The epidemiology of diaphyseal fractures of the tibia

AO Documentation collected reports of nearly five thousand diaphyseal tibial fractures occurring in the 1980s. The following conclusions can be drawn: i. The number of fractures affecting men is twice that affecting women. ii. These fractures occurred mainly in younger people (under 40 years of age) and no increase occurred in elderly people. iii. Most bending fractures occurred in young men (20-30 yrs) and the torsion fractures affected men and women of about 40 equally. iv. The number of simple fractures (type A) is about the same as for fractures with one fragment (type B).

The point of view of the clinician: a prospective study of the mechanism of accidents and the morphology of tibial and fibular shaft fractures

In a prospective study of 210 tibial shaft fractures, the accident mechanisms and the resultant fracture morphologies were analyzed. 86 fractures occurred due to indirect impact. The fracture morphology in this group consisted of short and long spiral fractures resulting from rotational injuries complicated by anterior torsion butterfly fragments if the person fell forward, posterior torsion butterfly fragments if they fell backwards and complicated by multiple torsion butterfly fragments if it was a high velocity injury. 124 fractures occurred due to direct impact. The fracture morphology in this group consisted of transverse, oblique segmental or crush fractures, complicated by one or more butterfly fragments due to bending, the injury depending on whether it was pure, one-point, three-point, or four-point-bending and on additional axial loading and velocity. In the indirect impact group, there were a few soft tissue injuries and fibular fractures at a different level to the tibial fracture. In the direct group, a large number of soft tissue injuries and fibular fractures at the level of impact were found.

Radiographic fracture assessments: which ones can we reliably make?

OBJECTIVE

To identify the fracture characteristics that can be reliably assessed by analysis of plain radiographs of tibial plateau fractures.

DESIGN

Radiographic review study.

PARTICIPANTS

Five orthopaedic traumatologists served as observers.

INTERVENTION

Observers made assessments based on the radiographs of fifty-six tibial plateau fractures. Precise definitions of the assessments to be made were agreed on by all observers. The tested assessments included raters' abilities to identify and locate fracture lines, identify the presence of fracture displacement and comminution, make quantitative measurements of displacement, and characterize qualitative features of fractures. For thirty-eight of the fractures that had a computed tomography (CT) scan available, assessments were repeated using both radiographs and CT scans.

MAIN OUTCOME MEASURES

To characterize interobserver reliability, percentage agreement and kappa statistics were calculated for categorical variables, and intraclass correlation coefficients (ICC) were calculated for noncategorical variables.

RESULTS

Reliability of the assessments varied widely. Determining the location of fracture lines had the greatest reliability, whereas the subjective assessments of fracture stability and energy showed the poorest reliability. Although the ICCs for quantitative measurements approached acceptable levels, the tolerance limits were extremely wide. The addition of a CT scan improved the reliability of most assessments, but not to a statistically significant degree.

CONCLUSIONS

Many basic radiographic interpretations relied on in making treatment decisions are made variably by observers. Using experienced raters and precise definitions of fracture assessments does not guarantee a high level of agreement. Discrete assessments have higher interrater agreements than do more qualitative assessments. Quantitative measures have wide tolerance limits and, therefore, probably cannot be used reproducibly to classify fractures or make treatment decisions. We conclude the reliability of fracture classification is limited by raters' abilities to agree on basic radiographic assessments.

[Magnetic resonance tomography in the diagnosis of intra-articular tibial plateau fractures: value of fracture classification and spectrum of fracture associated soft tissue injuries]

PURPOSE

To compare magnetic resonance imaging (MRI) and X-ray tomography in assessing the type of fracture, degree of comminution and amount of articular surface depression in acute tibial condylar fractures and to describe the associated soft tissue injuries diagnosed with MRI.

METHOD

27 patients with acute tibial plateau fractures were investigated using linear X-ray tomography and MRI employing T1-weighted and proton density turbo spin echo, STIR, and T2-weighted gradient echo images. Fractures were classified according to the AO classification system. The degrees of depression and comminution were measured and soft tissue injuries were recorded.

RESULTS

Fractures were classified as type B1 in 7, as B2 in 6, and as B3 in 6 cases by MRI. More complex C-type fractures were diagnosed in 8 cases. MR and X-ray grading were consistent with the exception of two B3 fractures, which were graded as B1 by X-ray tomography. X-ray tomography under-estimated the degree of comminution 63% of the patients had either meniscal tears or complete ruptures of their cruciate or collateral ligaments. Ten meniscal tears were diagnosed in 9 of 27 patients. Complete tears of the anterior cruciate ligament were seen in 4, and avulsions of the posterior cruciate ligament in 2 patients.

