Review Question - QID 218934

This patient suffered a medial tibial plateau fracture (Schatzker Type IV). While this injury pattern does have a higher incidence of ACL and neurovascular injury, meniscal tears remain the most common concomitant soft tissue injury.

Tibial plateau fractures are a complex group of injuries that often manifest with a severe ligamentous or meniscal injury that can be challenging to manage in the setting of ORIF. Meniscal tears are common, and entrapment may hinder the anatomic reduction of the plateau. It is critical for the orthopedic surgeon to recognize this common pathology and the factors that are associated with tears. Tears involving the lateral meniscus are more common than the medial meniscus and are most commonly associated with Schatzker II fracture patterns, >10mm articular depression, and >6mm condylar widening. While medial meniscal tears are more commonly associated with Schatzker IV fractures, studies have largely failed to discern a difference in incidence between lateral and medial meniscal tears related to fracture pattern (hence why medial meniscus was not also an answer choice). Because meniscal injuries can lead to posttraumatic arthrosis and decreased knee function, it is important that meniscal tears be accurately repaired or débrided to maintain knee joint stability and congruency and to minimize articular contact pressure.

Warner et al. performed a prospective cohort study of 82 patients to determine if ligamentous and meniscal injuries as determined by initial magnetic resonance imaging altered clinical outcomes after the fixation of tibial plateau fractures. They reported that on injury MRI, 73% of patients had injuries to at least one soft tissue structure and that patient-reported outcomes and range of motion assessments were not significantly different in patients with and without medial meniscal tears, lateral meniscal tears, and complete MCL ruptures. They concluded that sutured lateral meniscal tears, untreated medial meniscus tears, and complete MCL ruptures did not significantly affect clinical outcomes and that obtaining a preoperative MRI in patients with tibial plateau fractures to diagnose soft tissue injuries may not alter the surgical treatment or alter patient prognosis for midterm outcomes.

Gardner et al. performed a prospective cohort study of 103 patients to determine the incidence of injury to soft tissue structures of the knee in tibial plateau fractures scheduled for surgery. They report that 77% sustained a complete tear or avulsion of 1 or more cruciate or collateral ligaments, 91% had evidence of lateral meniscus pathology, 44% had medial meniscus tears, 68% had tears of 1 or more of the posterolateral corner structures of the knee. They conclude the incidence of complete ligamentous or meniscal disruption associated with operative tibial plateau fractures was higher than previously reported.

Figure A demonstrates an AP radiograph of a medial tibial plateau fracture (Schatzker Type IV).

Incorrect Answers:
Answers 2-5: Meniscal tears are the most common concomitant soft tissue injury associated with tibial plateau fractures.