Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 36-43  

Management of the proximal tibia fractures by mini external fixation: A case series of 30 cases


Department of Orthopedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

Date of Web Publication10-Dec-2013

Correspondence Address:
Samar K Biswas
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.122769

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  Abstract 

Background: Management of high velocity trauma is a challenging problem because of morbidity of trauma and sometime residual problems of failure of proper healing of fractures with the restriction of movements of knee, shortening, and added risk of compartment syndrome in the proximal tibia fracture. There is always risk of post-operative infection and infected non-union in extensive open surgical procedure and internal fixation. Hence, there is always look out for the middle path procedure for a solution to the above said problems with the added advantage of less hospital stay and early return to work by minimal invasive procedure and stabilization of fracture reduction by multiple K-wire fixation with a frame applied externally. Stabilization of fracture with reduced pain allows early movements of neighbouring joint knee and ankle; hence, reduces the chances of fracture diseases. With this we have been stimulated to take-up the study of managing the proximal tibia fracture by mini external fixator. Aim: The aim of this study was to manage proximal tibia fractures by mini external fixator and evaluate the results and efficacy of this method. Material and Method: A total of 30 patients having proximal tibial fractures admitted at our center between 2008 and 2010 were taken and the procedure carried out was closed manipulative reduction and stabilization with mini external fixator. All acute proximal tibia fractures including tibial plateau fractures above 17 years of age of either sex were included in the study. Fracture more than 3 weeks old were excluded from the study. Result: Out of 30 cases 13 were excellent, 14 cases good, and 3 showed fair. It was found that type 5 and 6 of Schatzker's classification have lesser outcome type of fractures Conclusion: We have found that management of the proximal tibia fractures by mini external fixation method has a better outcome. Early mobilization of knee in the proximal tibia fractures after stabilization with mini external fixator results in good functional outcome of the knee and reduces hospital stay. Complications associated with this method of treatment are minimal.

Keywords: K-wire, mini external fixation, proximal tibia fractures


How to cite this article:
Biswas SK, Puri SR, Salgia A, Sanghi S, Mir F, Mehta R. Management of the proximal tibia fractures by mini external fixation: A case series of 30 cases. Med J DY Patil Univ 2014;7:36-43

How to cite this URL:
Biswas SK, Puri SR, Salgia A, Sanghi S, Mir F, Mehta R. Management of the proximal tibia fractures by mini external fixation: A case series of 30 cases. Med J DY Patil Univ [serial online] 2014 [cited 2019 Nov 20];7:36-43. Available from: http://www.mjdrdypu.org/text.asp?2014/7/1/36/122769


  Introduction Top


Mechanization of the modern world has increased incidence of road traffic accident. It is the price we pay for our scientific progress. With the increasing incidence of road traffic accidents, there is also a rise in polytrauma with complicated musculoskeletal injuries and their post traumatic problems, especially "fracture disease." The person involved at a time is the only bread-earner of the family. Earlier and effective management of fracture is essential and hence that the person can return to his work at the earliest. A longer stay in the hospital means loss of more number of working days and money, thereby worsening the economic conditions of family.

Every fracture leads to a complex tissue injury involving bone and surrounding soft-tissues. Immediately after fracture and during the repair phase, we see local circulatory disturbance and manifestations of local inflammation as well as pain and reflex immobilization. These three factors, namely circulatory disturbance, inflammation, and pain as a result of dysfunction of joints and muscle leads to the so called fracture disease [1] (lucas-Championnier, 1907).

Fracture disease is caused by two main pathological factors : pain and lack of physiological challenge to the bone - muscle complex by movement and changing mechanical load. Every fracture disease is therefore a clinical stage manifestated by chronic edema, soft-tissue atrophy, and patchy osteoporosis. Edema as such induces intramuscular fibrosis and muscle atrophy this fibrotic process causes the muscle to develop unphysiological adhesion to bone and fascia there by leading to stiffness of adjacent joints.

Seventy five years ago, fractures of the proximal tibia described as "bumper fractures" because they resulted from low energy pedestrian accidents versus car fender accidents. [2] Presently, the majorities of the proximal tibia fractures are secondary to high speed motor vehicle accidents and fall from heights. Advance in mechanization and acceleration of travel have been associated with an increase in number and severity of the fracture. Fractures of the upper part of the tibia are no exception to this.