CONCLUSION

MRI allows a detailed assessment of acute tibial plateau fractures and can replace conventional X-ray tomography. The high rate of fracture-associated soft tissue lesions makes MRI an especially valuable tool.

Which displaced spiral tibial shaft fractures can be managed conservatively?

The aim of the present study was to establish a threshold for the initial displacement of a spiral tibial shaft fracture beyond which its retention in an acceptable position cannot be guaranteed by plaster immobilization. We reviewed the records and radiographs of 131 plaster cast-treated patients with spiral tibial shaft fracture, initially displaced 50% or less, for patients whose fracture had either lost its acceptable retention or consolidated in an unacceptable position. The fractures were classified, according to the true initial displacement as measured on the first radiographs, into four pairs of categories using cut-off points of 10, 20, 30 and 40% of the diameter of the tibial diaphysis. Comparison was then made of the proportions of failed treatments between each of these pairs. Plaster cast treatments failed in 28% when the true initial displacement was 30% or less, and in 46% when the true initial displacement was more than 30%. The risk of failed plaster cast treatment increased when true initial displacement exceeded 30%. In all patients whose plaster cast treatment was interrupted the true initial displacement was more than 30%. We therefore conclude that diaphyseal fractures of the tibia for which the initial displacement exceeds 30% are not suitable for plaster cast treatment.

Complications after treatment of tibial pilon fractures: prevention and management strategies

Complications after treatment of tibial pilon fractures can occur intraoperatively or in the early or late postoperative period. Perioperative complications include malreduction, inadequate fixation, and intra-articular penetration of hardware, all of which may be minimized by preoperative planning and meticulous operative technique. Wound complications can lead to deep infection, with potentially catastrophic consequences. The incidence of wound complications may be lessened by delaying surgery 5 to 14 days, until the posttraumatic swelling has subsided. Temporary fixation with a medial spanning external fixator is recommended if definitive internal fixation is delayed. Fracture blisters should be left undisturbed until the time of surgery. Incisions through blood-filled blisters should be avoided whenever possible. Limited incisions to achieve reduction and fixation should be made directly over fracture sites, to minimize soft-tissue stripping. An indirect reduction technique involving the use of ligamentotaxis and low-profile small-fragment implants that minimize tension on the incision should be used. Late complications, such as stiffness and posttraumatic arthritis, correlate with the severity of the initial injury and the accuracy of reduction. Loss of ankle motion can be minimized by early range-of-motion exercise after stable fixation has been achieved. Posttraumatic ankle arthrosis should be initially treated with anti-inflammatory medication, activity modification, and walking aids. Symptomatic patients often require an ankle arthrodesis.

Functional outcome of patients with salvageable limbs with grades III-B and III-C open fractures of the tibia

Numerous reports list predictive criteria to determine whether Gustilio-type tibial III-B and III-C fractures of the tibia are salvageable. What is lacking are long-term reports of comprehensive functional outcome of these severe injuries. We evaluated the functional outcome of patients with our own seven-scale score. Fifty-four patients with 57 types III-B (n = 41) and III-C (n = 16) open tibial fractures sustained between 1980 and 1989 were recalled for evaluation. There were 45 men and 9 women (average age, 28.4 years; range, 4-68 years). Follow-up periods averaged 48.2 months (range, 12-116 months). Salvage rate for the III-B fractures was 75% (n = 31) and for the III-C fractures 37% (n = 6). We conclude that the functional score is a simple and complete method for assessing the functional outcome of patients undergoing limb salvage procedures.

Tibial plateau fractures. A new classification scheme

Fractures of the tibial plateaus are common injuries. Various classification schemes have been used to describe these injuries. Although each system has its own purpose, the simpler systems do not allow comparison with more complex divisions. The problem is compounded by the variable use of adjectives that describe these fractures. A comprehensive classification of tibial plateau fractures should group fractures that are similar in topography, morphology, and pathogenesis, requiring similar treatment, and having a similar prognosis. Fracture dislocations and standard tibial plateau fractures should be incorporated into a single classification to avoid the use of two complementary classifications. Any such classification should not be difficult to remember or to use. Keeping in mind these requirements, the authors devised a simple yet comprehensive classification. The authors studied 80 cases of tibial plateau fractures from January 1988 to September 1997, and used contemporary classifications of tibial plateau fractures as a database to formulate the new classification. A new fracture, subcondylar bicondylar with coronal split, has been classified for the first time. An alphanumeric system has been developed that has made nomenclature easy to remember and use. An effort has been made to address the profoundly confusing issue of variable adjectives that describe these injuries. A review of the literature shows that fractures in the authors' classification have been grouped according to similar pathomechanics, treatment, and functional results.

