| Abstract|| |
Background : Proximal tibial fractures involving the condyles are often a matter of debate with regards to surgical management. The purpose of this study was to evaluate the efficacy of using closed reduction with an eschmarch bandage, gentle hammering, and use of percutaneous cannulated cancellous screws for fixation and buttressing the fracture, as a treatment modality for specific tibial condyle fractures.
Methods : We evaluated 90 closed upper end tibia fractures, Schatzker types I, III, and IV, treated with closed reduction using an esmarch bandage and minimally invasive percutaneus fixation with cannulated cancellous screws.
Results : We achieved excellent results in 33.3% of the cases, good result in 50%, a fair result in 13.3 %, and a poor result in 3.3 % cases.
Conclusion : This minimally invasive modality of treatment of upper end tibia fractures gives satisfactory results. The use of esmarch bandage and gentle hammering to help achieve acceptable reduction has the advantage of being relatively simple and easily reproducible, without the use of any expensive extra medical equipment. The percutaneous fixation with cancellous screws has minimal morbidity. Thus, this is a good modality of treatment of tibial condlyle fractures of Schatzker types I, III and IV.
Keywords: Tibial condyle fractures; Schatzker′s classification; Esmarch bandage; Percutaneous cannulated cancellous screws; Buttress screw; Holh′s Criteria.
|How to cite this article:|
Shete K, Sancheti P, Kamdar R. The role of Esmarch bandage and percutaneous cannulated cancellous screws in tibial condylar fracture. Indian J Orthop 2006;40:173-6
|How to cite this URL:|
Shete K, Sancheti P, Kamdar R. The role of Esmarch bandage and percutaneous cannulated cancellous screws in tibial condylar fracture. Indian J Orthop [serial online] 2006 [cited 2018 Dec 17];40:173-6. Available from: http://www.ijoonline.com/text.asp?2006/40/3/173/34486
| Introduction|| |
Fractures of proximal tibia involve a major weight bearing joint and are serious injuries, which, if not treated well, result in functional impairment. To preserve normal knee function one must strive to maintain joint congruity, preserve the normal mechanical axis, ensure joint stability and restore full range of motion. Most injuries affect the lateral plateau (5570 %)  . Isolated injuries to the medial plateau occur in 10 - 23 % of cases  , whereas bicondylar fractures are present in 1030 % cases  .
The objective of this study is to evaluate the efficacy of treatment of upper end tibial fractures by closed reduction using an eschmarch bandage and gentle hammering, and stabilizing and buttressing the fracture with percutaneous half threaded cannulated cancellous screws.
| Materials and methods|| |
Ninety cases (63 males and 9 females) of closed tibial plateau were studied prospectively between May 1995 and January 2005. Eighty eight of the patients were between 25 to 75 years of age while 2 were above 75 years of age. All fractures were classified according to Schatzker's system of classification [Table - 1] ,, . Inclusion criteria were: closed fractures (Schatzker types I, III, IV), articular step of more than 10mm, articular depression of less than 5mm.
All patients were evaluated using X-rays of the knee joint in the antero-posterior view, lateral view, internal oblique view, and external oblique views. Seventy patients were initially treated with above knee medio-lateral clamp slab support and 12 with lower tibial pin traction over Thomas splint. Eighty one patients were operated within 24 hours of injury, while 3 were operated within 7 days. Preoperative planning included study of fracture anatomy to decide to approach and calculate the size of the screws that would be required.
All patients received intravenous antibiotics half an hour prior to surgery. Spinal or general anaesthesia was given as per the anaesthetists' discretion. All were operated under a pneumatic tourniquet.
We assessed ligamentous instability under anaesthesia as ligament injuries occur with 10-33% of tibial plateau fractures  .
