Review Question - QID 5420

This patient has a medial tibial plateau fracture. Medial buttress plating (MBP) is indicated.

Medial tibial plateau fractures (Schatzker IV, Hohl and Moore II) may represent fracture-dislocations of the knee. Neurovascular injuries must be excluded. In these instances, the medial fragment represents the stable fragment, and the rest of the tibia is the fractured fragment, with the entire leg acting as the lever arm.

Berkson et al. reviewed high-energy tibial plateau fractures. Medial fractures may be treated with a medial plate or external fixation. Open reduction may be necessary because of fracture line obliquity and the propensity of the medial plateau to shorten and rotate in the sagittal plane. Meniscal injuries should be repaired and avulsed cruciates fixed early. Collateral ligaments should be reconstructed after obtaining bone healing and range of motion.

Ratcliff et al. compared the stability of lateral locked plates and medial buttress plates in a cadaver model. They found that the medial buttress plate had greater fixation strength/failure force (4136N) compared with the lateral locking plate (2895N), although maximum cyclic displacement and residual displacement results were not different. They concluded that for vertically orientated medial tibial plateau fractures, medial buttress plates were more stable.

Figure A is an AP radiograph of the right knee with a medial tibial plateau fracture (Schatzker IV) without significant displacement, shortening, or angulation. Figure B is an AP coronal CT scan of the right knee with an isolated medial tibial plateau fracture without extension into the lateral condyle. Illustration A shows a medial tibial plateau fracture fixed with a medial buttress plate (cadaveric model with fibula removed). Illustration B shows the Hohl and Moore Type II fracture involving the entire condyle.

Incorrect Answers:
Answer 1: Lateral locked plating is biomechanically inferior to medial buttress plating for medial tibial plateau fractures (see reference above).
Answer 2: Medial bridge plating is appropriate for segmental or comminuted fractures
Answer 4: Lag screw fixation alone is contraindicated because of the long lever arm of the leg may lead to implant failure.
Answer 5: Temporary spanning external fixation may be appropriate for extensive comminution or soft tissue injury/swelling. Definitive external fixation (non-joint spanning) with olive wires, monolateral half-pins or both (hybrid) are possible options but less preferred as wires <14mm from the articular surface risk joint capsule penetration and septic arthritis.