Case Report | Open Access | Peer Reviewed

Open Schatzker VI Tibial Plateau Fracture with Tibial Tuberosity and Patellar Tendon Involvement

Rómulo Silva, Ricardo Branco, Filomena Ferreira, Margarida Areias, Bruno Alpoim, Carolina Oliveira

Department of orthopedics; Unidade Local de Saúde do Alto Minho; Viana do Castelo, Portugal

  • Abstract
  • Full Text
  • Tables & Figures
  • References

ABSTRACT

The authors report a case of a Gustilo-Anderson grade IIIB open Schatzker VI tibial plateau fracture with involvement of the anterior tibial tuberosity and patellar tendon. Temporary external fixation was performed followed by definitive open reduction and internal fixation. Despite the high complexity injury and the staged sequential treatment, positive outcomes are possible.

KEYWORDS

knee, tibial plateau, fracture, extensor mechanism

INTRODUCTION

Tibial plateau fractures are common lower limb injuries, which can result from high or low-energy trauma, with complex pattern usually being related to motor vehicle accidents. Several factors influence the treatment, such as the age, functional demands and soft tissue status of the patient.1 Open fractures in general, and Gustilo-Anderson IIIB fractures in particular, are associated with high risk of nonunion and infection, demanding a well-planned surgical approach and soft tissue coverage.2

CASE REPORT

 A 68 year-old female without relevant medical comorbidities came to the emergency room after a crush injury with a tree branch. The patient presented an open knee injury with more than 10 cm (Figure 1), without vascular impairment. Radiographs were taken, showing a Schatzker VI fracture pattern (Figure 2). The injury was classified as a Gustilo Anderson IIIB Open Tibial Plateau Fracture with grade VI in the Schatzker classification.

Open wound in the emergency room

FIGURE 1 Open wound in the emergency room.

Emergency room radiographs

FIGURE 2 Emergency room radiographs.

In the operating room, after intensive lavage and exploration of the soft tissue damage, the decision for an external fixator was made, based on wound closure difficulty and extensive damage to the anterior compartment muscles. After the temporary fixation, a foot dorsiflexion deficit was documented (with preserved sensitivity), most likely related to the traumatic muscle damage, and a post-operative CT scan was performed (Figure 3) for further detailing and definitive pre-operative planning. Three weeks later, the patient underwent definitive management of the plateau fracture with open reduction and internal fixation with an anterolateral plate, a medial plate, autologous allograft from the iliac crest and screw fixation of the anterior tibial tuberosity. After the fixation of the tibial tuberosity, an almost total rupture of the patellar tendon was observed, and its re-insertion with an anchor was performed (Figure 4). Following surgery a splint was applied for 5 weeks followed by progressive physical therapy.

At 1 year follow up, the patient presents an acceptable radiographic alignment (Figure 5), a rage of motion of 0-90º (Figure 6), great wound closure, regained dorsiflexion of the foot (Figure 7) and no pain in her daily life activities.

Post-external fixator CT scan

FIGURE 3 Post-external fixator CT scan.

Post-Definitive ORIF Radiographs

FIGURE 4 Post-Definitive ORIF Radiographs.

One year follow up radiographs

FIGURE 5 One year follow up radiographs.

Range of motion and wound healing

FIGURE 6 Range of motion and wound healing.

Dorsiflexion of the foot and wound closure

FIGURE 7 Dorsiflexion of the foot and wound closure.

DISCUSSION

The treatment of tibial plateau fractures depends on anatomical reduction, internal fixation and early functional exercises for an effective treatment. Complex fracture lines are often associated with severe soft tissue injuries and the timing of definitive surgery is controversial in the literature.1 Open fractures are classified by the Gustilo-Anderson classification, with type 3B being associated with infection rates of approximately 30% and non-union.2 The use of temporary external fixators in severe soft tissue injuries is well documented, allowing the alignment and distraction of fragments while improving skin and soft tissue conditions.1 The association of these injuries with a fracture of the anterior tibial tuberosity is easily overlooked in complex injuries, with devastating results in terms of the extensor apparatus and knee function.3

Rana et al4 report a similar case to our own, without the complexity of the serious open fracture, with similar fixation technique and good result. The article underlines the importance of early recognition and treatment of the tuberosity fracture, with emphasis on the early rehabilitation and stiffness prevention.

CONCLUSION

The authors present a complex case, with an overlapping of serious injuries such as a Schatzker VI tibial plateau Gustilo Anderson grade IIIB open fracture with detachment of the anterior tibial tuberosity and patellar tendon injury. Attention to the surrounding soft tissues is essential in minimizing complications and often the definitive treatment has to be postponed until ideal conditions are met. Despite the delay in definite treatment and rehabilitation, satisfactory results are possible.

CONFLICT OF INTEREST

The patient gave full signed consent for the publication of this case. All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. On behalf of all authors, the corresponding author states that there is no conflict of interest to declare.

REFERENCES

  1. Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev. 2017;1(5):225-232.
  2. Singh A, Jiong Hao JT, Wei DT, et al. Gustilo IIIB Open Tibial Fractures: An Analysis of Infection and Nonunion Rates. Indian J Orthop. 2018;52(4):406-410.
  3. Tan L, Li YH, Li Y, Lin T, Zhu D, Sun DH. Tibial plateau fractures (AO type B3) combined with tibial tubercle fracture: Case report and review of the literature. Medicine (Baltimore). 2018;97(36):e12015. 
  4. Rana R, Ganesh A, Behera S, Behera H. Tibial Plateau Fracture with Avulsion Fracture of Tibial Tuberosity: A Case Report and Review of Literature. Cureus. 2020;12(4):e7756.

TABLES & FIGURES

Open wound in the emergency room

FIGURE 1 Open wound in the emergency room.

Emergency room radiographs

FIGURE 2 Emergency room radiographs.

Post-external fixator CT scan

FIGURE 3 Post-external fixator CT scan.

Post-Definitive ORIF Radiographs

FIGURE 4 Post-Definitive ORIF Radiographs.

One year follow up radiographs

FIGURE 5 One year follow up radiographs.

Range of motion and wound healing

FIGURE 6 Range of motion and wound healing.

Dorsiflexion of the foot and wound closure

FIGURE 7 Dorsiflexion of the foot and wound closure.

REFERENCES

  1. Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev. 2017;1(5):225-232.
  2. Singh A, Jiong Hao JT, Wei DT, et al. Gustilo IIIB Open Tibial Fractures: An Analysis of Infection and Nonunion Rates. Indian J Orthop. 2018;52(4):406-410.
  3. Tan L, Li YH, Li Y, Lin T, Zhu D, Sun DH. Tibial plateau fractures (AO type B3) combined with tibial tubercle fracture: Case report and review of the literature. Medicine (Baltimore). 2018;97(36):e12015. 
  4. Rana R, Ganesh A, Behera S, Behera H. Tibial Plateau Fracture with Avulsion Fracture of Tibial Tuberosity: A Case Report and Review of Literature. Cureus. 2020;12(4):e7756.

Conflict of Interest

The patient gave full signed consent for the publication of this case. All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. On behalf of all authors, the corresponding author states that there is no conflict of interest to declare.

License: This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright: © 2021. The Author(s). Article is published by Carpel Press.

Publisher’s Note: Carpel Press remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Spread the love
more