Tibial plateau

fractures
By
Yasser Alwabli
Objectives

• Anatomy
• Mechanism of injury
• Classification
• Diagnosis (History, Physical examination and
Imaging)
• Management
• Complications
Anatomy
• The tibial plateau is the • AO defines tibial
proximal end of the plateau as the
tibia including the metaphysis to a distal
metaphyseal and distance equal to the
epiphyseal regions as width of the proximal
well as the articular tibia at the joint line.
surfaces made up of
hyaline cartilage.
Distinction between medial and lateral condyles
• Medial:
o Slightly concave shape
o Larger in both width and length.
o Cartilage thickness ~ 3 mm
• Lateral:
o Convex
o 2-3 mm superior (proximal)
to the medial.
o Cartilage thickness ~ 4
mm
• Medial proximal tibial angle
(MPTA) 85 – 90.
• Posterior slope ~ 9 degrees
(Posterior proximal tibial
angle)
• Both plateaus covered with
hyaline cartilage.
Muscle attachments
• ITB to Gerdy’s tubercle
• Patellar tendon to
anterior tibial tubercle
• Pes Anserine tendons
(S, G, ST) to AM tibia ~
7 cm below joint line
Menisci
• Lateral meniscus
– semicircular
– covers 50 % of the plateau
– Attached to PCL via
ligaments
• Humphry (anterior)
• Wrisberg (posterior)
– No attachment to LCL
• Medial meniscus
– C-shaped
– Thick posteriorly, so
promoting posterior
stabilization.
– intimately attached to
MCL
Ligaments
• Four subdivisions: ACL,
PCL, PM and PL corner
ligament complexes.
• ACL:
o Two bundles: AM tight in
flexion, PL tight in
extension.
o Prevents anterior
translation
o From PM corner of lateral
femoral condyle to
anterior tibial
intercondylar area.
• PCL:
o Two bundles: AL tight in
flexion, PM tight in
extension.
o Prevents posterior
translation
o From antermedial
femoral condyle to
posterior sulcus of tibia
Ligaments
• PM corner: o PL corner:
o MCL and oblique popliteal o Arcuate ligament
ligament o Popliteus
o Prevents valgus instability
and PM translation of tibia o Posterolateral capsule
o MCL: o Lateral collateral ligament
o From medial femoral o Popliteofibular ligament
epicondyle o Lateral head of
o Superficial and deep gastrocnemiius
components
o Deep to medial
mensicus
o Superficial to distal
plateau
Neurovascular structures
• Common peroneal • Popliteal artery
nerve:
– The common peroneal
nerve courses around
the neck of the fibula
distal to the proximal
tibia-fibula joint before
it divides into its
superficial and deep
branches
– The trifurcation of the
popliteal artery into the
anterior tibial, posterior
tibial, and peroneal
arteries occurs
posteromedially in the
proximal tibia.
Mechanism of injury

1. Force directed medially (valgus deformity) or

laterally (varus deformity) or both.
2. Axial compressive force.
3. Both axial force and force from the side.
Classification
• Shatzker classification
– Six types
• AO\OTA
– Three types
Schatzker classification

• Type I:

o Split-wedge fracture of
lateral plateau without
any joint depression or
impaction
o In young patients
o Lateral meniscal
pathology may be
present
Schatzker classification

• Type II:

o Split fracture of the

lateral tibial condyle
with associated
impaction or depression
of the articular surface
o Greater energy than
type 1
o Commonly in fourth
decade of life
Schatzker classification

• Type III:

o Pure depression of
the lateral articular
surface only.
o Common in elderly
Schatzker classification

• Type IV:

o Split fracture of medial

plateau with associated
comminution of
intracondylar eminence
or medial plateau
articular surface.
Schatzker classification
• Type V:
o This is a total articular
fracture in the
configuration of an
inverted “Y,” with both
plateaus separated from
each other and from the
distal tibia. The
nonarticular
intercondylar eminence
region remains largely
intact.
Schatzker classification
• Type VI:

o Tibial Plateau Fx with

Metaphyseal -
Diaphyseal Separation
AO/OTA Classification

• Type A - Extraarticular
• Type B - Partial Articular
• Type C - Intra-articular and Metaphyseal
Posterior shear fracture
• Pure posterior fracture
fragments
• Does not fit into
Schatzker’s
classification, may be
bicondylar, or a knee
dislocation variant.
• Needs posterior
approach
Intercondylar eminence fracture
• Usually cruciate
ligament avulsions.
Associated injury
• Injury to collateral ligaments occur in 7% to 43%
• ACL rupture up to 23 %
• Meniscal injuries up to 50 % (in split type, may be
incarcerated)
• Any widening of the femoral-tibial articulation
greater than 10° upon stress examination indicates
ligamentous insufficiency
Diagnosis