Epiphyseal fractures of the proximal tibia

Fractures of the proximal tibial epiphysis and apophysis are rare. Data of ten patients seen in the last 17 yr with an epiphyseal (6) or apophyseal (4) fracture of the proximal tibia were reviewed. Three patients with an epiphyseal fracture were treated by open reduction and fixation, the other three by closed reduction. All apophyseal fractures were treated by open reduction and internal fixation. No major complications occurred. The final results were good.

Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients

Of 53 patients with unilateral, displaced and closed or grade 1 open tibial shaft fractures, 27 patients (group I) were randomized to treatment with an intramedullary nail and 26 patients (group II) to treatment with a plaster cast. 12 fractures in the latter group were considered stable enough for treatment with only a cast (group IIa), while 14 fractures in group II showed redisplacement during reduction under anesthesia or at 1 week follow-up. Therefore, these fractures were stabilized with cerclage or screws (group IIb), which was a prerequisite for continuing cast treatment. The mean time-to-union was 19 weeks for group I, and 25 weeks for group II. 6 patients in group I and 16 in group II had delayed union. The Nottingham Health Profile index scores on physical mobility, social isolation, work ability, and sexual life were significantly better in group I than in group II at 3 months after injury. Delayed union, malunion, and restricted range of motion at the ankle joint were common complications when these fractures were treated with a cast. We recommend intramedullary nailing for these fractures.

On the behavior of closed tibial fractures: clinical/radiological correlations

OBJECTIVE

To review the treatment of closed diaphyseal tibial fractures with functional braces and to identify patient and fracture characteristics, as well as possible correlations, that could be used to determine final outcomes.

DESIGN

A comprehensive review of data obtained from 1,000 diaphyseal tibial fractures.

SETTING

Major university teaching hospital.

INTERVENTION

Identification of patient and fracture characteristics, including type and level of fracture, initial shortening and angulation, and severity of injury, to be correlated with final shortening and angulation and speed of healing.

MAIN OUTCOME MEASUREMENTS

Degree of shortening and angulation; speed of healing.

RESULTS

Neither the level nor the type of tibial fracture significantly influenced healing time, although there was a considerably higher probability of delayed union in fractures produced from vehicular accidents, as well as in comminuted and segmental fractures. Any delay in application of the functional brace resulted in slower healing. Maximum shortening of the fractures occurred at the time of the initial injury, with no additional shortening experienced after the introduction of graduated weight-bearing ambulation. Compared with a mean initial shortening of 4.25 millimeters, the overall final shortening of fractures was 4.28 millimeters.

CONCLUSIONS

Correlations exist between patient and fracture characteristics that influence the final outcome for closed diaphyseal fractures treated with functional braces.

Distal tibial and fibular epiphyseal fractures in children: prognostic criteria and long-term results in 158 patients

From 1974 to 1993, 158 injuries of the ankle joint were treated at the Department of Orthopedics and Traumatology of Santobono Children's Hospital. One hundred thirty-two patients were treated conservatively; 26 patients underwent surgical treatment. Fibular fractures of the malleolus without epiphyseal separation or dislocation (68 patients) were excluded from this review. Of the 158 patients, 113 (70%) were available for follow-up. The mean age of patients was 11 years. The mean follow-up was 6 years (range 3-15 years). In this review, the authors compare, based on the degree of epiphyseal separation or dislocation, the Carothers-Crenshaw classification, which is based on the mechanism of trauma, with the Salter-Harris classification, which is based on anatomical-radiographic criteria. The aim is to review the authors' patients based on these classifications, to verify the prognostic ability of these criteria and thus to establish a better and more viable treatment for these injuries. Therefore, two fundamental factors should be considered for the prognosis: the mechanism of trauma and damage to the epiphyseal plate. Compressive trauma and adduction-supination trauma are the most dangerous types of injury, and any damage or gap in the physis should be perfectly reduced, by open means if necessary, to prevent a bone bridge from forming.

