The principles of intra-

articular
fracture care
Joseph Schatzker
M.D., B.Sc.,(med.), F.R.C.S.(C )
There is a great deal of
strong clinical evidence in
support of operative treatment
of intra-articular fractures
Must examine experimental and
basic scientific facts in support of
operative treatment of
intra-articular fractures
Friedrich Pauwels: joint homeostasis

Articular Articular
Cartilage Cartilage
regenerations destruction
Stress = Force/Area

• Anatomic reduction
• Correction of axial deformity
Pathophysiology
of
joint cartilage
Continuous passive motion
• Brief plaster immobilization potentiates
articular damage

• Prolonged immobilization can result

on cartilage necrosis and or obliterative
arthritis

• Continuous passive motion is a

powerful stimulus to cartilage
regenerations
Nelson Mitchell
The influence of :

•Accuracy of reduction
•Stability of fixation

Articular cartilage
regeneration
 No reduction
osteotomy and no fixation
Anatomic reduction but Anatomic reduction and
no fixation stable fixation
The healing of step of defects associated with
Different degrees of displacement

•Negative and positive step off

•Twice the thickness of articular cartilage
(Llinas and Sarmiento)
 Step-off deformit
Llinas JBJS 1993 75A

1x 2x

No more than 2x the thickness of articular

cartilage. Damaging effect of CPM on opposing
joint surface in positive step off defects
Factors important in joint
preservation

• Congruence
• Axial alignment
• stability
 Lessons learned from clinical
practice
• Plaster immobilization……….stiffness
• ORIF and immobilization……greater
stiffness
• Traction and early motion……preserves
joint mobility
 Lessons learned from clinical
practice
• Intraarticular fractures which are
not treated by open reduction and
stable fixation should be treated by
traction and early motion
 Lessons learned from clinical
practice
• Impacted
intraarticular
fractures will not
reduce with
manipulation and
traction and can
be reduced only
by open reduction
 The value of clinical
examination
• State of the soft tissue envelope and
timing of surgery
• Integrity of ligaments
• Vascular status
• Neurological status
• Presence of compartment syndrome
 Imaging
• Articular
fractures must
have an AP, a
lateral and two
obligue
projections
 Imaging
• Complex articular
fractures require CT
in order to determine
joint depression,
comminution,
direction of fracture
lines, intraarticular
fragments
 Imaging
• Complex articular
fractures require CT
in order to determine
joint depression,
comminution,
direction of fracture
lines, intraarticular
fragments
Timing of surgery- the indications
for immediate intervention
• Open fracture
• Vascular injury
• Compartment syndrome
• Irreducible fracture dislocation
• Nerve injury with dislocation
 Timing of surgery- the indications
for delayed intervention
• High energy
axial loading or
crush injuries
Timing of surgery- the indications
for delayed intervention
• Complex intra- • Acetabular fractures
articular fractures • Pilon fractures
requiring • Tibial plateau
supplemental fractures
imaging and
specialized surgical • Supracondylar
expertise such as : fractures
 Operative detail
• Preoperative plan
• Surgical exposure
• Reduction of
articular surface -
direct or indirect
( arthroscopy, C-
arm ), the impacted
fracture and
elevation of
fragments
 Operative detail
• Anatomic reduction
of joint surface
• Correction of axial
deformity
• Bone grafting of
metaphyseal defects
• Stable fixation
 Operative detail
• Repair torn menisci and collateral
ligaments
• Delay cruciate repair
• In open fractures preserve portions
of articulation essential for stability
• Secure cover for articular cartilage
• Avoid tight closures
 Operative detail-
postoperative care
• Splinting and elevation
• CPM
• Active range of motion
• Cast-bracing if ligament damage or
unstable fixation
• Delay weight-bearing
• Recognize complications and intervene
 Conclusion - factors
beyond surgical control
• Degree of articular cartilage damage
• Degree of comminution and displacement
• Associated injuries:
- skin and muscle
- artery and nerve
- ligament
- associated system injuries
- CNS injury
 Conclusion - factors
under surgical control
• Atraumatic handling of soft tissue and
bone
• Anatomic reduction of the joint, bone
grafting of the metaphysis and correction
of axial deformity
• Stable fixation
• Correct post-operative care