Fracture of the proximal tibia involve major weight bearing joint and neurovascular structures are at risk in these fractures associated with the high energy trauma. [2]

In early years of management of these fractures was to do plaster cast immobilization by long leg cast followed by protective weight bearing and early range of motion in hinged knee brace. Apley [3] described the use of skeleton traction to provide alignment of displaced tibial plateau fracture that allowed knee joint range of motion. The major limitation of this form of treatment include in adequate reduction of the articular surface and ineffective limb alignment control. [4] Furthermore, the extended period of hospitalization and recumbences are not cost-effective in today's health-care environment. Historically cast bracing has provided reasonable functional results. [5] The concept of the biological fixation with the use of limited internal fixation, and external methods. External fixation method is able to maintain reduction by closed method and promote early mobilization. As a result hospital stay is decreased. In the present prospective study, management of the proximal tibia fractures by mini external fixation was studied as a case series.


  Materials and Methods Top


The study was carried out on 30 patients in Dr. D. Y. Patil Medical College, Hospital and Research Center, Pimpri, Pune over a period of about 2 years from June 2008 to September 2010. Patients are explained about the procedure and informed written consent [Appendix A] is obtained. The subject of the study was patients with proximal tibia fractures and the procedure carried out was mini external fixation.

Aim

The intention was to study the management of the proximal tibia fractures by mini external fixation to obtain a stable, pain free, mobile joint, to prevent the development of knee stiffness, and to assess the efficacy of this method in terms of functional result.

Inclusion/Exclusion Criteria

All acute proximal tibia fractures including tibial plateau fractures above 17 years of age of either sex were included in the study. Fracture more than 3 weeks old were excluded from the study, Patients unfit for surgery.

Method

On the arrival of the patient in casualty/out-patient department a detailed history, clinical examination and investigations were done. Radiographs of affected proximal tibia are taken in anteroposterior views and lateral views were carried out [Figure 1]. Magnetic resonance imaging and computed tomography were carried out in doubtful articular depression fractures. Injury is classified according to Schatzker's classification system. Knee aspiration was carried out to relieve hemarthrosis, Robert Jones bandage application. Immobilization with above knee slab or calcaneal pin traction on Bohler's Braun. Intravenous antibiotics were started. Care of associated injuries and illness were taken with equal enthusiasm. Patients were investigated for P. A. fitness.
Figure 1: Antero-posterior and lateral view of proximal tibia showing tibia plateau fracture

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Surgical Technique

[Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7] the proposed surgery was performed under general or spinal anesthesia and the patient was kept supine on the operating table with knee flexed upto 30°. After scrubbing, painting, drapping, and inflating the tourniquet fracture reduction was carried out with an image intensifier using the Eshmarch bandage or reduction forceps with traction. A K-wire is inserted anteriorly in tibial plateau taken center of the tibia as a reference point followed by a posterior K-wire parallel to anterior K-wire. Another anterior K-wire is introduced inferior and parallel to first K-wire to give stability for the fracture. K-wire should be passed under articular surface. This is followed by two or more K-wires in the metaphyseal and diaphyseal region all should be parallel to each other. Number of K-wire in the distal fragment is determined by stability of the frame. If there is articular split depression fracture, fracture depression is raised through cortical window and fixed with cannulated cancellous screw under image intensifier, bone grafts were applied to fill osseous gaps. All K-wires are connected using connecting rods, Z rods and L rods after giving traction and pre-tensioning of wires. After achieving adequate reduction, the system was locked and secured. The reduction was then confirmed by C-arm. Stability of the frame is checked and flexion/extension of the knee is carried out to check the joint movements and post-operative X-ray was taken [Figure 8].
Figure 2: Reduction with Eshmarch

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Figure 3: Anterior and posterior K-wires introduced

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Figure 4: K-wires introduced

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Figure 5: Connecting rods introduced

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Figure 6: K-wires with connecting rods

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Figure 7: Inserting a cc screw