Scintigraphic evaluation of tibial shaft fracture healing

A scintigraphic study of the healing process of type A and B closed tibial shaft fractures was carried out in 40 cases treated non-operatively, comprising 32 men and eight women aged 30.6 yr on average. Scintigraphic scans were obtained with technetium methylenediphosphonate (MDP-Tc99m, 25 mCi) at 6, 12 and 24 weeks after the fracture and an activity index was calculated taking the mean of three consecutive uptake counts for both fractured and normal opposite leg, used for comparison. The results showed that the activity index in general decreased progressively from the first to the third evaluation, with little difference in behaviour between the two types of fractures. However, for B type fractures the activity index remained stable from the first to the second evaluation, followed by a marked decrease at the third evaluation, with a comparable end result for both fracture types. It was concluded that a decrease of the activity index occurs in both types of closed fractures undergoing uneventful healing and that such a decrease can be taken as a parameter for further studies which include delayed union and non-union.

Combined limited internal fixation with circular frame external fixation of intra-articular tibial fractures

High-energy intra-articular fractures of the tibial plateau and plafond cause ongoing management problems for the orthopedic surgeon. This study retrospectively evaluated 37 such fractures treated with limited internal fixation and circular frame external fixators. Seventeen plateau fractures (5 open) and 20 plafond fractures (9 open) were treated. Time to union, number of procedures, complications, and functional outcomes were evaluated. All tibial plateau fractures healed within an average of 3.8 months. Eighteen of 20 plafond fractures healed at an average of 4.8 months. There was a high complication rate as is common with these injuries, but most of the complications were minor and easily treated.

Physeal fractures of the ankle

Because the distal tibia is the third most common physeal injury, being able to assess and treat such a fracture accurately is a skill worth enhancing. Many factors contribute to the outcome of physeal injuries, but the physician's general knowledge of the physis, ability to order the right diagnostic tests, and classify the fracture can be the determining factors of quality care.

[Fractures of the intercondylar eminence of the tibia in children. Apropos of 25 cases with a 1-20 year follow up]

PURPOSE OF THE STUDY

This study tries to clarify the diagnostic strategy in intercondylar eminence fractures of the tibia and aids the deduction of therapeutic options based on the analysis of the long-term morbidity of anterior laxity.

MATERIAL AND METHODS

This retrospective, monocentric study of 25 children with a mean age of 11.8 years (7-15 years) was performed with an average follow-up of 7.2 years (1-20 years). Fractures are itemized with Meyers-McKeever modified by Zaricznyj and Zifko-Gaudernak classifications. Conservative treatment (16 patients) consisted of hemarthrosis aspiration, ligament examination, manipulation into extension and cast immobilization under general anesthesia. Surgical treatment (9 patients) consisted of wire suture fixation (4 times), wire suture fixation held by a screw (3 times) and direct screw fixation (2 times). Four patients were lost to follow-up. Patients were evaluated with the Lysholm (21 patients) and IKDC (15 patients) scores systems. Anterior laxity was checked with a KT-1000 arthrometer. Antero-posterior and lateral X-rays were performed. The statistical analysis was carried out with Mann-Whitney and Fischer tests.

RESULTS

There are 18 good or very good results and only 3 medium with the Lysholm score and 5 knees graded A, 9 graded B and 1 graded C with the IKDC score. Mean anterior laxity is 1.86 mm (0 to 4 mm) after conservative treatment and 1.5 mm (-1 to 4 mm) after operative treatment. 5 patients have an anterior laxity and only 2 an anterior instability. No arthritic lesions, 1 nonunion, and 11 malunions have been observed, mainly after conservative treatment.

DISCUSSION

Ligament examination under general anesthesia is useless for displaced fractures and dangerous for those were not displaced. Diagnostic arthroscopy is not yet allowed. Magnetic Resonance Imaging is useful to explore osteochondral fractures and symptomatic meniscal lesions. Laxity is the consequence of anterior cruciate ligament elongation.

CONCLUSION

The diagnosis of these fractures rests on a simple radio-clinical examination to determinate the exact position, the displacement and the size of the osteochondral fragment in order to choose the best treatment. Conservative treatment will be chosen preferentially because of a poor long-term morbidity. Treatment will be surgical, preferably arthroscopic, in the others cases.

Pilon fractures of the distal tibia

Pilon fractures are one of the most complicated injuries confronting the lower extremity traumatologist. When faced with the pilon fracture, the surgeon must adhere to the principles of anatomic reduction and rigid stabilization to achieve early range of motion. Open reduction and internal or external fixation or a combination of fixation techniques, expertly placed, ensure the best possible outcome with the least complications. A functional lower extremity following a pilon fracture is possible with meticulous evaluation and repair.

