1

C OPYRIGHT Ó 2019 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Comparative Analysis of Mechanism-Associated

3-Dimensional Tibial Plateau Fracture Patterns
Xuetao Xie, PhD, MD,* Yu Zhan, MD,* Yukai Wang, MD, Justin F. Lucas, MD, Yingqi Zhang, MD, and Congfeng Luo, MD

Investigation performed at Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China

LE
Background: The association between tibial plateau fracture morphology and injury force mechanism has not been well
described. The aim of this study was to characterize 3-dimensional fracture patterns associated with hypothesized injury
force mechanisms.

C
Methods: Tibial plateau fractures treated in a large trauma center were retrospectively reviewed. Three experienced
surgeons divided fractures independently into 6 groups associated with injury force mechanisms proposed from an
analysis of computed tomographic (CT) imaging: flexion varus, extension varus, hyperextension varus, flexion valgus,

TI
extension valgus, and hyperextension valgus. The fracture lines and comminution zones of each fracture were graphically
superimposed onto a 3-dimensional template of the proximal part of the tibia. Fracture characteristics were then sum-
marized on the basis of the fracture maps. The association between injury force mechanism and ligament avulsions was
calculated. AR
Results: In total, 353 tibial plateau fractures were included. The flexion varus type pattern was seen in 67 fractures
characterized by a primary fracture apex located posteromedially and was frequently associated with concomitant anterior
cruciate ligament (ACL) avulsion (44.8%). The extension varus pattern was noted in 60 fractures with a characteristic
medial fragment apex at the posteromedial crest or multiple apices symmetrically around the crest and was commonly
completely articular in nature (65%). The hyperextension varus pattern was seen in 47 fractures as noted by anteromedial
articular impaction, 51% with a fibular avulsion and 60% with posterior tension failure fragments. The flexion valgus
S
pattern was observed in 51 fractures characterized by articular depression posterolaterally, often (58.9%) with severe
comminution of the posterolateral cortical rim. The extension valgus patterns in 116 fractures only involved the lateral
ES

plateau, with central articular depression and/or a pure split. The hyperextension valgus pattern occurred in 12 fractures
denoted by anterolateral articular depression. A moderate positive association was found between flexion varus fractures
and ACL avulsions and between hyperextension varus fractures and fibular avulsions.
Conclusions: Tibial plateau fractures demonstrate distinct, mechanism-associated 3-dimensional pattern characteris-
tics. Further research is needed to validate the classification reliability among other surgeons and to determine the
R

potential value in the diagnosis and formulation of surgical protocols.

T
-P

ibial plateau fractures are challenging intra-articular
injuries with a broad spectrum of presentations, pri-
marily resulting from excessive loads on the tibial plateau
that combined a compressive and a varus or valgus compo-
IN
Based on 2-dimensional computed tomographic (CT)
images, Wang et al.5 classified 287 cases of tibial plateau frac-
tures into 4 categories according to their injury force mecha-
nism: extension varus, extension valgus, flexion varus, and

nent1-4. Recognition of fracture patterns and the mechanism of
injury helps to prepare surgeons to provide optimal treatment5-7.
Multiple cadaveric investigations of tibial plateau fractures
revealed a correlation between certain fracture patterns and
the injury force mechanism, including the orientation of force
vectors and the knee position at the time of the injury3,4,8,9.
*Xuetao Xie, PhD, MD, and Yu Zhan, MD, contributed equally to this work.
flexion valgus. The updated Schatzker classification system6
also introduced the assessment of injury force mechanism in
these 4 dimensions (extension, flexion, varus, and valgus) to
help to guide surgical fixation. Recently, hyperextension tibial
plateau fractures have been reported as a unique fracture pat-
tern with a poor prognosis7,10. Although some characteristics of

Disclosure: This study was supported by the National Natural Science Foundation of China (Grant No. 81572118). The Disclosure of Potential Conflicts
of Interest forms are provided with the online version of the article (http://links.lww.com/XXXXXXX).

