Tibial Plafond Fracture Classifications

The pilon fracture has two classifications that are commonly used. The first classification is the Ruedi-Allgower Classification, which is an old classification, and the second is known as the AO/OTA Classification.

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The Ruedi-Allgower Classification is separated into three types. Type I fractures are cleavage fractures with no significant joint incongruity and no displacement of the fractured fragments. Type II fractures have a significant articular incongruity with minimal metaphyseal comminution or impaction. Type III fractures have significant articular comminution and a metaphyseal impaction; this is a very bad injury.

You will find three types of AO/OTA classifications and they are as follows: Extra-articular, partial articular, and complete articular. The extra-articular fractures are further broken down into simple (A1), metaphyseal wedge (A2), and metaphyseal complex fractures (A3). All of these extra-articular fractures are named “A”, followed by a number based on the complexity of the fracture. Partial-articular fractures are classified further with the letter “B” and are identified as Pure Split (B1), Split Depression (B2), and Multi-fragmentary depression (B3).

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Split Depression fractures are a supination/adduction fracture of the ankle which is identified as a vertical fracture of the medial malleolus. The anteromedial portion of the plafond may also be impacted. The impaction or depression unique to this fracture is commonly missed, making this fracture a classic question on orthopaedic examinations. If the surgeon misses the impaction fracture after fracture fixation, they will need to revise the fixation and be sure to elevate the impaction or depression; additionally, they will need to restore the joint congruity before fixing the fracture. The surgeon will need to fix the fracture with a plate or screws. If screws are used, they have to be parallel to the joint in order to compress the fracture. If a plate is used, it should be an anti-glide plate.

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The “C” fractures are Complete Articular fractures and have complete joint involvement. The Complete Articular fractures are broken down into Articular Simple/Metaphysis Simple (C1), Articular Simple Metaphysis Multi-fragmentary (C2), and Articular Multi-fragmentary/Metaphysis Multi-fragmentary (C3). C3 fractures are a very difficult fracture and probably has the worst prognosis.

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Classically, there is a typical pilon fracture fragment. Usually there are three main joint fragments. The Three fragments are the:

  1. Medial Malleolus
    1. Attached to the deltoid ligament
  2. Anterolateral Fragment
    1. Chaput Fragment- attached to the anterior inferior tibiofibular ligament
  3. Volkmann Fragment
    1. Posterolateral fragment attached to the posterior inferior tibiofibular ligament

When the fibula is intact, the lateral collateral ligament of the ankle may rupture (fibula is intact in 20% of the cases).

Distal Clavicle Osteolysis

Osteolysis is bone erosion, the bone is dissolving or lost. There is a localized area of inflammation, hyperemia, microfracture, bone resorption, and eventually arthritis of the AC joint. The condition affects the distal end of the clavicle due to micro stress fractures. It typically affects younger male patients. It occurs from activities that require overhead heavy lifting, repetitive motion, and the use of a jack hammer. The condition is also common in weight lifters.

acromion

During the examination, you will find localized pain, swelling, and tenderness over the AC joint area. Additionally, the provider will find a positive cross body adduction test. An x-ray will show erosion of the outer end of the clavicle. The acromion is okay. There may be osteopenia, osteolysis, tapering and cystic changes of the clavicle. An MRI may be obtained to rule out additional shoulder pathology. An MRI will show a high signal in the distal clavicle.

Imaging

Acromioclavicular Joint Radiography- Zanca View

imaging

Direction of the x-ray beam: The beam is directed with the cephalad angle of 10 degrees. Clavicular osteolysis can be assessed using the Zanca view. The acromion will be normal with the abnormality isolated to the distal clavicle. The Zanca view is also used for diagnosis of arthritis of the AC joint. It will show osteophytes and joint space narrowing. The findings of the x-rays may not represent the patient’s real symptoms.

Differential Diagnosis

Erosion or absence of the distal ends of the clavicle may be seen in a wide range of conditions.

Bilateral Erosions

  • Hyperparathyroidism
  • Rheumatoid arthritis
  • Scleroderma

Unilateral Erosionerosion of bone

  • Post-traumatic Osteolysis
  • Myeloma
  • Metastases
  • Osteomyelitis

 

Treatment consists of rest, NSAIDs, ice, and activity modification. Injections may be given blindly or with ultrasound guidance. If pain persists despite conservative methods, surgery may be considered. An arthroscopic or open resection of the distal clavicle may be performed. An arthroscopy allows for evaluation of the shoulder joint. In open surgery, repair the trapezius and deltoid fascia adequately. Surgery is successful in about 90% of cases. The surgeon will resect 5-10mm of bone and keep the posterior-superior ligament intact because it maintains horizontal stability of the clavicle.

 

Supracondylar Fractures of the Humerus in Children

Supracondylar fractures constitute approximately 50% of all elbow fractures. The supracondylar region is thin and weak and thus can fracture easily. These fractures are classified into two different types: extension and flexion.

fracture typesExtension type fractures are the most common type, occurring approximately 95% of the time. Extension fractures typically occur due to falling onto an outstretched hand. With extension fractures, the distal fragment of the humerus displaces posteriorly. Anterior interosseous neurapraxia is the most common nerve palsyOKsign occurring with supracondylar fractures. Injury to the anterior interosseous nerve will lead to weakness of the flexor digitorum profundus muscle to the index finger and the flexor pollicis longus muscle. The patient will not be able to make an “OK” sign or bend the tip of his index finger. Radial nerve neurapraxia is the second most common palsy and is evident by weakness in wrist and finger extension.

