The tibial plateau is the flat, expanded top of the shin bone or tibia which makes up the lower half of the knee joint. It is a very important part of the body for load bearing and any disruption of this area can cause abnormalities in alignment of the knee, knee stability and movement especially weight bearing and walking. Early recognition and treatment of this injury is vital to avoid the potential disability which could ensue and the longer term consequences of knee arthritis. More than half the sufferers from this fracture are over fifty years of age.

This fracture is more common in older women which reflects the increased incidence of osteoporotic changes in these patients. If this fracture occurs in younger people then it is likely to be secondary to more energetic injuries. The typical method of fracture in tibial plateau fractures is a force applied to the knee in a knock knee direction with weight bearing loads applied at the same time. The lateral condyle of the femur compresses down on the tibial plateau on the outside and crushes down the bone on that side. Many injuries are related to motor vehicle injuries with a smaller number deriving from sport.

Pedestrians who are hit by the bumper of a car in slow speed events make up about a quarter of this patient group as the bumper is at the right height to apply the required forces. Sporting events such as horse riding or falls from a height can also cause this type of fracture. The levels of energy involved in the precipitating events can make a significant difference to the types of fracture which result. Lower energy events more typically cause depression fractures whilst the result of a higher energy occurrence is more likely to be a splitting fracture. The complex nature of these fractures has resulted in many efforts at classification, with Schatzker and co-workers’ now accepted.

Assessment of the patient will not only include the state of the bone but the condition of the soft tissues which can also be damaged, the blood vessels, nerves and muscles. Tibial plateau fractures are accompanied in about 50% of cases by damage to the knee menisci (cartilages) and the cruciate ligaments which may require surgery. The medial collateral ligament, the ligament on the inside of the knee, is more vulnerable to damage due to the incident forces being more typically on the outside of the knee in a knock knee direction. Medial plateau fractures result from bigger events as the bone is stronger on that side, with more frequent soft tissue problems.

It may be appropriate to accept a number of fracture displacement types for non-operative or conservative treatment but if the fracture depression is over 5 millimetres it may be decided to raise up the depressed surface and place a bone graft under it. If the fracture is an open one (with an open wound) then surgery will be required, as it will in cases of damage to the vascular system and in the case of the development of compartment syndrome. If the fracture is not severe then it should be treated conservatively and operation may be avoided, at least temporarily, in cases where extensive soft tissue damage threatens tissue integrity.

With the diagnosis established the treatment plan can begin with treatment modalities targeted at lowering oedema and inflammation, including limb elevation, tissue compression, immobilisation of the area and resting the part. The removal by surgery of any non-viable dead and dying tissues (debridement) is vital to safeguard the remaining healthy tissues. Fasciotomy may be required to release excessive pressure from one or more of the leg compartments should compartment syndrome threaten the viability of the limb.

Treatment of fractures of the tibial plateau is aimed at restoring the stability of the knee joint, its correct alignment and anatomical relationships of the joint along with full movement in the knee so the knee will function well, is painless and will not suffer arthritic change. If the joint is unstable then surgery will have to be performed, holding the fragments with as little movement as possible. In younger patients with good bone quality then internal fixation may be successful, however older patients with poor bone quality may need to be functionally braced or have total knee replacement.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, Physiotherapists in Bournemouth, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Instability of the shoulder in multiple directions is moderately often encountered, occurring normally on both sides of the body and is not related to accident or injury. The underlying difficulty is the laxity of the capsule of the shoulder and the deficiencies of these stabilising ligamentous structures. This ligament laxity shows itself in excessive joint mobility in all anatomical directions. Patients may describe joint instability as the shoulder may sublux (partial dislocation) or wholly dislocate from time to time. However, the patient may not suffer such obvious symptoms and complain only of pain.

Conservative treatment is the first line of management for this condition, with physiotherapy treatment consisting of strengthening of the muscular parts of the scapular stability and rotator cuff systems. Once conservative treatment has been attempted and not been successful then consideration can be given to surgery. Surgery can tighten up the shoulder capsule, increasing the strength of the static stabilisers. Typically surgery has been done in open technique but arthroscopic technique is become more prevalent.

The incidence of this instability problem in the general public is not obvious and shoulder instability from accidents is much more common as a secondary effect from shoulder dislocation. The shoulder instability types are classified in various ways and TUBS stands for:

* Trauma involved in the cause

* Unidirectional instability (only unstable in one direction)

* Bankart lesion presence – this is injury to the cartilage rim around the socket

* Surgery

TUBS summarises the typical shoulder picture which results from single or multiple episodes of shoulder dislocation.

The multidirectional type of shoulder dislocation is summarised by AMBRI, standing for:

* Atraumatic onset (no injury or accident to explain the onset)

* Multidirectional – the shoulder is lax in all directions

* Bilateral – both shoulders are always involved due to general laxity

* Rehabilitation – this is the initial treatment process

* I refers to the technical types of surgery and where they are performed.

