Intraarticular fractures: Past, present and future? - Punjab ...

Review Article
Intraarticular fractures: Past, present and future
Bhavuk Garg*, Rajesh Malhotra**
*Assistant Professor, ** Professor
Department of Orthopaedics
AIIMS, New Delhi
INTRODUCTION
Intraarticular fractures, if not properly handled, inevitably
lead to stiffness, pain or osteoarthritis (posttraumatic) 1 . Sir
John Charnley advocated non-operative management of
intraarticular fractures in his famous book on conservative
management of fractures entitled “The Closed Treatment of
Common Fractures” 2 . Several other authors including Neer et
al 3 and Stewart et al 4 also advocated the same. Unavailability
of proper internal fixation devices as well as lack of proper
understanding of orthopedic surgical principles was the main
reason for this favor for conservative management.
After foundation of AO group in 1958, a lot of
improvements in orthopedic internal fixation devices as well as
an improved understanding of orthopedic surgical principles
prevailed. AO/ASIF group reported better outcome of
intraarticular fractures with open reduction and internal fixation 5 .
Several other authors echoed similar results 6, 7 . It was also
observed that intraarticular fractures that underwent ORIF as
well as immobilization had much more stiffness and worse
outcome than fractures, which were either, underwent ORIF
and early motion or immobilization alone 8 . AO group also
advocated that intraarticular fractures behave in a different
biological and functional manner as compared to diaphyseal
fractures.
PRINCIPLES OF INTRAARTICULAR FRACTURE
MANAGEMENT
Mitchell and Shepard 9 reported that articular cartilage
regenerate after intraarticular fractures provided anatomical
reduction and absolute stability. Salter et al 10 showed that
continuous passive motion stimulates articular cartilage healing
as well as regeneration. Schatzker et al 11 pointed out following
principles of intraarticular fracture treatment:
1. Immobilization of intraarticular fractures leads to stiffness
of joint.
2. Immobilization combined with ORIF of intraarticular
fractures causes much more stiffness.
3. Depressed and impacted articular fragments will not reduce
by closed manipulation or ligamentotaxis.
4. Big articular defects do not fill by fibrocartilage, resulting
in instability due to their displacement.
5. Anatomical reduction and as well as absolute stability is
vital to the optimum healing of articular fractures. (Fig. 2)
6. Metaphyseal voids should be bone grafted (Fig. 3)
(however with use of current locking plates, this has
become controversial).
7. Any metaphyseal and diaphyseal displacements should
be reduced to prevent extra load on the joint (This reduction
need not to be anatomical)
8. More important is to restore the joint congruity as well as
axial alignment.
Corresponding Author :
Dr Bhavuk Garg,
Assistant Professor,
Department of Orthopaedics,
AIIMS, New Delhi-110029
Email: drbhavukgarg@gmail.com
Pb Journal of Orthopaedics Vol-XIII, No.1, 2012
Fig 2. A depressed intra-articular fracture of proximal tibia
managed by anatomical reduction, stable fixation and early
c motion. Patient had excellent functional result
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Garg and Malhotra
Fig 4. CT gives much detailed description of intraarticular
fracture anatomy
Fig 3. Bone grafting should be done in cases of metaphyseal voids,
particularly in osteoporotic bones
9. Early motion is essential for optimal healing of articular
cartilage and best outcome. Stable internal fixation is a
must for this.
BASIC SCIENCES FACTS ABOUT INTRAARTICULAR
FRACTURES
Articular cartilage is an aneural structure with no blood or
lymphatic supply and is dependent upon diffusion from
surrounding tissues for nutrition.Relationship between articular
cartilage injury and subsequent development of osteoarthritis
is a complex phenomenon. Articular cartilage healing leads to
formation of fibrocartilage, however it does not restore the
structural and mechanical properties of a normal articular
cartilage 12 . Larger the defect, larger is the alteration of
mechanical properties; larger is the risk of progression to
osteoarthritis. 12 . Marsh et al 13 reported that development of
posttraumatic osteoarthritis correlate with the severity of
articular damage. Several other authors have also reported the
same findings 14, 15 .
The thickness of articular cartilage varies from joint to
joint and is also variable at different sites in a single joint 16
(Ankle 1.0 - 1.62mm, Knee 1.69 - 2.55mm, Patella 1.76 - 2.59mm).
Articular cartilage step-offs do remodel but have limited
capability 17 . Articular step-offs that exceeds the full thickness
of articular cartilage usually do not remodel completely. These
step offs lead to localized and altered mechanical peak pressures,
leading to rapid progression of osteoarthritis 18 . Usually a stepoff
of less than 2 mm is acceptable 12 . Extra-articular deformities
also affect the development of osteoarthritis after intraarticular
fractures by virtue of altered mechanical axis and eccentric
joint loading 19 . Management of soft tissue surrounding joint
is also very important in determining the optimal outcome
following intraarticular fractures 20, 21 . Joint immobilization
causesraised joint pressure( leading to loss of nutrition and
chondrocyte death. There is also liberation of several enzymes
like proteases, which lead to articular surface degeneration.
