| Anatomy |
- Osteology
- lateral tibial plateau
- convex in shape
- proximal to the medial plateau
- medial tibial plateau
- concave in shape
- distal to the lateral tibial plateau
- Muscles
- anterior compartment musculature
- attaches to anterolateral tibia
- pes anserine
- attaches to anteromedial tibia
- Biomechanics
- medial tibial plateau bears 60% of knee's load
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| Classification |
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| Schatzker Classification |
| Type I |
Lateral split fracture |
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| Type II |
Lateral Split-depressed fracture |
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| Type III |
Lateral Pure depression fracture |
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| Type IV |
Medial plateau fracture |
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| Type V |
Bicondylar fracture |
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| Type VI |
Metaphyseal-diaphyseal disassociation |
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Hohl and Moore Classification of proximal tibia fracture-dislocations  |
| Type I |
Coronal split fracture |
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| Type II |
Entire condylar fracture |
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| Type III |
Rim avulsion fracture of lateral plateau |
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| Type IV |
Rim compression fracture |
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| Type V |
Four-part fracture |
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Classification useful for
1) true fracture-dislocations
2) fracture patterns that do not fit into the Schatzker classification (10% of all tibial plateau fractures)
3) fractures associated with knee instability |
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| |
| Presentation |
- History
- high-energy trauma in young patients
- low-energy falls in elderly
- Physical exam
- inspection
- look circumferentially to rule-out an open injury
- palpation
- consider compartment syndrome when compartments are firm and not compressible
- varus/valgus stress testing
- any laxity >10 degrees indicates instability
- often difficult to perform given pain
- neurovascular exam
- any differences in pulse exam between extremities should be further investigated withanke-brachial index measurement
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| Imaging |
- Radiographs
- recommended views
- AP
- lateral
- oblique
- oblique is helpful to determine amount of depression
- optional views
- findings
- on AP
- depressed articular surface
- sclerotic band of bone indicating compression fx
- abnormal joint alignment
- on lateral
- posteromedial fracture lines must be recognized
- CT scan
- important to identify articular depression and comminution
- findings
- lipohemarthrosis indicates an occult fracture
- fracture fragment orientation and surgical planning
- MRI
- indications
- findings
- useful to determine meniscal and ligamentous pathology
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| Treatment |
- Nonoperative
- hinged knee brace, PWB for 8-12 weeks, and immediate passive ROM
- indications
- minimally displaced split or depressed fractures
- low energy fracture stable to varus/valgus alignment
- nonambulatory patients
- Operative
- temporizing bridging external fixation w/ delayed ORIF
- indications
- significant soft tissue injury
- polytrauma
- external fixation with limited open/percutaneous fixation of articular segment
- indications
- severe open fracture with marked contamination
- highly comminuted fractures where internal fixation not possible
- outcomes
- similar to open reduction, internal fixation
- open reduction, internal fixation
- indications
- articular stepoff > 3mm
- condylar widening > 5mm
- varus/valgus instability
- all medial plateau fxs
- all bicondylar fxs
- outcomes
- restoration of joint stability is strongest predictor of long-term outcomes
- postoperative infection after ORIF associated with
- male gender
- smoking
- pulmonary disease
- bicondylar fracture patterns
- intraoperative time over 3 hours
- timing of definitive fixation (before, during or after) relative to fasciotomy closure does not increase the risk of infection
- worse results with
- ligamentous instability
- meniscectomy
- alteration of limb mechanical axis > 5 degrees
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| Techniques |
- External fixation (temporary)
- technique
- two 5-mm half-pins in distal femur, two in distal tibia
- axial traction applied to fixator
- fixator is locked in slight flexion
- advantages
- allows soft tissue swelling to decrease before definitive fixation
- decreases rate of infection and wound healing complications
- External fixation with limited internal fixation (definitive)
- technique
- reduce articular surface either percutaneously or with small incisions
- stabilize reduction with lag screws or wires
- must keep wires >14mm from joint
- apply external fixator or hybrid ring fixation
- post-operative care
- begin weight bearing when callus is visible on radiographs
- usually remain in place 2-4 months
- pros
- minimizes soft tissue insult
- permits knee ROM
- cons
- Open reduction, internal fixation
- approach
- lateral incision (most common)
- straight or hockey stick incision anterolaterally from just proximal to joint line to just lateral to the tibial tubercle
- midline incision (if planning TKA in future)
- can lead to significant soft tissue stripping and should be avoided
- posteromedial incision
- interval between pes anserinus and medial head of gastrocnemius
- dual surgical incisions with dual plate fixation
- indications
- bicondylar tibial plateau fractures
- posterior
- can be used for posterior shearing fractures
- reduction
- restore joint surface with direct or indirect reduction
- fill metaphyseal void with autogenous, allogenic bone graft, or bone graft substitutes
- calcium phosphate cement has high compressive strength for filling metaphyseal void
- internal fixation
- absolute stability constructs should be used to maintain the joint reduction
- screws
- may be used alone for
- simple split fractures
- depression fractures that were elevated percutaneously
- plate fixation
- non-locked plates
- non-locked buttress plates best indicated for simple partial articular fractures in healthy bone
- locked plates
- advantages
- fixed-angle construct
- less compression of periosteum and soft tissue
- postoperative
- hinged knee brace with early passive ROM
- gentle mechanical compression on repaired osteoarticular segments improves chondrocyte survival
- NWB or PWB for 8 to 12 weeks
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| Complications |
- Post-traumatic arthritis
- rate increases with
- meniscectomy during surgery
- axial malalignment
- intra-articular infection
- joint instability
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