Orthopaedic Surgery - Tibial Plateau Fracture

Basics

The tibial plateau is the:

Proximal weight-bearing articular surface of the tibia.

It articulates with the:

Femoral condyles

to form the:

Knee joint.

The plateau is divided into:

Medial

and

Lateral compartments.

Definition

A tibial plateau fracture is any fracture involving the:

Proximal articular surface of the tibia.

The injury may involve:

One condyle

Both condyles

or separation of the entire articular segment from the:

Tibial shaft.

Clinical Importance

These fractures can disrupt:

Joint congruity

Mechanical alignment

and

Knee stability.

They are also frequently associated with injury to:

Ligaments

Menisci

and other:

Soft-tissue structures.

Schatzker Classification

Tibial plateau fractures are commonly described using the:

Schatzker classification.

Schatzker Type I

Type I is a:

Lateral plateau split fracture.

It consists primarily of a vertical cleavage through the:

Lateral tibial plateau

without substantial:

Articular depression.

Schatzker Type II

Type II is a:

Lateral split-depression fracture.

There is both:

Cortical splitting

and

Depression of the articular surface.

Schatzker Type III

Type III is a predominantly:

Articular depression fracture

of the lateral plateau, traditionally described as a:

Central depression injury.

There may be minimal cortical:

Splitting.

Schatzker Type IV

Type IV involves the:

Medial tibial plateau.

The fracture may or may not involve the:

Intercondylar eminence.

Importance of Type IV Injuries

Medial plateau fractures often result from substantial:

Varus or high-energy force

and may behave like:

Fracture-dislocations.

They have an increased association with:

Neurovascular injury

and

Ligamentous disruption.

Schatzker Type V

Type V is a:

Bicondylar fracture

involving both the:

Medial

and

Lateral tibial plateaus.

Schatzker Type VI

Type VI consists of a plateau fracture with:

Metaphyseal-diaphyseal dissociation.

The entire articular segment is separated from the:

Tibial shaft.

High-Energy Injury

Type VI fractures are commonly produced by:

High-energy trauma.

Associated injuries may involve the:

Chest

Abdomen

Pelvis

Spine

Head

or other parts of the:

Musculoskeletal system.

Neurovascular Risk

Neurovascular injury and:

Compartment syndrome

can occur with any tibial plateau fracture.

The risk is greatest with:

High-energy Type IV, V, and VI injuries.

Associated Soft-Tissue Injury

Tibial plateau fractures frequently occur with significant injury to the:

Menisci

Cruciate ligaments

Collateral ligaments

and

Posterolateral corner.

Historical Soft-Tissue Injury Rates

Advanced imaging studies have reported associated injury to one or more:

Cruciate or collateral ligaments

in up to approximately:

77% of patients.

Meniscal Injury

Historical series have reported:

Lateral meniscal abnormalities in up to 91%

and

Medial meniscal tears in up to 44%.

Posterolateral Corner

Injury to one or more structures of the:

Posterolateral corner

has been reported in as many as approximately:

68% of selected patients.

These figures vary considerably according to:

Fracture pattern and imaging technique.

Epidemiology

Tibial plateau fractures account for approximately:

1% of all fractures.

Older Adults

Among elderly patients, tibial plateau fractures account for a larger proportion of fractures, historically reported at approximately:

8%.

Mechanism in the Elderly

In older adults, these injuries often occur after:

Low-energy falls

because of:

Reduced bone density.

Lateral Plateau Fractures

Isolated lateral plateau fractures are the most common pattern and account for approximately:

55–70%

of tibial plateau fractures in historical series.

Medial Plateau Fractures

Isolated medial plateau fractures account for approximately:

10–23%.

Bicondylar Fractures

Combined medial and lateral plateau fractures account for approximately:

11–31%.

Risk Factors

Risk depends strongly on:

Age

Bone quality

and exposure to:

Trauma.

High-Energy Risk Group

High-energy injuries are more frequent among people exposed to:

Motor vehicle collisions

Pedestrian trauma

Falls from height

and other:

High-velocity mechanisms.

Older Patients

Older adults with:

Osteopenia

or

Osteoporosis

may fracture the plateau after relatively minor:

Falls.

