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Cast Bracing Biocondylar Tibial Plateau Fractures After Combined Internal and External Fixation

Melvin Stills, C.O.
Kevin P. Christensen, M.D.
Robert W. Bucholz, M.D.
James N. Powell, M.D.

Introduction

The techniques of cast bracing lower extremity fractures have not changed significantly in the past several years. The introduction of synthetic casting tapes and polycentric fracture bracing joints has made application easier and has reduced time commitments.

The indication for cast bracing is to control motion about the fracture and anatomic joints. Indications in recent years have been expanded to include protection of reduction achieved with open reduction and internal fixation (ORIF). Cast bracing of the proximal tibia necessitates that the cast extend at least to the height of the junction of the proximal and middle third of the femur. Any involvement of the femur would require the cast brace to extend to the height of the greater trochanter. The appearance of the cast brace under these circumstances is very similar to when it was first introduced.

Cast bracing the lower extremity when an external fixation frame is used to maintain fracture alignment is a little more challenging. External fixation is used in the case of open fractures or when open reduction is contraindicated due to a poor surgical risk or fracture pattern. Cast bracing in conjunction with external fixation may be indicated if increased protection is needed to control motion about the fracture.

Since 1988, the Orthopaedic Department at Parkland Memorial Hospital has been treating high grade bicondylar tibial plateau fractures, Schatzker grade V and VI, with open reduction and internal fixation of the lateral tibial plateau and external fixation of the medial tibial plateau (Figure 1) . This combined approach first described by Claudi has reduced the incidence of infection first noted with double plating of this fracture pattern. This combined approach requires a cast brace that accommodates the external fixation. The cast brace is applied before discharge from the hospital or mobilization of the patient. The purpose of this paper is to describe the cast brace used and to report the results of the first 15 patients treated.

Application

Cast bracing Schatzker V and VI bicondylar fractures that have undergone this combined approach is complicated by the fact that the external fixation prevents the use of a standard medial fracture brace joint (Figure 2) . The standard joint cannot be deflected anteriorly or posteriorly enough to provide adequate clearance of the fixator frame.

Substituting the standard medial joint for a Neufeld roller traction joint (16) has worked satisfactorily (Figure 2 and Figure 3 ). A more stable custom-modified USMC fracture joint (17) has also been used successfully (Figure 4) .

The extremity to be braced is prepared in standard fashion. All wound areas are dressed, and stockinette is rolled onto the extremity, over the external fixation frame and held firmly at the proximal thigh. Cast padding is rolled onto the extremity from distal to proximal. The external fixation frame is included in the padding. No more than two to three firmly applied layers of padding are required. Particular attention should be paid to bony prominences. Padding the proximal section is done in the standard fashion. One-eighth inch orthopedic felt may be used to pad all circumferential edges (Figure 5) .

Synthetic cast material is rolled onto the tibial section starting from just distal to the metatarsal heads. The external fixation is included in the cast. Care must be taken to maintain the foot and ankle in a plantargrade position. Generally, the tibial portion of the cast will terminate at the level of the tibial tubercle. While the synthetic material is setting, it should be molded around the external fixation to reduce the tenting effect as it passes over the frame (Figure 6) .

A rope of material is needed at the proximal edge to prevent spreading of the cast after windowing. The rope is generally made of two to three wraps of three- or four-inch synthetic material used to complete the proximal portion of the tibial section. The rope is held in place by hand to ensure that it does not come in contact with the external fixation frame. Excessive clearance will make ambulation difficult. This rope serves only to reinforce the tibial cast at its proximal edge (Figure 2 , Figure 3 , Figure 4 , Figure 5 , Figure 6 , and Figure 7 ).

The proximal section is cast using the standard procedure. The stockinette is cut at knee center and reflected over the cast edges, both above- and below-knee center, and taped in place. The lateral upright is contoured to the extremity as usual. Location of the center of rotation is made difficult by the trauma to the area. Midline of the patella is an acceptable compromise. Once the lateral upright is appropriately contoured, it may be taped in place.

The medial Neufeld joint is a round rod and is easily contoured so that it falls posterior to the medial external fixation frame. It should lie flush against the cast. The proximal portion should follow the midline of the leg. The hook and eye joint should closely coincide with the polycentric joint and mid-patella (Figure 2 , Figure 3 , Figure 4 , Figure 5 , Figure 6 , and Figure 7 ).

The medial joint is then taped into position. Before securing the joint in place with synthetic tape, the alignment of the extremity and joint should be checked and adjusted if necessary.

