Extent Of Soft Tissue Injury Research Articles

Outcomes following soft tissue reconstruction for thermal hand burns

BackgroundAcute thermal burns can be severe injuries potentially requiring hospitalization and may even lead to limb amputation or permanent disability if not properly addressed. Primary burn reconstruction using flaps has been shown to be an effective method that optimizes tissue preservation, minimizes limb morbidity, and allows for early mobility. Previous studies have demonstrated the dependence of flap survival on several factors such as wound size, location, and specific tissue requirements (weight-bearing vs non-weight-bearing). Proper selection of soft tissue coverage for a wound defect is vital in ensuring adequate healing and recovery. Our objective was to identify whether the choice of flap leads to differences in near-term survival and postoperative complications in patients undergoing burn reconstruction for thermal hand injuries. MethodsRetrospective review was performed of our single institution burn database to identify patients who underwent primary soft tissue reconstruction for thermal hand burns between September 2014 and March 2022. All patients had wound defects with significant depth not amendable to skin grafting alone for coverage. Medical records were reviewed for demographics, injury specifics, treatment details, and post-operative outcomes. ResultsOf all patients admitted to our institution over an 8-year period for burn-related injuries, we identified 17 patients requiring 28 local or regional flaps for reconstruction. All but one flap survived a minimum of two weeks post-operatively with a success rate of 96%. Complications included partial necrosis in 1 flap, full necrosis in the failed flap, dehiscence in 2 flaps, and hematoma in 1 flap. One patient developed a donor site hematoma requiring evacuation, and another developed flap cellulitis treated with IV antibiotics. ConclusionLocal, regional, and distant flaps can reliably be used to salvage exposed tendons and neurovasculature in deep thermal hand burns. Flap success and subsequent outcomes rely heavily on the initial wound and extent of soft tissue injury, with flap type and timing acting as secondary predictors.

302 A Classification System and Surgical Algorithm for Pediatric Postburn Ear Deformities

Abstract Introduction The outward projection of the external ear makes this anatomically complex appendage susceptible to trauma. Notably, up to 40-60% of facial burns involve the ear, frequently impacting function and aesthetics. Significant postburn sensory deficits and changes to the ear’s intricate architecture can markedly impair physical health, psychosocial functioning, and quality of life. Scar tissue and contracture, traumatized cartilage, and compromised blood supply and surrounding soft tissues all influence the reconstructive plan. The authors describe a new classification system and surgical algorithm for pediatric postburn ear deformities informed by both their extensive operative experience on the traumatized ear and a retrospective study of different reconstructive techniques for more severe burn injuries to the pediatric ear. Methods To develop the classification system and surgical algorithm, three senior surgeons with over 85 years of combined experience reconstructing ears carried out an iterative joint review of their relevant clinical cases and insights, including their personal approach to assessing postburn ear trauma and developing an operative plan. Particular attention was focused on how the type and extent of soft tissue injury affects available reconstructive options. To inform classification of the most complex ear burn cases, a retrospective review was conducted on patients aged 0 to 21 years who underwent cartilage framework reconstruction between January 2004 to January 2021 at a specialized pediatric burn center. Medical records were screened and 54 patients (61 ears) who met study criteria were identified and patient demographics, procedural characteristics, and outcomes were analyzed. Results For postburn ear deformities (Table 1) involving total or near-total preservation of the ear’s anatomical structural elements (Type I and Type II deformities, respectively), scar release, local tissue rearrangement, and/or skin grafting are typically sufficient for optimal reconstruction. For cartilage defects involving less than or more than two-thirds of the helix (Type III and Type IV deformities, respectively), a partial to complete ear scaffold can be successfully reconstructed using a composite graft, conchal transposition flap, costal cartilage graft, or porous polyethylene implant. Conclusions The proposed classification system and surgical algorithm (not shown) for postburn ear deformities facilitate a tailored approach that addresses reconstructive course duration, anticipated aesthetic results, complication potential, and patient goals and expectations. Applicability of Research to Practice The authors provide a new classification system to pediatric postburn ear deformities that, along with a proposed surgical algorithm, can help guide planning for reconstruction.

Osteoradionecrosis of the Jaw-Comparison between Bone and Soft Tissue Injury and Their Influence on Surgical Outcomes-A Retrospective Cohort Study.

