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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
      • 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
        • 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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Questions (24)

(OBQ13.132) An ankle-brachial index is most commonly indicated after sustaining which of the following fracture patterns, seen in Figures A-E? Review Topic

QID:4767
FIGURES:
1

Figure A

0%

(6/1685)

2

Figure B

22%

(363/1685)

3

Figure C

70%

(1182/1685)

4

Figure D

2%

(26/1685)

5

Figure E

6%

(101/1685)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Figure C shows a Schatzker IV tibial plateau fracture, or medial fracture-dislocation of the knee. Of the fracture patterns shown, Schatzker IV tibial plateau fractures have the highest incidence of vascular injury and most often require measurement of an ankle-brachial index (ABI) to rule-out associated vascular injury.

Schatzker IV tibial plateau fractures (fracture of the medial plateau) are rare and are most commonly associated with high-energy trauma after a varus/axial load. At the time of initial injury, the fracture pattern produces a temporary dislocation of the knee, placing tension on the peroneal nerve and popliteal artery. Because of the likelihood of associated popliteal artery injury, ankle-brachial indices, frequent neurovascular checks, and arteriography are commonly performed following injury.

Berkson et al. review high-energy tibial plateau fractures. They state that Schatzker IV fractures are usually the result of high-energy trauma, and have a high incidence of popliteal artery and peroneal nerve injury. In contrast, Schatzker V and VI are more commonly associated with compartment syndrome.

Gardner et al. review 103 tibial plateau fractures. 77% of fractures had an associated rupture of either cruciate or collateral ligaments. 86% of Schatzker IV fractures had an associated medial meniscus tear.

Illustration A is a worksheet for calculating the ankle brachial index. An ABI less than 0.90 has been shown to have a sensitivity exceeding 87% and a specificity exceeding 97% for identifying lower-extremity arterial injury.

Incorrect Answers:
Answer 1: Figure A shows a non-displaced Schatzker I tibial plateau fracture. These are more commonly associated with lateral meniscal pathology.
Answer 2: Figure B shows a Schatzker V tibial plateau fracture. While it occurs through a high-energy mechanism, vascular compromise is less common than Schatzker IV fractures.
Answer 4: Figure D shows a distal 1/3 tibial shaft fracture. These should be monitored carefully for compartment syndrome.
Answer 5: Figure E shows an ankle fracture-dislocation. After successful reduction, vascular status usually returns to normal and further diagnostic imaging is not needed unless the foot is avascular.

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(OBQ12.22) A 32-year-old man sustains the knee injury seen in Figure A after falling from a ladder. Which of the following options is the most biomechanically stable and appropriate definitive surgical treatment? Review Topic

QID:4382
FIGURES:
1

Spanning knee external fixation

1%

(34/2714)

2

Lateral plateau locking plate

1%

(38/2714)

3

Posteromedial locking plate

1%

(26/2714)

4

Lateral plateau percutaneous lag screws and posteromedial plate

4%

(113/2714)

5

Lateral plateau and posteromedial plating

92%

(2487/2714)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The above clinical scenario is consistent with a bicondylar tibial plateau fracture. Bicondylar tibial plateau fractures are best definitively treated with dual incision technique using separate lateral plateau and posteromedial plates.

Yoo et al perfored a biomechanical study comparing locking and nonlocking single and dual plating constructs in maintaining posteromedial fragment reduction in a bicondylar tibial plateau fractures. They found that the posteromedial fracture fragment tolerated higher loads with a posteromedial conventional plate construct. The superiority of this dual plating construct may be caused by unreliable penetration of the posteromedial fragment by the lateral locking screws alone.

Zeng et al also performed a biomechanical study comparing the biomechanical strength of four different fixation methods for the posteromedial tibial plateau split fracture. The four following constructs: anteroposterior lag-screws, an anteromedial limited contact dynamic compression plate (LC-DCP), a lateral locking plate, or a posterior T-shaped buttress plate were studied. They found that the posterior-based buttress plating technique was the most biomechanically stable fixation method allowing the least amount of fracture subsidence for posteromedial split tibial plateau fractures.

Figure A shows an AP radiograph of a bicondylar tibial plateau. Illustration A shows a post-operative radiograph following the dual-plating technique for bicondylar tibial plateau fractures.