Etiology

The fracture may result from:

Varus force

Valgus force

Axial compression

or a combination of these:

Loading patterns.

Common Causes

Frequent mechanisms include:

Motor vehicle collisions

Pedestrian-versus-vehicle trauma

and

Falls from height.

Sports Causes

Less commonly, injuries result from:

Skiing

Cycling

or other:

Sports-related trauma.

Diagnosis

Diagnosis is based on:

Mechanism

Physical examination

and

Imaging.

Signs and Symptoms

Patients typically present with:

Knee pain

Swelling

and sometimes:

Visible deformity.

Weight Bearing

Patients may be unable to:

Bear weight

or may tolerate only:

Partial weight bearing.

Motion

Knee motion is usually:

Painful

and may be substantially:

Restricted.

Displaced Fractures

Patients with displaced fractures often resist:

Any knee movement

because of severe:

Pain.

Trauma Assessment

High-energy injuries require a complete:

Trauma evaluation

before focusing exclusively on the:

Knee.

Soft-Tissue Examination

Carefully inspect the:

Skin

and

Subcutaneous tissues.

Open Versus Closed Injury

Determine whether the fracture is:

Open

or

Closed.

Any nearby wound should be assumed potentially to communicate with the:

Fracture.

Skin Quality

Look for:

Swelling

Fracture blisters

Tenting

Ecchymosis

and threatened:

Skin necrosis.

Neurologic Examination

Perform a detailed neurologic examination.

The nerve most commonly at risk is the:

Common peroneal nerve.

Peroneal Nerve Function

Assess:

Ankle dorsiflexion

Great-toe extension

and sensation over the:

Dorsum of the foot.

Vascular Examination

Assess:

Dorsalis pedis pulse

Posterior tibial pulse

Capillary refill

and overall:

Limb perfusion.

Asymmetric Pulses

If pulses are diminished or asymmetric, obtain an:

Ankle-brachial index.

Abnormal findings require urgent further assessment and often:

Vascular surgical consultation.

Vascular Imaging

When vascular injury is suspected, evaluation may include:

CT angiography

or other vascular imaging.

Urgent:

Revascularization

may be required if arterial injury is confirmed.

Compartment Syndrome

Every patient should be evaluated for:

Acute compartment syndrome.

Warning Signs

Concerning findings include:

Increasing pain

Pain with passive toe or ankle motion

Tense compartments

and progressive:

Sensory or motor changes.

Ligamentous Examination

Varus and valgus stability may be assessed:

Carefully

when the patient’s pain and fracture pattern permit.

Pseudolaxity

Apparent ligamentous laxity may result from:

Articular collapse

rather than true ligament rupture.

This is termed:

Pseudolaxity.

Imaging

Plain Radiographs

High-quality:

AP

and

Lateral radiographs

are the initial studies.

Radiographic Assessment

Radiographs help identify:

Fracture lines

Condyle involvement

Articular depression

Widening

and

Alignment.

Oblique Views

Oblique radiographs may provide additional information about:

Fracture orientation

but CT has largely replaced them for detailed:

Preoperative assessment.

CT

CT is a critical adjunct in evaluating:

Tibial plateau fractures.

Role of CT

CT helps define:

Articular depression

Comminution

Posteromedial or posterolateral fragments

and overall:

Fracture morphology.

Surgical Planning

CT frequently changes:

Operative strategy

because it more accurately demonstrates the:

Three-dimensional fracture pattern.

CT Technique

Thin-section imaging with multiplanar reconstruction is preferred.

Modern CT protocols are generally more detailed than the historical recommendation for cuts of:

5 mm or less.

MRI

MRI is useful for evaluating associated:

Meniscal

Ligamentous

and other:

Soft-tissue injuries.

Occult Fractures

MRI can also identify:

Nondisplaced or occult fractures

when radiographs are negative but clinical suspicion remains:

High.

Differential Diagnosis

Important alternatives or associated injuries include:

Distal femur fracture

Supracondylar femur fracture

Femoral condyle fracture

Proximal tibial metaphyseal fracture

and

High tibial shaft fracture.

Soft-Tissue Differential Diagnosis

Isolated injuries involving the:

ACL

PCL

MCL

LCL

or

Menisci

may produce similar pain and swelling.