Surgical therapy of osteoradionecrosis of the jaw (ORN) is challenging and requires treatment of the affected hard and soft tissue. To understand how tissue injury after irradiation influences surgical outcomes, the objective of this study was to find out whether (a) bone-related, (b) soft tissue-related, and (c) treatment-related parameters influence the surgical success of patients with ORN. A total of 175 patients (324 lesions) were included in this retrospective, single-center study. All patients were diagnosed with ORN and underwent surgical therapy. The primary outcome was complete soft tissue recovery (mucosa/skin) and the absence of symptoms 3 months after surgery. At the time of follow-up, 58% of patients (189 of 324 lesions) had intact intraoral or extraoral soft tissue. The extent of bone destruction had no effect on treatment success, whereas soft tissue injury due to fibrosis (OR: 0.344; CI 0.142-0.834; p = 0.01818) and xerostomia (OR: 0.163; CI 0.064-0.419; p = 0.00016) increased the probability of treatment failure. Soft tissue reconstruction with a microvascular graft improved therapeutic success compared to local wound closure (OR: 2.998; CI 1.371-6.555; p = 0.006). Thus, for the treatment of ORN, it is extremely important to pay attention not only to the extent of bone destruction but especially to soft tissue defects. Because the extent of soft tissue injury is a predictor for therapeutic success, it should influence the choice of surgical treatment.

A Descriptive Study of Concomitant Vascular and Bone Injuries of the Limbs in a Tertiary Care Hospital in South India

Background: We studied patients with concomitant vascular and orthopedic trauma to limbs to assess their outcome and factors that affect the outcome of the limb. Methodology: We conducted a retrospective descriptive study and data from 68 patients was collected. Factors such as demography, mode of injury, and clinical parameters such as pulses, capillary refill time (CRT), sensory-motor function, compartment syndrome, type of bone and vessel injury, and ischemia time were compared and analyzed. Results: Out of 68 patients (n = 68) with concomitant vascular and orthopedic injury included in the study, 63 (92.65%) patients were males, and the mean age in the study was 30.16 ± 16.33 years; 56 (82.35%) patients sustained road traffic accident and 12 (17.65%) patients sustained fall from height, 7 (10.29%) patients were hypertensive, and 2 (2.94%) patients had diabetes mellitus; popliteal (30 patients – 22.06%) and brachial arteries (30 patients – 22.06%) are the most (total 44.12%) followed by femoral artery (seven patients, 10.29%) and radial artery (one patient, 1.47%); sensory function was absent in 20 (29.4%) patients; CRT was more than 3 s in 49 (72.06%) patients. No mortality occurred during the hospital stay in any of the 68 patients. The overall rate of amputation in the study was 20.59% (14 amputations). Significant association of amputation rate was found with increased CRT (P = 0.01), fracture (P = 0.05), open fracture (P = 0.05), transected vessel (P = 0.017), nonextremity injury (P = 0.01), and compartment syndrome (P = 0.002). Fasciotomy was done for 49 (72.06%) patients, and no significant association was found with the amputation rate. Mangled extremity severity score (MESS) was 7 or more than 7 in 23 (33.82%) patients. All the 14 (100%) patients who required amputation in the study had a MESS of 7 or more (P = 0.01), and limb salvage index (LSI) was 6 or more in 17 patients; among the 14 patients who underwent amputation, 13 patients had an LSI of 6 or more than 6 (P = 0.01). The vascular repair was redone in 3 (21.4%) patients, excessive bleeding requiring blood transfusion happened in 2 (14.3%) patients, and hypotension occurred in 4 (28.6%) patients. Intraoperative complications were associated with an increased rate of amputations (P = 0.001). The mean ischemia time was 15 ± 6.5 h with a median of 15 h; the shortest ischemia time was 10 h, and the longest was 19 h. The mean ischemia time was 14 h in the limb salvage group and 18.5 h in the amputation group. Long ischemia time was associated with increased amputation rates (P = 0.03). There was no significant difference in time between the time of injury and presentation to the hospital, the time between presentation and surgery, and the duration of surgery between the two groups (amputated vs. salvaged). Conclusion: The extent of soft-tissue injury and ischemia time are prime determinants of outcome in cases with concomitant vascular and skeletal injury. Early diagnosis, quick referral, addressing compartment syndrome, and proper vascular repair are the critical factors in salvaging a limb.