The shoulder is designed for maximum mobility to allow the hands to be placed in a myriad of useful positions, usually in front of the eyes so we can see what we are doing. This mobility is extreme and at the expense of the stability of the joint, leading to instability problems under certain physical stresses.

In considering what stability of the shoulder means it is useful to think about various concepts. Balance is the concept that the head of the humerus should be centred on the centre of the glenoid socket. The rotator cuff muscles are the main controllers of this positional requirement, allowing the shoulder to be moved around by the large nearby muscles. If the rotator cuff muscles or the muscles stabilising the scapula weaken this can alter the ability to maintain balance. The muscles compress the head into the socket which is made deeper by the labrum, the cartilage rim around the socket.

The upper half of the shoulder socket adds to the resistance against upwardly movement of the head of the humerus which the rotator cuff also provides by its compressive function. Synovial fluid makes the joint surfaces wet and so they adhere to each other to a degree, the convex ball and the concave deepness of the socket combining to push any air out and create an amount of suction force holding the joint in place. A tight joint typically has a degree of negative pressure and this helps it hold together too. These methods of enhancing stability work in the mid ranges of the joint, the parts of the joint range where the ligaments are least effective.

The joint capsule acts passively to hold back excessive movement of the shoulder and keep it within safe limits, with thickened areas of the capsule developed into the ligaments of the shoulder, the most important of which is the inferior glenohumeral ligament. This does not mean that the muscles, the dynamic stabilisers of the shoulder system, are not very important in the normal function of the shoulder. Physiotherapy concentrates on strengthening and re-educating the rotator cuff and scapular stability muscles.

Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Sheffield visit his website.

Lower limb amputation is a major undertaking and greatly affects the life of the individual, adding psychological stresses to the physical efforts of rehabilitation, fitting for a new limb and learning the skills of walking again. The surgeon will plan the process so that the patient can manage the prosthesis easily, participate as soon as possible in rehabilitation and expend the lowest levels of energy in gait. The patient has to learn a large number of new skills – putting the prosthesis on and taking it off, monitoring the skin for areas of excessive pressure, walking on even and uneven surfaces and getting around when they are not wearing the artificial limb.

To manage all these skills and learn how to be as independent as possible the patients need a skilled team to manage them which includes their own doctor, the surgeon, a physiotherapist, an occupational therapist a prosthetist and perhaps an employment adviser. The number of lower limb amputations is likely to continue to rise as the elderly populations increase in more advanced industrialised countries, with ischaemic vessel disease the primary cause. The proportion of above knee to below knee amputations has changed as surgeons became more skilled at preserving the knee joint so that the present ratio is 30% above knee to 70% below knee.

The most common reason for amputation is PVD, peripheral vascular disease, and a large number of the mostly elderly patients suffer a second amputation of the other limb within three years. This elderly patient group develops problems with ischaemia which results from diabetes, often developing into peripheral neuropathy and ulcers and eventually changes due to gangrene. If the lower limb suffers trauma involving the nerves and arteries then modern treatment can often salvage the limb but this may be unhelpful in some cases as amputation would allow rehabilitation to go ahead and the achievement of early independence.

Other reasons for amputation are less common and include tumours, infections and congenital abnormalities of the lower limbs. Overall amputation is considered an operation which involves reconstruction rather than just removal of a limb, as the patient’s future life and independence is the crucial matter. The higher that the surgeon has to amputate the limb the higher levels of energy are needed for walking, with the speed of walking decreasing and the required oxygen consumption increasing. Low below knee amputation may make little difference to the energy required for gait, however once the level moves up to mid thigh the load may be over 50% more.

The energy requirements for gait are extremely important as amputated patients frequently suffer from ischaemic tissue problems or other medical conditions which lead to walking consuming much of their energy abilities. Independence in functional activities may be hard to achieve as much of their limited energy supplies is taken up with simply walking. After the amputation, due to the skin viability and ischaemic diagnosis, healing may be delayed and this can have an important bearing on the eventual outcome for the patient’s independence. The soft tissues at the site of amputation must act as the connecting point between the leg and the prosthesis.

Allowing a bony area higher up to take some of the weight transfer indirectly can be successfully integrated with weight transfer sideways through the soft tissues of the lower leg. There may still be pain issues for patients despite the many advances made in modern prosthetics. Significant pain can lead to a reduction in function, reduced use of the prosthesis and even to further surgery.

More indirect weight transfer can be accomplished by allowing a higher bony area to take some of the force with other forces being transferred across the sides of the soft tissues of the leg. Pain may still be an issue for many patients despite the great advances made in prosthetic technology. If the pain is severe enough it can lead to further surgery, reduced function and limited wearing of the artificial limb.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapist in northampton, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.