Current principles of treatment in the clinical practice of articular fractures

The current treatment of fractures involving articular surfaces is based on fracture surgery principles evolved over the past 40 years, suggesting that anatomic reduction and stable fixation is required for optimal recovery of joint function. These principles are outlined here. However, the evidence supporting such treatment methods is based on limited understanding of the response of articular cartilage to injury. Poor outcomes are still encountered despite careful adherence to these principles, and satisfactory outcomes are seen in some joint fractures despite residual incongruity. Is perfect reduction required in all cases, or are some joints able to tolerate incongruity better than others? Many different factors may influence outcome, such as severity of injury, bone quality, and complications. Rigid application of the current principles may not be possible or advisable in all cases if complications are to be minimized. Our ability to assess the quality of reduction is limited and our understanding of tolerance of malreduction is still lacking. Such dilemmas support the need for further research. The current principles should not be abandoned, but as clinicians, we should strive to better understand these injuries to provide an optimum outcome with the least complications.