Open ankle fractures: Factors influencing unplanned reoperation

IntroductionAnkle fractures are amongst the most common open fracture injuries presenting to major trauma centres (MTC) and their management remains a topic of debate. Incidence is increasing particularly in the elderly population however the optimal surgical approach and risk factors for unplanned reoperation remain scarce. We therefore conducted a retrospective case study to analyse our institution's outcomes as well as identify risk factors for early unplanned reoperation. Materials and methodsSixty-five consecutive open ankle fractures were identified using our institutional database between July 2016 and July 2020. Medical records and operation notes were reviewed to identify patient age at injury, Sex, co-morbidities and other co-morbidities, fracture configuration, extent of soft tissue injury, fixation type and post-operative complications. The data was categorised into four groups for analysis, 1) age, 2) AO-OTA classification 3) Sex 4) Gustilo-Anderson grade. Statistical analysis was undertaken to identify predictors of unplanned reoperation. ResultsThe mean age of patients at the time of injury was 60.8. Unplanned reoperation rate was 17.5%. Age and Gustilo-Anderson classification grade were both statistically significant predictors of unplanned reoperation. AO-OTA classification, Sex and Diabetes were not statistically significant factors associated with unplanned reoperation. ConclusionAge and quality of soft tissue envelope are significant risk factors for unplanned reoperation. Patients with these risk factors may benefit from an alternative surgical approach.

Common Extensor Complex Is a Predictor to Determine the Stability in Simple Posterolateral Elbow Dislocation: Analysis of MR Images of Stable vs. Unstable Dislocation

Simple posterolateral elbow dislocations (SPLED) may be treated nonoperatively using closed reduction, followed by controlled mobilization. However, the extent of soft tissue injuries might affect the choice of treatment, rehabilitation approach, and prognosis. The purpose of this study is to compare the characteristics of soft tissue injuries between patients with unstable and stable SPLED using MRI findings. Thirty MRIs of elbows with SPLED (unstable group (n = 15); stable group (n = 15)) were randomly reviewed by two experienced musculoskeletal radiologists. Soft tissue injuries were characterized as an intact, partial tear or complete tear for the: medial collateral ligament (MCL) complex, common flexor complex, lateral collateral ligament (LCL) complex, common extensor complex, anterior capsule, and posterior capsule. Moderate to substantial interobserver reliability and substantial to perfect intraobserver reliability were observed for medial and lateral complexes in SPLED. The proportion of soft-tissue injuries of the common extensor complex were significantly different between the unstable (four partial tears and 11 complete tears) and stable groups (11 partial tears and four complete tears). In conclusion, based on MRI findings, the degree of common extensor complex injuries may be a predictor of stability and help inform treatment decisions for SPLED.

Comparison of Clinical Outcomes After Intramedullary Fixation of Tibia Fractures Caused by Blunt Trauma and Civilian Gunshot Wounds: A Retrospective Review.

To assess the outcomes of patients who sustained blunt trauma tibia fractures compared with tibia fractures from civilian gunshot injuries when treated with intramedullary fixation. Retrospective chart review. Level I trauma center. Two hundred and seven patients underwent intramedullary nailing for 211 tibia fractures. A retrospective review of tibia fracture(s) treated with intramedullary fixation with comparison of closed, open, and gunshot wound (GSW) fracture outcomes. Outcomes included infection and nonunion. The infection rate in closed and GSW tibia fractures was significantly lower compared with the infection rate of open fractures (1% vs. 9% vs. 20%; P = 0.00005). Significantly lower rates of nonunion in closed fractures compared with open fractures and GSW fractures were appreciated (8% vs. 20% vs. 30%; P = 0.003). There was no difference in infection or nonunion between GSW fractures with small wounds, no exposed bone, and minimal comminution and closed injuries (P = 0.24, P = 0.60). Conversely, there was a significantly higher nonunion rate in GSW fractures with large wounds, exposed tibia, and comminution compared with blunt injuries (P = 0.0014). This study suggests that tibia fractures from civilian GSWs are heterogeneous injuries, and outcomes are dependent on the extent of soft-tissue injury, bone exposure, and bone loss. There are comparable infection rates in all fractures due to civilian GSWs and closed fractures, which are lower than high-grade open fractures. Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Retraction Notice: Floating knee management

