Sports Medicine: Just the Facts

CHAPTER 64 • TIBIAL AND ANKLE FRACTURES 379

than cast immobilization in closed tibial fractures even

in cases demonstrating significant displacement of frac-

ture fragments (Hooper, Keddell, and Penny, 1991).

• Acceptable postreduction parameters of a tibial shaft
  fracture are commonly less than 5°of varus or valgus
  angulation, less than 10°of anterior-posterior angula-
  tion, less than 10°of rotational deformity, and less than
  1 cm of shortening. Many authors have demonstrated,
  however, that clinical and radiographic outcomes are
  often unaffected by various amounts of anterior, poste-
  rior, varus, or valgus angulation (Court-Brown, 2001).
  Compressive forces are necessary for adequate healing
  as it has been shown that 5 mm of distraction may delay
  healing up to 1 year (Koval and Zuckerman, 2002).

TIBIAL PLATEAU FRACTURES

•Tibial plateau fractures comprise less than 1% of all
fractures and approximately 8% of fractures in elderly
patients. In 70 to 80% of the cases, fractures of the
tibial plateau occur on its lateral margins (Koval and
Zuckerman, 2002).
•Tibial plateau fractures often occur after violent varus
or valgus stress coupled with axial loading. For this
reason, there are often associated ligamentous or car-
tilage injuries.
•Tibial plateau fractures are classified according to the
Schatzker classification system. Schatzker classified
tibial plateau fractures relative to their location and
associated articular depression (Merchant and Dietz,
1989) (Table 64-3).
•Tibial plateau fractures can be managed successfully
both operatively and nonoperatively. Nonoperative
treatment is favored in patients that demonstrate
nondisplaced or minimally displaced fractures radi-
ographically and who do not demonstrate ligamentous
laxity by physical examination. Nonoperative treat-
ment is also favored in patients with multiple comor-
bidities or advanced osteoporosis.

• Indications for operative treatment are displaced frac-
  tures of the tibial plateau that demonstrate a varying
  degree of depression, compartment syndrome or neu-
  rovascular compromise, instability, or laxity of the knee.

All open fractures must also be treated operatively.

Research does not support operative intervention in a

patient that is neurovascularly intact and demonstrates

mild radiographic evidence of articular depression.

Jensen et al found no association between the degree of

fracture displacement and clinical outcome (Schatzker,

McBroom, and Bruce, 1979). Additionally Lucht and

Pligaard demonstrated that the majority of patients with

up to 10 mm of articular depression had acceptable, func-

tional results at 7 years follow-up (Jensen et al, 1990).

TIBIAL PLAFOND FRACTURES

•Tibial plafond fractures comprise 7 to 10% of all tibial

fractures. Fractures of the plafond usually occur fol-

lowing falls from heights with significant axial com-

pression, shear forces at the distal tibial articulation,

or a combination of both (Lucht and Pligaard, 1971).

•Patients with plafond fractures are often reluctant to

ambulate, with variable gross deformities of the distal

tibia or ankle mortise. Patients often present with a

great deal of pain and edema.

•Anterior-posterior, lateral, mortise, and 45°oblique

views of the ankle are necessary. An occasional CT is

required for better understanding of complex fracture

patterns and intra-articular involvement.

• Nonoperative therapy is only indicated for nondis-
  placed fractures or plafond fractures in severely debil-
  itated patients. Operative treatment is ideally aimed at
  anatomic reduction, but often requires temporary
  external fixation to relieve articular surface pressure
  until swelling and inflammation around the joint
  resolve. There is a high incidence of soft tissue com-
  plications if swelling is not controlled at the time of
  surgery. For this reason, it is particularly important to
  control associated swelling and edema with ice, ele-
  vation, and immobilization.


• Successful anatomic reduction and congruity does not
  appear to affect patient outcome and rehabilitative
  success. DeCoster et al demonstrated that the mechan-
  ics and energy of the initial insult to the plafond pre-
  dicted patient outcome measures more reliably than
  anatomic reduction (DeCoster et al, 1999).

ANKLE FRACTURES

INTRODUCTION

• The true incidence of ankle fractures in the general
  population is unknown, as it changes with increased
  participation in athletics and trends in fashion
  footwear. There is also a great deal of interobserver
  reliability when it comes to classifying these fractures.

TABLE 64-3 Schatzker’s Classification of Tibial
Plateau Fractures

TYPE FRACTURE DESCRIPTION

1 Lateral plateau, split fracture, no associated articular depression

2 Lateral plateau, split fracture with associated articular depression

3 Lateral plateau, moderate articular depression

4 Medial plateau

5 Bicondylar plateau

6 Plateau fracture with metaphyseal-diaphyseal dissociation