Incorrect answers:
Answer 1: External fixation is not the most appropriate definitive care for bicondylar tibial plateau fractures.
Answers 2-4: Not as biomechanically stable as dual plating technique for bicondylar tibial plateau fractures.

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(OBQ12.139) A 45-year-old patient sustains the injury shown in figure A. What radiographic finding most highly suggests a lateral meniscal injury? Review Topic

QID:4499
FIGURES:
1

Joint depression of 3mm

35%

(1201/3448)

2

Ipsilateral femoral shaft fracture

1%

(24/3448)

3

Joint widening of 6mm

50%

(1708/3448)

4

Ipsilateral tibial shaft fracture

1%

(21/3448)

5

Displaced tibial spine fracture

14%

(481/3448)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Figure A shows a Schatzker II tibial plateau fracture. Joint widening of 6mm is commonly asociated with a lateral meniscal injury.

Tibial plateau fractures are commonly associated with soft tissue injuries and the operative surgeon needs to be aware of these commonly associated injuries.

Gardner et al. (2005) examined 62 consecutive Schatzker type II fractures with radiographs and MRIs preoperatively. They found that joint depression greater than 6mm and widening of greater than 5mm was associated with a lateral meniscal injury over 80% of the time.

Gardner et all. (2006) that looked at MRIs for 103 consecutive patients with all types of tibial plateau fractures, only one patient had no soft tissue injuries. 94 (91%) patients had a lateral meniscal injury, 79 (77%) patients had cruciate ligament injury and 70 (68%) patients had a posterior lateral corner injury.

Figure A: shows a Schatzker type II fracture of a tibial plateau.

Incorrect Answers:
Answer 1: The above mentioned articles only found associations with lateral meniscal injuries when joint depression was at least 6mm.
Answer 2: No known association with soft tissue injuries after tibial plateau fractures.
Answer 4: No known association with soft tissue injuries after tibial plateau fractures.
Answer 5: Suggestive of an ACL injury, not an injury to the lateral meniscus.


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(OBQ12.261) A 23-year-old healthy male was involved in a motor vehicle collision and sustained the injury seen in Figure A. Physical examination after ORIF of the plateau fracture revealed a Grade 3 Lachman, varus laxity at both 0 and 30 degrees of knee flexion, and 15 degrees of external rotation asymmetry at 30 degrees of knee flexion. Which of the following structures (indicated with asterisk*) must be surgically repaired to restore stability to the knee? Review Topic

QID:4621
FIGURES:
1

Figure B

4%

(45/1219)

2

Figure C

50%

(615/1219)

3

Figure D

26%

(315/1219)

4

Figure E

4%

(44/1219)

5

Figure F

16%

(194/1219)

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PREFERRED RESPONSE 2

This patient sustained a high-energy injury to the left knee, including a tibial plateau fracture as well as both anterior cruciate ligament (ACL) and posterolateral corner (PLC) injuries as indicated on the physical examination findings. In addition to ORIF of the plateau fracture, the surgical plan should include ACL reconstruction as well as posterolateral corner (PLC) reconstruction, specifically with lateral meniscal repair and allograft reconstruction of the lateral collateral ligament (LCL,asterisk in Figure C) and popliteofibular ligaments.

The PLC consists of static (LCL, popliteus tendon, popliteofibular ligament, lateral capsule) and dynamic (biceps femoris, popliteus muscle, IT band, lateral head of the gastrocnemius) structures. Failure to identify a PLC injury associated with an ACL injury often leads to failure of ACL repair.

Stannard et al. reported on the clinical outcomes of 22 patients with PLC injuries (7 isolated) who underwent modified 2-tailed reconstruction of the popliteofibular ligament and LCL utilizing transtibial and transfibular bone tunnels. At an average 29.5 months post-operatively, the authors noted excellent results with restoration of range of motion and stability in both the isolated and multiligamentous injured groups.

Stannard et al. reported on a separate cohort of 56 patients with PLC injuries either undergoing direct repair or modified 2-tailed reconstruction. The authors noted significantly inferior results in the repair group (37% failures) compared to the reconstruction group (9%) failures, and concluded that reconstruction is the procedure of choice for the majority of patients who sustain high-energy PLC injuries.