Floating knee injury is described as the simultaneous ipsilateral disruption of skeletal integrity above and below the knee. It is usually associated with high-energy impact and often a part of polytrauma. Management of associated life-threatening injuries should take precedence over the orthopedic injury. The soft tissue trauma to the limb is significant and it is prudent to be wary. Each fracture in a floating knee injury is unique and treatment should be decided based on individual analysis and the extent of soft-tissue injuries. A combination of multiple fractures might influence the choice of treatment in complex cases.

Floating knee management

Floating knee injury is described as the simultaneous ipsilateral disruption of skeletal integrity above and below the knee. It is usually associated with high-energy impact and often a part of polytrauma. Management of associated life-threatening injuries should take precedence over the orthopedic injury. The soft tissue trauma to the limb is significant and it is prudent to be wary. Each fracture in a floating knee injury is unique and treatment should be decided based on individual analysis and the extent of soft-tissue injuries. A combination of multiple fractures might influence the choice of treatment in complex cases.

Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement.

The Spinal Cord Society constituted a panel tasked with reviewing the literature on the radiological evaluation of spinal trauma with or without spinal cord injury and recommend a protocol. This position statement provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. PubMed was searched for the corresponding keywords from January 1, 1980, to August 1, 2017. A MEDLINE search was subsequently undertaken after applying MeSH filters. Appropriate cross-references were retrieved. Out of the 545 articles retrieved, 105 relevant papers that address the present topic were studied and the extracted content was circulated for further discussions. A draft position statement was compiled and circulated among the panel members via e-mail. The draft was modified by incorporating relevant suggestions to reach a consensus. For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material.

Acute Septic Arthritis Following Supra-Patellar Nailing of an Open Diaphyseal Tibia Fracture in an Immune Compromised Patient

The supra-patellar approach represents one approach to intramedullary nailing (IMN) of diaphyseal tibia fractures. Violation of the knee joint utilizing an intra-articular start point represents a risk for septic arthritis of the knee in the post-operative period. Previous retrospective studies of open tibia and femur fractures demonstrated that post-operative knee sepsis is rare, occurs in the chronic phase after injury, and due to extent of soft tissue injury rather than immune compromise. Here, we review current literature on post-operative knee sepsis, and present a case of acute septic arthritis of the knee following supra-patellar nailing of an open tibia fracture in a patient on chronic immune suppression. In this unique case, co-morbid patient factors likely led to this manifestation of a rare complication.

Ultrasonography and return to play of the different clinical grading of quadriceps contusions: a case series.

Prognostication of quadriceps contusion is based on the patient's active knee flexion after the injury. Unlike ultrasonography, clinical grading does not define the extent of soft tissue injury and may provide inaccurate time for return to play. The purposes of this report are to describe the ultrasound findings of the different clinical grading of quadriceps contusion and document the return to play of each case. Seven patients were evaluated in this series. Results showed discrepancies in the disability time between clinical grading and ultrasound findings. Clinical grading did not consistently estimate the return to play as described in previously published literature. Contusions with hyperechoic lesions had earlier return to play compared to patients with hypoechoic findings. Contusions with hypoechoic lesions might require aggressive monitoring and therapy to decrease disability time and avoid complications such as myositis ossificans.

The treatment of simple elbow dislocation in adults.