• History :
• Age
• Comorbidities
• Patient activity level, employment, recreational …
• Mechanism of injury
• Direction of force
• Physical examination:
• ATLS
• Open wounds, deformity, swelling, instability, crepitus
• Test of compartment syndrome
• Vascular assessment; API and ABI
• Distal pulses
• Assessment and monitoring of soft tissue swelling
Radiology
• Plain X-Ray:
• Supine AP and lateral view for all patients
• Internal and external oblique view
• Obtain contralateral AP and Lateral (compare)
• Tibial plateau view: AP with knee extended and beam directed
15 degrees caudally

• CT scan:
• increases the diagnostic accuracy
• indicated in cases of articular depression
• shown to increase the interobserver and intraobserver
agreement on classification in tibial plateau fractures
• excellent adjuncts in the preoperative planning
Radiology
• MRI:
• alternative to CT scan or arthroscopy
• osseous as well as the soft tissue components of the injury
• cost prohibitive for use in standard situations

• Duplex US and Arteriography:

– To evaluate associated arterial injury.
Management
• Non-operative management:
– Indicated for non-displaced or minimally displaced
fractures
• Method:
– Protected weight bearing and early range-of-knee motion
in a hinged fracture brace.
– Isometric quadriceps exercises and progressive passive,
active-assisted, and active range-of-knee motion
exercises.
– Partial-weight bearing (30-40 Ib) for 8 to 12 weeks with
progression to full weight bearing.
Operative treatment
• Indications:
– Accepted range of articular depression varies from < 2
mm to 1 cm
– Instability > 10 degrees of nearly extended knee compared
to the contralateral side
– Open fractures
– Associated compartment syndrome
– Associated vascular injury
Principles of management
• Goals of treatment:
– reconstruction of the articular surface
– re-establishment of tibial alignment
• Treatment involves reducing and buttressing of
elevated articular segments with bone graft
• Soft tissue reconstruction including menisci and
ligaments
• Spanning external fixator as a temporizing measure
in patients with high-energy injuries or significant
soft tissue injury.
• Arthroscopy
Implant options
• Plates and screws, screws alone or external fixation.
(The choice of implant is related to the fracture patterns,
degree of displacement, and familiarity of the surgeon).
– Plates and screws:
• Functions: buttressing against shear forces or neutralize
rotational forces
• Thinner plate
• Percutaneous plating
• Double plating
– Screws alone:
• Simple split fractures, or depressed that are elevated
percutaneously
Implant options
• External fixation:
– Advantages of external fixation include
• minimal soft tissue dissection
• ability to alter frame stiffness and thus control
compression across comminuted fracture fragments.
• can be dynamized during fracture healing, which may
help if delayed or nonunion occurs in the metaphyseal
regions.
• provides excellent stability in cases where there is
severe soft tissue or bony defect.
• allows for correction if there is a malalignment or
deformity.
– spanning external fixators
Operative treatment
• Type I:
– Closed reduction then stabilized cancellous lag screws
with washers to gain compression.
• Type II:
– OR and elevation of depressed fragment
– Bone graft is placed to support the elevated fragments
– Screws are placed across the reduced split fracture
fragments in lag mode
Operative treatment
• Type III:
– elevation through cortical fenestrations
– supported with subchondral screws and bone graft

• Type IV:
– requires a medial buttress plate to counteract the shear
forces acting on the medial plateau
– lag screws alone are not sufficient to stabilize these
fractures
Operative treatment
• Type V:
– locking plates, laterally placed plates with screws that
lock to the plate creating a fixed angle construct provide
enough stability to counteract forces seen by the medial
tibial plateau.
Operative treatment
• Type VI:
– Following articular reconstruction, the articular segment
has historically been stabilized to the tibial shaft using a
single plate, double plates, a single plate and a
contralateral two-pin external fixator, or a thin-wire
fixator. If the fracture is transverse, a single plate will
suffice. Oblique fracture lines exiting the opposite cortex
require a second plate or external fixator to resist shearing
forces.
Complications
• Early:
– most commonly is infection (3 – 38 %)
• Superficial
• Deep
– Thromboembolic complication (DVT, PE)
• Late:
– Painful hardware
– Loss of fixation
– Posttraumatic arthritis
– malunion