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Figure 8: Clinical photo with radiograph after 10 weeks

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Post-operative care consisted of daily performed thorough pin care, from the first post-operative day, with normal saline and betadine as well as immediate passive range of motion of the knee. For highly comminuted fractures, a posterior splint was applied and after 48 h the patient was encouraged to start controlled knee movement as soon as possible. Intravenous antibiotics and anti-inflammatory were continued for 4-5 days. Patients were discharged from the hospital between the 5 th and 15 th post-operative day, depending on their general condition. They were instructed not to bear weight on the operated limb and to regularly perform pin site care. Progressive weight bearing was allowed between the 8 th week and 12 th week depending on the radiographic appearance of callus and the clinical sign of union [Figure 9], [Figure 10], [Figure 11]. The weight bearing started with 10 kg and based on the clinical and radiographic signs of union, advanced to 30 kg after 1 month. In most of our cases, the external fixator was removed at 3.4 months after surgery depending on the radiological appearance of union [Figure 12].
Figure 9: Radiograph 4 months post-operative

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Figure 10: Antero-posterior and lateral post-operative radiograph

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Figure 11: Post-operative clinical photo at 8 weeks

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Figure 12: Post-operative clinical and radiograph after 12 weeks

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  Results Top


In our study, the majority of the patients are found to be between the age group of 21-40 years (n = 20) [Table 1]. The remaining numbers of cases are found in the age group between 51 years and 70 years. The mean age was 37.06 years and the youngest being 21 years eldest being 64 years. Major preponderance of upper tibial fractures is seen in people with the high level of activities, who indulge themselves in travelling like a business man, because a majority of morbidity is due to road traffic accident (RTA) and fall. Workers and laborers tend to have a violent injury commonly due to industrial accidents automobile accidents. Housewives sustain fractures due to fall from height, where climbing up ladder or stool to pick up object from shelf. In a majority of the patients, mode of injury was RTA. 53.33% followed by fall from height 33.33%. Right sided predominance is seen as compared to left side. Majority of cases were male (n = 21).
Table 1: No. of patients in different age groups


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Type of Fracture

In our series, majority of the fractures according to Schatzker's classification were found to be type 1 (26.67%) followed by type 5 (20%) and type 2 (20%) [Table 2]. None of the patients was immobilized when adequate reduction by mini fixation was carried out. In three cases reduction was not very secure hence these patients were immobilized up to 2 weeks and associated fractures in these cases also contributed in delay in mobilization of joint and ambulation [Table 3].
Table 2: No. of patients according to Schatzker's classification


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Table 3: No. of patients according to weeks of immobilization


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Period of the hospital was counted from day of admission to day of discharge; average hospital stay in our study was 12.5 days [Table 4]. Not a single case of nonunion noted in our series. Average time for union was 13.6 weeks (range 10-24 weeks). Three cases developed extension lag. Average range of motion in our study was 0° to 120°. Incidence of pin tract infection was seen in two cases, which were superficial and managed by antibiotics and dressing [Table 5].
Table 4: No. of patients according to hospital stay in days


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Table 5: No. of patients with complication


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Functional outcome of the study was evaluated by Rasmussen's scoring for functional evaluation: Pain, walking capacity, extensor lag, range of motion, stability. Excellent results - total minimum of 27 points. Good results-total minimum of 20 points. Fair results total minimum of 10 points. Poor results total minimum of 06 points.

Out of 30 cases, 13 cases shows excellent results 14 cases came out with good results, three cases show fair outcome mainly due to the severity of injury. It was found that type 5 and 6 have lesser outcome types of fractures [Table 6].
Table 6: Functional outcome in different Schatzker's type


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  Discussion Top


Proximal tibia fractures are most common injuries occurring as a result of RTA, fall from height, violence. It is sometimes associated with other bony or soft-tissue injuries. Any fracture around the joint (especially weight bearing knee joint in the lower limb) is of paramount importance as would result in significant morbidity and quality of life. Hence, the treatment of upper tibial fractures with intra-articular extension has become a challenge for the orthopedic surgeons. The majority of fractures in our study occur between the age of 20 years and 60 years with maximum incidence being involving the productive age group 31-40 years (36.67%). The average age was 37.06 years Honkonen et al. [6] showed age incidence 20-60 years with an average age of 39.8 years, which correlates with the present study. Kataria et al. [7] in their study reported average age of 32 years

In our series, majority of patients were males (70%). This can be attributed to our Indian set-up where the female population largely work indoor and do not travel much. In the study by Hitin Mathur et al. [8] in 2005 had similar observation in sex distribution, where male preponderance (74.1%) was seen. Similar study carried out by Kataria et al. [7] there was male dominance of 84.2%.