Simple elbow dislocation is a complex soft-tissue injury that can cause permanent symptoms. Its incidence is 5 to 6 cases per 100 000 persons per year. Its proper treatment is debated; options range from immobilization in a cast to surgical intervention. We systematically reviewed the literature on the treatment of simple elbow dislocation and performed a meta-analysis, primarily on the basis of clinical scores and secondarily with respect to pain, range of motion, and return to work. A randomized controlled trial (RCT) showed that clinical results at short-term follow-up were superior for early functional treatment compared to immobilization in a cast. Brief immobilization, however, reduced pain initially, and the long-term results of early mobilization and immobilization in a cast were the same. Our meta-analysis showed that early mobilization enables patients to return to work earlier (difference of mean values -2.91, 95% confidence interval [CI] -3.18 to -2.64), and that the extent of soft-tissue injury is correlated with the clinical outcome (inverse relationship; difference of mean values -12.07, 95% CI -23.88 to -0.26). Surgical and conservative treatment were compared in a single RCT, which revealed no significant difference in outcomes. A meta-analysis of two retrospective comparative studies showed no advantage of immediate ligament repair over delayed surgery. Early functional treatment is the evidence-based therapeutic standard for simple elbow dislocation. The past few years have seen further developments in surgery for simple elbow dislocation. Further study is needed to determine whether surgery for elbow dislocation with high-grade instability can prevent persistent pain, limitation of motion, and chronic instability.

Imaging Patterns in MRI in Recent Bone Injuries Following Negative or Inconclusive Plain Radiographs.

Few bony injuries and most soft tissue injuries cannot be detected on plain radiography. Magnetic resonance imaging (MRI) can detect such occult bony injuries due to signal changes in bone marrow. In addition to excluding serious bony injuries, it can also identify tendon, ligament, cartilage and other soft tissue injuries and thus help in localizing the cause of morbidity. To determine the MRI imaging patterns in recent bone injuries (less than 4 weeks) following negative or inconclusive plain radiographs. To determine the role of MRI in recent fractures. Out of the 75 individuals with history of recent injury of less than 4 weeks duration, fracture line was demonstrated in 16 patients (21%) who had no obvious evidence of bone injury on plain radiographs. Bone contusion or bruising of the bone was demonstrated in 39 (52%) patients. This was the commonest abnormality detected in MRI. The remaining 20 patients did not show any obvious injury to the bone on MR imaging however, soft tissue injury could be demonstrated in 12 (16%) patients which show that the extent of soft tissue injury was relatively well demonstrated by MR imaging. The present study showed that occult injuries commonly occur at the Knee followed by Ankle, Wrist, Foot, Elbow, Leg, Hands, Hips & Spine. The study showed that MR is efficient in the detection of occult bone injuries which are missed on radiography. Compared to radiographs, MRI clearly depicted the extent of injuries and associated soft tissue involvement. MRI demonstrates both acute and chronic injuries and also differentiates both, whereas radiography has poor sensitivity for acute injuries. Also, the soft tissue injuries like tendionous and ligamentous injuries cannot be identified on radiographs.

Antecubital Venipuncture Resulting in Compartment Syndrome of the Anterior Brachium: A Case Report.

Acute compartment syndrome is uncommon, but it can be a limb-threatening condition if not treated1,2. The outcome of compartment syndrome varies from complete recovery3-7 to permanent impairment1,8,9, depending on the extent of soft-tissue injury, which in turn depends on the magnitude and duration of increased intracompartmental pressure. The potentially disabling sequelae following this event make compartment syndrome a serious and urgent orthopaedic concern. Acute compartment syndrome in the arm, defined as the portion of the upper extremity above the elbow, is rare and is usually caused by injury2,3. We are aware of three reports of isolated arm compartment syndrome developing from either a noninvasive blood pressure monitoring device1,4 or from a vitamin B12 injection6, but, to the best of our knowledge, there are no reports of arm compartment syndrome developing from venipuncture. Additionally, anticoagulation is a risk factor for the development of compartment syndrome2,3. However, reported cases of compartment syndrome after anticoagulation involve a traumatic injury3,5,7,8, and we are not aware of any reported cases of compartment syndrome caused by venipuncture in anticoagulated patients. We report a case of compartment syndrome of the anterior brachium that developed in an anticoagulated patient after venipuncture and without traumatic injury. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A seventy-three-year-old woman presented to the emergency department (ED) with symptoms of excruciating and worsening pain with swelling in the dominant, right upper arm, with numbness and tingling extending into the hand. She stated that …

Pediatric Lower Extremity Mower Injuries

Lawn mower injuries in children represent an unfortunate common problem to the plastic reconstructive surgeon. There are approximately 68,000 per year reported in the United States. Compounding this problem is the fact that a standard treatment algorithm does not exist. This study follows a series of 7 pediatric patients treated for lower extremity mower injuries by a single plastic surgeon. The extent of soft tissue injury varied. All patients were treated with negative pressure wound therapy as a bridge to definitive closure. Of the 7 patients, 4 required skin grafts, 1 required primary closure, 1 underwent a lower extremity amputation secondary to wounds, and 1 was repaired using a cross-leg flap. Function limitations were minimal for all of our patients after reconstruction. Our basic treatment algorithm is presented with initial debridement followed by the simplest method possible for wound closure using negative pressure wound therapy, if necessary.

