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And where on? Hello? So do I have access to, uh, can all, can everyone who's, um, online speak? Now? I think they'll be typing and then we can, we can tell them, tell you what they're saying. OK. All right guys. Cool. Well, it's nice to meet you. My name's Mr. I'm one of the consultants at Norfolk and Norwich specialize in s hip, knee, revision, knee surgery. And obviously we will do trauma. So I specialize in trauma around the knee. The presentation I'm gonna give you guys now is on, um, tibial plateau fractures. Um, it's gonna, I'll ask a lot for you guys to just contribute to mainly because there's not gonna be any pressure or stress in this session. So I'm hopeful that the other, other registrars will concur that when I give teaching, I try and make it as friendly as possible. I don't mind if you don't know the answer to something. I don't even mind if what you say. Sounds silly to you. I can guarantee you. I've probably thought all of the wrong answers 1000 times over my training. Um, the point of this isn't for you to get every answer. Right. It's just to get you thinking about stuff. Ok. So, um, here we go. So what we're gonna go through, I, I'm gonna cover the mechanism of injury because that defines how fractures happen and help you decide how to operate and fix them. We'll go through some useful statistics that hopefully try and help stick in your mind while these fractures are important. Um, it's important to be aware of useful classifications and I'll go into detail about that a bit further. We'll go into relevant radiology and I've got two case studies that we'll talk through together. Um We'll think about what your initial clinical review and temporizing management should be and then what your definitive management should be. We'll look at what the rough outcomes of tibial plateau fixation surgery is. Um I'll summarize all of that information and then I'm happy to give uh answers to any questions you may have. I think I've been given about 30 minutes for this. The talk probably won't be more than 15 to 20. Um Depending on how much interaction there is from you guys. OK. So mechanism of injury, this is a really useful definition. OK. So tibial plateau fractures are a consequence of or um the result of the proximal tibial anatomy, combining with the direction of force that is applied to a limb and the amount of energy that is applied to that limb. So, if we go into those things in a bit more detail. If you look at the proximal tibia, the lateral plateau is higher and smaller than the medial side and the medial side. But the the your screen that your presentation is not showing, it's not sharing. I had to press er I said share whole screen, didn't I I can see your title. Yeah, go back to it. OK. One second, I'm going to stop sharing and start sharing again. And it said uh it said share screen is what it was told me to do. Yeah, you can see me or the presentation, I can see just you. I think you closed the presentation, right? I'm gonna go back and it says to share entire screen. Yep. Uh So that's the anti screen and then see your screen back now. Yeah. Yeah. It's working. Can you see the next slide? And yeah. And am I good? Fine. So I'll take it from here again. Sorry about that guys. So what I was saying is a useful definition for tibial plateau fractures is that they're a consequence of the proximal tibial eloy interacting with the direction of force applied in addition to the amount of energy that's applied to that limb. And I want you to constantly think about that as we go through and look at cases thinking about the proximal tibial anatomy and bear in mind for us s I'm over simplifying things to a level that you need to be able to understand this. I'm not gonna take you up to ST seven ST eight level, bear in mind that the lateral plateau. So the lateral side of the knee, the side that the fibula is on is higher and smaller than the medial side. So the medial side is larger, it's lower and it also bears 60% of the load of the of the knee when you're walking and you apply an axial force. Therefore, it makes sense that the medial side is denser and harder than the lateral side is. OK. Bear that in mind. Second factor I was talking about was the direction of force applied the average leg to interrupt again, but it's uh the screen is gone again. This is totally unacceptable. Um how it's intermittent, it's come back again, it it sort of keeps coming off but when you change the slide, it returns. So, um OK, so go back and forth each time you in direction of force applied slide at the moment with the program from hip and knee. But so sorry about, sorry about the uh the lack of continuity with slides guys, if you look at the direction of force applied, when you actually load your leg, it's in three degrees of valgus. So bearing in mind the anatomy with the lateral side being higher, if you then apply a valgus, normal load on the knee, it makes sense. Therefore, that lateral sided plateau fractures should be more common. If you land on your leg roughly straight. Ok. So that's the direction of force applied. If you then consider the amount of force applied, the amount of energy, the higher the energy, the worse the injury. So the two pictures I've got there really reflect old bone and young bone in older bone. It's softer, more osteoporotic and therefore, it's less likely to um smash in half and cleave down the middle and you're more likely to crunch the surface like a foot stepping in snow. So those fractures are gonna have more uh association with depressed areas of bone that need to be elevated, younger bone though requires a higher energy to break. And when it does break, it's more likely to split. So you're more likely to get um vertical fracture lines in addition to depressions. So remember, the higher the energy, the more significant the fracture's going to be some useful statistics to bear in mind. This only represents 2% of all fractures. And if you look through the trauma lists that we've had over the past few months, you'll see that there's 11 tibial plateau come up probably every four or five lists. You might see the same knee twice if it's having further procedures undertaken. It usually occurs in younger men and by younger, I'm talking around the age of 40 to 50 with an average age of 50. I it says in most books or it happens in older women. So younger men are gonna require higher energy because their bones are going to be stronger. Older people are gonna require lower energy because their bones softer osteopenic, so much like hip fractures, these are low velocity injuries in elderly patients. The most frequent side to fracture as I explained earlier is the lateral side. So it most frequently goes from later to medial. And as I said, if you think about it, if you simply land on the leg, that's straight, applying a normal valgus load to the lateral side, which is, which is innately softer than the medial side. That's the side that wants to fracture. So 70% are roughly lateral and there's an even split between which are either by condylar, both sides or isolated medial. Can anyone tell me why you're more likely to get a medial sided fracture? Anybody for anybody? Ben sorry, your um slides have disappeared again. Are you able to send them to one of us and we'll be able to share it on your behalf? So I think it might be because of your Yeah, Matt says it's the weight bearing side. It's the weight bearing side. Yeah, it, it is the weight bearing side. Remember you've got a valgus alignment to your leg. So why is it gonna be on the, on the lateral side, guys on the medial side? So why are