Occupationally proximal tibia fractures were seen in people with the high level of activity, movement and travel. It is most commonly seen with people who travel, more like businessman, agriculturist. In our series, majority were businessmen (33.33%), followed by laborers (26.67%), students (20%), employee (10%), and housewives (10%).

Most common mode of injury was road traffic accident 53.33% followed by fall from height 33.33%, athletic injury 6.67%, and assault 6.67%. Our reports correlates with the study carried out by Honkonen and Jarvinen [9] on 131 proximal tibia fractures, where the common mode of injury was road traffic accident 45%, followed by fall from height 28% and athletic injury 11%.

Nearly, 43.33% patients sustained an injury to the left limb and 56.66% patients to the right limb. Rasmussen [10] reported the fractures in the right and left limb are 51% and 49% respectively.

Type I pure cleavage fractures are seen more predominantly seen 26.67% followed by type II and V, which are 20%. Other fractures, type III is 6.67%, type IV 10% and type VI is 13.33%. Schatzker [11] in 1979 did a study on proximal tibia fractures in which type III and II fractures are commonly reported in the series.

Lateral condyle fractures in our study were 46.66%, medial condyle and bicondylar fractures were 10% and 20% respectively. Rasmussen [10] reported 70% of injuries affecting lateral condyle, 12% affecting medial condyle and bicondylar lesions in 18%. Lansinger et al. [12] reported 70% affecting the lateral condyle, 11% medial condyle and 19% bicondylar fracture. Our study correlates with the studies carried out by Rasmussen [10] and Lansinger, [12] where we can observe lateral condyle fractures predominates in the proximal tibia fractures.

It was found that type V and VI fractures which are high velocity injuries have lesser functional outcome than other type of fractures, this finding correlates with study carried out by Mills and Nork [13] where high velocity injuries (type IV, V and VI) have poorer functional outcome than low velocity injuries (type I, II and III), Duwelius et al. [14] in 1997 also noted poor outcome in high velocity injuries. We have started mobilizing the knee by post-operative day 2 in 27 cases. Other three cases, we had delayed mobilization due to insecure reduction and associated injuries.

All the 27 cases in which early physiotherapy was started, has regained normal function of the knee joint. Other three cases in which the post-operative immobilization period was extended show extensor lag of 10° to 15°. This study demonstrates that early post-operative mobilization of knee in the proximal tibia fractures results in good functional outcome of knee. Similar results were shown by Gausewitz and Hohl [15] in 1986 in their study on 112 cases of the proximal tibia fractures, they stated that post-operative immobilization tend to give poor functional results. Schatzker et al. [11] in 1979 also shown that long term immobilization can cause decreased function of the knee joint. Early physiotherapy facilitates early active joint movements; early active joint movement avoids Fracture Disease. It shortens the period of hospitalization and rehabilitation; thus, helps in early return to work, which in all minimizes the economic burden on family. Hospital stay from the day of admission to day of discharge on average was 12.5 days with most of the patients being discharged in lesser than 15 days (70%), which helps the patient to return to his daily life. De Boeck and Opdecam [16] reported 15 days has average hospital stay in his study on proximal tibia fractures.

In the study carried out by Weigel and Marsh [17] on proximal tibia fractures for 30 cases, in which cases were treated with monolateral external fixator and limited internal fixation, had average range of motion of 3° to 120°.

Martinez et al. [18] in the study of closed fractures of the proximal tibia treated with a functional brace observed 2.7% non-union in 108 cases with average union time of 14 weeks. Weiner et al. [19] in his study of the proximal tibia fractures for 50 cases treated by combined internal fixation and hybrid external fixation observed incidence of 4% non-union. Cole et al. [20] observed 2.6% non-union in his study on proximal tibia fractures by internal fixation.