Levy et al. reported on 28 patients with multiligament knee injuries undergoing either direct PLC repair with staged cruciate ligament reconstruction or delayed single-stage multiligament reconstruction. The authors noted a significantly higher rate of failure in the repair/staged group compared to the delayed reconstruction group, and deemed reconstruction to be a more reliable option than repair alone in the multiligamentously injured knee.

Figure A includes AP and lateral radiographs of the left tibia demonstrating a comminuted lateral tibia plateau fracture. Figure C demonstrates a gross dissection of the posterolateral corner (left knee), with the asterisk on the lateral collateral ligament (LCL)

Incorrect answers:
Answer 1: Figure B demonstrates a gross dissection of the posterolateral corner (left knee), with the asterisk on the IT band
Answer 3: Figure D demonstrates a gross dissection of the posterolateral corner (left knee), with the asterisk on the biceps femoris
Answer 4: Figure E demonstrates a gross dissection of the posterolateral corner (left knee), with the asterisk on the peroneal nerve
Answer 5: Figure F demonstrates a gross dissection of the posterolateral corner (left knee), with the asterisk on the lateral head of the gastrocnemius


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(OBQ11.71) A 38-year-old male suffers the injury shown in Figure A. During operative fixation, free osteoarticular fragments are encountered and reconstruction of these pieces is attempted. Postoperatively, which of the following will have the most beneficial effect on the healing potential of the surviving chondrocytes within these reconstructed articular segments? Review Topic

QID:3494
FIGURES:
1

Gentle compressive loading of the affected joint through early range of motion exercises

94%

(2138/2281)

2

Strict joint immobilzation for three weeks

2%

(53/2281)

3

Shear loading of the affected joint

1%

(22/2281)

4

Joint distraction with a spanning external fixator for three weeks

2%

(53/2281)

5

Glucosamine chondroitin sulfate supplementation

1%

(12/2281)

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PREFERRED RESPONSE 1

Figure A demonstrates a comminuted tibial plateau fracture with significant intra-articular involvement. Basic science evidence has demonstrated that post-operative gentle compressive loading may have a positive impact on articular cartilage healing; however, excessive shear loading may be detrimental.

Irrgang et al provide guidelines for rehabilitation following surgical management of articular cartilage lesions of the knee. They state that after articular cartilage repair, exercises to enhance muscle function must be done in a manner which minimizes shear loading of the joint surfaces in the area of the lesion. The authors also discuss the benefits of gentle compressive loading and motion of the joint, and its positive effects on chondrocyte nutrition. Furthermore, they recommend a period of protected weight bearing as often being necessary, and that this should be followed by progressive loading of the joint.

Illustration A is a diagram showing the different layers of joint cartilage.

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(OBQ11.212) Which of the following tibial plateau fractures would be most appropriately treated by buttress plating alone? Review Topic

QID:3635
FIGURES:
1

Figure A

0%

(3/1431)

2

Figure B

2%

(31/1431)

3

Figure C

0%

(7/1431)

4

Figure D

95%

(1361/1431)

5

Figure E

2%

(23/1431)

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PREFERRED RESPONSE 4

Buttress plating is best indicated for simple partial articular fractures, such as shown in Figure D. Buttress plates can support a metaphyseal fragment and neutralize the shear and compressive forces across the cancellous bone. The actual buttress effect is only on the side of the plate. Pre-shaped plates are frequently used as buttress plates, as they conform to local anatomy, however exact contouring of the plate is necessary. Buttress plating is not appropriate for articular depression fractures, such as those shown in Figures A, C, and E. Furthermore, buttress plating would provide inadequate fixation for a metadiaphyseal fracture, such as that shown in Figure B.

Illustration A shows an example of a buttress plate used to treat a tibial plateau fracture.

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(OBQ10.65) Vascular complications are most commonly seen with which of the following fractures about the knee? Review Topic

QID:3152
FIGURES:
1

Figure A

0%

(4/1771)

2

Figure B

71%

(1265/1771)

3

Figure C

2%

(31/1771)

4

Figure D

2%

(27/1771)

5

Figure E

25%

(438/1771)

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PREFERRED RESPONSE 2

Figure B represents a medial plateau fracture/dislocation pattern (Schatzker IV). This fracture typically requires more energy to occur than the corresponding lateral plateau injury, which is due to the more dense bone on the medial side. A fracture-dislocation of the knee must be suspected with these injuries, as the femur will sometimes follow the displaced medial tibial condyle. Along with a proper vascular exam, ankle brachial indices (ABI) must be immediately taken and if abnormal further vascular testing is warranted. Furthermore, these injuries which are a hybrid of a dislocation and a fracture will often have a benign appearance on radiographs, but a high rate of vascular complications.