you gonna have a fracture on the medial side? What position does the knee need to be in to get fracture on to the medial side. So uh she said because of the axis of the weight bearing uh running through the medial side and Matt said extremes of virus in response to your answer. So you're gonna need a virus load in order for that to happen, guys, basically. OK. I'm also now exercising my ability to multitask. So has anyone seen tibia plateau's fractures before? Occasionally, I have occasionally I have that fits with a 2%. But amongst the Sh Os, have you been to clark any of these patients in A&E Matt saying lots, they're usually labrador induced. Yeah. So they usually have a direct blow cause don't they on a flexed knee? Um and we'll talk about how you manage these patients uh soon enough. So it makes sense to say that lateral meniscal tears are more likely to happen with laterals sided f um injuries and those are lateral sided injuries with more than a two millimeter split or depression. You're more likely to get a lateral meniscal tear. Now, that doesn't mean that that lateral meniscal tear will be symptomatic. Most of people that your MRI will have some fraying or minor tears to menisci, it doesn't make them symptomatic. Some people do advocate fixing tibial plateau fractures, followed by an arthroscopy to address any lateral medial meniscal tears. Personally, I'd deal with the fracture and any consequences thereafter can be investigated at a later point. It also therefore follows that medial meniscal tears are more common when you've got medial splits and depressions. But these soft tissue injuries are important to bear in mind because a fracture, by definition is a soft tissue injury with a breach in the cortex of the bone. Anyone see this slide when classifications are useful? Uh hopefully you've got it up and running. So hopefully it is now working. Ok. Can anyone tell me when classification systems are useful? So what do you think makes a classification system useful about to say, to guide good? So to guide management, that's a useful classification. Any other reason? So I might um I'm sorry, say that again. I think I've already given him the answers with the slide. Oh, you, you went forward on fair enough. OK, fine. So classifications have to help you understand what has happened with the mechanism of injury. So it there's no point having a classification that lists something from 1 to 6 because 1 to 6 doesn't necessarily tell you what the pattern of injury would have been depending on how that person fell. Classifications are really important because they allow us to communicate with each other. So if you were as the sho were to call the registrar and say I've got a classification x fracture tibial plateau in A&E they already know just by that information that associated with that there may be more significant injuries that need to be assessed and ruled out. And hence that's why they help to guide treatment. Classifications are also really useful if they help you to predict what the outcome will be. So, in the classifications that I'll show you soon enough, you can imagine that the more severe or higher the number, it should hopefully correlate with the more severe injury. It's a common sense way of helping you to um uh classify, classify and deal with what the consequences of fractures might be. And they have to have a high intra observer um reliability. And by that, I mean, if I put 10 of you in a room, teach you a classification system and show you a whole bunch of x-rays, the m overwhelming majority of you should be able to classify them correctly with a classification system where there's lots of um variability between what everyone thinks a classification system is. It usually reflects the fact that the classification system isn't clear now. Hopefully no one's moved on beyond this slide. But does anyone know any classifications for tibial plateau fractures? So I think the problem with the slide is, er, they do disappear but I think it's from time to time. So well, we'll try and get, make sure they work. OK, cool. I, I think, I think it's not you, I think it's metal. Uh but OK, someone said a swear word there. What was that word? Shat. Yes. So shat. Classification um is the one that actually internationally is preferred mainly because it's got the highest intra observer reliability. So most people talking from one country to the next, if they discuss shat, um, they can make sense with each other about what's happening. Anyone know any other classifications? There's one universal biblical organization in orthopedics. Any what? Oh, I did mention it earlier. You did? Yeah, for someone else. Ok. Do you want to mention it again? Charlie. Uh A O Yeah. A O, so A O always has a classification system for everything. Um And the good thing about the A O classification and we'll talk about that in a second is that actually it's relatively logical and common sense. There is a third classification system and that's er which we're not gonna talk about, but I'll mention the name of in a moment which is basically used because not all tibial plateau fractures fit into either the TSA or the A O classification. And the third classification therefore helps to define those fractures and hence guide their management. So the first classification mentioned is Shaka, OK. Now, CHS classification isn't hard to do isn't hard to learn. You just have to kind of rope memorize it. First thing to say is it always goes from the later side, that's the outside by the fibula and finishes on the medial side. OK. The first there is TSA, one to si 1 to 6 and 1 to 3 are low energy, 4 to 6 reflect high energy. So just by saying that aloud, you know that the four to sixes are on the medial side and those ones probably have a higher risk of neurovascular injury and other complications. And the 10% that don't fit into this classification are described by Ho and Moore and you guys don't need to know about that one. Ok. So it's essentially from the lateral to medial side. You either have a lateral split, then a later split with a depression or third one, just a depression. So you can see how you're going from split to split, depression to just depression. Then a four is a fracture on the medial side, any fracture. A five is a bicondylar fracture. So a fracture on both sides and a six extends into the metaphyseal diaphyseal region. Ok. So you can see that a six must have required a hell of a lot more energy than a one. And you can also imagine that a one, by the fact there's only one piece of bone to fix back on is gonna be a lot easier to manage than a six. Have you all heard of S chats classification before? Yes or no's will be fine in the, in the chat from all of you just so we know you're still online. Er Yeah, a lot of the participants um said SSA directly when asked good. Ok. So the shaka one, if you were call a registrar or a consultant on call, it would be if you said shat to us, we're already relaxed thinking, you know what you're talking about and it's also the most important and common one to know about the second classification, which we mentioned is the A O classification. And basically it goes from simple to hard. So a simple fracture is gonna be an a nonarticular fracture because you're basically just putting um joint line back onto shaft, then it goes through to partial articular all the way through to complete articular. So just think of it is nonarticular, partial or complete and then going through the 12 threes that exist within each one of them, it has increasing levels of comminution and that's quite nice. Cos you can imagine a simple nonarticular fracture. That's the