SNOW SPORT TIBIA PLATEAU FRACTURES

Baqueira-Beret Medical Center

SNOW SPORT TIBIA PLATEAU FRACTURES

Baqueira BeretMain data from last 10 ski seasons

Data

2005 to 2014

22.894 snow sport

lesions have been

treated at Centre

Mèdic Baqueira.

Data

•Ski: 2,4 per thousand

ski days

•Snowboard: 5,3 per

thousand ski days

Injuries per seasonMain data from last 10 ski seasons

http://www.google.es/url?sa=i&rct=j&q=skiers+image&source=images&cd=&cad=rja&docid=mUx29ZDhYMUenM&tbnid=QK-hY7NzqAb7uM:&ved=0CAUQjRw&url=http://www.autocarhire.com/travelblog/featured/top-skiing-destinations-from-around-the-world/&ei=jh2_UeGaIYzu0gXh_IGQDA&bvm=bv.47883778,d.d2k&psig=AFQjCNHFpfmX6O8aoUUJlYdq8fMkMFxFXg&ust=1371565814837391

http://www.google.es/url?sa=i&rct=j&q=skiers+image&source=images&cd=&cad=rja&docid=mUx29ZDhYMUenM&tbnid=QK-hY7NzqAb7uM:&ved=0CAUQjRw&url=http://www.autocarhire.com/travelblog/featured/top-skiing-destinations-from-around-the-world/&ei=jh2_UeGaIYzu0gXh_IGQDA&bvm=bv.47883778,d.d2k&psig=AFQjCNHFpfmX6O8aoUUJlYdq8fMkMFxFXg&ust=1371565814837391

Probability of injuriesDistribution per gender & age

Mean Age: 33 Mean Age: 26

52.44

47.95

ALPINE SKI INJURIES BY GENDER

% MALE ALPINE SKI

% FEMALE ALPINE

SKI

69.00

29.93

SNOWBOARD INJURIES BY

GENDER

% MALE

SNOWBOARD

% FEMALE

SNOWBOARD

http://www.google.es/url?sa=i&rct=j&q=skier+snowboarder&source=images&cd=&cad=rja&docid=g7ZXZM97_gXkrM&tbnid=KWHvQMzxw87IHM:&ved=0CAUQjRw&url=https://shop.nd.edu/C21688_ustores/web/product_detail.jsp?PRODUCTID=3814&SINGLESTORE=true&ei=ASG_Ua3fHbKa0QWt-ICICA&psig=AFQjCNHddKspmxk_SVn4ITNo6aQ5njcc8w&ust=1371566692761356




9.195 knee injuries in 10 seasons

37.90%

47.00%

21.69%

4.62%

ACL TOTAL

PCL TOTAL

MCL TOTAL

LCL TOTAL

SPRAIN/CONTUSIONS TOTAL

O'DONAHUE TOTAL

SEGOND TOTAL

TIBIAL EMINENCE TOTAL

TIBIAL TUBEROSITY TOTAL

Tibia Plateu Fractures

Accidents according to Ski Patrol versus MCMain data from last 4 ski seasons

Total of skiers in 4 seasons: 3,098,359

-

2,000

4,000

6,000

8,000

10,000

12,000

ACCIDE BAQUEIRA S/PISTAS ACCIDE BAQUEIRA S/CM

8,060 11,085

Materials & Methods

For the present study,

we have reviewed Knee Injuries seenat Baqueira Beret Medical Centre during 4 consecutive seasons.