The second type of fractures, flexion type fractures are rare and occurs due to falling flexionfxdirectly on a flexed elbow. In flexion type fractures, the distal fragment is displaced anteriorly. This type of fracture may be accompanied with ulnar nerve neurapraxia. Injury to the ulnar nerve will lead to a loss of sensation along the little finger. Later on, the patient may also have weakness of the intrinsic hand muscles and clawing.

 

Gartland Classification System

gartland classificationThe Gartland Classification System provides physicians with a way to categorize supracondylar humerus fractures. There are four classifications and are as follows: Type I fractures are nondisplaced fractures; Type II are angulated with an intact posterior cortex; Type III are completely displaced; and Type IV has complete periosteal disruption with instability in both flexion and extension.

Radiology

Plain AP and lateral x-rays should be obtained. A posterior fat pad sign seen on a anterior humeral linelateral view x-ray should increase your suspicion of an occult fracture around the elbow. On a lateral view x-ray, the anterior humeral line is drawn along the anterior border of the distal humerus. Normally, the anterior humeral line should run through the middle third of the capitellum. In extension type fractures, the capitellum will be displaced posteriorly, relative to the anterior humeral line.

The Baumann’s Angle is formed by a line perpendicular to the axis of the humerus and a line going through the physis of the capitellum. Normally, the Baumann’s angle should measure at least 11° (variable).

 

Physical Examination

It is important to assess the neurovascular structures. The anterior interosseous nerve is assessed by asking the patient to do the “OK” sign with their hand. The radial nerve is assessed by asking the patient to extend their wrist and fingers. Ulnar nerve damage is usually indicated by the loss of sensation along the little finger; however, later on the patient may have weakness of the intrinsic hand muscles and clawing.

finger extensionTreatment

Nonoperative treatment is usually indicated for type I fractures. This treatment usually consists of splinting or casting the elbow for a duration of 3-4 weeks. It is very important to remember not to flex the elbow in the splint or cast beyond 90° in order to avoid vascular compromise and compartment syndrome.

closed reductionOperative treatment is usually indicated for Types II and III, and are usually treated by a closed reduction and percutaneous pinning. During reduction, pronation of the forearm during elbow flexion helps to correct a varus deformity. After reduction, the surgeon will want to check for a gap in the fracture, as the neurovascular bundle may be trapped there. The surgeon will need to free the brachialis muscle from the fracture site if it is interpositioned there. Fixation is usually achieved with 2-3 ulnar nerve pinningdivergent lateral pins, depending on stability. Medial pins may also be added depending on stability; however, the surgeon will need to be aware of the ulnar nerve when placing the medial pin.

Open reductions are only performed when closed techniques are unable to achieve the appropriate reduction of the fracture. The surgeon will want to avoid posterior dissection in order to preserve the vascularity of the fractured segment. Fracture reduction and fixation should be done emergently in cases of vascular compromise.

Complications

Neurapraxia is a common complication of supracondylar fractures and usually resolves on its own—thus, treatment is observation only. A cubitus varus deformity may occur due to a malunion of the fracture. This only presents as a cosmetic problem since it does not affect the function of the arm or elbow. Additionally, this cubitus varusdeformity can be corrected later on by a supracondylar valgus osteotomy. Vascular problems, such as compartment syndrome, may also occur. Volkmann’s ischemic contracture may occur due to a compression of the brachial artery with then patient is placed in a cast with the arm in hyperflexion (more than 90°).

Important Scenerios

A patient may present with a Displaced Type III fracture and a pulseless hand. He may have adequate circulation—which is evident by the normal temperature and color of the hand—or he may have inadequate circulation—indicated by a cold blue hand. In both cases, an urgent closed reduction and percutaneous pinning is required. Once this has been performed and the circulation is adequate, the surgeon can observe the patient and place them in a splint that is at a 45° angle. However, if the patient continues to have inadequate circulation after the closed reduction, then the patient will require a vascular exploration and repair.

Carrying Angle of the Elbow

The carrying angle of the elbow is the clinical measurement of the varus-valgus angulation of the arm with the elbow fully extended and the forearm fully supinated. With the arms extended at the sides and the palms facing forward, the forearm and hands are normally slightly away from the body.

axis The intersection of the axis of the upper arm and axis of the forearm defines the carrying angle. The carrying angle is greater in shorter persons compared to taller persons. The shorter the forearm bone length is, the greater the carrying angle will be. The normal carrying angle of the elbow is between 5-15°. The carrying angle is greater in women and in throwing athletes. It is difficult to assess if there is a flexion contracture of the elbow. This angle permits the forearms to clear the hips in swinging movements during walking, and is important when carrying objects.

carrying angleCubitus varus is the opposite of cubitus valgus, causing the elbow to have inward angulation towards the midline of the body. Cubitus valgus is a deformity which causes the forearm when it is fully extended to be angled away from the body in a greater degree than normal. Supracondylar fractures usually occur in children.

If the fracture is malaligned and if it heals in a malaligned position, the fracture may develop into a severe varus deformity of the elbow which decreases the carrying angle of the elbow. This decrease of the carrying angle causes the elbow to have more of an inward angulation towards the midline of the body. This creates what is called a “gunstock deformity”. The deformity is caused by fracture malunion. This is usually a cosmetic deformity with little functional limitation.leading

A fracture of the lateral condyle of the humerus can lead to:

  1. Cubitus Valgus
  2. Stretching of the ulnar nerve

If the fracture did not heal or the fracture is malaligned, the medial part of the humerus will grow and the lateral part will not grow. The forearm will drift into valgus malalignment. The carrying angle will increase (cubitus valgus) and the ulnar nerve will be stretched and may need transposition. The nonunion of the lateral condyle of the humerus may need fixation in order to stop progression of the valgus deformity. 30° of varus or valgus angulation is tolerated in fractures of the humerus without any clinical functional significance.thirty