worst of its subgroup is gonna be a lot harder to manage because more energy's probably gone through that to cause the comminution compared to an articular fracture of a level three, which essentially describes quite an obliterated joint surface. Has anyone heard of AO classifications before? Yes or no? You'll be fine in the group chat. Yes, they have good with A O And I'm sure Charlie or someone else may have explained to you already. It's a really good website for looking at different fractures, their management. Um and also the surgical ways of execute, executing the management. OK. Whichever system you use. There are a few important things to take away from it. Essentially lateral fractures are gonna be lower energy because it's along the correct axis of the femur along that three degrees valgus with an axial load, the higher the energy, the higher the chance there's gonna be of a neurovascular injury skew this into your brains. Medial sided fractures are the worst ones of the lot. Ok. With a medials sided fracture, the leg hasn't been in a normal anatomical alignment. It's probably been under a significant varus load in order to have the fracture. Medial sighted fractures are associated with knee dislocations. And as a result, you've got a high chance of neurovascular injury. The vascular injury is gonna be the popliteal artery because that would be under tension with a knee dislocation. And I've seen two of those in my time. If you, anyone was at dinner last week, who you saw the other two, you can also have the the most likely nerve injury is common perineal nerve. And that makes sense with a medial sided fracture. If you've got a knee which is under a varus load, ie the knee is going outwards away from the midline, you're gonna stretch the common perineal nerve temporarily and then it will ping back to its normal place. So usually common perineal nerve injuries and neurapraxia, they're temporary stretches of the nerve that should recover with time. But occasionally you can have common perineal nerve um lacerations which need surgical intervention or at least need to be identified and managed by plastics. For example, soft tissue injuries are common with medial sided fractures. So it's usually the lateral collateral ligament or the anterior cruciate ligament, they're injured with medial sided fractures and I'll talk to you about when you examine these patients, when you see them in A&E what you should and shouldn't do with regard to all of this stuff. So burn into your brains, medial side, it is worse, higher energy, worse chance of a neurovascular injury. And the higher the grade be it A S ska 4 to 6 or any of the A O subgroups to a level three are gonna be worst injuries. OK? If there's a higher energy being applied to a limb, for it to fracture the bone, then more energy has gone through the soft tissues. And hence there's a higher chance of a significant soft tissue injury. And that's an a again, an important consideration when you're thinking about surgical intervention. OK. Relevant radiology. What do you guys think we always start with? They write them down in the group chat for me. What do you always start with anybody? Plain film A P and lateral is yeah, plain film A P and later. Good. So uh we'll go through some images in a moment but you say you do a plain film A P and later. Um is that good enough for me to say? Right? I know what I'm gonna do surgically. If I'm gonna fix this with a plate and screws yes or no's in the group chat. Majority. Yes. Is one knows. No, coming up good. Um And why is the reason that a nap and natural isn't good enough for me to make my operative plan based on guys any answers in the group chat for that one. Although Matt Matt has said sometimes if it's an obvious fracture or maybe the pattern, yeah, you can kind of tell what you need to do. So, Matt, I'll tell you now, um, the words obvious and assume they go into the same category if you're gonna become a surgeon. Ok. Nothing is obvious. And you never assume because that's when you'll get caught short surgically. Ok. So what can you not assume based on the plain x-ray? So the answer is you can't assume that the fracture line that you're seeing is the only fracture present. And if you're thinking about fixing this internally with plates and screws, your decision's gonna be, is it an approach from the lateral side, medial side or both? Or actually do I need a posterior approach? Because there's a vertical shear fragment that needs a buttress plate. If there are undisplaced fractures that you aren't aware of, and then you fix what you can see when you follow that patient up, they would have collapsed into varus or valgus and they can then develop posttraumatic arthritis, which is gonna be a lot harder to come back from me legally, if you haven't investigated them fully before you took them to surgery. So, what's the next investigation of choice. Therefore, CT or MRI, those are your options. Uh guys write either CT or MRI if you think uh whichever one you think should be the next investigation to us for your CT. Any for MRI, any for CT. Yeah, three CTS so far. Any, any MRI S no MRI S at present. And when I my pulses, my con says, say again and you, if you're worried about pulses, so you, you're only gonna do a CT angio for pulses or you're gonna get AC T to get you two for one pulses and to have a look at the fracture. So you, you'd get it two for one. Which cases are you gonna get CT angio for which tsk did I say were the worst? Medial mad says yeah, good. So medial fractures, the more high energy fractures. Those are shat 4 to 64 to 6 and the 4 to 64 and six are the most commonly associated with neurovascular injuries and compartment syndrome. So if you have a TSA 4 to 6 or a medial sided fracture, those are the ones you'd be considering getting a CT angio for. So a CT looks at the bone stock, the angio looks at the blood supply. Would anyone get an MRI scan preoperatively? Any yeses or nos of in group chat? Nobody's said anything yet. OK. Somebody say yes or a no. I want to see at least three answers for whether or not, they'd uh consider a, an MRI. So we've got a dependence. Uh, we've got a, if like if an injury is suspected and uh too long to do and to organize, I would have thought. Ok, so, um, always think in your world of an optimistic place if you, yeah, so take out the fact that it's a time thing because we all know that if the spine can get CT MRI scans super fast, if we really wanted one for an acute injury, that was for surgery, we could get it done. The reason MRI scans aren't useful, in my opinion, preoperatively is because everything will light up like a Christmas tree that knee may as well have had a hand grenade go off in there. So you're gonna find bony edema, uh blood, it's gonna be difficult to know what's a real soft tissue injury from what isn't. Um And hence, I don't think acute MRI scans are useful. Um And there's not much um uh chat in the literature about people finding it useful preoperatively. Remember I said the main injuries you're gonna find are either gonna be a medial lateral meni lateral collateral ligament or an AC L injury. Um So if you imagine based on that, those are things that I can assess intraoperatively um or post-operatively after I fixed the main problem, which is the fracture. So MRI not so significant. Ok. So you, you've gone through the four main um modalities we look at there plain x-ray then up to a CT plus minus CT angio and an MRI scan. Um OK. Can everyone see this x-ray on the screen going to uh we can Yeah. Yeah. OK. So I I'm not gonna ask you to give me a, a holistic, you know, this is an A p later