Childhood accidental spiral tibial (CAST) fractures

OBJECTIVE

To further define and describe the spectrum of presentations for accidental spiral tibial fractures of childhood.

DESIGN

A retrospective review.

METHODS

Children 8 years of age or younger who had sustained a tibial fracture within the last five or ten years were collected from the patient populations of two large tertiary medical centers in Southern California, Riverside General Hospital (RGH) and Loma Linda University Medical Center (LLUMC). A total of 189 tibial fractures were documented from both locations. Of the 189 patients, the 55 children with isolated spiral tibial fractures and no criteria for exclusion were selected for further review and analysis. These patients were reviewed for age at time of injury, gender, specific extremity involved, mechanism of injury, fracture location, degree of displacement, and whether child protective services involvement occurred.

RESULTS

Patients with isolated spiral tibial fractures ranged in ages from 12 months to 94 months (7 years 10 months). The mean age was 50.7 months. Eighteen (32.7%) of the patients were less than or equal to 36 months of age. No patient was under one year of age. Males (38/55 or 69%) sustained the fracture slightly more frequently than females. The right extremity was injured slightly less frequently (45.5%) than the left extremity (54.5%). Overall, the lower two thirds of the tibia contained the fracture in 95% of the injuries. Displacement of the fracture segments was most frequently none or minimal. While Child Protective Service referrals or investigations were not accomplished on the majority of the children, no injury was confirmed to have occurred as a result of non-accidental trauma.

CONCLUSION

Isolated spiral tibial fractures are a common injury of children less than 8 years of age and are most frequently accidental. The original description of a distinct clinical entity matching the original definition of the toddler's fracture does not appear to exist. Instead, the previously defined toddler's fracture is simply part of a spectrum of presentations of childhood accidental spiral tibial, or CAST, fractures. Consequently, our findings further support new nomenclature suggested for this fracture (1, 2).

Arthroscopic management of tibial plateau fractures: an unselected series

The present series reports the results of arthroscopically assisted fixation of tibial plateau fractures. No effort was made to include or exclude any specific fracture type from the all-arthroscopic reduction technique. Fourteen of 17 tibial plateau fractures treated arthroscopically, with an average follow-up of 14.6 months (range, 5-30 months), were retrospectively evaluated. The average patient age was 43 years (range, 25-65 months). The average knee range of motion obtained was 5 degrees-126 degrees, with 9 of 14 patients regaining full symmetric motion. The Lysholm scale was administered to this group with 5 (36%) receiving an excellent rating, 6 (43%) receiving a good rating, and 3 (21%) receiving a poor rating. Two patients experienced complications: one had painful hardware requiring removal, and the other had an infection that resolved after appropriate treatment. The present report advances the treatment of tibial plateau fractures by documenting the feasibility of the arthroscopic management of many fracture types.

Effect of smoking on tibial shaft fracture healing

Of 146 consecutive closed and Grade I open tibia shaft fractures treated with cast immobilization, external fixation, or intramedullary rod fixation during a 4-year period, 44 of 76 (58%) tibias of patients who smoked and 59 of 70 (84%) tibias of patients who did not smoke had followup to union or followup beyond 1 year. The demographics, fracture patterns, and treatments of the two groups were similar. Two of the 44 patients who smoked had nonunions at the 1-year followup, whereas none of the patients who did not smoke had nonunions. Of the 103 tibias with complete followup to union, the median time to clinical healing for patients who smoked (269 days) was significantly greater than that of patients who did not smoke (136 days). Likewise, there was a 69% delay in radiographic union in the group that smoked as interpreted by a radiologist blinded to the two groups. Statistical differences in clinical and radiographic healing rates between those who smoked and those who did not smoke were observed for patients receiving intramedullary fixation or external fixation. Statistical differences were not seen in the clinical and radiographic healing of tibias treated with cast immobilization, although tibias of patients who smoked took 62% longer to heal. The current data suggest that tibias of patients who smoke who require treatment with intramedullary nailing or external fixation require more time to heal than do those of patients who do not smoke.

Closed reduction/percutaneous fixation of tibial plateau fractures: arthroscopic versus fluoroscopic control of reduction

OBJECTIVE

To evaluate arthroscopic versus fluoroscopic reduction and percutaneous fixation of lateral tibial plateau fractures of AO/OTA Types 41.B1 to 41.B3.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS AND INTERVENTION

One hundred sixty-eight patients underwent operative treatment for a tibial plateau fracture from 1988 to 1995. Thirty-three of these patients had monocondylar fractures of the lateral plateau that were treated by percutaneous reduction and fixation techniques. In the first ten cases, arthroscopic control of reduction was used. The following twenty-three consecutive cases were treated by reduction and fixation solely under fluoroscopic control. The arthroscopy group was followed for a mean of fifty-two months and the fluoroscopy group for thirty-eight months.

