POSTGRAD. MED. J. (1964), 40, 543

TIBIAL CONDYLAR FRACTURESTHE LATE RESULTS OF CONSERVATIVE TREATMENT

P. R. SHIRES, F.R.C.S.*Rowley Bristow Orthopaedic Hospital, Pyrford.

IT is generally accepted that fractures intojoints must, if possible, be afforded perfectreduction, and that when accurate reductionhas not been achieved, some considerablestiffness and degenerative arthritis may confi-dently be expected. This was once commonlyillustrated by the malunited fracture-disloca-tion of the ankle, and incongruities of thescaphoid, olecranon and acetabulum provokeearly wear of their respective joints. Anexception to this general rule is the tibialcondylar fracture, which may be treated byskeletal traction and early movement withjustifiable optimism.The lateral tibial condyle is fractured when

a valgus force acts on a knee through whichweight is being taken, causing the correspond-ing femoral condyle to be driven downwardsinto the tibia. This combination of valgus andcompression seems to occur in middle-agedpeople who fall short distances. The term"bumper fracture" or "fender fracture",introduced by Cotton and Berg in 1929, mis-states the cause more often than not, and butfor its useful brevity could well be discarded.Both the radiographic appearances and themechanics of the fracture have in the pastsuggested problems in treatment which havedivided surgeons into two distinct schools,namely, those who recommend open reductionand internal fixation, and those who arecontent to rely on closed methods.Three types of lateral condylar fracture are

customarily recognised, according to theclassification of Palmer (1951).(1) A vertical fracture splits off a wedge oflateral condyle, which may be little displaced,or displaced downwards and outwards. Thistype is most amenable to simple closed re-duction, and also provides the simplest condylarfracture for internal fixation.(2) There is a variable degree of compres-sion of the lateral tibial plateau; a radiographic

* Now at St. Thomas's Hospital, London.

appearance of minor plateau depression maybelie extensive comminution, or the wholecondyle may clearly be shattered.(3) Comminution may involve both condyles,the fracture line resembling an inverted T or Y.With any of these three, the fracture line mayextend through the neck of the fibula.

Fractures of the medial tibial condyle aloneare seen much less frequently, being causedby a varus force on the straight knee. Theirmanagement is essentially similar to that oflateral condylar fractures.

It is argued by many protagonists of openreduction that such disruption of the articularsurface of the tibia must inevitably lead toearly degenerative arthritis of the knee: otherssimply affirm that the results of operationare better than the classical conservativetreatment of attempted closed reduction andplaster external splintage. Palmer (1951) feelsthat conservative management of displacedfractures leaves too much to chance, and heoperates on the displaced split type of frac-ture and on the comminuted depressed ones.Leadbetter and Hand (1940) believe thatconservative treatment leaves genu valgum,lateral instability, limited movement and pain-ful knees. This has certainly been quite con-trary to our experience. Most authors whofavour operative treatment agree that fixationof a comminution mosaic is difficult. Hohl andLuck (1956), in a classic paper, admit thatthe functional results of closed treatment areoften considerably better than the anatomicalor cosmetic results, and that operative reduc-tion gives poor functional results, or, "at leastas much recovery of function as comparablecases treated by conservative means"-asomewhat negative recommendation for sur-gery. Rombold (1960), appreciating thevalue of early movement, has for this pur-pose performed several tours de force offixation of the shattered upper tibia with bolts,plates and screws. Perkins (1940), Furlong(1953) and Apley (1956) advocate a simplemanagement of skeletal traction and early

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544 POSTGRADUATE MEDICAL JOURNAL September, 1964

.... .::::.:.'.:.: :: :: .......I. E

(a)

(b)

FIG. 1.-(a) and (b). With ten lbs. tibial traction,the patient extends his knee and flexes throughthe distal half of the bed. Range at 3 weeks.

movement of the knee, for which this paperseeks further justification.For many years it was widely assumed that

the mechanism of injury must necessarilydamage the internal lateral ligament of theknee: and that even if operative repair ofthe ligament is not required, at least a periodof plaster splintage must be accepted forligamentous healing. But Martin's (1960)experimental work showed that, althoughsufficient valgus force could both tear theinternal lateral ligament and fracture thelateral tibial condyle, the fracture could beproduced without any associated ligamentdamage. Fairbank (1954) suspected that

TABLE 1CAUSES OF INJURY

Fall 23Pedestrian struck by vehicle 2Knocked from cycle 3Unspecified road accident 6Association football 2Struck by falling object on leg 3Unknown 1Total 40

ligamentous damage in bumper fractures wasuncommon. In our experience it has beenclincally absent or trivial.