radiograph, blah, blah, blah, someone just tell me what they think the most obvious pathology is. Can you hear me now? Can you hear me? Yes, I can hear you. Oh, great. Uh There's a he arthrosis, lipo hemarthrosis in, in the knee. Good. So that most people wouldn't have picked up. So, can everyone see uh my mouse doesn't work? Now, can anyone see that meniscus just at the superior pole of the patella that flat line across the top? Don't worry if you don't say yes or no, but essentially that's where the hem arthrosis is. Ok. What? So that heme arthrosis, if you see blood within a knee, there has to have been either a soft tissue injury or a fracture that has resulted in bleeding which has caused that. Now, a meniscal tear isn't gonna cause a massive heme arthrosis. I've had one on each one of my knees and I probably ended up with about 20 mils of blood in each one. And that wouldn't be enough to show up a significant heme arthrosis on a knee. But bear in mind, the knee only has two mils of synovial fluid in it. So as soon as you get more than five or 10 mils, that's gonna become a swollen knee that doesn't want to move very much fine. So the hem arthrosis has suggested to you that there may be a fracture or a soft tissue injury. I'll guide you by saying that there's gonna be a fracture based on the fact that we're doing tibial plateau teaching. So can anyone see a fracture on this x-ray that ask you a question, question, Charlie point you to it with a person. OK. That's not showing up on my screen. But you said a lateral tibial plateau fracture. Was that? Yeah, there's a shots of one or two. I think there's a degree of depression. OK. So that's the good, that's right there. You're um you're not very sure of whether it's a one or two already tells you you need further imaging. So correct, there's a lateral sided fracture. And if you guys are looking at the x-ray, you're always taught to follow one cortex of the bone up and round. And if you follow it from the medial side on the metastasis, take it up to the joint line, it skirts along the top surface of the medial plateau, you skirt over the two mountains which are the tibial spines. But as you go down onto the lateral side, there is a point that you can't see where you would be walking on if that was solid ground. So there's a discontinuity in the cortex of the bone there. And if you had the full radiograph suck with better resolution, you'd see that there is a hint of the longitudinal fracture line there. Then if you look on the lateral radiograph and look at the proximal tibia, you should see two straight lines. If you get a perfect lateral of the proximal tibia representing the medial and lateral joint line, but there's a depressed sor alike region on the lateral that you can see there. So, unfortunately, because we're not all in the same room, I can't show you that with the naked eye and a curse. I've been trying to draw it out. Yeah. Thanks Charlie. Um So what investigation would you ask for next guys? The answer's gonna be AC T. So I've put up the two most salient slices for this CT. So does this CT show you how much clearer that degree of depression is on that lateral side? Yeah. Yeah. So laters on the left and then if you look on the side, sorry, the lateral side is on the left side of the A P radiograph. So the left image is an A P version of the knee, a coronal slice through the knee and you can see that that lateral joint line is mush. So you're gonna have to elevate that back up and then hold it there with draft screws and a plate in order to get that to heal if you look at the sagittal view, which is the same as a lateral view of the knee. And that's the image on the right hand side with the mouse cursor on it. Can you see that significant depression? And that's definitely more than two mils. So this is likely to be associated with a lateral meniscal tear. There's another slice through the coronal view, which I haven't saved, which shows a vertical component to the fracture. So you've got a split and you've got a depression which therefore makes it what guys, a TSA 12 or a three, three think again, cut in 23. So what's a 11 is a split? So it's a two because it's a split and a depression. Yeah. So that's the thing about the CHS classification. You'd think that split depression would be a three because it's both combined. So you'd think it'd be a split, then a depression, then a split depression, but it's not, it's a split, split, depression or pure depression. And you can imagine a pure depression is gonna be softer bone really? Isn't it for a valgus load? But it would require more energy to, instead of smash the bone just to crunch it all the way down. So this is a shat s good too. So how do you think they would fix this? Would they fix it internally externally from the Sh Os any thoughts? So you want to restore the congruity of the joint as best as possible, even if that leads a defect in the tibia. So you try and smoosh it up to get your joint surface back as much as possible. Maybe you need to then use a buttress plate to try and get rid of that. The split as well. So you might use a buttress plate, um, with some, with some raft screws across from the lateral side. Maybe. Is that mat online? Yes, it is. That is I recognize your do at to. Hi. Um, so, er, also can you appreciate Matt looking at that coronal view of the knee that the proximal tibia is wider than it should be. It doesn't fit below the proximal tibia. Yes. So if you, you see the lateral side of the knee, if you took that, that, that line that's adjacent to it and put it next to it, it will pass the lateral side of the proximal tibia by about three mils. And if you think about it by punching down the bone, by depressing it, you're stuffing that side and blowing it out to the side. So to weight, bear on that knee will not conform, confer the normal tibial um femoral pressures to the joint line, you're gonna get posttraumatic arthritis because you're gonna have abnormal joint forces running on that joint. So you have to restore the stability of the proximal tibia. That's the keys, the stability. So it doesn't matter, doesn't matter to a certain extent if your fracture lines aren't perfectly at a bridge next to each other. But if the width of the proximal tibia and the joint line is not elevated and it's not held stable, those fractures have a much higher chance of a worse outcome. So just as you're suggesting, that's what they did, they elevated it up. This isn't one of mine. Otherwise I'd be, you know, bragging about it, but they elevated it back up to the joint line. And you remember what we said, the lateral side of the proximal tibia is higher than the medial side. So if you see these fixed and they're at the same level, you know, it hasn't been fixed correctly. The width of the proximal tibia runs beautifully under the proximal uh the distal femur and it's been fixed with rough screws in a buttress mode. OK. Mm. Um What time? Say again. Very nice. Yeah, it wasn't me. It wasn't me. I just found this from the trauma list recent recently. So I did have a second case which is a medial sided fracture, but I'm aware it's minutes to nine and mental faculties are gonna start fading. OK. So let's talk about your initial clinical review. I had a had a listen to Charlie's presentation as he was going through before and it sounds like he's taught you a nice holistic way of approaching this in ABC de way. Always keeping your mind guys, if you get referred from a ND a tibial plateau fracture. And they're saying words to you like S Shatt four or shat five, you know, it's high energy. So you have to think about the mechanism of injury and think that