In our study of 30 cases, we observed two cases of minor pin traction (6.67%), which was managed by 1 week of intravenous antibiotics and regular pin tract dressings. In three cases, we came across incidence of extensive lag; this was due to prolonged post-operative immobilization. In our study, average range of motion was 0° to 128°. All fractures healed with no incidence of non-union and delayed union. Average union time was 13.5 weeks range (10-24 weeks). Stability of the frame was good; there are no cases of pin loosening and loss of fixation.

Rasmussen [10] in 1973, a series of 260 proximal tibia fractures was studied; fractures were treated by conservative (56%) and operative methods (44%). The overall functional result was 87% satisfactory. Scotland and Wardlaw [21] in 1981 presented a study on the use of cast bracing in treatment of the proximal tibia fractures in a series of 29 patients, after a period of 2½ years his functional results outcome was 89% satisfactory. Lansinger et al. [12] in 1986 reported on proximal tibia fractures managed by conservative and operative methods using plaster cast immobilization and open reduction with internal fixation procedures, after a follow-up of 7.3 years in 204 patients the results were 87% satisfactory as per Rasmussen's scoring system, at a longer follow-up of 20 years the results were 90%. In bicondylar fractures the results were 83.33% satisfactory. Honkonen and Jørvinen [22] in 1992 reported a study on 131 proximal tibia fracture managed by conservative and operative procedures. 42% fractures were treated conservatively and 58% fractures were treated operatively by open reduction with internal fixation. After 2 years, follow-up functional results in conservatively treated cases was 85.5% satisfactory and 81.6% satisfactory in operatively treated cases. Duwelius et al. [14] in 1997 studied 76 proximal tibia fractures managed by limited internal fixation after a minimum follow- up of 12 months the results were 87% satisfactory, with poor outcomes in type VI Schatzker fractures.

Kataria et al. [7] in 2007 assessed the results of small wire external fixation using a ligamentotaxis technique in 38 patients. The average Rasmussen functional score was 26 (range 17-30), with a satisfactory result of 94%. In our study, 43.33% excellent outcome, 46.67% good outcome and 10% fair outcome, and cases with poor results were nil. All cases progressed to union, with average union time of 13.4 weeks. Most of the patients in our study were able to return to their normal functional status.


  Conclusion Top


At the end of our study, following conclusions could be drawn from the management of the proximal tibia fracture by mini external fixation. The majority of fractures occur between the age 30 years and 60 years with maximum incidence being involving the productive age group 31-40 years. Occupationally proximal tibia fractures were seen in people with the high level of activity, movement and travel. Common mode of injury is due to road traffic accidents due to increased automobiles, zeal for modernization and frequent travelling. Incidence of lateral condyle involvement is seen commonly in the proximal tibia fractures and bicondylar fractures are also not so uncommon. Our results conclude that management of the proximal tibia fractures by mini external fixation method has a better outcome. This study demonstrates that early post-operative mobilization of knee in the proximal tibia fractures results in good functional outcome of the knee, which is achieved by mini external fixation method in treating these fractures. Early active mobilization at the knee joint is essential. Early active mobilization has its own advantages-prevents fracture disease and respects the guiding principle- "Life is Movement, Movement is Life." Hospital stay was less in our study; hence, the incidence of hospital acquired infections was absent and patients were able to regain the sense of psychological well-being. Complications associated with this method of treatment are minimal such as superficial pin tract infection and terminal extensor lag; there was no incidence of deep infection, pin loosening, non-union and delayed union. Stability of the frame was intact; there are nil cases of instability in frame.