Initially reduction was achieved by tightening a sterile eshmarch bandage and with the help of gentle hammering. The hammering was only over the eshmarch bandage and never directly on the soft tissue or bone. The reduction was maintained with the help of pointed reduction clamps. Reduction was considered acceptable if the articular step was less than 5 mm and the depression of the articular surface was less than 1.5 mm  . The entire procedure was carried out under image intensifier guidance. Guide wires were then inserted. The fracture was percutaneously fixed using half threaded cannulated cancellous screws with washers. The approach was either medial or lateral depending on the condyle affected. Two screws were used in 84 cases, and three screws in 2 cases. An additional screw was used as a buttress screw in 88 cases. In most cases, post operative immobilization was not required. A crepe bandage was applied for the first 5 days. In those cases with ligamentous instability, post operative immobilization was given in each case in the form of above knee cast in 15 degrees of flexion at the knee. Post operative check X-rays in the antero-posterior and lateral views were taken.
All patients received 4 doses of intravenous antibiotics and were discharged on the second post operative day. Oral antibiotics were given for 5 more days. Knee range of motion exercises were started on the 2 nd post operative day. The patients were advised to be non weight bearing on the affected limb, with the help of 2 crutch supports. The patients were followed up at 4 weeks. Cast removal was done where appropriate. Serial follow up was maintained at 6 weeks, 10 weeks and 12 weeks. After clinical and radiological assessment, the patient was allowed full weight bearing without support.
| Results|| |
The patients were followed up for a minimum of 5 years. The post operative evaluation was done using Holh's criteria [Table - 2] , , which considers subjective, objective (functional), as well as anatomical (radiological) parameters. More importance is given to functional outcome in this evaluation method. The various parameters were given points and the total was assessed in terms of an excellent result, good result, fair result, and poor result. Out of the 90 cases, 30 cases had an excellent result (33.3%), 45 cases had a good result (50%), 12 cases had a fair result (13.3%), and 3 cases had a poor result (3.3%).
Out of the three cases with the poor outcome, 2 patients had a redisplacement of the fracture. Both these cases were fractures of the lateral condyle, with associated fracture of the fibular head. We had not used buttress screws in them, thus resulting in the redisplacement and the subsequent malunion with persistant pain and deformity, with restricted range of motion. They were from the initial part of our series after which we started using buttress screws additionally where needed. Re-displacement of the fracture fragments occurred in one case due to early weight bearing by the patient himself, without our prior assessment. One case developed post operative infection. He was a known case of diabetes, and required an additional 10 days of intravenous antibiotics. The infection subsided without any adverse effect on function. We had one complication in the form of delayed wound healing with blistering of the surrounding skin. It resolved by itself without the need for any active intervention. We had no cases of implant failure.
| Discussion|| |
Intra-articular fractures of the tibia are difficult to treat. "These fractures are tough!" were the words used by Mason Holh  in 1967. These words hold true even today. The goal is to provide a stable painless knee joint with normal range of movement controlled by normally acting muscles. However, this ideal result may not be possible in every fracture.
There are various methods used to treat tibial condyle fractures. These include cast bracing, internal fixation with buttress plates  , percutaneous plating  , use of Ilizarov's ring fixator  , and the use of hybrid fixators  that combined internal fixation with an external fixator. The use of eschmarch bandage with occasional gentle hammering for closed reduction had the advantage of simplicity, non invasive in nature, without the need of any extra resources. It proved to be an effective method for achieving acceptable reduction.
The pre-operative assessment with regards to fracture anatomy, the class of fracture, and assessment of ligamentous stability under anaesthesia helped us decide cases for inclusion and exclusion. We have also found that image intensifier assisted percutaneous fixation has results as good as those studies involving arthroscopic assisted surgery for the same  .
The two half threaded (16 or 32 mm) 6.5 mm cannulated cancellous screws give sufficient stability. We found in those cases of lateral tibial condyle fractures with associated fibular fracture, a third screw used as a buttress screw helped prevent inferior displacement of the fragment. This is in contrast to the study by Koval et al  which states the use of an antiglide screw or buttress plate does not offer an advantage over solitary lag screw fixation alone for the treatment of noncomminuted upper end tibial fractures.
The emphasis should be on early mobilization. Salter  showed the importance of better neo-chondrogenesis with mobilization of the joint. Fixation of the fractures percutaneously, allows early mobilization.
Koval et al  had done a similar percutaneous cancellous screw fixation for fractures of the upper end tibia. They reported an excellent result with 33% of cases (as compared to 33.3% in our series), a good result in 56% cases (as compared to 50% in ours), a fair result in 11% cases (as compared to 13.3% of our cases), and no poor result (as compared to 3.3% in our series).