this could be a distracting injury. So manage this as paras principles with an ABC D approach and make sure you haven't missed any other injuries. This is slight, not so much higher level, but this is important for you to think about, OK, you've seen the x-ray because A&E have referred it to you. You know, there's a broken bone, there is no benefit whatsoever in ranging this knee, it hurts, it's swollen, it's broken. You're not gonna learn anything else from ranging. The knee do look circumferentially for an open fracture because that changes the pace within which this needs to be managed considerably. And also then puts it onto a different algorithm needing things like antibiotics, saline soap dressings, um an emergence wash out closure before you think about definitive stabilization, always assess the compartment syndrome. And I'm going to talk about that in a moment. There are many ways to consider what would need um either an ankle break or pressure index or a CT angio in my world. If you've got a shots of 4 to 6 or a medial sided fracture, that needs a CT angio until proven otherwise. So you can crack on and do your ankle, brachial pressure index. But if you're not being able to read it properly and it's not like any of us practice it frequently. You may miss something that actually does have a vascular injury that hasn't been noted. Distal neurovascular exam basically focuses on the common perineal nerve. So, anterior compartment and first dorsal web space don't bother looking for an AC L or a lateral collateral ligament injury. Again, that's a ranging the knee and ranging the knee causes pain. When you do a tibial plateau fixation of theater. Once it's fixed and it's stable, then you can assess your ACL PCL and medial lateral collateral ligaments. And if you have any concerns after follow up at 6 to 8 weeks, you can have an MRI scan when everything on the E on the MRI should have settled down and may show up any further injuries that need further investigation or management. Preferentially for me by a soft tissue knee surgeon. I like bone. I don't like the soft stuff. Ok. Compartment syndrome. Does anyone know a decent definition of compartment syndrome? I think I can't know so not properly. But um I the medal thing was, was only ran up to half eight when it was booked. But I think that's why it's been kicking us out and I can't share the slides anymore. Like it just doesn't work. I can see the slide with Compartment syndrome and a fingerprint. Is that what's meant to be? You can, I think anyone else they can do is anyone else still on? You can very temperamental with us with, with everything. How can you book a virtual space that essentially exists in infinity? Know, sorry, sorry, sorry, you can, you can delete that part of the, tell us about compartment syndrome. Go on that. Now you've had a chance to go on Wikipedia. So actually the truth, the definition of it is um but it's rising pressures within a confined space um which leads to neurovascular deficit. That's probably not the exact correct wording. Um You're along the right lines. So the compartment you speak of is an osteo fascial compartment because it's divided by bone with the fascia. Ok. So osteo fascial, it's a rise in the pressure within that compartment. And the consequence of that is it starts to occlude first venous blood supply because it's lower pressure. So easier to compress, followed by the arterial blood supply. And the consequence of cutting off the life source to the muscles and the nerves or the myoneural tissue is myoneural ischemia. So, if you are gonna sex up that statement, essentially what you're saying is it's a rise in osteo fascial pressure that causes first venous, then arterial occlusion resulting in myoneural ischemia. It sounds a lot more impressive than it is. But essentially what you were saying, Matt is totally correct, increase pressure, shut off the taps, starve the tissue, the tissue dies. So that's more likely to happen in a shat 456 tibial plateau fracture. And from recollection, it's not the popliteal artery, that's the cause there. It's the recurrent branch of the anterior tibial artery that gets cut. And then with a tibial plateau fracture, you end up breaching the um capsule of the knee joint. So the blood can spread further than simply within the knee joint. And hence, you start getting compartment syndrome, usually in the anterior or lateral compartments. So that's what causes compartment syndrome. That's what the definition of it is. But um so do you, so you say no, so the knee becomes you. So theoretically, you could test for compartment pressures using an intraarticular probe. No, because you remember by by breaching the capsule of the knee joint, the pressure, the the uh Hema hemarthrosis, the blood, it's not only just within the knee, then. So think about the fracture line itself. If you have a S Chaska six fracture that has gone to the metha dile region, that bleeding is within the medullary canal of the bone of the bone. And also that's a soft tissue injury. It's not just the blood loss that you're having, it's a soft tissue injury. So a lot of high energy has been conferred to the compartments of the leg. OK. Can you see like you can see the shots of the classification I thrown back up again, if you basically, it's around sort of like this level around that where you've got some of the recurrent arteries around and you, those can be disrupted and then they'll bleed into the muscles and soft tissues exactly in these areas. So, it's not coming from within the knee or up that although the ex up there tachy region. Yeah. Correct. Um, so the patient, how will they present? I have pain out of proportion to the injury that they've sustained. And the easiest way to diagnose compartment syndrome isn't on that. It's on picking a tendon within the compartment that's under pressure and putting it on this passive stretch. So most commonly, they always teach you about the big toe and that's because it will do the anterior compartment. Um So the the point is pick a tendon within that compartment and passively stretch it. If it causes absolute exquisite pain, there's a high chance of compartment syndrome, medica legally, you've got a lower chance of being sued if you do undertake fasciotomies with a clinical basis rather than waiting and watching and resulting in contractures and muscle death and neural tissue death within a compartment. If a patient's unconscious, then you wouldn't go on just a clinical diagnosis. But you'd use compartment monitoring to assess that. And that's a whole different topic. So we're not gonna go any deeper into it than it is now. But I do believe there's a course it will be advertised soon at the I CE Center in Colchester, which I might be running, which will be covering all of that. So, any ideas for how you would temporarily manage these patients in A&E. So would everyone write down the first thing that they would do on middle, the very first thing they would do. I don't want history on examination. I mean, in terms of how you manage these patients, got you anyone for to the ward sent to the, please tell me someone didn't actually say that having fun. Ok, fine. So basically guys, the first thing I wanna hear you guys saying is pain relief, pain relief, pain relief. If you ever had an injury or been a hospital, patient, pain relief is the only thing on your brain. And until that's dealt with, you can't really focus on anything else. Be a conversation, discuss and consent knowing what your management's gonna be. Get on top of that patient's pain control first. Ok? If it's an open fracture, you need to make sure antibiotics have