Total skiers in 4 seasons: 3,098,359

Total ski accidents : 11.085

Total of knee injuries: 2.538

Knee InjuriesMain data from last 4 ski seasons

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

TOTAL

FRACTURAS

EXTREMIDADES

TOTAL

FRACTURAS EN LA

RODILLA

NUMERO TOTAL

FRACTURAS

ESPINAS TIBIALES

NUMERO TOTAL

FRACTURAS

MESETA TIBIAL

1,708

291 189 102

Series1

Fractures in Lower Extremities & in the KneeMain data from last 4 ski seasons

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

NUMERO TOTAL

LESIONES EN LA

RODILLA

NUMERO TOTAL DE

RX

NUMERO TOTAL

FRACTURAS MESETA

TIBIAL

2,538 4,466

102

Series1

Tibia Plateau FracturesMain data from last 4 ski seasonsStudy of 4.466 Knee X-rays

Schatzker classification

High Energy

LowEnergy

Skier Level Classification CriteriaSource: Baqueira-Beret Ski Resort

• BEGINNER: A skier who is skiing for the firsttime and in beginners area.

• INTERMEDIATE: A skier who can ski throughoutresort easily and can ski red slopes/pistes.

• EXPERT: A skier who can ski throughout resorteasily and can ski black slopes as well as offpiste.

Results

0

10

20

30

40

50

60

70

HOMBRES MUJERES

38

64

Tibia Plateu Fractures by Gender

Mean Age 49 y.o.

47.5

48

48.5

49

49.5

50

HOMBRES MUJERES

50

48.6

Snow Sport Category/Type

0

10

20

30

40

50

60

70

80

90

100

ESQUI SNOWBOARD

35

3

62

2

MUJERES

HOMBRES

Skier Level by Gender

0

10

20

30

40

50

60

70

PRINCIPIANTES INICIADOS EXPERTOS

5

27

6

14

43

7

HOMBRES

MUJERES

Division by GroupsSchatzker Classification

0

10

20

30

40

50

60

70

80

ALTA ENERGIA BAJA ENERGIA

15

4910

28HOMBRES

MUJERES

0

20

40

60

80

100

120

EDAD MEDIA ALTA ENERGIA EDAD MEDIA BAJA ENERGIA

45.4 49.63

56.1 48.75

MUJERES

HOMBRES

High Energy – Low Energy

High Energy FracturesSchatzker Classification

0

2

4

6

8

10

12

14

GRADO IV GRADO V GRADO VI

9

3

13

0

5

10

15

20

25

30

35

40

45

50

GRADO I GRADO II GRADO III

14 15

48

Low Energy FracturesSchatzker Classification

Schatzker Classificationand Ski Level

0

2

4

6

8

10

12

14

16

18


4

17

4

HIGH ENERGY

Schatzker Classificationand Ski Level

0

10

20

30

40

50

60


15

53

9

LOW ENERGY

0

10

20

30

40

50

60

MAÑANA TARDE

58

44

Time of Injury

0

10

20

30

40

50

60

DURA POLVO PRIMAVERA

26

60

16

Snow Type

Conclusions

In the present study, Tibia Plateau Fractures represent

• 4% of all knee injuries

• 6% of total fractures in lower extremities and

• 1% of all fractures seen in our Center in the past 4 seasons

102 Tibial Plateau Fractures

• 62% were Female and 37% were Male

• Mean age 48.6 yrs.

• 68% were intermediate skiers,

• 18% beginners and

• 12% experts.


• 75% were low energy fractures ( grade I,II,III) and

• 24% of fractures were high energy fractures (grade IV, V, VI).


• 58.8% were skiing in powder snow

• 25.4% were skiing in hard snow

• 15.6% were skiing in wet snow

• 56% of fractures occured before 13 pm

• 44% of fractures occured between 13&17 pm


Risc factors must be taken into accountin addressing prevention of

Tibia Plateau Fractures.