Berkson et al present a review article and they stress the importance of safeguarding tissue vascularity and while emphasizing joint reduction and restoration of the mechanical axis of the limb.

Ottolenghi et al in their review article showed a vascular injury rate of 2% for tibial plateau fractures.

Stark et al in their review showed a very high incidence of acute compartment syndrome in Schatzker IV and VI injuries. In their series, 18% of Schatzker VI and 53% of Shatzker IV fractures developed compartment syndrome.


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(OBQ10.158) A 58-year-old man injures his knee in a high-speed motor vehicle collision. Radiographs and CT are shown in Figures A thru C. What is the most appropriate surgical plan based on the images provided? Review Topic

QID:3246
FIGURES:
1

ORIF with medial and lateral plating with grafting of metaphyseal defect

2%

(7/379)

2

ORIF with lateral plating with grafting of metaphyseal defect

91%

(346/379)

3

ORIF with medial plating

0%

(0/379)

4

ORIF with lateral plating

4%

(15/379)

5

Percutaneous articular fragment reduction and screw fixation

3%

(10/379)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The injury is a Schatzker type 2 with a significant split and depressed lateral tibial plateau fracture. The anteromedial cortex and medial plateau remain intact and connected to the tibial shaft making this a partial articular fracture (AO type B) and obviating the need for medial plate fixation. The best fixation strategy includes reduction of the articular surface with metaphyseal support with bone graft or bone substitute and a lateral plate for buttress support and subchondral screw support of the articular fragment.

Marsh et al revisited the OTA and AO fracture and dislocation classifications to unify coding of these fractures. Illustration A shows the Schatzker classification of tibial plateau fractures.

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(OBQ10.175) A 21-year-old male sustains the injury shown in Figures A through D. Which of the following is the most appropriate definitive treatment of this injury? Review Topic

QID:3268
FIGURES:
1

Spanning external fixation

0%

(5/1274)

2

Lateral locking plate

3%

(34/1274)

3

Lateral buttress plate

3%

(40/1274)

4

Medial buttress plate

93%

(1186/1274)

5

Medial bridging plate

1%

(7/1274)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

Figures A through D show a medial tibial plateau fx, best classified as a Schatzker IV. This injury is high-energy in nature and often requires a staged approach incorporating initial reduction and spanning external fixation. Appropriate treatment of this injury involves a medial buttress plate to hold the medial tibial condyle in position. This fracture pattern can be associated with a knee dislocation (see Illustration A). In a fracture-dislocation, the femur often displaces with this medial condylar fragment and is involved with a significant rate of neurovascular injury/compartment syndrome. Along with a proper vascular exam, ankle brachial indices (ABI) must be immediately taken and if abnormal, further vascular testing is warranted.

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(OBQ10.176) Lipohemarthrosis of the knee is most likely secondary to which of the following? Review Topic

QID:3269
1

Seronegative monoarticular arthritis

1%

(3/443)

2

Patellar tendon rupture

4%

(16/443)

3

Medial meniscus tear

2%

(8/443)

4

Medial patellofemoral ligament rupture

2%

(7/443)

5

Occult fracture

91%

(405/443)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Lipohemarthrosis is formed when an intraarticular fracture occurs and can be detected with arthrocentesis or imaging such as xray, MRI, ultrasound, or CT. It is most commonly seen with occult tibial plateau fractures but can be associated with any intra-articular fractures. Up to three layers are visible on an MRI (fat/serum/cellular parts of blood), and this separation may take up to 3 hours to appear after injury. An example of hemarthrosis as seen on CT is shown in Illustration A. The referenced article by Ahn et al is a review of MRI findings in intraarticular knee injuries. They note that detection of lipohemarthrosis on an MRI is very sensitive and specific for intraarticular fracture. The referenced article by Schick et al reports that MRI can be as sensitive as arthrocentesis in detecting lipohemarthrosis (occult fracture).