either been given at the scene or given immediately in A&E there's a very good evidence that says that early antibiotic treatment reduces the risk of infection in the longer term. If it's an open fracture with gross contamination, remove the gross contamination place in a saline soak cause there's much debate about whether you consider using a cast or whether you treat these patients with a brace. If a patient's got a TSA thr er 456 fracture, in my opinion, I'm going to be putting them into a cast. And the reason for that is, and that's a back slab. So 32 3rd of the circumference of the leg uh cast. And the reason for that is it's a high soft tissue injury. And then hence the patient is gonna be in a lot of pain and discomfort if that area is not supported. And that's what the cast is doing. If it's a Shatt ska one shat two, that's the normal valgus alignment. It might be a split or a split, depression and the patient's comfortable. There's no m there's minimal swelling. At that point, I would be happy to treat them in a hinge knee brace or a cricket pad. Splint locked in extension. The truth is a hin a lock. A cricket pad splint will still allow you to flex your knee to 20 to 30 degrees if you really want to. But it's sufficient to make the patient feel that the knee is comfortable. Do you admit them or do you discharge them? Is the next question. Um And while I could ask you about the debate about whether you would or wouldn't given the time, I'll just discuss it with you. So I would always admit a tibial plateau fracture that I feel requires surgical intervention. And if I think there's time for that to happen on the following day's trauma list, especially if I've got them admitted, I can get the CT scan done ASAP, which then can be used for operative planning to go on an appropriate surgeon's list. Be it a trauma list or on an elective list of cases being canceled? The only ones I would think about discharge are the ones that are clinically well, that I definitely would not consider operating on and we're gonna move on to which ones do we do operate on? And which ones we don't next? Any questions before I move further. Taesa in the chat has asked what antibiotics, uh, should, should you be using? Are you familiar with both guidelines? Is the question? Um So I don't mean to answer a question with a question, but the both guidelines are set in place to for management of open fractures. Colo is first line in patients that don't have penicillin allergy. There's also a local guideline in place to tell you what to use. If they do have penicillin allergy and patients are treated with IV antibiotics until there's definitive wound closure. Does that happen? Does that help? Sorry. She says yes, cool. Um Any other questions? So Tara, so you, you've raised an important point there, which is important. It's really important for you guys to know the best guidelines for open fractures because the chances are when you go to A&E some of it may have been done but not all of it. And it's very important for us to follow because you will be questions about that in the trauma meeting in a non bullying and engaging way. No, it's the best thing for the patient though, right? 100% Charlie. Not just, I don't know, I'm on the other side now, Charlie, I'm being clouded by my, just remember to remember the r just remember what it was like. Um So guys, which of these fractures just put in the chat, which fractures would you leave alone and not operated on, not operate on? No. Um Someone's writing a dissertation on the Sorry, that's me. OK. So what, what kind of answers do we have guys? Well, I, I put um so the one I wouldn't actually, I did send someone home just before leaving, who was running in by a Labrador and she had a lateral plateau that seemed to be very minimally displaced. The hemarthrosis gave the game away, got her a CT sorry in A&E and then sent her home because she was the ambulant and she could have been unmanaged potentially non operatively. I saw the, she did actually have an operation but is whether there's a degree of any lateral translation at all, if there's no lateral translation of that fragment of the lateral fragment, is that the only ones that really the only one out of all six that could not have an operation? Yeah, for me, so for me just based on radiology, so the ones you leave alone, the first answer would be based on a radiological diagnosis where it's barely viewable on an A P x-ray. Hence, it clearly is less than a millimeter displaced a CT has defined it as you've stated and you've got a sensible patient who, if you told them to not weight bear or to treat them in a hinge brace which is locked and has progressive increases degrees of flexion, they will comply with doing. And they also need to be aware that there's still a chance of them needing surgery. If on serial x-rays the fracture displaces or it become, or it demonstrates itself to become unstable. So, the radiological ones, they're undisplaced. Yep, that's the first one to say. Those are the ones we leave alone. Now, take off your surgeon's hat mat and just think like a normal human, decent human being. Who else would you not operate on, er, the very crumbly? Yeah, exactly. So, the totally comorbid who are gonna have a really high chance of infection or failure of metal work. And hence, even though it looks bad on an x-ray, now it can look a lot worse for them in the medium, in the short medium and long term. Those ones I wouldn't operate on now, I would not make that decision independently. They would still be admitted. They'd be discussed in the trauma meeting. I'd want probably two consultants to agree that it wasn't a good idea and I may even have an anesthetic assessment to assess their suitability for surgery as well, followed by a discussion with the patient and, or their next of kin. So, the ones you don't operate on often require far more work than the to in the lead up to a no than the ones you do operate on and in the lead up to a yes. Anyone else you wouldn't operate on your text after in the gateway with moving on the slide. Did you? I probably said something on there. What you said the mini be displaced it, yeah. The non ambulatory are the ones that to consider the operating on as well if they don't walk and they've had this fracture because they were hoist transferred and the knee knocked into something. Those aren't patients that need a functional knee and they're probably in a flexed position anyway. And they don't weight bear. Those are again, patients that aren't comorbid, but by their mobility status they've probably ruled themselves out of being fixed. They likely they probably will have some comorbidities. Yeah. But you could simply be a paraplegic who's now reached their mid eighties. You know, and you do see some patients who you assume are, they must have some new onset neurological disorder and know it's just that they've been paraplegic for a long period of time. Um, or they're so demented that they can't walk anymore and don't, or they've had previous hip girdle stones for a failed hemi and bed bound for the past two years. You know, some of my patients, I've seen Charlie Howe's name on a few notes. Ok. So which ones would you fix? Then guys, you've clearly really seen the next slide. So for me, it's always definitely medial fractures as long as none of the ones in orange apply. So I'd always wanna fix those. Those are the depressed or displaced are ones for which you're gonna have an abnormal joint surface. It's not gonna be congruent and the, the proximal tibia is probably gonna be wider than it should. So those are again, ones, I'd want to fix the high