In conclusion, for fractures of the tibial condyles (Schatzker types I, III, and IV ) with an articular step less than 10 mm, articular step less than 10mm, and articular depression less than 5 mm, this technique of closed reduction using eschmarch bandage and gentle hammering, with percutaneous fixation using cannulated cancellous screws gives excellent functional results. It offers a middle path approach for treatment of such fractures, with advantages of being minimally invasive, having minimal instrumentation, early mobilization, and less morbidity, without the need of any additional expensive medical equipment of surgical expertise. It is particularly helpful in patients where formal open surgery is not possible. Severely depressed or comminuted fractures or fractures with significant metaphyseal and diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.
| References|| |
|1.||Hohl M. Fractures of the proximal tibia and fibula. In: Rockwood C, Green D, Bucholz R, eds. Fractures in adults, 3rd ed. Philadelphia: JB Lippincott,1991:1725-1761. |
|2.||Schatzker J. Fractures of the tibial plateau. In: Schatzker J, Tile M, eds. Rationale of operative fracture care. New York: Springer-Verlag, 1987:279. |
|3.||Schatzker J. Tibial plateau fractures. In: Browner BD, Jupiter JB, Levine AM, et al. eds. Skeletal trauma. Philadelphia: WB Saunders,1993:1745. |
|4.||Schatzker J, McBroom R, Bruce D. Tibial plateau fractures: the Toronto experience 1968-1975.Clin Orthop. 1979;138:94-104. |
|5.||Rasmussen PS. Tibial condylar fractures: impairment of knee joint stability as an indicator for surgical treatment. J Bone Joint Surg (Am). 1973; 55:1331-1350. |
|6.||Brown TD, Anderson DD, Nepola JV, et al. Contact stress aberrations following imprecise reduction of simple tibial plateau fracture. J Orthop Res.1988; 6:851-862. |
|7.||Hohl M. Tibial condylar fractures. J Bone Joint Surg (Am). 1967; 49:1455- 1467. |
|8.||Hohl M, Luck JV. Fractures of the tibial condyle. J Bone Joint Surg (Am). 1956; 38:1001-1018. |
|9.||Duwelius, PJ et al. Treatment of Tibial Plateau Fractures by Limited Internal Fixation.. Clin Orthop. 1997; 339:47-57 |
|10.||Kankate RK, Singh P, Elliott DS. Percutaneous plating of low energy unstable tibial plateau fractures: a new technique. Injury. 2001; 32(3):229-32 |
|11.||Buckle R, Blake R, Watson JT. Treatment of complex tibial plateau fractures with the ilizarov external fixator. J Orthop Trauma. 1993; 7: 167 |
|12.||Marsh L, Smith ST, Do TT. External Fixation and Limited Internal Fixation for Complex Fractures of the Tibial Plateau. J Bone Joint Surg (Am). 1995;77:661-673 |
|13.||Lobenhoffer P, Schulze M, Gerich T, Lattermann C, Tscherne H. Closed Reduction/Percutaneous Fixation of Tibial Plateau Fractures: Arthroscopic Versus Fluoroscopic Control of Reduction. J Orthop Trauma. 1999; 13(6):426-431 |
|14.||Koval KJ, Polatsch D, Kummer FJ et al. Split Fractures of the Lateral Tibial Plateau: Evaluation of Three Fixation Methods. J Orthop Trauma. 1996; 10(5):304-308 |
|15.||Salter RB, Simmonds DF, Malcolm BW, et al. The biological effect of continuous passive motion on the healing of full thickness defects in articular cartilage: an experimental investigation in the rabbit. J Bone Joint Surg (Am). 1980; 62:1232-1251. |
|16.||Koval KJ, Sandes R, Borrelli J et al. Indirect reduction and percutaneous scew fixation of displaced tibial plateau factures. J Orthop Trauma. 1992; 6(3) : 340-6 |
Sancheti Institute of Orthopaedics and Rehabilitation, 16, Shivajinagar, Pune-411005. Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure - 1]
[Table - 1], [Table - 2]