Review Question - QID 217339

This patient has a bicolumnar tibial plateau fracture with a large posteromedial fragment. This fragment will be best addressed through the posteromedial approach. The interval for this approach is between the pes anserine tendons and the medial head of the gastrocnemius (Answer 5).

Tibial plateau fractures are periarticular injuries of the proximal tibia. in younger patients, they typically occur secondary to high-energy trauma, while in older patients they occur secondary to low-energy falls. These injuries are often associated with soft-tissue injury, and injuries to the lateral meniscus, medial meniscus and/or anterior cruciate ligament are common. While classically described and classified based on the involvement of the medial and lateral plateau, or some combination thereof, recent literature has postulated that these injuries are best rationalized based on a three-column system (Illustration A). Supporters of this theory purport that a column-based classification helps to drive appropriate approach selection, and can improve outcomes for patients with these devastating injuries. Large fragment involvement of the posterior column is best approached through a posteromedial approach, which lies in the interval between the medial head of the gastrocnemius and the pes anserine tendons. Structures at risk during this approach include the saphenous nerve and vein and the posterior tibial recurrent artery.

Zhu et al. provide the first published description of the three-column classification system for tibial plateau fractures. Their study includes 278 consecutive patients at a single hospital. The authors performed measurements of both inter- and intraobserver reliability between four observers. The authors note that while 14 cases did not fit the classic Schatzker classification system, all 278 cases could be classified by the three-column system. Both inter- and intraobserver reliability were higher for the three-column system when compared to the Schatzker system. They conclude that the three-column system is a useful supplement to the Schatzker classification system, and has the potential to aid in surgical planning and decision making.

Zhang et al. reported on the efficacy of combined lateral peripatellar and posteromedial approaches in patients with large posteromedial fragments. Their study included 18 patients with large posteromedial fracture fragments. According to the Knee Society Score (KSS) criteria, 14 patients had excellent clinical outcomes and 4 had good. Overall, the authors conclude that a two-approach technique is an effective means by which to address tibial plateau fractures with a large posteromedial fragment.

Foster and co-authors provide a supplement article reviewing the nuances of the prone posteromedial approach. The authors state that this approach can be used for posteromedial, posterolateral and posterior column shear-type injuries. They note that care must be made to avoid injuries to the saphenous nerve and vein and that excessive distal and lateral dissection can result in injury to the posterior tibial recurrent artery.

Figure A demonstrates a lateral radiograph of the tibial plateau demonstrating a large posteromedial fragment. Illustration A demonstrates the three-column classification system for tibial plateau fractures.

Incorrect Answers
Answer 1: This is the interval for the posterolateral approach to the tibial plateau.
Answer 2: This is not a classically described surgical interval.
Answer 3: This is the interval for the posterolateral approach to the ankle.
Answer 4: This is the interval for the anterolateral approach to the tibial plateau.