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CLASIFICAREA I TRATAMENTUL FRACTURILORPLATOULUI TIBIALGh. Tomoaia, B. Baciu, H. Benea, M. Grin, C. Barda, I. StanClinica Ortopedie-Traumatologie Cluj-Napoca

Cuvinte cheie: fractur, platou tibial, nfundare, separare, osteosintez.

Fracturile platoului tibial sunt traumatisme complexe care afecteaz attosul, ct i esuturile moi (cartilajul articular, ligamentele genunchiului,meniscurile). Realizarea unui plan terapeutic optim este esen ial i depinde deevaluarea adecvata severitii traumei. Traumatismele de energie nalt ce aparla pacienii tineri sunt tratate prin intervenii chirurgicale, ntruct fracturilecomplexe tratate nonoperator au nregistrat rezultate nesatisfctoare. Factoriicare au un rol n aprecierea fracturii includ: (1) gradul de deplasare, (2) gradul decominuie, (3) extinderea leziunilor esuturilor moi, (4) asocierea leziunilor

neurovasculare, (5) gradul afectrii suprafeei articulare, (6) calitatea osului, (7)prezena altor leziuni i gravitatea acestora. Aprecierea acestor fracturi se face nbaza clasificrii AO i mai recent n baza clasificrii Schatzker mult rspndit iacceptat. Conform clasificrii AO fracturile platoului tibial sunt codificate cu 41 igrupate n trei tipuri notate cu A, B, C, n ordine cresctoare a gravitii lor.Fracturile tip A sunt fracturi extraarticulare, tipul B sunt parial articulare (suprafaaarticulari menine continuitatea cu diafiza), tipul C sunt fracturile n caresuprafaa articular pierde continuitatea cu diafiza. Dup clasificarea Schatzkerfracturile platoului tibial cuprind 6 categorii, cu severitate crescnd i reflectattmrimea forei cauzatoare a leziunii, ct i gravitatea prognosticului. Tipul I fractura cu separare pur, este frecvent la tineri i poate fi fixat cu 2 uruburi de

spongie, tipul II fractura cu separare combinat cu nfundare. Se produce lavrstnici i dac nfundarea este mai mare de 5 mm, sau dac este prezentinstabilitatea trebuie tratate prin reducere deschis, ridicarea fragmentului

nfundat, gref osoas i fixarea cu uruburi de spongie i plac de susinere pecortexul lateral. Tipul IIIfractura cu nfundare pur central, suprafaa articulareste nfundat n platoul tibial, cortexul lateral este intact, se p roduce pe oaseosteoporotice. Dac depresiunea este sever sau exist instabilitate, fragmentularticular trebuie s fie ridicat, gref osoas, fixare cu uruburi de spongie i placde susinere pe corticala extern.Tipul IVfracturi ale condilului medial. Acesteapot fi: cu separare pur cu un singur fragment sau cominutive i cu nfundare.Cuprind adesea spinele tibiale itind s se anguleze n varus, trebuie tratate prin

reducere deschis i fixare cu plac de susinere i uruburi de spongie pe parteaintern. Tipul V fracturi bicondiliene, ambele platouri sunt cu separare, iarmetafiza i diafiza rmn n contact. Ambii condili trebuie fixai cu plci desusinere i uruburi de spongie. Tipul VI fractura de platou tibial cu deplasareametafizei i diafizei. Reprezint o fractur transversal sau oblic a tibieiproximale, asociat cu fractura unuia sau ambilor condili i a suprafeelor articu -lare. Separarea diafizei de metafiz face ca aceast fractur s fie tratat prinfixare intern cu plci de susinere i uruburi pe ambele pri ale condililor tibiali.

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Tratamentul nonoperator este indicat n fracturile ce apar consecutiv unuitraumatism de energie joas, fracturile platoului lateral cu mic deplasare, dar frinstabilitate articular sau unele fracturi ale platoului tibial lateral cu un grad deinstabilitate la pacieni cu osteoporoz, prezena unor afectiuni semnificativecardiovasculare, pulmonare, neurologice sau metabolice.

CLASSIFICATION AND TREATMENT OF TIBIAL PLATEAUFRACTURESGh. Tomoaia, B. Baciu, H. Benea, M. Grin, C. Barda, I. StanOrthopedics and Traumatology Clinic Cluj-Napoca,

Keywords: fracture, tibial plateau, depression, separation, osteosynthesis.

Tibial plateau fractures are complex injuries that affect both bone and softtissue (articular cartilage, knee ligaments and menisci). Achieving optimaltreatment plan is essential and depends on proper evaluation of trauma severity.High energy trauma occurring in young patients is treated by surgery, whereascomplex fractures treated non-operative scored unsatisfactory. Factors that play arole in fracture assessment include: (1) the degree of displacement, (2) degree ofcomminution, (3) extension of soft tissue injuries, (4) association withneurovascular lesions, (5) degree of articular surface damage, (6) bone quality, (7)presence and severity of other injuries. Assessment of fractures was doneaccording to AO classification and more recently to Schatzker classification, morewidespread and accepted. According to AO classification, fractures of tibialplateau are coded 41 and grouped into three types noted A, B, C, in ascendingorder of their gravity. Type A fractures are extraarticular fractures, type B arepartially articular (articular surface maintains continuity with the shaft), type C arefractures of the articular surface with interruption of continuity with the shaft.

According to Schatzker classification, tibial plateau fractures include 6 categorieswith increasing severity which reflects both the size of force causing the injury andthe severity of the outcome. Type I - fracture with pure separation is common inyoung and can be fixed with two cancellous screws, type II - fracture withseparation combined with depression. It occurs in elderly and whether thedepression is more than 5 mm, or if instability is present, it should be treated withopen reduction, elevation of the depressed fragment, bone graft and fixation withscrews and buttress plate on lateral cortex. Type III - fracture with pure central

depression, the articular surface is depressed into the tibial plateau, the lateralcortex is intact, occurring on osteoporotic bones. If depression is severe or there isinstability, articular fragment must be elevated, bone graft and fixation withcancellous screws and buttress plate on lateral cortex. Type IV medial condylefractures. These include: pure separation of a single fragment or with comminutionand depression. Tibial spines are often included, the fractures tend to deviate invarus, and they should be treated with open reduction and fixation with buttressplate and cancellous screws on the internal cortex. Type Vbi-condylar fractures,

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both plateaus are separated, metaphyseal and diaphyseal regions remain incontact. Both condyles should be fixed with buttress plates and cancellous screws.Type VI - fracture of the tibial plateau with diaphyseal and metaphysealdisplacement. It is a transverse or oblique fracture of the proximal tibia, associatedwith fracture of one or both condyles and articular surfaces. The separation of the

shaft from the metaphyseal area requires treatment by internal fixation withbuttress plates and screws to support both sides of the tibial condyles.Conservative treatment is indicated in fractures that occur due to low energytrauma, lateral plateau fractures with minor displacement, but without jointinstability, or few lateral tibial plateau fractures with a degree of instability inpatients with osteoporosis, in the presence of major cardiovascular, pulmonary,neurological or metabolic diseases.