Lateral Tibial Plateau Fracture Depression as a Predictor of Lateral Meniscus Pathology

The goal of this study was to determine if the degree of lateral tibial plateau fracture depression on computed tomography (CT) images predicted the presence of lateral meniscus tears. The study group comprised 85 patients who sustained a lateral tibial plateau fracture and underwent open reduction and internal fixation by the same surgeon. Degree of plateau depression was measured in millimeters by CT. Operative reports were retrospectively reviewed to determine if the lateral meniscus tear was intact or torn at the time of surgery. Twenty-eight patients had a lateral meniscus tear noted at the time of surgery. No significant differences existed in gender, mechanism or energy level of injury, Schatzker classification, or type of fracture among patients with a lateral meniscal tear as compared to those without a tear. Patients with > or =10 mm of plateau depression had an eight-fold increase in risk of having a lateral meniscus tear compared to those with <10 mm of depression. Patients younger than 48 years had a four-fold increase in risk of having a lateral meniscus tear than older patients.This study demonstrated an association between the amount of tibial plateau depression and the likelihood of a lateral meniscus tear. These findings may be used to predict those who have sustained a tear of the lateral meniscus and to advise the surgeon to prepare for a repair. Further prospective studies using magnetic resonance imaging as a tool to evaluate the extent of soft tissue injuries in plateau fractures is needed.

Use of External Fixation and Primary Wound Closure in an Open Comminuted First Metatarsal Fracture: A Case Report

Management of open, comminuted fractures presents a challenge for the foot and ankle surgeon. Reconstructive surgery for such injuries has a high potential for the development of serious complications, and factors such as the extent of soft tissue injury, neurovascular status to the foot, and fracture stability must be taken into consideration before determining a surgical plan. This article describes the case of a patient who presented with an open, comminuted first metatarsal fracture as a result of a chainsaw injury. The patient was treated with a uniplanar mini-external fixator, demineralized bone matrix, primary wound closure, and external bone growth stimulation. At 1-year follow-up, the interview and examination revealed the patient to be pain free with a functional first ray. ACFAS Level of Clinical Evidence: 4.

MR Imaging of Trauma: Elbow and Wrist

The use of magnetic resonance imaging (MRI) in the setting of acute trauma is increasing due to many factors including availability and demand. The ability to evaluate for occult fractures in addition to concomitant soft tissue injuries has a significant impact on patient management and MRI is the ideal adjunct to plain radiography. Occult fractures in the forearm, particularly the radial head and scaphoid, are common and often lead to repeated examinations and delayed diagnosis, which can be avoided by the use of MRI early in patient investigation. Orthopedists are increasingly performing ligament repairs at the time of fracture fixation and therefore benefit from preoperative MRI to assess the extent of soft tissue injury.

Injury severity assessment in tibial plateau fractures.

Assessment of injury severity is an integral component of the care of the patient with a fracture of the tibial plateau. Devising ways to reliably quantify injury severity, and to make predictive links between injury severity and outcome, however, has been difficult. Assessment of patient-related factors, such as age, functional capabilities, and medical comorbidities, are necessarily subjective, but certain of these factors clearly shape the treatment plan for a patient with a tibial plateau fracture. Clinical examination findings, such as extent of soft tissue injury and mediolateral stability of the knee, also play an important role in determining treatment and predicting outcome. Radiographic classification of tibial plateau fractures also is an important determinant of treatment, but current classification systems have suffered from disappointing interobserver reliability. Although the severity of injury to the articular cartilage almost certainly affects outcome, there currently are no validated modalities to measure this important factor. More carefully validated tools are needed in many of these areas if we are to perfect our understanding of injury severity and establish more accurate correlations between injury severity and outcomes.