Take home message

Thank you for your attention

Agenda

1.Baqueira Beret – Epidemiology

2. Barcelona Teknon – Treatment

Agenda - Treatment

1. Explore the Fracture ID

2. Classify

3. Treatment Options

4. Take Home Message

Fracture Characteristics

- Soft Tissue Injuries

- Grade of Dislocation

- Grade of Comminution

- Grade of Joint Injury

- Grade of Osteoporosis

- Nerve or Blod Vessel Injuries

Kennedy JC and Bailey WH, 1968, Experimental tibial plateau fractures. JBJS

Evaluate complementary tests

- X-Ray in two planes

- CT Scann

- Angiography

- MRI

Classify the Fracture

A = extra articular:A1 = avultion fractureA2 = metafisaria simpleA3 = metafisaria multifragmentaria

AO 41B (B1-B2-B3) = Schatzker type I – II y III

AO 41C (C1-C2-C3) = Schatzker type IV – V y VI


Schatzker type I – II y III = AO 41B (B1-B2)


Schatzker type IV – V y VI = AO 41C (C2-C3)

Classify the FractureAccording to MRI




TREATMENT

• Conservative Treatment

• Urgent Surgical Treatment

• Difered Surgical Treatment

1.- Conservative Treatment

• Step lower than 2 mm (CT)

• Axial Stability

• General/Local contraindications

• Preserv Soft Tissues. Vascular Decompresion

• Restore Mechanical Axis

• Reconstruct Joint Surfaces

2.-Surgical Treatment. Goals

2.- Surgical Treatment

Urgent

Diferred

2A.- Urgent Treatment

When:

• Vascular Injury

• Compartimental Syndrome

• Open Fractures

• Floating Knee

• Politrauma

Decision Making:

• Soft Tissues

• Surgical Planning

2B.- Differed Treatment

1.-Bone Grafting:

• - Autograft

• - Alograft

• - Bone Substitutes

2.-Stabelize the fracture:

• - Screws

• - One or more Plates

• - Hybrid Fixation

• - Joint Fixation

Surgical Planning

2.- Stabilize the Fracture:

• - Screws




Decision Making


• - Screws




Decision Making


• - Screws




Decision Making


• - Screws




Decision Making

We have reviewed tibia tuberosityfractures surgically treated between2011 and 2014

TIBIA TUBEROSITY FRACTURES

and

• 7 fractures 41 B1 y B2

• 23 fractures 41 B3

• 12 fractures 41 C3

42 Tibia Tuberosity Fractures X-ray

• 2 fractures 41 B1(7 fractures 41 B1 y B2)

• 14 fractures 41 B3(23 fractures 41 B3)

• 26 fractures 41 C3(12 fractures 41 C3)

42 Tibia Tuberosity Fractures CT

• 2 fractures 41 B1 y B2(7 fractures 41 B1 y B2)



42 Tibia Tuberosity Fractures 3D CT

Does classifying the fracture help in decision making?

There are no rules



42 Tibia Tuberosity Fractures 3D CT

The final decision is the result of several factorsincluding surgeon’s skill, surgical planning andlogistics. (equipment and graft) in each case.

Does classifying the fracture help in decision making?



Arthroscopy guided and percutaneous surgery…


…except for 6 cases where 3D CT scans influencedour inicial decision.

In 6 B3 fractures the 3D CT scan showed the need of ananatomical designed plate


• 26 fractures 41 C3

Double plate system was used in 26 C3 fractures butwith complications…

• 7 arthroscopy artroslisis

• 2 fractures needed upper tibia osteotomy

• 1 distal femur osteotomy

• 3 plate infections

• 2 failed fracture fixation

• 2 fractures 41 C3 lost their fixation

• Why did the fixation failed?

Front Lateral Posterior

• 2 fractures 41 C3 lost their initial fixation

Agenda - Treatment

1. Explore the Fracture ID

2. Classify

3. Treatment Options

4. Take Home Message

Take Home Message

1.- 3D CT Reconstruction

Define radiological instability critiera. (postero-medial fragment and head of the fibula)

Take Home Message

2.- Soft Tissue Care

Release compartments

Repair meniscus and soft tissues

Close by layers

Take Home Message

3.- Surgical Pearls

Restore extensore mechanism

Make metaphysis functional and stable

Anatomical reconstruction and rigid fixation for theepifisis

Take Home Message

… Surgical pearls

Harvest sufficient bone graft

Have required surgical logistics

Be prepared to solve complications

Thank you for your attention

Documents

SNOW SPORT TIBIA PLATEAU FRACTURES