energy comminuted fractures. The ones extending into the metastasis. Basically, anything that suggests a high energy is probably gonna be a more significant fracture that's gonna need to be fixed. Mm. So what to use? And when this is a difficult question to answer because I'm not a frame surgeon spanning external fixators are never my first thought process. But if you speak to Mr Cartoon and Mr Gill for them as well, it's probably not their first option either, but it is a weapon in their armory that they can use if they want to. So my first question, whenever I'll look at a fracture, is, is this something that I can fix with my skill set and fix well enough? Or is it something that would be better left to a frame surgeon if I think I can fix it, then I'm gonna be using a combination of plates, screws, bone graft, et cetera in order to fix that fracture. If it's an obliterated fracture with too many fragments for which me opening up is gonna denude the bone, full blood supply. Then actually, what I'm gonna do is put it in a temporizing external fixator, which will give it at least reasonable alignment with ligamental taxis. I may even consider using percutaneous screws to fix specific fracture points. But otherwise I'm planning on this being managed by a frame surgeon or at least having their opinion with regards to whether it can be fixed with a frame or internal fixation. If I don't think it can be fixed with internal fixation, but a frame surgeon thinks it can be, then their skill set must be better than mine. And I'm not being sarcastic and hence I would leave it to them to manage as they see fit. It's really important as you guys progress through your training to realize that your skill set is not infinite. You need to know what you're good at and what you're not. And at what point you should hand it over to others. And there's been two occasions now where I've handed over cases to the frame surgeons because it's beyond my skill set. Any questions about that, what's your catastrophic option here? So for the thing is, is there an equivalent to the hindfoot nail for those patients that just need something to temporize and allow them to maybe ambulate, not be in pain. So the nuclear option is a proximal tibial replacement, which the which means fracture in the bin and basically a complex primary knee replacement. That's the nuclear option for this. How, how often have you found yourself having to do that? I have never had to do that now. Sure enough. I, no, let me rephrase. I have never done that. So, proximal tibial replacements are not, are no harder than distal femoral replacements. But I have not done a proximal tibial replacement. OK. It's the function with the proximal tibial replacement. Is it vaguely close to a normal knee or? So, the answer is a bit of a used car salesman answer in the sense that it depends on the patient's preoperative range of movement. So if you have good preoperative range and then you have a proximal tibial replacement, you should have a reasonable postoperative range. And now bear in mind, many of these are essentially uh rotating platform hinges. So they may only give you naught to 90. And if you're locking naught to 100 degrees range of movement. But as soon as you start increasing the degree of constraint within an artificial knee, you shorten the life span of it and the higher chance of revision. And remember, a high energy fracture is most likely to happen in a younger male in his forties or fifties. It's not gonna be an elderly patient in their eighties. So actually, even if the knee is obliterated, it's better that you reconstruct the tibial um plateau to a shape. That's correct. So that when the patient develops or if the patient develops posttraumatic arthritis, all you're then doing is a complex primary knee replacement rather than a catastrophic big nuclear operation. So for me, it will always be retain what the patient has if it's a younger higher energy fracture. Sounds good. No other questions. Any other questions? Um Yeah, the, the two that you had to hand over to the frame surgeons, what was the configuration of pattern of uh of injury? So it wasn't so much the configuration, it was the complication. So the only one I can er sorry, I'll rephrase. It was one case, not two because the other one was um um who was the other one? The other was a open ankle fracture. So yeah, that doesn't count. So the other one was a metaphyseal fracture in a patient patient that had a triple T for a tip tu tuberosity transfer for some issues with his patella alignment. So technically, it was a TSA six or you could describe it as a proximal tibial fracture, but the patient's abnormal bone anatomy meant that I was unable to nail it and hence I fixed it with a single lateral plate. And the reason I opted for a single lateral plate is because to use a bicondylar plate as in a plate on either side, I would have denuded the bone on both sides of blood supply. So if that failed, and the patient then needed a frame they would have no blood supply left either within the canal or outside of the bone for a frame surgeon to work with. But long story short, a BM patient of 48.5 with a single lateral plate um and multiple comorbidities, the plate broke. Hence, the patient needed a frame to fix it instead. So Charlie, you were probably involved in that case. I'm sure you work with, er, Miss Mr. Yeah, I remember. Yeah, you were personally there. Yeah. No, no, no, no, no, I did see him in A&E a few times though. Oh, ok. Fair enough. Yeah. So that was the case I handed over. The other one was an ankle. And basically they're, they need to be, er, flapped and fixed internally within 48 hours. Otherwise they're gonna need a frame and the plastic surgeons promised to operate on a 48 hour day and didn't. Hence, they moved into the, um, temporizing to definitive frame fixation, which is unfortunate for the patient. Any other questions? Ok. So outcomes generally speaking, if you restore the alignment and the joint stability, you're gonna have a good outcome from surgery. Now, good outcomes from surgery are different for what surgeons expect, what patients expect. But from my perspective, as a knee surgeon, if it's an awful fracture that restores stability and alignment, I know that my bailout option of a complex primary knee replacement will then have a good outcome. So it's selfish, but you look at outcomes from a very much a surgical perspective. If you combine higher energy injuries with multiple comorbidities and a long surgical time of beyond two hours. For example, then you're clearly going to increase the risk of complications in these patients. They're gonna have higher rates of wound discharge problems, uh postoperative infections, delayed or mal unions. 5% of patients that have tibial plateau fractures and bear in mind. These are usually probably the, the tsk of 4 to 6 is at 10 years. 