CLASIFICAREA I

PLATOULUI TIBIAL

TRATAMENTUL

FRACTURILOR

Gh. Tomoaia, B. Baciu, H. Benea, M. Grin, C. Barda, I. Stan

Clinica Ortopedie-Traumatologie Cluj-Napoca
Cuvinte cheie: fractur, platou tibial, nfundare, separare, osteosintez.
Fracturile platoului tibial sunt traumatisme complexe care afecteaz att
osul, ct i esuturile moi (cartilajul articular, ligamentele genunchiului,
meniscurile). Realizarea unui plan terapeutic optim este esenial i depinde de
evaluarea adecvat a severitii traumei. Traumatismele de energie nalt ce apar
la pacienii tineri sunt tratate prin intervenii chirurgicale, ntruct fracturile
complexe tratate nonoperator au nregistrat rezultate nesatisfctoare. Factorii
care au un rol n aprecierea fracturii includ: (1) gradul de deplasare, (2) gradul de
cominuie, (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 n
baza clasificrii AO i mai recent n baza clasificrii Schatzker mult rspndit i
acceptat. Conform clasificrii AO fracturile platoului tibial sunt codificate cu 41 i
grupate 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 (suprafaa
articular i menine continuitatea cu diafiza), tipul C sunt fracturile n care
suprafaa articular pierde continuitatea cu diafiza. Dup clasificarea Schatzker
fracturile platoului tibial cuprind 6 categorii, cu severitate crescnd i reflect att
mrimea 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 la
vrstnici i dac nfundarea este mai mare de 5 mm, sau dac este prezent
instabilitatea trebuie tratate prin reducere deschis, ridicarea fragmentului
nfundat, gref osoas i fixarea cu uruburi de spongie i plac de susinere pe
cortexul lateral. Tipul III fractura cu nfundare pur central, suprafaa articular
este nfundat n platoul tibial, cortexul lateral este intact, se produce pe oase
osteoporotice. Dac depresiunea este sever sau exist instabilitate, fragmentul
articular trebuie s fie ridicat, gref osoas, fixare cu uruburi de spongie i plac
de susinere pe corticala extern. Tipul IV fracturi ale condilului medial. Acestea
pot fi: cu separare pur cu un singur fragment sau cominutive i cu nfundare.
Cuprind adesea spinele tibiale i tind s se anguleze n varus, trebuie tratate prin
reducere deschis i fixare cu plac de susinere i uruburi de spongie pe partea
intern. Tipul V fracturi bicondiliene, ambele platouri sunt cu separare, iar
metafiza i diafiza rmn n contact. Ambii condili trebuie fixai cu plci de
susinere i uruburi de spongie. Tipul VI fractura de platou tibial cu deplasarea
metafizei i diafizei. Reprezint o fractur transversal sau oblic a tibiei
proximale, asociat cu fractura unuia sau ambilor condili i a suprafeelor articulare. Separarea diafizei de metafiz face ca aceast fractur s fie tratat prin
fixare intern cu plci de susinere i uruburi pe ambele pri ale condililor tibiali.

Tratamentul nonoperator este indicat n fracturile ce apar consecutiv unui

traumatism de energie joas, fracturile platoului lateral cu mic deplasare, dar fr
instabilitate articular sau unele fracturi ale platoului tibial lateral cu un grad de
instabilitate la pacieni cu osteoporoz, prezena unor afectiuni semnificative
cardiovasculare, pulmonare, neurologice sau metabolice.

CLASSIFICATION AND TREATMENT OF TIBIAL PLATEAU

FRACTURES
Gh. Tomoaia, B. Baciu, H. Benea, M. Grin, C. Barda, I. Stan
Orthopedics and Traumatology Clinic Cluj-Napoca,
Keywords: fracture, tibial plateau, depression, separation, osteosynthesis.
Tibial plateau fractures are complex injuries that affect both bone and soft
tissue (articular cartilage, knee ligaments and menisci). Achieving optimal
treatment plan is essential and depends on proper evaluation of trauma severity.
High energy trauma occurring in young patients is treated by surgery, whereas
complex fractures treated non-operative scored unsatisfactory. Factors that play a
role in fracture assessment include: (1) the degree of displacement, (2) degree of
comminution, (3) extension of soft tissue injuries, (4) association with
neurovascular lesions, (5) degree of articular surface damage, (6) bone quality, (7)
presence and severity of other injuries. Assessment of fractures was done
according to AO classification and more recently to Schatzker classification, more
widespread and accepted. According to AO classification, fractures of tibial
plateau are coded 41 and grouped into three types noted A, B, C, in ascending
order of their gravity. Type A fractures are extraarticular fractures, type B are
partially articular (articular surface maintains continuity with the shaft), type C are
fractures of the articular surface with interruption of continuity with the shaft.
According to Schatzker classification, tibial plateau fractures include 6 categories
with increasing severity which reflects both the size of force causing the injury and
the severity of the outcome. Type I - fracture with pure separation is common in
young and can be fixed with two cancellous screws, type II - fracture with
separation combined with depression. It occurs in elderly and whether the
depression is more than 5 mm, or if instability is present, it should be treated with
open reduction, elevation of the depressed fragment, bone graft and fixation with
screws and buttress plate on lateral cortex. Type III - fracture with pure central
depression, the articular surface is depressed into the tibial plateau, the lateral
cortex is intact, occurring on osteoporotic bones. If depression is severe or there is
instability, articular fragment must be elevated, bone graft and fixation with
cancellous screws and buttress plate on lateral cortex. Type IV medial condyle
fractures. These include: pure separation of a single fragment or with comminution
and depression. Tibial spines are often included, the fractures tend to deviate in
varus, and they should be treated with open reduction and fixation with buttress
plate and cancellous screws on the internal cortex. Type V bi-condylar fractures,

both plateaus are separated, metaphyseal and diaphyseal regions remain in

contact. Both condyles should be fixed with buttress plates and cancellous screws.
Type VI - fracture of the tibial plateau with diaphyseal and metaphyseal
displacement. It is a transverse or oblique fracture of the proximal tibia, associated
with fracture of one or both condyles and articular surfaces. The separation of the
shaft from the metaphyseal area requires treatment by internal fixation with
buttress plates and screws to support both sides of the tibial condyles.
Conservative treatment is indicated in fractures that occur due to low energy
trauma, lateral plateau fractures with minor displacement, but without joint
instability, or few lateral tibial plateau fractures with a degree of instability in
patients with osteoporosis, in the presence of major cardiovascular, pulmonary,
neurological or metabolic diseases.