Motion promoteshealing of full thickness articular cartilage
defects with hyaline articular “cartilage like” material.
IMAGING OF INTRAARTICULAR FRACTURES
A detailed radiographic workup is essential to understand the
fracture anatomy of intraarticular fractures. AP and lateral x-
rays alone are usually not sufficient. Computed tomography is
very useful for delineating the fracture configuration and has
proved invaluable in current planning and management of
intraarticular fractures (Fig. 4). This is more important in certain
complex fractures like acetabular fractures, distal humerus
fractures, distal tibia fractures etc.CT gives detailed description
of articular gap and step offs 22, 23 . According to a study by
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Intraarticular Fractures
Fig 6. Travelling temporary fixator
Fig 5. Infection and wound healing problems are common
if surgery is done early through traumatic soft tissue envelope
Fig 7a. AP and lateral X-rays of intraarticular radial head fracture
Fig 7b. Exposure of fracture
Tornetta 24 , surgical plan changed in 64% cases after CT and
additional information was available in 82% cases.
Recently intraoperative 3-D fluoroscopy has been
introduced, which usually provide inferior quality images than
intraoperative CT but is much cheaper but has similar clinical
value. Several studies 26-27 have proved the usefulness of this
investigation and have led the surgeons to change their implant
placement during surgery.
TIMING TO OPERATE
Intraarticular fractures rarely require urgent ORIF except in open
fractures, fractures with neurovascular complications,
associated compartment syndrome and irreducible fracture
dislocations. Proper management of intraarticular fractures
requiresappreciation of fracture anatomy as well as soft tissue
injury. (Fig. 5). So it is prudent to wait for soft tissue healing
before embarking upon the surgery. This can vary from days to
weeks 11 . In between the time, one can use bridging external
fixators also known as travelling fixators (Fig. 6) with definitive
fixation later on. Several indirect reduction techniques and
biological fixation concepts have also come to reduce trauma
to soft tissue envelope.
It is also important to assess the resources of surgeon as
well as of the institution and cases should be referred to higher
centers if facilities are inadequate.
SURGICAL PRINCIPLES (FIG 7)
An atraumatic surgical approach should be used. Both
minimally invasive and open approaches are available, however
all articular fragments must be reduced anatomically and
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Garg and Malhotra
Fig 7c. Reduction of articular surface
Fig 7d. Provisional fixation of fracture with K wires
motion in intraarticular fractures. Active assisted exercises are
preferable, muscles & joints both are rehabilitated. Continuous
passive motion (CPM) does not prevent muscle atrophy
(however still a useful tool in the management of intraarticular
fractures. Sometimes stability of fixation can be of concern.
Some sort of additional stability can be provided with ROMsplints.
Plaster immobilization should not be used after ORIF
of intraarticular fractures as it leads to more stiffness. Patients
are kept non-weight bearing until articular fracture is healed.
Fig 7e. Postop x-rays showing definitive fixation
with plates and screws
preferably under vision. Ligamentotaxis will only work for
fragments with ligament attachment ( i.e. some split fractures
of the tibial plateau.
Surgical reconstruction begins with anatomical reduction
of articular surface.
Sometimes depressed fragments need to be elevated. Bone
graft or bone substitute is used to support this elevated
fragment if necessary. This articular reduction is then secured
with K-wires or screws and then this articular block is fixed to
the metaphysis with the help of definitive implant. Now a day,
periarticular anatomical locking plates have become
indispensable in the management of these fractures. All
measures are taken to minimize trauma to the surrounding soft
tissue.
POSTOPERATIVE REHABILITATION
Several studies 29-31 have reported beneficial effects of early
EMERGING TECHNOLOGIES
T1-rho MRI mapping, which measure relaxation times in cartilage
can assess specific components of articular cartilage
biochemistry and ultra-structure. It has shown to be more
sensitive to cartilage degradation than conventional MRI
techniques 32-34 .
Recently virtual operative plan can be made preoperatively
with the help of electronic templating. Electronic templating is
also useful in planning of implant needs as well as positioning
over the bone fragments. Superior softwares are being
introduced to improve the efficacy as well as extent of
application of this technology. 35
Navigation is another important breakthrough which helps
in the management of complex intraarticular fractures like
acetabular fractures. Both CT based as well as fluoroscopy
36, 37
based navigations are available in today’s world.
New technologies are being added to orthopedics day by
day. Some technologies like nanotechnology have the potential
to change the current orthopedic practice completely.
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Intraarticular Fractures
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