Treatment of Patients with fractures of the proximal tibial epiphysis complicated by craniofacial trauma A.V. Blinov, A.S. Kornaev, A.U. Kostyanov, G.D. Lazishvili, M.V. Liadova, G.G. Shaginian
Russian Medical Journal 2006: 16(14): 957–962 Fractures of the proximal region of the tibia comprise 6.9% of all fractures of the extremities and according to the authors, 20.7% of all epi-metaphyseal fractures associated with cranio-cerebral trauma. These are difficult fractures to be treated especially if associated with cranio-cerebral trauma. This is related to gross anatomical displacement and dubious prognosis for functional recovery of the extremities. The authors reviewed 53 patients (31 males and 22 females) between December of 2003 and September 2007. The age of the patients was between 16 to 72 years. All patients had fractures of the proximal tibiae associated with cranio-cerebral trauma. The cranio-cerebral trauma was evaluated with Glasgow Coma Scale (GCS) and the severity of the fractures of the extremities according to AO/ ASIF classification. 11 patients had severe cranio-cerebral trauma. 3 patients had GCS below 8. 8 patients had GCS 9-12. There were 7 patients with severe focal deficits. 2 patients had cerebral contusion with subdural haematoma. 2 patients had depressive cranial fractures with epidural haematoma. From this group, there were 2 lethal cases (19%). In 3 patients, the duration of coma was over 2 weeks. Two patients had haemodynamic instability after intracranial interventions, which eventually progressed to vegetative state. This precluded early osteosynthesis of fractures of the extremities.
17 patients had moderate cranio-cerebral trauma. 11 of these patients had open reduction and internal fixation (ORIF) of the fractures.
25 patients had cerebral commotion or contusion. All patients had traumatic shock. In this group, there were 67.7% depressed cranial fractures (17 patients). The authors presented 2 representative cases of severe craniofacial and cerebral trauma associated with proximal tibial fractures treated with early ORIF of craniofacial and extremities fractures. Both patients had excellent recovery.
8 patients had fractures B1 (5 patients), B2 (2 patients) and C2 (1 patient). All underwent ORIF with titanium plates with angular stability and auto-transplantation of bone from the iliac crest. The control group included 9 patients, who had conservative therapy of the fractures of the tibia. 5 of these patients had severe cerebral trauma (1 patient in vegetative state, 4 patients with severe cerebral contusion with lethal exitus in 2 of the patients). 4 of these patients had type B1 without displacement. The treatment outcomes were followed-up from 6 months to 4 years. The functional outcome for the tibia was based on the Rassmunsen scale. In the majority of the cases the results were good (23 fractures – 43.4%) and excellent (15 fractures – 28.4%). In 11 cases (20.7%) the results were satisfactory. Unsatisfactory results were found in 4 patients (7.5%). Two of these patients had lethal exitus. Based on their observation, the authors drew the following conclusions:
The precise diagnosis based on CT/ MRI is paramount for the choice of optimal surgical intervention.
The surgical treatment of fractures of the tibial plateau needs to be treated surgically early, if possible concomitantly with the ORIF of craniofacial fractures.
In cases of severe, especially open fractures type C, early method of treatment is non-focal fixation (Elizarov’s fixateur).
Arthroscopically controlled osteosynthesis, the utilization of external fixators and the utilization of composite biomaterials could significantly shorten the duration of surgical intervention, enhanced vascularization of the fractures with minimal invasiveness, which is paramount in patients already with severe cranio-cerebral traumas.