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(OBQ09.86) A 53-year-old man sustains the injury seen in figure A and later undergoes open reduction and internal fixation. What variable will most significantly increase his rate of degenerative arthritis in the long-term? Review Topic

QID:2899
FIGURES:
1

Postoperative joint stepoff

36%

(606/1682)

2

Alteration of limb mechanical axis

61%

(1032/1682)

3

Fracture type

2%

(28/1682)

4

Male sex

0%

(5/1682)

5

Age greater than 50

1%

(9/1682)

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PREFERRED RESPONSE 2

Maintenance of mechanical axis correlates most with a satisfactory clinical outcome when managing an intra-articular fracture of the proximal tibia.

According to the study of plateau fractures with up to 27 year follow-up by Rademakers et al, malalignment of the limb by greater than 5 degrees tripled the rate of degenerative osteoarthritis (27% v. 9%). Age at time of injury had no effect on outcome; 31% had joint space narrowing but 64% of those knees were well tolerated.

Weigel and Marsh's study looked at high energy plateau fractures treated with staged external fixation followed by internal fixation, and noted a low rate of severe arthrosis even with mild to moderate joint incongruity.

Stevens et al noted a worse outcome with increasing age at presentation with these injuries; fracture type had a small influence and adequacy of reduction had no significant influence on outcome.

Figure A is a coronal CT image showing a lateral tibial plateau fracture with significant joint depression.


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(OBQ09.118) A 56-year-old carpenter sustains the closed injury seen in Figures A, B, and C. After temporary spanning external fixation is performed and soft tissue conditions improve, what strategy provides the optimal fixation for this fracture pattern? Review Topic

QID:2931
FIGURES:
1

Anatomic lateral locking plate

2%

(31/1619)

2

Posteromedial and lateral plates

77%

(1252/1619)

3

Anatomic medial locking plate

7%

(115/1619)

4

Conversion of the spanning external fixator to a hinged external fixator

0%

(3/1619)

5

Posterior buttress plate

13%

(213/1619)

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PREFERRED RESPONSE 2

Figures A and B show a bicondylar tibial plateau fracture, with a typical appearing lateral fracture line and a posteromedial fracture line. The posteromedial sheared fracture piece is difficult, and/or sometimes impossible, to achieve appropriate stable fixation with a single lateral locking plate, as there will be limited screw purchase and fixation into the posteromedial fragment.

The referenced article by Georgiadis notes that a dual incision approach is safe and is associated with improved outcomes over their historical comparisons. They describe the dual incisions and approaches in length, and review risks/issues with each approach.

The other referenced study by Bhattacharyya et al notes that these fractures have a typical appearance of the posteromedial fracture piece and that articular reduction quality is correlated with short-term results. They recommended buttress-type fixation of these fracture pieces.


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(OBQ09.128) In treating a lateral split-depression type tibial plateau fracture, which of the following adjuncts has been shown to have the least articular surface subsidence when used to fill the bony void? Review Topic

QID:2941
1

Crushed cancellous allograft

11%

(114/1053)

2

Hydroxyapatite

4%

(44/1053)

3

Calcium phosphate cement

73%

(772/1053)

4

Autogenous iliac crest

10%

(102/1053)

5

Bisected diaphyseal humeral allograft

2%

(19/1053)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

In treating tibial plateau fractures, calcium phosphate has been shown to have the least amount of articular subsidence on follow-up examinations.

The referenced study by Russell et al noted a significantly increased rate of subsidence at 12 months with autograft as compared to calcium phosphate cement (in types I-VI).

The other referenced study by Lobenhoffer et al noted improved radiographic outcomes and earlier weightbearing with usage of calcium phosphate cement.


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Question COMMENTS (14)

(OBQ09.166) A large posteromedial tibial plateau fracture pattern, as seen with the bicondylar tibial plateau fracture shown in Figures A and B, is important to recognize because of which of the following factors? Review Topic

QID:2979
FIGURES:
1

Association with posteromedial corner of the knee injury

12%

(41/341)

2

Association with anterior tibial artery injury

11%

(37/341)

3

Possible need for dual plate fixation

74%

(253/341)

4

Possible need for single extensile anterior approach to the knee

1%

(2/341)

5

Increased risk of deep venous thrombosis

2%

(7/341)

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PREFERRED RESPONSE 3

Figures A and B show a bicondylar tibial plateau fracture with a large posteromedial fracture piece. This has clinical importance, as currently available plate/screw constructs often have poor fixation of this fracture segment, and this pattern often requires a second, posteromedial, approach and placement of a second plate/screw construct.