Ten-inch strips of three- or four-inch synthetic tape are used to secure the joints in place. The lateral joint is secured with one strip wrapped around the upright at the proximal edge of the tibial cast. The tails are directed anteriorly and posteriorly. At least three strips are used for the medial joint- one strip at the proximal edge, one at the midpoint, and one at the distal end. These tails are wrapped around the rod and let fall directly posteriorly. This will aid in preventing pullout of the joint following windowing. All strips are incorporated into a tightly wrapped final roll. Molding is needed to prevent tenting and to ensure good contact.

The proximal joints are incorporated into the cast in a standard fashion. After the synthetic material has set sufficiently, approximately seven to 10 minutes, the distal section can be windowed to provide clearance for the external fixation frame. There must be no contact between the cast and frame. Adequate clearance is also needed for daily pin and wound care. If sufficient padding was included over the frame, there is generally little difficulty in windowing this area.

Gaps may be noted on the medial side between the first layer of material and that used to secure the joints in place (Figure 8) . It may be necessary to reinforce this area with raw resin. Material available from Johnson and Johnson (18) has been used successfully. Other fast setting resins can be used. This resin is also an efficient method of securing stockinette around the window. Standard adhesive tape does not stick well when the cast is fresh. Cast edges at the toe and the proximal femur are rounded by reflecting stockinette back and securing it in place.

If free range of motion at the knee is desired, the cast brace must be trimmed to permit 0 degree to 90 degree range of motion (Figure 9) . If motion is to be limited, an adjustable lateral joint should be used.

If swelling decreases or atrophy occurs, the cast brace may need to be changed. Patients are generally protected in this system for 12 weeks. After removal of the external fixation, another standard cast brace may be required. Patients are generally kept non-weightbearing for the first full 12 weeks.

Results

This paper will report the results of the first 15 patients treated. Of the 15 patients treated, one had a Schatzker type V injury, and 14 had Schatzker type VI injuries. Six were a result of motorcycle injuries, four from motor vehicle-pedestrian .injuries, three from falls from heights and two from assaults. Eight of the 15 had open injuries including two Gustillo type II, four Gustillo type IIIA, and two Gustillo type IIIB. Two patients developed compartment syndromes and one an arterial injury. Other injuries included one aortic transection, one closed head injury, three femur fractures, one wrist fracture and one ankle fracture. Patients ranged in age from 18 to 54 years, with an average age of 32. All were males.

Early complications included five pin tract infections which resolved with removal of external fixator and antibiotic administration. Two malreductions went unrecognized in the operating room.

The late complications included one delayed union which occurred in the diaphysial region of the tibia. This responded to immobilization and electrical stimulation. One patient collapsed medially and healed in five degrees of varus. A varus malunion of five degrees was also noted in one non-compliant individual who was weightbearing contrary to instructions. Of the two unrecognized intraoperative malreductions, one healed in varus with a neutral femoral-tibial angle and the other in valgus with a femoral tibial angle of 14 degrees.

The range of motion post operatively averaged 10 degrees to 60 degrees at two weeks and 8 degrees to 90 degrees at 10 weeks. The poorest results were 0 degrees to 60 degrees in a patient with a IIIB open comminuted injury with a comminuted supracondylar distal femur and a comminuted type VI fracture of the proximal tibia.

There were no deep wound infections noted. An earlier published report indicated approximately a 25 percent wound infection rate when double plating techniques were used. One pin tract osteomyelitis was reported that responded without complication to pin tract curettage and antibiotic therapy.

Functional activity assessment indicated that 10 patients returned to pre-injury levels, two had decreased levels of activity, two were lost to follow-up and one patient died as a result of his injuries.

Conclusion

Early results are encouraging. This combined approach remains the preferred option for Schatzker type V and VI injuries at this institution. Cast braces that accommodate the external fixation are part of the standard treatment protocol. Twenty-two patients have been treated with this approach since first introduced. Complications remain limited, and no complications have been attributed to the cast brace.

Melvin Stills, C.O. is an assistant professor in the Department of Orthopaedics, University of Texas SW, Dallas, Texas.

Kevin P. Christensen, M.D., is a major in the U.S. Army, Operation Desert Storm.

Robert W. Bucholz, M.D., is chairman of the Department of Orthopaedics, University of Texas SW, Dallas, Texas.

James N. Powell, M.D., is with the Division of Orthopedics, Sunnybrook Medical Center, Toronto, Canada.

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