred one patients with tibial fractures with satisfactory Delta P were studied. Forty-one patients had elevated intramuscular pressures of over 30 mm Hg for more than 6 hours continuously. These patients were compared with a control group of 60 patients who had pressures of less than 30 mm Hg throughout. Outcome was measured prospectively in terms of muscular power and return to function over the year after injury.

RESULTS

No significant differences were found.

CONCLUSION

Provided Delta P remains satisfactory, patients with elevated intramuscular pressures after tibial fracture do not have a greater incidence of complications than those with low pressures. These patients can therefore be observed safely.

Periprosthetic fractures of the tibia and patella in total knee arthroplasty

Periprosthetic fractures of the tibia and patella associated with total knee arthroplasty are less common than periprosthetic fractures of the distal femur and therefore have been less frequently reported in the literature. Because more total knee replacements are now being performed and implant and patient survival has improved, periprosthetic fractures of the tibia and patella may be recognized more frequently in association with both primary and revision total knee replacement. Several risk factors associated with both types of fractures have been identified, and addressing patient factors, surgical techniques, and implant designs that may contribute to increased risk is an important aspect of management.

Outcomes in open tibia fractures: relationship between delay in treatment and infection

BACKGROUND

Emergent irrigation and debridement has been accepted as a mainstay of open fracture treatment. The purpose of this study was to evaluate the infectious outcome of open tibia fractures relative to the time from injury to operative irrigation and debridement.

METHODS

One hundred seventy-eight patients with 191 consecutive fractures were retrospectively reviewed. Of these, 103 patients with 106 fractures were available for this study, with an average follow-up of 10.23 months.

RESULTS

Results revealed 21.7% type I fractures, 43.4% type II fractures, 16.0% type IIIa fractures, 11.3% type IIIb fractures, and 7.5% type IIIc fractures. Of all fracture types, 22.6% became infected and 5.7% went on to have osteomyelitis. The average time to treatment was not significantly different in infected versus noninfected fractures across fracture types. No infection occurred when the time to surgery was within 2 hours; however, no significant increase in infection was discovered with respect to patients treated after 6 hours compared with those treated within 6 hours.

CONCLUSION

The results support the Gustilo grading system of open fractures as a significant prognostic indicator for infectious complication. We continue to support the emergent treatment of open tibia fractures.

Combined physeal/apophyseal fracture of the proximal tibia with anterior angulation from an indirect force: report of 2 cases

Physeal fracture of the proximal tibia is a rare injury, comprising less than 2% of all physeal injuries. The literature distinguishes between tibial tubercle avulsions (apophyseal injuries) classified by Ogden, Tross, and Murphy as type I, II, and III and Salter-Harris II fractures. An extensive review of the literature located only 5 cases in which patients sustained a combined fracture of the proximal tibial physis and tibial tubercle. We report 2 such cases, which are not amenable to classification by current systems, and agree with Ryu and Debenham's suggestion to add a fourth type, avulsion hinge fracture of the proximal tibial epiphysis, to the Watson-Jones/Ogden classification.