The referenced article by Barei et al notes a prevalence of posteromedial fracture pieces of nearly 33% of all bicondylar tibial plateau fractures. They also recommend supplementary or alternative fixation techniques when this pattern is recognized.

The referenced article by Higgins et al notes a 59% incidence of this fracture pattern (consisting of nearly 25% of the total joint surface) in bicondylar tibial plateau fractures, and recommends appropriate fixation to combat the vertical shear instability through a separate approach.

The last referenced study by Higgings et al notes a significantly increased rate of late fracture displacement in a biomechanical model with a single lateral locking plate as compared to a dual plate construct.


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(OBQ09.182) In an uninjured proximal tibia which statement best describes the shape and position of the medial tibial plateau relative to the lateral tibial plateau? Review Topic

QID:2995
1

More concave and more proximal

14%

(49/348)

2

More convex and more proximal

6%

(20/348)

3

More concave and more distal

75%

(261/348)

4

More convex and more distal

4%

(15/348)

5

Symetric in conture and more distal

0%

(1/348)

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PREFERRED RESPONSE 3

The medial tibial plateau is more concave and more distal relative to the lateral tibial plateau.

Watson et al report "the medial tibial plateau has a more concave shape and is larger in both length and width than the lateral tibial plateau, which has a slightly convex shape. The lateral tibial plateau lies proximal to the medial plateau. The convexity of the lateral plateau helps differentiate it from the medial plateau on a lateral radiograph of the proximal tibia."

Illustration A shows the relative concavity of the medial and lateral proximal tibia.

ILLUSTRATIONS:

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(OBQ09.245) Buttress plating is most appropriate in which of the following clinical situations? Review Topic

QID:3058
FIGURES:
1

Figure A

0%

(1/312)

2

Figure B

1%

(2/312)

3

Figure C

96%

(301/312)

4

Figure D

1%

(3/312)

5

Figure E

2%

(5/312)

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PREFERRED RESPONSE 3

There are 4 main types of plating techniques: 1. Bridging 2. Neutralization 3. Dynamic Compression 4. Buttress plating. Plates can utilize locking or non-locking screws.

Buttress plating is appropriate for a Shatzker Type I (see illustration C), as it can prevent collapse and axial deformity from shear or bending forces.

Karunakar et al showed that there was no significant difference between split depression tibial plateau fractures (Shatzker II) fixed with either a buttress plate with rafting screws versus a periarticular plate with built in rafting screw hole options, similar to the commonly used pre-contoured periarticular locking plate.


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(OBQ08.14) When elevating the joint surface in the injury pattern seen in Figure A, what material has the highest compressive strength when filling the metaphyseal void? Review Topic

QID:400
FIGURES:
1

Calcium phosphate

59%

(199/336)

2

Tricalcium phosphate

24%

(79/336)

3

Cancellous autograft

12%

(42/336)

4

Cancellous allograft

4%

(14/336)

5

rhBMP-7

0%

(1/336)

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PREFERRED RESPONSE 1

Figure A illustrates a depressed lateral tibial plateau. One of the key components of fixing a depressed articular segment is maintaining the reduction.

Trenholm et al reviewed an experimental study where a split depression (Schatzker II) fracture was created in a cadaveric model. The stiffness of the elevated fragment in cadavers using calcium phosphate cement versus cancellous bone graft as support showed no difference, but calcium phosphate cement was found to have greater compressive strength than cancellous bone alone.

The review article by Hak reviews the composition, advantages, and disadvantages of commerically available bone graft substitutes.

Incorrect answers:
2: Tricalcium phosphate is a bone graft substitute that is osteoconductive, but has less compressive strength.
3-4: Cancellous bone has less compressive strength than calcium phosphate.
5: rhBMP-7 is not used as a bone filling agent in this instance, as it is typically provided on a easily compressible collagen sponge.


