Summary Tibial Plateau fractures are periarticular injuries of the proximal tibia frequently associated with soft tissue injury. Diagnosis is made with knee radiographs but frequently require CT scan for surgical planning. Treatment is often ORIF in the acute setting versus delayed fixation after soft tissue swelling subsides. Epidemiology Incidence 1-2% of all fractures 10.3 per 100,000 people annually Demographics mean age 52 bimodal distribution males in 40s (high-energy trauma) females in 70s (low energy falls) Location lateral plateau 70-80% bicondylar 10-30% medial plateau 10-20% Etiology Mechanism Vector of applied load, amount of energy, and quality of bone determine type of fracture valgus load login to view 1 more bullet varus load login to view 1 more bullet axial load login to view 1 more bullet combination login to view 4 more bullets low energy login to view 1 more bullet Associated conditions meniscal tears lateral meniscal tear login to view 4 more bullets medial meniscal tear login to view 1 more bullet ACL injuries more common in type IV and VI fractures (25%) compartment syndrome associated soft tissue injuries have little bearing on final outcomes neurovascular injury commonly associated with Schatzker IV fracture-dislocations login to view 1 more bullet common peroneal nerve is most common nerve injury higher rates with hyperextension bicondylar injuries Anatomy Osteology lateral tibial plateau convex in shape proximal to the medial plateau less dense bone medial tibial plateau concave in shape distal to the lateral tibial plateau alignment of proximal tibia posterior tibial slope login to view 1 more bullet varus slope login to view 1 more bullet Ligaments ACL inserts anteriorly between tibial spines primary restraint against anterior tibial translation secondary stabilizer of tibial rotation PCL inserts on posterior tibial sulcus below articular surface primary restraint to posterior tibial translation MCL two components login to view 6 more bullets LCL inserts on anterolateral aspect of fibular head primary restraint to varus stress at 30 deg Meniscus lateral meniscus covers larger portion of articular surface more mobile login to view 1 more bullet medial meniscus less mobile due to coronary ligaments Muscles 4 compartments in lower leg anterior compartment lateral compartment superficial posterior deep posterior Tendons patellar tendon inserts anteriorly on tibial tubercle iliotibial band inserts on anterolateral aspect of proximal tibia at Gerdy's tubercle hamstring tendons pes anserine insert on anteromedial aspect of proximal tibia Neurovascular structures popliteal artery runs just posterior to knee capsule and bifurcates anterior tibial artery posterior tibial artery tibial nerve courses posteriorly along with popliteal artery sensory: plantar aspect of foot motor: innervates posterior compartments which control ankle plantarflexion and inversion of foot common peroneal nerve course around fibular neck two branches login to view 6 more bullets Biomechanics medial tibial condyle bears 60% of load through knee lateral tibial condyle bears 40% of load through knee Kinematics flexion-extension 0-140 degrees functional ROM for walking 0-70 degrees posterior femoral rollback screw-home mechanism login to view 2 more bullets net effect login to view 2 more bullets Classification Schatzker classification Schatzker Classification Type I Lateral split fracture young patient with strong subchondral bone Type II Lateral Split-depressed fracture most common Type III Lateral Pure depression fracture uncommon, elderly osteoporotic Type IV Medial plateau fracture associated fx-dislocation high rate of NV and ligamentous injuries Type V Bicondylar fracture tibial spines remain continuous with shaft Type VI Metaphyseal-diaphyseal disassociation significant soft-tissue injury Hohl and Moore Classification Useful for true fracture-dislocations fracture patterns that do not fit into the Schatzker classification (10% of all tibial plateau fractures) fractures associated with knee instability 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 3-column concept tibial plateau divided into 3 columns medal column lateral column posterior column utility includes posterior plateau fractures that are not considered in Schatzker classification helps determine fixation strategy Presentation History mechanism of injury high-energy vs low-energy unable to bear weight after injury baseline functional status comorbidities Physical exam inspection look circumferentially to rule-out an open injury assess soft-tissues for timing of operative intervention palpation evaluate for compartment syndrome varus/valgus stress testing any laxity >10 degrees indicates instability often difficult to perform or deferred in acute setting given pain stability assessed in full extension neurovascular exam perform ankle-brachial index if any asymmetry in pulses login to view 1 more bullet assess tibial and common peroneal nerve function Imaging Radiographs recommended views AP lateral oblique login to view 1 more bullet optional views plateau