TreatmentTibial skeletal traction is applied under

general anaesthetic, a Denham pin beinginserted some three inches below the lowestextreme of the fracture as seen in the X-ray.Occasionally in certain fractures a crackextends down the tibial shaft for some inches:we prefer a pin placed low in the tibia forthis type, rather than through the os calcis,provided that the foot is not in equinus whenthe pin is being inserted. A tense hamarthrosisis aspirated. An attempt may be made toreduce significant displacement of the frac-ture by correcting any valgus of the knee andapplying thumb pressure to the condyle, oroccasionally by winding an Esmarch bandageup to the knee. The patient's leg rests on apillow with 10 lbs. traction, the foot of thebed being raised for countertraction.

Physiotherapists encourage straight kneeleg raising from the start, and subsequentlyknee flexion, for which a "split" bed is idealthough not essential. Most of our patientsachieve 90 degrees of knee flexion and fullextension within four weeks (Fig. 1). Unionis presumed, and the traction discontinued, atsix weeks. An X-ray is taken, but does notinfluence treatment. The patient then usescrutches and takes little or no weight throughthe affected limb for a further six weeks. Atthe end of three months from injury theaverage patient has, under supervision, regainedfull or nearly full movement, and can beencouraged to return to normal life.

Fisk (1962), calling this management theSt. Thomas's Hospital tradition, criticises thelack of support for the limb during move-ment, and thinks that flexing the knee througha split bed is not a very natural exercise. How-

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September, 1964 SHIRES: Tibial Condylar Fractures 545

TABLE 2

SUMMARY OF TREATMENT ACCORDING TO SEVERITY OF INJURY

Traction & Early movement Plaster Internal_ early movement alone splintage fixation Totals

Severe 9 0 1 2 12Mod-erate 9 1 5 0 15Mild 4 6 3 0 13

Totals 22 7 9 2 40

ever, we have found this method simple andrewarding for both patient and staff in thetreatment of tibial condylar fractures. It istrue that a similar management of femoralshaft fractures provides more problems,demanding a vigilant nursing staff and skilledphysiotherapists.

Material and resultsForty patients were available for follow-up,

out of one hundred and fifteen patientstreated for tibial condylar fractures at St.Thomas's Hospital and the Rowley BristowOrthopaedic Hospital between 1942 and 1961.The average age was fifty-three years, theyoungest being twenty-seven, the oldest eighty-three. The average follow-up was 9.5 years,the shortest follow-up being three years andthe longest twenty-two years. The causes ofthe fractures are summarised in Table 1.Twelve of the patients were classified as

severe injuries, where there was considerablecomminution or condylar depression of fiveor more millimetres; fifteen were graded asmoderately severe, and thirteen as mild,where there was little displacement. Thetreatment is summarised in Table 2. Sevenfractures were treated by simple bed-rest andsupervised exercises until control of kneeextension and 90 degrees of flexion wereobtained, being mobilised, and avoidingweight-bearing with crutches.The results were assessed as follows:-

Excellent: painfree; full range of knee move-ment: no instability.Good: Painfree, or having occasional aching inthe knee; small loss of movement, usually offlexion; stable.Fair: Aching after exercise; symptomatic lossof knee flexion; slight instability or valgusdeformity.Poor: Pain at rest; less than 90 degrees ofknee flexion; marked deformity orinstability.

In Table 3 the results are presented in

TABLE 3

SUMMARY OF RESULTS

Excellent Good Fair PoorSevere 1 4 5 2Moderate 6 7 2 0Mild 7 6 0 0Totals 14 17 7 2

relation to the severity of the fractures. Twopatients, one of whom had a "moderate"condylar compression, one a mild split frac-ture, had forgotten which knee had beeninjured when reviewed twenty-two years later,and it was only the X-rays which showedevidence of the old fractures. Many of thoselabelled as good results were in fact verylittle short of excellent, having barometricaching in the knee or barely detectibleabnormalities on examination. Residual valgusdeformity of minor degree, and without anyinstability, was found in three patients; twopatients had asymptomatic trivial lateralinstability; two patients showed valgusinstability of some ten degrees, one complain-ing of this and the other completelysymptom-free.The number of cases is too small to draw

conclusions on the relative merits of treat-ment by plaster splintage and that of tractionwith movement. It is our definite impression,however, that early activity gives earlier returnof function: patients splinted from the startappear to achieve comparable results, buttheir recovery of knee flexion is necessarilyslower. Nor can comparison of these methodsbe made with internal fixation, used on onlytwo patients in this series. Both of these hadgross lateral condylar depression. The con-dyles were elevated and fixed with screws,in one patient as a delayed salvage procedure.One obtained a final knee range of 175 degreesto 90 degrees; the other continued to havesevere pain and has now had her kneearthrodesed.

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546 POSTGRADUATE MEDICAL JOURNAL September, 1964

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...--S_ S S iZ .S Sj9B | S _t U z ........~~~~~~~~~~~~~~~~~~~~~~~~.............. FIG. 2.-(a) Man aged 64 whofell from hayrick in 1944.Hemarthrosis aspirated,traction and movement for6 weeks. Later wore a cali-per for a few months. (b)Twenty years later, hecomplains of occasionalache in wet weather. Kneeflexion lacks 10 degrees,but is otherwise normal toexamination.

