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Updated: Feb 20 2024

Tibial Plateau Fractures

Images
https://upload.orthobullets.com/topic/1044/images/tibial plateau fx key image.jpg
https://upload.orthobullets.com/topic/1044/images/schatzker 2.jpg
https://upload.orthobullets.com/topic/1044/images/shatzker iv radiograph.jpg
https://upload.orthobullets.com/topic/1044/images/plateau 5.jpg
https://upload.orthobullets.com/topic/1044/images/tibial plateau.jpg
  • 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 
          • lateral plateau
        • varus load
          • medial plateau
        • axial load
          • bicondylar 
        • combination
          • fracture dislocation 
          • high energy
          • usually medial-sided plateau fractures 
          • frequently associated with soft tissue injuries
        • low energy
          • usually lateral plateau fractures
    • Associated conditions
      • meniscal tears
        • lateral meniscal tear
          • more common than medial
          • associated with Schatzker II fracture pattern
          • associated with >10mm articular depression
          • associated with >6mm condylar widening
        • medial meniscal tear
          • most commonly associated with Schatzker IV fractures
      • 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
          • perform ABIs in suspected fracture/dislocation 
        • common peroneal nerve is most common nerve injury 
  • 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 
          • 6-10 deg
        • varus slope 
          • 3 deg relative to mechanical axis of tibia
    • 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
          • superficial MCL
            • broad insertion on proximal tibia deep to pes anserinus
            • primary stabilizer of valgus stress
          • deep MCL
            • attaches to medial meniscus 
            • secondary stabilizer to valgus stress
      • 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
          • easier to assess articular surface laterally through submeniscal arthrotomy due to mobility of meniscus
      • 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
          • superficial peroneal nerve
            • sensory: dorsum of foot (except first dorsal webspace) 
            • motor: innervates lateral compartment which controls ankle eversion 
          • deep peroneal nerve
            • sensory: first dorsal webspace of foot
            • motor: innervates anterior compartment which controls ankle dorsiflexion
    • 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
          • medial tibial plateau is concave creating a pivot point
          • lateral plateau is convex allowing for rollback of femur during flexion
        • net effect
          • influences amount of terminal knee flexion
          • tibia externally rotates with knee extension 
  • Classification
    • Schatzker classification
      • Schatzker Classification
      • Type I
      • Lateral split fracture
      • young patient with strong subchondral bone
      • Lateral Split-depressed fracture
      • most common 
      • Type III
      • Lateral Pure depression fracture
      • uncommon, elderly osteoporotic 
      • 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
          • ABI <0.9 proceed with arteriogram 
        • assess tibial and common peroneal nerve function
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
        • oblique
          • oblique is helpful to determine amount of depression
      • optional views
        • plateau view
          • 10 degree caudal tilt to match posterior tibial slope
      • findings
        • on AP
          • depressed articular surface
          • sclerotic band of bone indicating depression 
          • abnormal joint alignment
          • fracture plane involving medial/lateral plateau
        • on lateral
          • posteromedial fracture lines must be recognized
          • abnormal tibial slope
    • CT scan
      • indication
        • negative radiographs with high index of suspicion for tibial plateau fracture
        • preoperative planning 
          • obtain after ex-fix if definitive fixation delayed if soft-tissues are not amenable for surgery
      • findings
        • articular depression
        • degree of comminution 
        • fracture plane and location 
          • posterior coronal split fracture best appreciated on axial and sagittal views 
        • lipohemarthrosis indicates an occult fracture
    • 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
          • minimally displaced split or depressed fractures
          • low energy fracture stable to varus/valgus alignment
          • nonambulatory patients
          • significant comorbidites that preclude surgical intervention
        • modalities
          • patella-tendon-bearing (PTB) cast
          • knee immobilizer
          • hinged knee brace
    • Operative
        • indications
          • articular depression > 5-10 mm
          • condylar widening > 5mm
          • varus/valgus instability >10 deg
          • medial plateau fractures
          • bicondylar fractures
        • timing
          • acute ORIF
            • lower-energy fractures with mild swelling 
            • temporizing knee-spanning external fixation w/ delayed ORIF
              • indications
                • significant soft tissue injury/swelling
                • polytrauma
        • outcomes
          • restoration of joint stability is strongest predictor of long-term outcomes
          • postoperative infection after ORIF associated with
            • male gender
            • smoking
            • pulmonary disease
            • bicondylar fracture patterns
            • intraoperative time over 3 hours
          • timing of definitive fixation (before, during or after) relative to fasciotomy closure does not increase the risk of infection
          • worse results with
            • ligamentous instability
            • meniscectomy
            • alteration of limb mechanical axis > 5 degrees
      • external fixation +/- limited fixation
        • indications
          • severe open fracture with marked contamination
          • highly comminuted fractures where internal fixation not possible
        • technique
          • limited fixation of the articular fragment may be internal or percutaneous
        • outcomes
          • higher malunion rates