J Bone Joint Surg Am. 2019;00:1-9 d http://dx.doi.org/10.2106/JBJS.19.00485

Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
 2
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
C O M PA R AT I V E A N A LY S I S O F M E C H A N I S M -A S S O C I AT E D
V O L U M E 0 0-A N U M B E R 00 D E C E M B E R 19, 2 019
d d
3-D I M E N S I O N A L T I B I A L P L AT E AU F R A C T U R E P AT T E R N S

LE
C
TI
AR
S
Fig. 1
The criteria to determine tibial plateau fracture injury mechanism in 2-dimensional CT images. fx. = fracture, MPTA = medial proximal tibial angle, and PSA =
ES

posterior slope angle.

certain mechanism-associated fracture patterns, such as
hyperextension varus and flexion valgus fractures, have been
described7,11, to our knowledge, no detailed demonstration,
particularly in a 3-dimensional manner, has been proposed.
R
fracture classification17 was used to identify type-B and C tibial
plateau fractures. Exclusion criteria consisted of open or path-
ological knee fractures; fractures concomitant with an ipsilat-
eral tibial shaft, femoral, or patellar non-avulsion fractures;

Additionally, although quite a few studies12-14 conducted tibial fractures in skeletally immature patients; developmental dys-
plateau fracture mapping, all of the results were presented in an plasia; or a history of knee surgery. CT imaging with axial cuts
axial view of the proximal part of the tibia. The fracture wider than 3 mm was also excluded. Ligamentous avulsions
-P

characteristics on the tibial columns, which play an essential
role in the implant placement and alignment restoration5,15,
were underappreciated.
The fracture-mapping technique, particularly in a 3-
IN
around the ipsilateral knee joint were recorded.
Fracture Injury Mechanism
Both the 2-dimensional CT images and the 3-dimensional

dimensional context16, is a good tool to define spatial fracture reconstruction images in the PACS (picture archiving and
features. The purpose of this study was to characterize mechanism- communication system) were independently reviewed by 3
associated tibial plateau fracture features. We hypothesized that 3-
dimensional fracture mapping would demonstrate distinct,
recurrent characteristics among mechanism-associated tibial
plateau fractures.

Materials and Methods

Subjects

A t a large, level-I trauma center, a retrospective search was

conducted in an orthopaedic database for the CT imaging
data of patients with a diagnosis of a tibial plateau fracture Fig. 2
between January and December 2017. The latest OTA/AO The 3-column tibial plateau concept and 6 types of injury force mechanism.

Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
 3
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
C O M PA R AT I V E A N A LY S I S O F M E C H A N I S M -A S S O C I AT E D
V O L U M E 0 0-A N U M B E R 00 D E C E M B E R 19, 2 019
d d
3-D I M E N S I O N A L T I B I A L P L AT E AU F R A C T U R E P AT T E R N S

LE
C
Fig. 3

TI
The method used for 3-dimensional CT mapping of tibial plateau fractures. In this example of a tibial plateau fracture, each fragment was reconstructed
(Fig. 3-A) and then virtually reduced (Fig. 3-B). When the fracture case was fit to a 3-dimensional model of the proximal part of the tibia, the articular
depression area was identified with a gray zone (Fig. 3-C) and the fracture line was marked with a red line (Fig. 3-D). After removal of the fracture case, a gray

orthopaedic surgeons experienced in the management of

AR
zone representing articular depression and red lines representing fracture lines were shown on the 3-dimensional template (Fig. 3-E).

flexion at the time of a valgus injury, with an unchanged slope

tibial plateau fractures and knowledgeable with regard to the 3-
column fixation concept5,18, knee biomechanics, and kine-
matics. Hypothesized fracture mechanism, including the
injury force vector and knee position, was determined in 2-
S
suggesting knee extension and a decreased or even reversed
slope suggesting a hyperextension injury7,10,19,20 (Fig. 1). The
measurements were performed in the context of Mimics
(Materialise) before fragment reduction. Thus, the fractures

dimensional CT images according to prior studies. Isolated were then categorized into the following 6 injury patterns:
medial plateau fractures resulted from a varus force, and pure flexion varus, extension varus, hyperextension varus, flexion
ES

lateral plateau fractures resulted from a valgus force1,2,4,6; for
fractures involving both plateaus, a diminished medial proxi-
mal tibial angle indicated a varus force, and otherwise it
indicated a valgus force5. Increased posterior tibial slope of the
medial plateau suggested knee flexion at the time of a varus
injury, whereas that of the lateral plateau suggested knee
R
-P
valgus, extension valgus, and hyperextension valgus (Fig. 2).
Reliability Analysis
Interobserver reliability among the 3 surgeons was assessed
before a panel consensus discussion was used to resolve any
disagreement. The results were then used for fracture mapping.