Treatment

Treatment depends on:

Fracture displacement

Articular congruity

Mechanical alignment

Stability

Soft-tissue condition

and

Patient factors.

Initial Measures

Initial management includes:

Ice

Elevation

and

Immobilization.

Bulky Dressing

A bulky dressing with splinting or a:

Well-padded knee immobilizer

can help control:

Pain

and

Swelling.

Nondisplaced Fractures

Stable nondisplaced fractures may often be treated:

Nonoperatively.

Hinged Knee Brace

After the acute swelling decreases, patients may transition to a:

Hinged knee brace.

This permits controlled:

Range of motion

while protecting the:

Fracture.

Weight Bearing

Weight bearing is generally restricted until there is sufficient:

Fracture healing.

The exact duration depends on:

Fracture pattern

Treatment

and

Radiographic progression.

Physical Therapy

Physical therapy focuses on:

Knee range of motion

and

Quadriceps strengthening.

Early Motion

Once the fracture is adequately stabilized, early controlled motion is encouraged to reduce:

Knee stiffness.

Rehabilitation Goals

Therapy progresses toward:

Full knee motion

Restoration of strength

and eventual normalization of:

Gait.

Medication

Acute fractures can produce substantial:

Pain.

Analgesia

Short-term opioid analgesics may be required initially for:

Severe pain.

As symptoms improve, treatment should transition toward:

Nonopioid analgesia

when appropriate.

Surgery

Operative treatment is indicated when the fracture produces unacceptable:

Articular incongruity

Instability

or

Malalignment.

Absolute Indications

Strong indications include:

Open fracture

and associated:

Vascular injury

or other urgent:

Limb-threatening conditions.

Historical Relative Indications

Traditional operative thresholds have included:

Articular step-off greater than approximately 3–5 mm

Condyle tilt greater than 5°

and clinically important:

Varus or valgus instability.

These values are not absolute and should be interpreted together with:

Fracture morphology

Patient age

Soft-tissue status

and

Functional demands.

Floating Knee

A tibial plateau fracture associated with an ipsilateral:

Femoral fracture

may create a:

Floating knee.

This high-energy pattern frequently requires:

Operative stabilization.

External Fixation

External fixation may be:

Temporary

or, in selected circumstances,

Definitive.

Bridging External Fixator

A temporary spanning fixator uses pins in the:

Distal femur

and

Tibial shaft

to stabilize the knee while allowing the:

Soft tissues

to recover.

Role of Temporary External Fixation

It is particularly useful in:

High-energy fractures

with major:

Swelling

Fracture blisters

or

Soft-tissue compromise.

Hybrid External Fixation

A hybrid frame may combine:

Tensioned periarticular wires

with more distal:

Tibial half-pins.

This can provide definitive fixation in selected:

Complex fractures.

Staged Treatment

High-energy fractures are frequently managed using:

Initial spanning external fixation

followed by:

Delayed internal fixation.

Benefit of Staging

Staged management allows time for:

Swelling to decrease

and the:

Soft-tissue envelope

to recover before major surgical exposure.

Internal Fixation

Internal fixation aims to restore:

Articular congruity

Mechanical alignment

and

Knee stability.

Elevation of Depressed Fragments

Depressed articular fragments are carefully:

Elevated

to restore the:

Joint surface.

Bone Graft or Substitute

The metaphyseal void created beneath an elevated fragment may be filled using:

Bone graft

or a:

Bone substitute

to maintain:

Articular support.

Percutaneous Fixation

Selected fractures may be treated with:

Cannulated screws

inserted percutaneously under:

Fluoroscopic guidance.

Limited Open Reduction

Percutaneous fixation may be combined with:

Limited open reduction

to elevate and restore:

Depressed articular fragments.

Arthroscopic Assistance

Arthroscopy may assist with:

Joint-surface visualization

and identification of associated:

Meniscal injury.

Caution With Arthroscopy

Fluid extravasation in a recently fractured limb may increase compartment pressures.

Care must therefore be taken to avoid:

Compartment syndrome.

Buttress Plating

A:

Medial or lateral buttress plate

may be used according to the:

Fracture pattern.

Subchondral Raft Screws

A row of subchondral screws, often called a:

Raft construct

can support the elevated:

Articular surface.