view login to view 1 more bullet findings on AP login to view 4 more bullets on lateral login to view 2 more bullets CT scan indication negative radiographs with high index of suspicion for tibial plateau fracture preoperative planning login to view 1 more bullet findings articular depression degree of comminution fracture plane and location login to view 1 more bullet lipohemarthrosis indicates an occult fracture certain fracture patterns are suggestive of associated soft tissue injury MRI indications not well established identify meniscal and ligamentous pathology occult fractures DIFFERENTIAL Distal femur fracture Knee dislocation Patella instability Patella fracture Patella tendon rupture Quadriceps tendon rupture ACL tear Meniscus tear Treatment Nonoperative closed reduction / immobilization indications login to view 4 more bullets modalities login to view 3 more bullets Operative ORIF indications login to view 5 more bullets timing login to view 7 more bullets outcomes login to view 12 more bullets external fixation +/- limited fixation indications login to view 2 more bullets technique login to view 1 more bullet outcomes login to view 1 more bullet arthroplasty indications login to view 1 more bullet outcomes login to view 2 more bullets Techniques Closed reduction & Immobilization technique NWB or PWB in a hinged-knee brace for 8-12 weeks early passive ROM is important to maintain motion Provisional External Fixation technique place pins outside area of planned definitive fixation login to view 1 more bullet axial traction applied to fixator login to view 2 more bullets advantages allows soft tissue swelling to decrease before definitive fixation decreases rate of infection and wound healing complications restores length and alignment which helps to better characterize fracture on preop CT findings transient increase in leg compartment pressures during external fixator placement login to view 1 more bullet External Fixation with Limited Internal Fixation technique reduce articular surface either percutaneously or through small incisions stabilize reduction with percutaneous lag screws or wires login to view 1 more bullet pros minimizes soft tissue insult cons pin site complications arthrofibrosis login to view 1 more bullet high malunion rates Open reduction internal fixation (ORIF) goals restore alignment login to view 3 more bullets normal condylar width congruent articular surface stable knee minimize additional soft tissue trauma approach anterolateral approach (most common) login to view 4 more bullets posteromedial approach login to view 7 more bullets posterolateral approach login to view 3 more bullets fibular neck osteotomy login to view 1 more bullet posterior login to view 1 more bullet midline incision (if planning TKA in future) login to view 1 more bullet dual surgical incisions with dual plate fixation login to view 2 more bullets reduction assess reduction login to view 3 more bullets depressed fragments login to view 2 more bullets fill metaphyseal void login to view 10 more bullets internal fixation absolute stability constructs should be used to maintain the joint reduction screws login to view 8 more bullets plate fixation login to view 8 more bullets postoperative hinged knee brace with early passive ROM login to view 1 more bullet NWB or PWB for 8 to 12 weeks Complications Post-traumatic arthritis incidence 25-35% login to view 1 more bullet risk factors for arthritis meniscectomy malalignment > 5 deg instability risk factors for future TKA age bicondylar fracture increasing comorbidities Compartment syndrome incidence 7-20% risk factors Schatzker type IV high-energy mechanism associated fibula fracture fracture length associated plateau-shaft injury young age treatment emergent fasciotomy Infection incidence 2-11% risk factors poor surgical timing based on swelling open fractures longer operative time reduced deep infection rates with intraoperative vancomycin powder application treatment irrigation and debridement + IV abx removal of hardware if loose or grossly infected login to view 1 more bullet retain hardware if fracture still healing and implant still providing stability Nonunion/malunion incidence 2-4% login to view 1 more bullet risk factors Schatzker type VI (metaphyseal-diaphyseal junction) comminution unstable fixation treatment revision osteosynthesis augmented with bone graft Knee stiffness incidence 10-25% generally all bicondylar tibial plateau fractures have similar long term ROM risk factors increasing age higher BMI severity of fracture prolonged immobilization involvement of tibial eminence polytrauma treatment arthroscopic lysis of adhesions with MUA login to view 1 more bullet Loss of reduction incidence 5-30% risk factors inadequate fixation severity of fracture osteoporosis treatment revision ORIF to address inadequate fixation login to view 1 more bullet Deep vein thromobosis incidence nonoperative 9% operative 6% Prognosis Mortality rate 5% at 1 year Return to work 70-90% at 1 year residual dysfunction or reduced work load is common Mean ROM 10-145 degrees at 1 year