TABLE I Patient Demographic Characteristics

Varus Valgus

Flexion Extension Hyperextension Subtotal Flexion Extension Hyperextension Subtotal Total

IN

No. of fractures 67 60 47 174 51 116 12 179 353

Age* (yr) 46.9 (16 to 70) 49.4 (22 to 68) 50.6 (24 to 85) 48.8 (16 to 85) 52.6 (17 to 77) 54.9 (16 to 89) 50.8 (44 to 59) 54 (16 to 89) 51.4 (16 to 89)

Sex†
Male 35 33 32 100 17 60 8 85 184‡
Female 32 27 15 74 34 56 4 94 167‡

Side of injury§
Left 48 34 24 106 33 76 5 114 220
Right 19 26 23 68 18 40 7 65 133
Fracture type§
B 62 21 36 119 51 113 11 175 294
C 5 39 11 55 0 3 1 4 59

*The values are given as the mean, with the range in parentheses. †The values are given as the number of patients. ‡There were 351 patients, and 1 male patient and 1 female patient had
bilateral tibial plateau fractures. §The values are given as the number of fractures.

Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
 4
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 0 0-A N U M B E R 00 D E C E M B E R 19, 2 019
d d
AR
S
ES
Fig. 4
R
The distribution of fractures by patient age (Fig. 4-A) and injury force
mechanism (Fig. 4-B).
-P
Another round of fracture categorization was performed among
the same 3 surgeons after an interval of 8 weeks to assess the
intraobserver reliability.
IN
Fracture Mapping
A 3-dimensional fracture-mapping technique16 was utilized to
demonstrate the spatial topography of tibial plateau fractures.
CT data were used to reconstruct and virtually reduce fractures
(Mimics). Additional processing was then performed to rotate,
normalize, and flip images if necessary to best match a 3-
dimensional template of the proximal part of the tibia (3-matic
software; Materialise). Landmarks including the osseous con-
tours of the medial and lateral plateau, tibial tubercle, Gerdy’s
tubercle, fibular head, and intercondylar eminence were ref-
erenced for alignment and standardization. Smooth curves
were drawn directly on the surface of the 3-dimensional model
to represent fracture lines, and articular depression or com-
Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
C O M PA R AT I V E A N A LY S I S O F M E C H A N I S M -A S S O C I AT E D
3-D I M E N S I O N A L T I B I A L P L AT E AU F R A C T U R E P AT T E R N S
minution and direct extensions into metaphyseal areas were
marked in zones (Fig. 3). Fragments of <1 cm2 were repre-
sented as comminution zones12. Lastly, all fracture lines and
comminution zones were overlapped onto the 3-dimensional
model to produce a spatial fracture map. The individual maps
were then combined for each fracture type, resulting in 6
overall fracture maps.
Data Analysis
A descriptive analysis of fracture maps was employed when the
LE
fracture features could not be quantitatively presented. A
comparison between categorical data was performed with chi-
square tests; the kappa coefficient was used to analyze the
interobserver and intraobserver reliability; the phi coefficient
(f) with the 95% confidence interval (CI) was used to measure
C
the association between fracture mechanism and ligament
avulsions or tibial tubercle fractures. Statistical calculations
TI
were performed using SPSS 23.0 (IBM). Significance was set at
p < 0.05.
Results
I n total, 353 tibial plateau fractures (294 type-B fractures and
59 type-C fractures) in 351 patients were included. Patient
demographic characteristics were summarized in Table I. The
mean age was 51.4 years (range, 16 to 89 years), with 185
fractures in 184 men and 168 fractures in 167 women. When
patients were £50 years of age, tibial plateau fractures were
more common in male patients than female patients in each
decade. In contrast, more fractures were seen in female patients
in the sixth, seventh, eighth, and ninth decades (Fig. 4-A).
In this study, 174 fractures resulted from a presumed
varus force, accounting for 49.3% of all fractures, and the re-
maining 179 fractures resulted from a valgus force. Varus force
produced significantly more type-C fractures (55 of 174 frac-
tures) than valgus force (4 of 179 fractures) (p < 0.01). Among
the 6 fracture modes, the most common was the extension
valgus fracture pattern (32.9%), whereas the least common was
the hyperextension valgus pattern (3.4%) (Fig. 4-B).
Reliability Analysis
In the first round of categorization, the mean kappa value was
0.63 (range, 0.58 to 0.70) for the interobserver reliability and
0.69 (range, 0.62 to 0.77) for the intraobserver reliability, both
representing substantial agreement according to the levels of
agreement proposed by Landis and Koch21.
Fracture Maps
Flexion Varus
Sixty-seven fractures were included for analysis. The most
consistent feature was a medial fragment spike located between
the tibial crest and the posterior midline at the level of the tibial
tubercle (Fig. 5-A). The medial fragments included varying
levels of articular involvement, ranging from a small postero-
medial portion to nearly the whole medial plateau. Fifty-five
fractures (82.1%) had articular depression concentrated in the
posteromedial quadrant of the lateral plateau. In 51 fractures
 5
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
C O M PA R AT I V E A N A LY S I S O F M E C H A N I S M -A S S O C I AT E D
V O L U M E 0 0-A N U M B E R 00 D E C E M B E R 19, 2 019
d d
3-D I M E N S I O N A L T I B I A L P L AT E AU F R A C T U R E P AT T E R N S