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(OBQ08.51) Based on the following radiographs of tibial plateau fractures, which one is most likely to have a concomitant medial meniscus tear? Review Topic

QID:437
FIGURES:
1

A

1%

(22/1667)

2

B

2%

(39/1667)

3

C

1%

(10/1667)

4

D

88%

(1459/1667)

5

E

8%

(127/1667)

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PREFERRED RESPONSE 4

Figure D shows a medial tibia plateau fracture (Shatzker IV). Gardner et al reviewed a 103 consecutive tibial plateau fractures to evaluate for associated soft tissue injury prevelance. The authors found that patients had a medial meniscal tear when they had a medial fracture (Shatzker IV) 86% of the time. To review the Shatzker classification of tibial plateau fracture: I) lateral split II) lateral split depression III) lateral compression (no split) IV) medial fracture V) bicondylar VI) metaphyseal dissociation. The correct choice makes intuitive sense since one would expect concomitant soft tissue injury with the bony fracture. Lateral meniscus pathology is the most common overall soft tissue injury with tibial plateau fractures (91%).


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(OBQ08.70) A 40-year-old female sustains the injury seen in Figure A. What other associated soft-tissue knee injury is most commonly associated with this fracture? Review Topic

QID:456
FIGURES:
1

Anterior cruciate ligament midsubstance tear

5%

(53/1151)

2

Horizontal cleavage lateral meniscus tear

6%

(74/1151)

3

Peripheral lateral meniscus tear

79%

(905/1151)

4

Lateral collateral ligament and popliteofibular ligament tear

3%

(35/1151)

5

Lateral meniscus posterior root avulsion

7%

(80/1151)

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PREFERRED RESPONSE 3

Figure A shows a displaced Schatzker II (lateral split-depression) tibial plateau fracture. These injuries are commonly associated with peripheral meniscal tears.

According to the referenced article by Abdel-Hamid et al, the overall incidence of associated soft tissue injuries of the knee in tibial plateau fractures is 71%. The incidence of each injury in their study was: meniscal tears (57% - usually peripheral tears), ACL (25% - more common in more severe fractures), PCL (5%), LCL (3%), MCL (3%), peroneal nerve (1%). No vascular injury was seen in their collection of 98 patients.


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(OBQ06.245) A 35-year-old male sustains a closed Schatzker VI tibial plateau fracture. Two weeks following external fixation, examination reveals intact sensation, palpable pulses and no soft tissue compromise. An axial CT image is shown in Figure A. What is the optimal surgical plan? Review Topic

QID:256
FIGURES:
1

Medial and lateral plate fixation through two approaches

81%

(279/345)

2

Medial and lateral plate fixation through a single anterior approach

2%

(6/345)

3

Lateral locking plate fixation

1%

(5/345)

4

Continued external fixation until union

6%

(22/345)

5

Multiplanar transarticular external fixator

9%

(32/345)

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PREFERRED RESPONSE 1

The Figure shows a bicondylar tibial plateau fracture. The goals that need to be met when treating tibial plateau fractures are the following: restoration of mechanical axis alignment (most important aspect), restoration of condylar width, articular reduction, and restoration of knee stability. Since the soft tissue envelope is favorable, open reduction internal fixation with dual incisions and dual plates will provide the best probablity of achieving those goals.

Gosling et al did a biomechanical evaluation in cadavers comparing lateral locked plating with a combined medial and lateral plate and found no difference in resistance to vertical subsidence even with loads exceeding the average body weight. However, this was a cadaveric study with no mention and capability of analyzing articular reduction. Lateral locked plating only allows for indirect reduction of the medial plateau.

Barei et al in a retrospective review found that comminuted bicondylar tibial plateau fractures can be successfully treated with open reduction and medial and lateral plate fixation using 2 incisions, and postulate that the use of 2 incisions may contribute to a lower wound complication rate. A two incision approach allows not necessarily for a stronger construct as some studies are controversial, but for a more accurate reduction and restoration of alignment.


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(OBQ05.14) A 35-year-old male sustains the fracture seen in Figures A and B. Which of the following substances has been shown to result in the least radiographic subsidence when combined with open reduction and internal fixation? Review Topic

QID:51
FIGURES:
1

Cancellous allograft bone chips

10%

(20/202)

2

Autograft iliac crest

18%

(37/202)

3

Femoral intramedullary reamings

6%

(12/202)

4

Calcium phosphate cement

60%

(121/202)

5

Calcium sulfate cement

6%

(12/202)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

Figures A and B show a plateau fracture with a lateral split and depression of the articular surface. In treating tibial plateau fractures, calcium phosphate has been shown to have the least amount of articular subsidence on follow-up examinations due to its high compressive strength.