 
  References Top

1.Holtz U, Murphy WM, AO philosophy and it's basis. In: Allgower MM, Muller ME, Schneider R, Willenegger H, editors. Manual of Internal Fixation: Techniques Recommended by the AO-ASIF Group. 3 rd ed. Berlin: Springer-Verlag; 1991. p. 18, 172, 226.  Back to cited text no. 1
    
2.Kenneth AE, Kenneth J. Koval fractures of proximal tibia. In: Robert BW, James HD, Charles CM, editors. Rockwood and Green's Fractures in Adults. 6 th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2006. p. 2000-27.  Back to cited text no. 2
    
3.Apley AG. Fractures of the lateral tibial condyle treated by skeletal traction and early mobilisation; a review of sixty cases with special reference to the long-term results. J Bone Joint Surg Br 1956;38-B:699-708.  Back to cited text no. 3
    
4.Hohl M. Articular fractures of the proximal tibia. In: Evarts CM, editor. Surgery of the musculoskeletal system. New York: Churchill-Livingstone; 1993. p. 3471-97.  Back to cited text no. 4
    
5.DeCoster TA, Nepola JV, el-Khoury GY. Cast brace treatment of proximal tibia fractures. A ten-year follow-up study. Clin Orthop Relat Res 1988; Jun;(231):196-204.  Back to cited text no. 5
    
6.Honkonen SE. Indications for surgical treatment of tibial condyle fractures. Clin Orthop Relat Res 1994;302:199-205.  Back to cited text no. 6
    
7.Kataria H, Sharma N, Kanojia RK. Small wire external fixation for high-energy tibial plateau fractures. J Orthop Surg (Hong Kong) 2007;15:137-43.  Back to cited text no. 7
    
8.Hitin Mathur, Shankar Acharya, VK Nijhawan, SP Mandal. Operative results of closed tibial plaeau fractures. Indian Journal of Orthopedics, 2005:39:108-112  Back to cited text no. 8
    
9.Honkonen, Jarvinen MJ. Classification of fractures of the tibial condyles. J Bone Joint Surg 1992;74-B:840-7.  Back to cited text no. 9
    
10.Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am 1973;55:1331-50.  Back to cited text no. 10
    
11.Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968 - 1975. Clin Orthop Relat Res 1979;138:94-104.  Back to cited text no. 11
    
12.Lansinger O, Bergman B, Körner L, Andersson GB. Tibial condylar fractures. A twenty-year follow-up. J Bone Joint Surg Am 1986;68:13-9.  Back to cited text no. 12
    
13.Mills WJ, Nork SE. Open reduction and internal fixation of high-energy tibial plateau fractures. Orthop Clin North Am 2002;33:177-98, ix.  Back to cited text no. 13
    
14.Duwelius PJ, Rangitsch MR, Colville MR, Woll TS. Treatment of tibial plateau fractures by limited internal fixation. Clin Orthop Relat Res 1997;339:47-57.  Back to cited text no. 14
    
15.Gausewitz S, Hohl M. The significance of early motion in the treatment of tibial plateau fractures. Clin Orthop Relat Res 1986;202:135-8.  Back to cited text no. 15
    
16.De Boeck H, Opdecam P. Posteromedial tibial plateau fractures. Operative treatment by posterior approach. Clin Orthop Relat Res 1995;320:125-8.  Back to cited text no. 16
    
17.Weigel DP, Marsh JL. High-energy fractures of the tibial plateau. Knee function after longer follow-up. J Bone Joint Surg Am 2002;84-A:1541-51.  Back to cited text no. 17
    
18.Martinez A, Sarmiento A, Latta LL. Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop Relat Res 2003;37:293-302.  Back to cited text no. 18
    
19.Weiner LS, Kelley M, Yang E, Steuer J, Watnick N, Evans M, et al. The use of combination internal fixation and hybrid external fixation in severe proximal tibia fractures. J Orthop Trauma 1995;9:244-50.  Back to cited text no. 19
    
20.Cole PA, Zlowodzki M, Kregor PJ. Treatment of proximal tibia fractures using the less invasive stabilization system: Surgical experience and early clinical results in 77 fractures. J Orthop Trauma 2004;18:528-35.  Back to cited text no. 20
    
21.Scotland T, Wardlaw D. The use of cast-bracing as treatment for fractures of the tibial plateau. J Bone Joint Surg Br 1981;63B:575-8.  Back to cited text no. 21
    
22.Honkonen SE, Järvinen MJ. Classification of fractures of the tibial condyles. J Bone Joint Surg Br 1992;74:840-7.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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