LE
C
TI
AR
Fig. 5
Representative views of the 3-dimensional maps of the flexion varus (Fig. 5-A), extension varus (Fig. 5-B), and hyperextension varus (Fig. 5-C) fracture
S
patterns. Fracture lines are depicted in red; both the articular depression and posterolateral cortex comminution are represented in the gray zones; darker
colors mean a higher frequency of injury events.

Flexion Valgus
ES

(76.1%), articular depression extended posteriorly, resulting in

crushing of the posterolateral rim and metaphysis.
Extension Varus
Among the 60 fractures in this group, the medial plateau
fragments had either 1 main fracture apex located at the medial
R
All 51 fractures had articular depression in the posterolateral
plateau, closely adjacent to the posterior rim, and 30 fractures
(58.9%) had a disrupted posterolateral wall (Fig. 6-A). No
fractures compromised the medial column.

crest (25 fractures) or 2 split fragments with apices distributed Extension Valgus
symmetrically around the crest (35 fractures) (Fig. 5-B). Most Among 116 fractures in this group, nearly all were located in
fractures involved both medial and lateral plateaus, with 39 the lateral plateau (Fig. 6-B); 7 (6%) were only split, 23 (19.8%)
-P

(65%) being completely articular. Fifty-one fractures (85%)
had articular depression, frequently involving the intercondylar
eminences and the medial half of the lateral plateau. Addi-
tionally, the posterolateral cortex wall containing the rim was
IN
were only depressed, and the remaining 86 (74.1%) were both
split and depressed. All of the depression zones were located in
the central portion of the lateral plateau. The apices of the
lateral fragments, if present, were located anterolaterally, most

comminuted in 35 fractures (58.3%).
Hyperextension Varus
Forty-seven fractures were included. These fractures were char-
acterized by anteromedial plateau articular depression involv-
ing the anterior rim and were associated with concomitant
anteromedial metaphyseal impaction (Fig. 5-C). Posteriorly, it
was noted that tension-type failure fragments containing the
posterior cruciate ligament (PCL) insertion were more com-
mon than not and were seen in 28 fractures (59.6%). The
medial tibial plateau fragments had a variable degree of artic-
ular surface involvement, ranging from a small anteromedial
portion to nearly the whole medial tibial plateau.
exiting below Gerdy’s tubercle but above the tibial tubercle. No
fractures had posterolateral cortical disruption.
Hyperextension Valgus
All 12 fractures had articular depression concentrated in the
anterolateral plateau involving the anterior cortical rim, and 8
had split fragments, with the main fracture apex located an-
terolaterally at the level of the tibial tubercle (Fig. 6-C).
Knee Ligament Avulsions
Knee ligament avulsions were not uncommon in tibial plateau
fractures (Table II). In 67 flexion varus fractures, 30 (44.8%)
were associated with ACL avulsions, with a moderate positive

Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
 6
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 0 0-A N U M B E R 00 D E C E M B E R 19, 2 019
d d
AR
Fig. 6
S
Representative views of the 3-dimensional maps of the flexion valgus (Fig. 6-A), extension valgus (Fig. 6-B), and hyperextension valgus (Fig. 6-C) fracture
patterns. Fracture lines are depicted in red and the articular depression is depicted in the gray zones; darker colors mean a higher frequency of injury events.
association (f = 0.47) (Table III). Two ACL avulsions were
ES
observed in 116 extension valgus fractures, with a fair negative
association (f = 20.23) (Table III). Moreover, 51.1% (24) of
hyperextension varus fractures had proximal fibular avulsions,
indicating posterolateral complex (PLC) injuries, with a mod-
erate positive association (f = 0.51) (Table III).
R
Tibial Tubercle Fractures
In most fractures, the tibial tubercle remained in continuity
-P
with the intact diaphyseal portion. In this series, 11 tubercle
fractures were noted as being associated with proximal frag-
ments and 8 were found to be isolated fragments (Table II).
Fracture involvement of the tibial tubercle was significantly
IN
more common in varus fractures (17 cases) compared with
valgus fractures (2 cases) (p < 0.01) and had a fair positive
association with extension varus fractures (f = 0.29) (Table
III), in which 13 cases (21.7%) were observed.
Discussion
I n this study, the 3-dimensional fracture mapping techniques
were applied to a large series of tibial plateau fractures to
demonstrate the 6 types of theorized mechanism-associated
fracture patterns to improve understanding of this challenging
injury. The characteristics of each type have been elucidated in
Table IV, and representative cases are shown in the Appendix.
Unlike previous 2-dimensional mapping studies12-14, which
Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
C O M PA R AT I V E A N A LY S I S O F M E C H A N I S M -A S S O C I AT E D
3-D I M E N S I O N A L T I B I A L P L AT E AU F R A C T U R E P AT T E R N S
LE
C
TI
focused on recurring fracture lines and depression zones in the
articular surface, this study presented fragment cortical spikes
together with articular depression stereoscopically, allowing for
the accurate localization of primary fracture planes. Varus force
produced more type-C fractures and tibial tubercle fractures in
comparison with valgus force. A moderate positive association was
found between the ACL avulsions and flexion varus fractures and
between the PLC avulsions and hyperextension varus fractures.
Currently, at least 38 tibial plateau fracture classification
systems are available22. Among the most utilized are the
Schatzker, OTA/AO, and Luo systems. The Schatzker classifica-
tion23 was based on conventional radiographs. The latest OTA/
AO classification17 introduced the use of axial CT views to further
describe the location of articular depression. The Luo classifica-
tion18 introduced the 3-tibial-column concept as a tool to guide
the application of fracture-specific fixation. Later, Wang et al.
emphasized the role of theorized injury mechanism in an up-
dated 3-column concept, but did not provide 3-dimensional
fracture patterns5. In 2018, Kfuri and Schatzker extended the
original Schatzker classification to analyze the theorized injury
mechanism and main fracture plane6. Additional classifications
including 4 main characteristics12 and 10-segment systems24
based on 3-dimensional CTmorphology have been reported. The
fracture maps in this current study are unique in their ability to
extrapolate patterns as they associate with injury force mecha-
nism with respect to the triangular proximal part of the tibia. A
 7
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
C O M PA R AT I V E A N A LY S I S O F M E C H A N I S M -A S S O C I AT E D
V O L U M E 0 0-A N U M B E R 00 D E C E M B E R 19, 2 019
d d
3-D I M E N S I O N A L T I B I A L P L AT E AU F R A C T U R E P AT T E R N S

TABLE II Knee Ligament Avulsions and Tibial Tubercle Fractures

Varus Valgus
Flexion Extension Hyperextension Subtotal Flexion Extension Hyperextension Subtotal Total

Ligament
avulsions
ACL 30 tibial 3 tibial 0 33 tibial 9 tibial 2 tibial 0 11 tibial 44 tibial
insertions insertions insertions insertions insertions insertions insertions
PCL* 2 tibial 2 tibial 4 tibial 8 tibial 0 2 tibial 1 tibial 3 tibial 11 tibial