1 may need a total knee replacement. And the important statement here is may need a total knee replacement. We've all seen patients as registrars and consultants in clinic with bad x-rays that don't want joint replacement surgery because they're happy with their level of function. So it doesn't mean they have to have one, but they may need one in um in a 10 at the 10 year point. Um There is reduced range of movement in up to a quarter of patients that can be due to their preexisting degree of range of movement. For example, if they're elderly, if they've been fixed incorrectly or if they've developed postoperative arthritis. So in summary, they do represent significant injuries, but they're only 2% of all of the fractures that we see. There's more than one classification that you can use. Chatzky is the most common and the most eea um easy one to discuss between clinicians. But what's useful is that it helps to guide your treatment. Your initial assessment, as s chose picks up the significant potential injuries which I can then manage. So your assessment is pivotal and your understanding of the fracture is pivotal surgery. As we can find increasingly as we get more senior is not always the answer conservative management can and is often a good answer for these patients. If you do undertake surgery, you have to address the normal lie limb access and restore joint stability to improve your outcomes. And if you undertake surgery in a timely manner, outcomes of tibial plateau fracture fixations are very good. Any questions? Uh There's just one question from the chat by uh Addie saying, um how common is an osteosarcoma at the fracture side? Who, who asked this question? Um Who's Addie? It's not that we know it, it's not that a OK. I thought it was the add we know how o at the F site. OK. So the answer to that question and this is a good way of answering most questions that you ever get asked in orthopedics is simple. How fra how common are osteosarcoma not very common at all. Therefore, the incidence of osteosarcoma at tibial plateau fracture sites is gonna be incredibly uncommon unless you work in a bone sarcoma unit. So with the answer, Adie, I've not answered the question at all, but I've answered the question that is to say, I don't know mate, but it must be really uncommon, really uncommon. Why does that, why do you, why do you wonder adi it's a unique question. We do see pathologic fractures, don't you? Because the fractures that a sort of separate? What's my algorithm? I'm so. Oh yeah, you can see the other question from me. Yeah. Is that in relation to the osteosarcoma already or? I see if it's a separate follow up question just in general. OK. To fix poster electrical fracture fragments and tibial plateau fractures. When you do rra plating through a modified Antero electral approach? What's your, no, what's your algorithm? I'm confused now. No, no, no. To what Eddie, I think we, we can discuss um plateau fractures because your question clearly requires more than a, a two second answer. Eddie, we, we can have a chat about plateau fractures whenever you like um on the phone or via email. I'm happy to answer those questions, Eddie. Um But for the sho teaching, I think it's a, a little bit beyond their level of expertise. Any other questions? Yeah, I've got one. So for those, those rare patients that you're able to send home in a hinge brace, do you, when do you get the weight bearing? Is it? Yeah. Or do you get the weight bearing on? What? So um basic science principles apply with tibial plateau fractures um or any fracture you want to make sure there's some callus before you allow the bone to bear weight and we know that in the range of essentially naught to 60 naught to 90 degrees, you're not gonna have any contact on that lateral side as yet before you get the roll back. So, for me, I'll have definitely have them nonweight bearing for the first six weeks, I'll put them in a hinge brace lock, an extension for the first two weeks and increase it by 30 degrees every two weeks. So that when I see them at the six weeks, six week mark, they've been non weight bearing. I have an x-ray and I know their range is already naught to 90 but obviously I'll see them at a two week mark anyway, in two week intervals to make sure that there's no, um, displacement of the fracture, but essentially six weeks non-weight bear naught to 90 by six weeks. If that x-ray is ok, I'll allow, then have them partially weight bear for six weeks and then fully weight bear thereafter. You've also got bear in mind stuff like what is the patient's underlying morbidity? What's the bone quality like? Are they osteopenic normally? Can they tolerate with a non weight bearing or partial weight bearing? Can you trust the patient? So the ones you treat conservatively, you really need to make sure they've ticked a lot of the boxes to say that. Yes, this is a patient who I think could follow um, a, an appropriate protocol to get them, get away without operating on. So, Yeah, so there's no weight bearing element from 0 to 60 on the medial side. So is it just any contact with? No, no medial side? I'm, I'm a pleasure. Er medial um medial side. I'm I'm uh always. Yes, sorry. There you are sorry I was, I was doing two things at once. My apologies. Yeah, medial side I'm always fixing um unless there's an indication not to. Yeah. So it says you back on of that patient, you sent home with non ing them, you're not weight bearing them despite the fact that if you had them in an extension, fully locked out, um um Donjoy Splint, they wouldn't be weight bearing on the lateral side anyway, if they were full. So is it not reduction their mobility with? Uh Yeah, they're not weight bearing anyway or is it just any? So because bear in mind, well, bear in mind for a a fracture that's valgus three. So you're normal three degrees valgus alignment. This is a fracture on the lateral side that happened probably with an axial load in extension. So you're still gonna create joint reaction forces on the later side with the weight bearing and extension until that fracture's gummy. I don't want them putting weight on it. And what's important with any fracture is always early active range of movement. I can do that without the weight bearing. It's not gonna cost them anything in the first six weeks. If you think about ankle fractures. We've moved to this vogue now where you can fix fractures and have them weight bear on them immediately. Right. That's what a lot of people now want to do in the front and ankle community. But we've been for years fixing them for putting them in a cast for six weeks and weight bearing them. The cast problem is the fact that it's the IMIL then not being able to move the ankle range of movement. I can do that in a hinge knee brace so they can get that. I don't care about the weight bearing in the early point. Um And for me, you've got to remember that while you see them in A&E and then send them to me. I'm gonna have to be worrying about them for the whole period that they're conservative and not having them weight bear for six weeks. Takes away that worry for me for six weeks without any impact on their outcomes. Thank you. Thank you very much, Mister Kwanza for volunteering even the Thank you very much for uh I volunteered. Ka promised me 300 lbs in a night out. Still recording, still recording. Thank. Thank you very much. It's a pleasure. It's a pleasure. I'm happy to answer any questions you want um whenever you guys want. Um And yeah, it, it was nice to teach you guys any other questions or something you wanna email me about afterwards, just send me an email guys. Ok? Thank you. Pleasure. Good night. I managed to not wake up my kids. So mister. So I was saying uh by next uh next week we're going to be doing by Mister Peter. How? No, no. Uh This is just uh I, I think just promoting next week's session while I've got you on that. So, uh yeah, next week is going to be Mister Peter Hallam taking us through proximal humerus fractures and then we'll talk about midshaft and distal humerus fractures as well. Uh Yeah, but uh thank you guys for uh for joining us today. I think we still have as many people as we did when we started. So, excellent presentation, Mister Zal was great. Thank you. I'll, I'll, I'll, I'll bounce out because I'm, I'm starting to get inappropriate. Have a lovely day. Bye bye. Uh Cool. All right. Go get some dinner guys at night, night.