Musculoskeletal case studies for medical students

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Problem Management History Male, 30 yrs old, after a motor accident. Neurovascular intact, closed injury. Initial X ray Description AP X ray X ray Description CT reconstruction Problem The 30 year old male with a medial plateau fracture. How this was managed, and why. X ray after treatment Description Normal Arteriogram Post management further view Description X ray after ORIF Classification Most plateau fractures are lateral. This involves predominantly the medial plateau. There is medial subluxation of the knee, from injury to the lateral collateral ligament complex. It can be classified as a Shatzker 4 injury. Discussion of management These injuries have a high incidence of ligament and other soft tissue injuries including neurovascular damage. An arteriogram was done to exclude vascular damage. It was normal. A knee spanning exfix was applied as a temporary stabiliser. Ten days later the patient was internally fixed by means of a medial plate and screws. Shatzker 4 to 6 injuries are serious and often need temporary fixation by means of an exfix before a definitive fixation can be undertaken. Computer tomogramme images are used to plan these operations. In the acute setting, be wary of neurovascular injuries as well as associated knee ligament injuries. Not all need an exfix, and if the knee is stable a backslab is a useful temporary measure. The definitive fixation needs to be done by someone experienced with these fractures, and is best undertaken later when the danger of further swelling has subsided.