      • arthroplasty
        • indications
          • consider in patients >65-years-old with osteoporotic bone
        • outcomes
          • earlier time to weight bearing
          • improved outcomes for primary TKA compared to TKA for failed ORIF
  • 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
          • two 5-mm half-pins in femur and two in tibia shaft
        • axial traction applied to fixator
          • indirect reduction of fracture through ligamentotaxis 
          • fixator is locked in slight flexion to avoid tensioning posterior NV structures
      • 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
          • not been shown to increase risk of compartment syndrome
    • External Fixation with Limited Internal Fixation
      • technique
        • reduce articular surface either percutaneously or through small incisions
        • stabilize reduction with percutaneous lag screws or wires
          • must keep wires >14mm from joint to avoid intracapsular pin placement 
      • pros
        • minimizes soft tissue insult
      • cons
        • pin site complications
        • arthrofibrosis 
          • incidence as high as 15% after temporizing external fixator 
        • high malunion rates
    • Open reduction internal fixation (ORIF) 
      • goals
        • restore alignment
          • coronal
          • sagittal
          • tibial slope
        • normal condylar width
        • congruent articular surface
        • stable knee
        • minimize additional soft tissue trauma
      • approach 
        • anterolateral approach (most common)
          • supine
          • lazy S or hockey stick incision centered over Gerdy's tubercle
          • elevate anterior compartment musculature and IT band
          • submeniscal arthrotomy to assess articular surface and meniscus tear
        • posteromedial approach
          • supine with leg in figure-4 or prone
          • interval between pes anserinus and medial head of gastrocnemius
          • can be extensile and access posterolateral column
            • release medial head of gastrocnemius off femur
            • elevate soleus and popliteus 
          • articular surface not routinely visualized directly
            • fluoroscopically or arthroscopically 
        • posterolateral approach
          • prone or lateral
          • biceps and peroneal nerve retracted lateral
          • lateral gastroc and soleus retracted medial 
        • fibular neck osteotomy
          • posterolateral access infrequently used due higher risk of NV complication
        • posterior
          • can be used for posterior shearing fractures
        • midline incision (if planning TKA in future)
          • can lead to significant soft tissue stripping and should be avoided
        • dual surgical incisions with dual plate fixation
          • indications
            • bicondylar tibial plateau fractures
      • reduction
        • assess reduction 
          • submeniscal arthrotomy
          • fluoroscopically 
          • arthroscopically 
        • depressed fragments
          • open fracture split and elevate ("open the book")
          • create cortical window and elevated with bone tamps
        • fill metaphyseal void
          • three main options
            • autograft (ICBG - rare)
            • allograft (cancellous chips) 
            • bone graft substitutes
              • calcium phosphate cement
                • high compressive strength for filling metaphyseal void
                  • less subsidence than ICBG
                • osteoconductive  
                • biodegradable 
                • highly porous 
      • internal fixation
        • absolute stability constructs should be used to maintain the joint reduction
        • screws
          • can be used in isolation but often used in conjunction with plate fixation 
            • isolated depression 
            • simple split fracture 
          • options
            • raft screws
              • placed in subchondral bone parallel to joint surface to support elevated articular fragments
            • lag screws
              • placed perpendicular to plane of split fractures
        • plate fixation
          • conventional non-locking plates
            • buttress plates best indicated for partial articular fractures 
              • posteromedial fractures
              • simple split 
          • peri-articular locking plates
            • fixed angle mitigates risk of varus collapse
              • comminuted fractures
              • osteoporotic bone
      • 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
      • incidence
        • 25-35%
          • 3-7% undergo TKA at 10+ years
      • 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
      • treatment
        • emergent fasciotomy
    • Infection
      • incidence 
        • 2-11%
      • risk factors
        • poor surgical timing based on swelling
        • open fractures
        • longer operative time
      • treatment
        • irrigation and debridement + IV abx
        • removal of hardware if loose or grossly infected
          • ex-fix and staged revision ORIF 
        • retain hardware if fracture still healing and implant still providing stability
    • Nonunion/malunion
      • incidence 
        • 2-4%
          • uncommon due to rich blood supply of cancellous bone
      • risk factors 
        • Schatzker type VI (metaphyseal-diaphyseal junction)
        • comminution
        • unstable fixation
      • treatment
        • revision osteosynthesis augmented with bone graft 
    • Knee stiffness 
      • incidence
        • 10-25%
      • risk factors
        • increasing age
        • higher BMI
        • severity of fracture
        • prolonged immobilization
        • involvement of tibial eminence
        • polytrauma
      • treatment
        • arthroscopic lysis of adhesions with MUA
          • indicated if unable to achieve 90 deg of flexion within 4 weeks
    • Loss of reduction
      • incidence
        • 5-30%
      • risk factors
        • inadequate fixation
        • severity of fracture
        • osteoporosis
      • treatment
        • revision ORIF to address inadequate fixation
          •  i.e. posteromedial buttress plate for coronal fracture not captured with lateral plate only 
    • 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
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