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Introduction
  • Periarticular injuries of the proximal tibia frequently associated with soft tissue injuries
  • Epidemiology
    • demographics
      • bimodal distribution
        • males in 40s (high-energy trauma)
        • females in 70s (falls)
    • location
      • unicondylar vs. bicondylar
        • frequency
          • lateral > bicondylar > medial
  • Mechanism
    • varus/valgus load with or without axial load
    • high energy
      • frequently associated with soft tissue injuries
    • low energy
      • usually insufficiency fractures
  • Associated conditions
    • meniscal tears
      • lateral meniscal tear
        • more common than medial
        • associated with Schatzker II fracture pattern  
        • associated with >10mm articular depression 
      • medial meniscal tear
        • most commonly associated with Schatzker IV fractures
    • ACL injuries
      • more common in type V and VI fractures (25%)
    • compartment syndrome
    • vascular injury
      • commonly associated with Schatzker IV fracture-dislocations 
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
Classification  
 
Schatzker Classification
Type I Lateral split fracture
 
Type II Lateral Split-depressed fracture
 
Type III Lateral Pure depression fracture
 
Type IV Medial plateau fracture     
Type V Bicondylar fracture
 
Type VI Metaphyseal-diaphyseal disassociation   
 
Hohl and Moore Classification of proximal tibia fracture-dislocations 
Type I Coronal split fracture
Type II Entire condylar fracture
Type III Rim avulsion fracture of lateral plateau
Type IV Rim compression fracture
Type V Four-part fracture
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
 
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 with anke-brachial index measurement
Imaging
  • Radiographs
    • recommended views
      • AP, lateral, oblique
        • oblique is helpful to determine amount of depression
    • optional views
      • plateau view
        • 10 degree caudal tilt
    • findings
      • 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
      • not well established
    • findings
      • useful to determine meniscal and ligamentous pathology 
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
        • 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 
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
      • pin site complications
  • 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
Complications
  • Post-traumatic arthritis
    • rate increases with
      • meniscectomy during surgery
      • axial malalignment
      • intra-articular infection
      • joint instability
 

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