Locking Plates

Anatomically contoured:

Locking plates

can provide strong fixation in:

Comminuted

or

Osteoporotic fractures.

Bicondylar Fractures

Bicondylar injuries may require:

Dual-column fixation

depending on:

Fracture morphology.

Dual Plating

When two plates are used, meticulous soft-tissue handling is essential to avoid excessive:

Periosteal stripping

and devascularization.

Dead Bone Sandwich

Extensive bilateral soft-tissue stripping can compromise bone vascularity, historically described as creating a:

“Dead bone sandwich.”

Modern approaches aim to minimize this complication through:

Careful surgical exposure.

Postoperative Motion

When fixation is sufficiently stable, patients should begin:

Early knee range of motion.

Weight Bearing After Surgery

Weight bearing is delayed until adequate:

Clinical and radiographic healing

is present.

Progression depends on:

Fracture severity

Bone quality

and

Fixation stability.

Follow-Up

Serial clinical and radiographic follow-up is necessary until:

Fracture union.

Prognosis

Tibial plateau fractures range from relatively minor injuries to:

Severe joint-threatening trauma.

Prognostic Factors

Outcome depends on:

Patient age

Initial displacement

Fracture location

Quality of reduction

Mechanical alignment

and associated:

Soft-tissue injury.

Posttraumatic Arthritis

The risk of posttraumatic arthritis increases with:

Articular cartilage injury

Residual incongruity

Malalignment

and

Instability.

Staged High-Energy Treatment

Historical studies of staged treatment using initial:

External fixation

followed by delayed reconstruction have reported relatively low rates of:

Major wound complications

in selected patients.

Functional Outcome

Despite severe initial injury, some patients with high-energy fractures treated appropriately can recover:

Good long-term knee function.

Complications

Potential complications include:

Skin compromise

Infection

Compartment syndrome

Loss of fixation

Malunion

Nonunion

Knee stiffness

Chronic pain

and

Posttraumatic arthritis.

Skin Compromise

High-energy fractures may cause severe damage to the:

Soft-tissue envelope.

Surgery should be timed according to:

Skin condition

rather than radiographs alone.

Infection

Infection risk increases with:

Open fractures

Extensive soft-tissue injury

and overly aggressive surgery through:

Swollen tissues.

Compartment Syndrome

Acute compartment syndrome is a major concern and has historically been reported in up to approximately:

10% of tibial plateau fractures

with higher rates in:

High-energy patterns.

Loss of Fixation

Fixation failure may result from:

Severe comminution

Poor bone quality

or premature:

Weight bearing.

Malunion

Residual:

Varus

Valgus

or abnormal plateau slope may alter:

Knee biomechanics

and contribute to:

Posttraumatic arthritis.

Nonunion

Nonunion is less common than malunion but may occur in:

High-energy

Open

or highly:

Comminuted fractures.

Stiffness

Prolonged immobilization and extensive soft-tissue injury may result in:

Loss of knee motion.

Early controlled rehabilitation helps reduce this risk.

Patient Monitoring

After fixation, patients should be monitored for:

Wound healing

Neurovascular status

Alignment

Fracture union

and restoration of:

Knee motion.

Radiographic Monitoring

Serial radiographs are often obtained approximately:

Monthly during early healing

or according to the treating surgeon’s protocol until adequate:

Union

has occurred.

Key Principle

A tibial plateau fracture is an intra-articular fracture of the proximal tibia that may disrupt joint congruity, mechanical alignment, and knee stability.

The:

Schatzker classification

describes six major patterns ranging from an isolated lateral split fracture to bicondylar and metaphyseal-diaphyseal dissociation injuries.

High-energy fractures require careful assessment for:

Soft-tissue damage, peroneal nerve injury, vascular injury, compartment syndrome, and associated ligament or meniscal injury.

CT is essential for defining:

Fracture morphology and surgical planning, while MRI is useful when detailed assessment of:

Ligaments and menisci

is required.

Stable nondisplaced fractures may be managed with:

Protected non-weight-bearing and hinged bracing, whereas displaced or unstable injuries often require:

Reduction and internal fixation, frequently using a staged protocol when the soft tissues are compromised.

Long-term outcome depends heavily on restoration of:

Articular congruity, limb alignment, knee stability, and early controlled motion.