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ARTICULAR FRACTURES:

PRINCIPLES
• Key factors that influence joint function and the risk of posttraumatic arthritis:
joint incongruity, malalignment, and instability
• Incongruity of the articular surface may cause increased contact stresses in the
joint. If this incongruity combines with instability, it may cause abnormal
movement with disproportionate increases in contact stress rate and
magnitude.
• Malalignment may shift the loading pattern of the articular surface in a joint,
which may be crucial to subsequent progression of osteoarthritis.
• Instability caused by fracture, ligament or meniscal injury can also lead to
cartilage degeneration and may be important in determining outcome.
• Joint malalignment, joint instability, and articular incongruity play a role in the
development of posttraumatic osteoarthritis.
• Most authors agree that it is necessary to secure an anatomical reduction of the
articular surface, restore joint stability & normal axial alignment to provide the
patient with the best possible chance of permanent joint preservation.
• The current philosophy of operative treatment of these injuries is based on the
following observations:
Plaster cast immobilization of intraarticular fractures → joint stiffness.
Plaster cast immobilization of intraarticular fractures after open reduction and internal
fixation → much greater stiffness.
Depressed central articular fragments are impacted and will not be reduced by closed
manipulation and traction.
Major articular depressions do not fill with fibrocartilage → instability is permanent.
Anatomical reduction and stable fixation of articular fragments is necessary to restore
and maintain joint congruity.
Metaphyseal defects beneath reduced articular segments must be filled with structural
bone graft or substitute to prevent articular fragment re-displacement.
Metaphyseal and diaphyseal displacement must be reduced to obtain proper limb
alignment and prevent joint overload.
Early motion is necessary to prevent joint stiffness and to maximize articular healing
and recovery. This requires stable internal fixation.
MECHANISM OF INJURY
•There are two common mechanisms of injury for articular fractures:
1.Indirect application of force
2.Direct application of force
RADIOLOGICAL EVALUATION
•For simple fractures, AP and lateral x-rays suffice. For more complex fractures,
oblique x-rays taken at 45° to the coronal plane will help to identify fracture
fragments
•Computed tomography with coronal & sagittal reconstructed images provides
additional information about the number and position of the articular fragments,
the presence of impacted articular segments, the location of metaphyseal
fracture lines, and the overall morphology of the injury
INDICATION OF OPERATIVE FRACTURE FIXATION
• Operative fracture fixation for displaced intraarticular fractures is
recommended to achieve anatomical reduction of the articular surface &
fixation with absolute stability
Absolute Indications
Articular fractures need operative treatment in the following circumstances:
• Open fractures (for soft-tissue management)
• Irreducible fracture dislocations.
• Associated neurological injuries when displaced fragments put pressure on
nerves
• Associated with vascular injuries
• Associated compartment syndrome
Relative Indications
Surgery for articular fractures should be strongly considered in the
following:
• Displaced articular surface > 2 mm
• Loose fragments within joint
• Displaced fractures resulting in instability
• Significant displacement of the mechanical axis of the limb
GENERAL PRINCIPLE OF OPERATIVE TREATMENT
TIMING
•Complex fracture reconstruction should not be performed and is often best delayed until the
window of opportunity at day 5–10 .
•The timing of surgery for complex articular fractures in polytrauma will depend on the soft
tissues, preoperative planning, and having the right surgical team.
•If an injury includes open contamination of a joint, very early (< 6 hours) surgery should be
performed and exposed articular cartilage must be treated with debridement, irrigation, and
early joint closure. Failure to do this will result in drying of the cartilage and very early joint
degeneration and destruction.
•If the soft-tissue envelope around the joint is swollen or traumatized with abrasions, fracture
blisters or degloving, open surgery within the first few days may be contraindicated
PREOPERATIVE PLANNING
•Preoperative planning is an important prerequisite in open reduction and internal fixation of
intraarticular fractures.
•Adequate x-ray analysis together with the soft-tissue assessment will allow the surgeon to
understand the personality of the injury and what will be needed to achieve the surgical goals.
• If there is inadequate stability, the large distractor or an external fixator may be
used to maintain distraction and axial alignment and to allow some indirect
reduction of fracture fragments.
• Bone defects remaining within the metaphysis can be filled with autogenous /
allogenic bone grafts or bone substitutes to provide early structural support to
the articular surface & to stimulate reconstitution of metaphyseal bone stock.
Articular Fractures with Metaphyseal/Diaphyseal Extension
• Hybrid external fixators and ring fixators can be used with limited surgical
exposure of the metaphysis/diaphysis
POSTOPERATIVE TREATMENT
• A removable splint may be used to maintain an optimal position of the joint
and limb until muscle control of joint motion is regained. It will help soft-tissue
recovery.
• Limited weight bearing (10–15 kg) is prescribed typically for 6–8 weeks after
surgery and can then be increased depending on clinical findings and x-rays.