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Tibial Plateau Fractures

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Topic updated on 06/08/14 7:56pm
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
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 Split-depressed fracture
 
Type III 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
Tpe 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
  • 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
    • pros
      • allows soft tissue swelling to decrease before definitive fixation
  • 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
      • daily pin 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 semimembranosus 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
      • 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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Qbank (27 Questions)

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

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Spanning knee external fixation
2. Lateral plateau locking plate
3. Posteromedial locking plate
4. Lateral plateau percutaneous lag screws and posteromedial plate
5. Lateral plateau and posteromedial plating

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

1. Joint depression of 3mm
2. Ipsilateral femoral shaft fracture
3. Joint widening of 6mm
4. Ipsilateral tibial shaft fracture
5. Displaced tibial spine fracture

PREFERRED RESPONSE ▶
TAG
(OBQ12.261) A 23-year-old healthy male was involved in a motor vehicle collision and sustained the injury seen in Figure A. He was treated initially with external-fixator placement. Physical examination approximately 3 weeks later 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. In addition to ORIF of the fracture, which of the following structures (indicated with asterisk*) must be surgically repaired to restore stability to the knee? Topic Review Topic
FIGURES: A   B   C   D   E   F

1. Figure B
2. Figure C
3. Figure D
4. Figure E
5. Figure F

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Gentle compressive loading of the affected joint through early range of motion exercises
2. Strict joint immobilzation for three weeks
3. Shear loading of the affected joint
4. Joint distraction with a spanning external fixator for three weeks
5. Glucosamine chondroitin sulfate supplementation

PREFERRED RESPONSE ▶
TAG
(OBQ11.212) Which of the following tibial plateau fractures would be most appropriately treated by buttress plating alone? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(OBQ10.65) Vascular complications are most commonly seen with which of the following fractures about the knee? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B   C      

1. ORIF with medial and lateral plating with bone grafting of metaphyseal defect
2. ORIF with lateral plating with bone grafting of metaphyseal defect
3. ORIF with medial plating
4. ORIF with lateral plating
5. Percutaneous articular fragment reduction and screw fixation

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B   C   D    

1. Spanning external fixation
2. Lateral locking plate
3. Lateral buttress plate
4. Medial buttress plate
5. Medial bridging plate

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

1. Seronegative monoarticular arthritis
2. Patellar tendon rupture
3. Medial meniscus tear
4. Medial patellofemoral ligament rupture
5. Occult fracture

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Postoperative joint stepoff
2. Alteration of limb mechanical axis
3. Fracture type
4. Male sex
5. Age greater than 50

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B   C      

1. Anatomic lateral locking plate
2. Posteromedial and lateral plates
3. Anatomic medial locking plate
4. Conversion of the spanning external fixator to a hinged external fixator
5. Posterior buttress plate

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Crushed cancellous allograft
2. Hydroxyapatite
3. Calcium phosphate cement
4. Autogenous iliac crest
5. Fibular allograft

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Association with posteromedial corner of the knee injury
2. Association with anterior tibial artery injury
3. Possible need for dual plate fixation
4. Possible need for single extensile anterior approach to the knee
5. Increased risk of deep venous thrombosis

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. More concave and more proximal
2. More convex and more proximal
3. More concave and more distal
4. More convex and more distal
5. Symetric in conture and more distal

PREFERRED RESPONSE ▶
TAG
(OBQ09.245) Buttress plating is most appropriate in which of the following clinical situations? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Calcium phosphate
2. Tricalcium phosphate
3. Cancellous autograft
4. Cancellous allograft
5. rhBMP-7

PREFERRED RESPONSE ▶
TAG
(OBQ08.51) Based on the following radiographs of tibial plateau fractures, which one is most likely to have a concomitant medial meniscus tear? Topic Review Topic
FIGURES: A   B   C   D   E  

1. A
2. B
3. C
4. D
5. E

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Anterior cruciate ligament midsubstance tear
2. Horizontal cleavage lateral meniscus tear
3. Peripheral lateral meniscus tear
4. Lateral collateral ligament and popliteofibular ligament tear
5. Lateral meniscus posterior root avulsion

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Medial and lateral plate fixation through two approaches
2. Medial and lateral plate fixation through a single anterior approach
3. Lateral locking plate fixation
4. Continued external fixation until union
5. Multiplanar transarticular external fixator

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Cancellous allograft bone chips
2. Autograft iliac crest
3. Femoral intramedullary reamings
4. Calcium phosphate cement
5. Calcium sulfate cement

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Schatzker type I tibial plateau fracture
2. Schatzker type III tibial plateau fracture
3. Schatzker type IV tibial plateau fracture
4. Schatzker type V tibial plateau fracture
5. Schatzker type VI tibial plateau fracture

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Bulky compressive splint
2. Open reduction and internal fixation
3. Closed intramedullary nailing
4. Spanning external fixation
5. Hinged spanning external fixation

PREFERRED RESPONSE ▶
TAG
(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 and 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? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Restoration of joint stability
2. Repair of associated meniscal pathology
3. Surgical fixation within 48 hours of injury
4. Correction of the articular depression
5. Tibial condylar diastasis < 3 mm

PREFERRED RESPONSE ▶
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