RESULTS

Nine of ten cases of the arthroscopy group had an excellent or good result in Rasmussen's knee score at follow-up. One patient with an unreduced anterolateral depression zone despite arthroscopic surgery required a total knee prosthesis after eighteen months. Sixteen cases in the fluoroscopy group met the follow-up criteria. Fifteen were graded good or excellent in Rasmussen's clinical score; sixteen were excellent or good in the radiological score. One patient claimed chronic medial joint line pain after a lateral split fracture and had arthroscopy revealing chondral degeneration on the medial side but had no pathological findings in the lateral compartment. No secondary meniscus or ligament surgery was performed in the follow-up period.

CONCLUSIONS

Percutaneous treatment of fractures of the tibial plateau can be performed using arthroscopy as well as image intensification to control reduction of the joint surface. We were not able to demonstrate any significant benefit from arthroscopy compared with fluoroscopic reduction. Reduction under image intensification is technically easier in our practice, especially in serial fractures and multiply injured patients. We reserve arthroscopy for cases with significant ligament injuries and for children with fractures of the median eminence.

[Osteosynthesis under arthroscopic control of separated tibial plateau fractures. 26 case reports]

PURPOSE OF THE STUDY

Arthroscopic treatment of tibial plateau fractures may reduce morbidity compared to open articular surgery. But bony fixation is necessarily percutaneous and minimal. The purpose of our study was not only to assess immediate results but also long term functional and anatomic results after arthroscopic treatment of tibial plateau fractures, with special reference to radiographical results.

MATERIAL AND METHODS

Twenty-six patients (mean age 42 years, range 18 to 70 years, 17 men, 9 women) were arthroscopically treated for a fresh tibial plateau fracture. According to Schatzker classification, there was 2 type I, 17 type II, 6 type III and 1 type IV. No type V or VI were treated in this series. The fixation device was: percutaneous cannulated screw in 23 cases, Kirchner wire in 2 cases, and bone cement filing of the fracture site in 1 case. We did not use cancellous bone graft but we used a hydroxyapatite plug in one case. There were 8 meniscal injuries: 2 underwent arthroscopic suture, 1 had partial meniscectomy and 5 were left in place. Twenty-six cases were suitable for immediate post op follow up. 19 were reviewed at long term. A clinical (Knee Society scoring system) and radiographical examination were done with an average follow-up of 32.7 months.

RESULTS

There were no complications except one immediate postoperative septic osteoarthritis (case with hydroxyapatite plug) and one bony depression of the lateral tibial plateau at the fourth month. Passive motion of the knee started at 1.8 days postop with no pain. Mean flexion at 3 months was 130 degrees. At revision, the average score was: 94.1 for the knee, 94.7 for the function. In two cases we found early signs of osteoarthrosis. There were no secondary bony depression or significant valgus deformity on X-rays.

CONCLUSION

Arthroscopic management of tibial plateau fractures allows a complete articular screening. Rapid rehabilitation, short hospital stay, and low rate of complications reduce morbidity. The long term results are as good as those with open surgical technique for the types of fracture that we have treated (type III and IV). A minimal, percutaneous osteosynthesis which was the only possibility under arthroscopic control, did not modify the anatomical results.

Describing severe limb trauma

Seventy-nine severe limb injuries were retrospectively reviewed to compare the AO/ASIF and the Gustillo classifications. Specifically, the suitability of these classifications with respect to prognosis and management of these cases was compared. A healed and stable wound was the ultimate outcome measure. Surrogate outcome measures used were: the time to healing; the number of anaesthetics until the wounds were healed; and the number of operations until the wounds were healed. Any change in lifestyle following the injury was also assessed. The primary healing rates of the AO/ASIF groups showed significant (P < 0.001) inter-group differences. However, when the injuries were classified using the Gustillo system, the primary healing rates did not show any differences between the groups. Also, differences in the other outcome measures were most pronounced when using the AO/ASIF system. Importantly, changes in lifestyle correlated with the injury score when using the AO/ASIF system (P < 0.05). Unlike the AO/ASIF system, the Gustillo system was not applicable in 100% of cases. A modified AO/ASIF scoring system is proposed which provides a good predictor of outcome.