The study by Lobenhoffer et al noted improved radiographic outcomes and earlier weightbearing with usage of calcium phosphate cement. Welch and Zhang reproduced tibial plateau fractures in goats and compared cancellous autograft to calcium phosphate cement augmentation. At 24 hours, four of five specimens treated with autograft had subsidence of the fragment. Only two specimens from limbs treated with cement showed minimal subsidence; the remaining were congruent.

Yetkinler’s study compared cement to no cement treatment in a model of depressed plateau fractures. Calcium phosphate cement of high compressive strength provided equivalent or better stability than conventional open reduction
and internal fixation with either auto/allograft bone which had both a lower compressive strength and reduced mechanical stability.


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(OBQ05.113) A 69-year-old female sustains the injuries seen in Figures A and B. This injury is best classified as which of the following? Review Topic

QID:999
FIGURES:
1

Schatzker type I tibial plateau fracture

3%

(25/811)

2

Schatzker type III tibial plateau fracture

94%

(764/811)

3

Schatzker type IV tibial plateau fracture

1%

(12/811)

4

Schatzker type V tibial plateau fracture

1%

(5/811)

5

Schatzker type VI tibial plateau fracture

1%

(5/811)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The radiographs and CT scan images show a depressed lateral tibial plateau fracture, which is correctly classified as a Schatzker III tibial plateau fracture. This fracture typically occurs as the result of the femoral condyle directly impacting the articular surface in older patients with osteopenia.

The referenced article by Bennett et al reviews the associated soft tissue injury with tibial plateau fractures. They found a 56% frequency of associated soft tissue injuries overall, with MCL injured in 20%, the LCL in 3% , the menisci in 20%, the peroneal nerve in 3%, and the anterior cruciate ligaments in 10%. Schatzker type IV and type II fracture patterns were associated with the highest frequency of soft tissue injuries.


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(OBQ05.118) A 28-year-old man is thrown from his motorcycle and sustains the closed injury seen in Figure A. The limb remains neurovascularly intact. What is the most appropriate initial treatment of this injury? Review Topic

QID:1004
FIGURES:
1

Bulky compressive splint

2%

(33/1582)

2

Open reduction and internal fixation

6%

(102/1582)

3

Closed intramedullary nailing

2%

(32/1582)

4

Spanning external fixation

86%

(1360/1582)

5

Hinged spanning external fixation

3%

(54/1582)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

Figure A shows a significantly displaced, high-energy proximal tibia fracture with intra-articular extension. Appropriate initial treatment includes application of a spanning external fixation device with fasciotomy if needed.

The referenced article by Egol et al noted a low rate of wound infection, improved access to soft tissues, prevention of further articular damage, and osseous stabilization. They reported the downside being residual knee stiffness.


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(OBQ04.88) A 27-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A through E. The articular surface is depressed 2 mm while there is 3 mm of condylar widening. Valgus instability of the knee is noted. Which of the following is most important to long-term success in surgical treatment of this case? Review Topic

QID:1193
FIGURES:
1

Restoration of joint stability

70%

(570/809)

2

Repair of associated meniscal pathology

3%

(26/809)

3

Surgical fixation within 48 hours of injury

0%

(1/809)

4

Correction of the articular depression

20%

(162/809)

5

Tibial condylar diastasis < 3 mm

6%

(50/809)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The clinical presentation and imaging studies are consistent with a tibial plateau fracture. Restoration of joint stability has been shown to be the strongest predictor of long term outcomes.

Honkonen reviewed 131 tibial condyle fractures and determined that articular stepoff <3mm and tibial widening <5mm did not negatively effect outcomes. In contrast, 70% of knees with moderate to severe malalignment went on to functionally unacceptable outcomes. They suggested operative fixation for all medial uni and bicondylar fractures, any lateral fractures with >5 degrees of valgus tilt, >3mm of articular depression, >5mm of condylar widening, or >5 degrees of valgus malalignment.

In the Marsh et al JAAOS symposium review, the authors noted that fractures with up to 10mm of articular depression and joint stability obtained acceptable functional outcomes. They also cited a 20 year follow-up which indicated that articular step-off alone was not a predictor of poor long-term results. More importantly, when instability is present with other factors, including step-off and central depression, poor results followed.

Illustrations A and B show the intraoperative films. Illustration C reviews the Schatzker classification system.

ILLUSTRATIONS:

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