W. Ss~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.°-;:.:. .. :.:: :..:..:°:::i!:.-....:.

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FIG. 3.-(a) This 63-year-oldpatient fell off a table.Treated by traction for tenweeks. (b) Four and a halfyears later, the knee achesin cold wet weather, andshe kneels with difficulty.There is a small degree ofvalgus but no wobble;range of 178 to 90 degrees.

DiscussionFollow-up radiographs of the knees in this

series showed that, where there had beeninitial displacement of the fracture, someimperfection of the tibial joint line usuallyremained; persistent condylar depression oroutwards spread was a common feature. Onsome films a little loss of lateral joint spacewas noted, but in no patient's X-rays was anygross degenerative arthritis apparent. Despiteradiographic appearances of malunion, late

symptoms of these tibial condylar fractures arevery few in the great majority of patients,and the functional results are surprisinglygood.Hohl and Luck (1956), after creating

artificial defects in the knees of monkeys,splinted some of the knees and encouragedmovement in others. The former groupdeveloped adhesions between the defect andthe infrapatellar fat pad; in the knees whichwere moved, no adhesions formed, and the

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September, 1964 SHIRES: Tibial Condylar Fractures 547

........~~~:........ l.........

FIG. 4.-(a) Aged 45, she felloff her bicycle. Initially theknee was said to be veryvalgus. Deformity correct-ed, traction and movementstarted. (b) Eight yearslater, only symptom isbarometric ache. Kneelooks slightly varus, lack10 degrees of knee flexion.

FIG. 5.-(a) Initial X-ray in 1950of a 66-year-old woman.(b) Fourteen years later,she denies all suggestedsymptoms. There is a smallbut definite valgus wobble,and a full painless range ofnormal movement.

defects filled with granulations and fibroustissue which was converted eventually tofibrocartilage. The united tibial condyle mustcertainly be smoother than the radiographsuggests, the gaps and crevices being filledwith fibro-cartilage. Treatment with tractionchecks further valgus deformity before unionoccurs, and movement will mould the frag-ments into reasonable congruity. (In contrast,plaster splintage must perpetuate incongruity).Instability from collateral ligament injury isa factor insufficient to make us distrust this

management. Accurate reduction and theholding of reduction of comminuted fracturesin cancellous bone are seldom if ever feasible;the results of more simple treatment arestrongly dissuasive from surgery.

Summary1. Forty tibial condylar fractures have beenreviewed after an average period of nine anda half years.2. Twenty-seven of these were treated byskeletal traction and early movement, or by

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548 POSTGRADUATE MEDICAL JOURNAL September, 1964

movement alone. The results of conservativemanagement were found to be satisfactory.3. Disability from degenerative arthritis orjoint instability is much less frequent than hasbeen supposed.

I am grateful to Mr. A. G. Apley for his encourage-

ment and suggestions for this paper, and to Mr. R. J.Furlong and Mr. F. A. Simmonds who treated someof these patients. My thanks are also due to theEditor of the Journal of Bone and Joint Surgeryfor permission to re-examine and report thirteencases from Mr. Apley's series published in thatjournal in 1956.

REFERENCESAPLEY, A. G. (1956): Fractures of the Lateral Tibial Condyle treated by Skeletal Traction and Early Mobilisa-

tion, J. Bone Jt. Surg., 38B, 699.COTTON, F. J., and BERG, R. (1929): 'Fender Fractures' of the Tibia at the Knee. New Engl. J. Med., 201, 990.FAIRBANK, T. J. (1954): Condylar Fractures of the Knee Joint, Proc. Roy. Soc. Med., 48, 95.FISK, G. R. (1962); Fractures Involving the Knee. In 'Modern Trends in Orthopaedics-Fracture Treatment

(3).' Ed. J. M. P. Clark. London: Butterworths.FURLONG, R. J. (1953): Modern Treatment of Fractures in the Knee Joint, Med. Press, 229, 73.HOHL, M., and LUCK, J. V. (1956): Fractures of the Tibial Condyle, J. Bone Jt. Surg., 38A, 1001.LEADBETTER, G. W., and HAND, F. M. (1940): Fractures of the Tibial Plateau, Ibid., 22, 559.MARTIN, A. F. (1960): Pathomechanics of the Knee Joint, Ibid., 42A, 13.PALMER, I. (1951): Fractures of the Upper End of the Tibia, Ibid., 33B, 160.PERKINS, G. (1940): 'Fractures.' London: Oxford University Press.ROMBOLD, C. (1960): Depressed Fractures of the Tibial Plateau, J. Bone Jt. Surg., 42A, 783.

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