LE
insertions insertions insertions insertions insertions insertion insertions insertions
MCL† 0 1 femoral 0 1 femoral 0 3 femoral 1 femoral 4 femoral 5 femoral
insertion insertion insertions insertion insertions insertions
PLC 0 4 fibular 24 fibular 28 fibular 0 1 fibular 0 1 fibular 29 fibular
insertions insertions insertions insertion insertion insertions

C
and 1 and 1 and 1
femoral femoral femoral
insertion insertion insertion

TI
Tubercle
fragments
Proximal‡ 2 7 0 9 1 1 0 2 11
Free§
Subtotal
0
2
6
13
2
2
AR 8
17
0
1
0
1
0
0
0
2 19
8

*The number of posterior tensile fragments containing PCL insertions was not included. †MCL = medial collateral ligament. ‡The tibial tubercle
fragment was connected with the proximal portion of the tibia. §The tibial tubercle fragment was free from the proximal and distal portions of the
tibia.
S
novel spatial perspective was offered to view fractures and infer enhance exposure and may facilitate adequate reduction28,29.
the potential injury mechanism from the resultant pathoanat- In a large prospective cohort, Wang et al.5 utilized the 3-column
omy. This assessment allows the identification of articular in- concept and fracture mechanism analysis in their surgical in-
ES

juries and fracture planes as well as the risk of secondary fragment
displacement and associated ligamentous avulsions, ultimately
aiding in fragment-specific treatment protocols.
Insight into the mechanism-associated fracture patterns
may aid fracture reduction and fixation. Carlson25 and Chang
R
terventions, achieving satisfactory results without fixation fail-
ure. It has been advised that fractures created by axial loading
be treated using a buttress plate applied to the fragment7,30 or
parallel to the main fracture plane6, which could be clearly
demonstrated in a 3-dimensional context. Posterolateral but-

et al.26 reported that a posteromedial split fragment, a primary tress plating demonstrated the strongest resistance against frag-
feature of a flexion varus injury, could be reduced in knee ment subsidence in the scenario of flexion valgus loading31;
extension or slight hyperextension. Contrarily, maximal dis- posteromedial buttress plating was most favored in the pos-
-P

placement of the posteromedial fragments common in the
flexion varus patterns occurred when a varus force was applied
to a flexed knee27. As for the posterolateral depression seen in
the flexion valgus group, knee extension and varus aid to
IN
teromedial split fractures seen in flexion varus injury32.
The injury force mechanism reflected by those unique
fracture patterns has a predictive value in diagnosing associated
soft-tissue injuries. The results in our study revealed a diagonal

TABLE III Association Between Fracture Mechanism and Knee Ligament Avulsions or Tibial Tubercle Fractures*

Fracture Mechanism ACL Avulsions PCL Avulsions MCL Avulsions PLC Avulsions Tibial Tubercle Fractures

Flexion varus 0.47 (0.34 to 0.60) 20.03 (20.09 to 0.07) 20.01 (20.08 to 0.10) 20.13 (20.16 to 20.10) 20.04 (20.11 to 0.05)
Flexion valgus 0.06 (20.05 to 0.12) 20.07 (20.09 to 20.04) 20.05 (20.07 to 20.03) 20.11 (20.14 to 20.09) 20.06 (20.11 to 0.03)
Extension varus 20.10 (20.17 to 20.01) 0.02 (20.07 to 0.15) 0 (20.07 to 0.13) 0.02 (20.08 to 0.13) 0.29 (0.14 to 0.42)
Extension valgus 20.23 (20.28 to 20.16) 20.04 (20.12 to 0.06) 0.05 (20.07 to 0.16) 20.17 (20.23 to 20.11) 20.13 (20.18 to 20.06)
Hyperextension varus 20.15 (20.18 to 20.12) 0.15 (0 to 0.30) 20.05 (20.07 to 20.03) 0.51 (0.35 to 0.65) 20.01 (20.09 to 0.11)
Hyperextension valgus 20.07 (20.09 to 20.05) 20.03 (20.05 to 20.02) 0.10 (20.03 to 0.35) 20.05 (20.07 to 20.04) 20.04 (20.06 to 20.03)

*The values are given as the phi coefficient (f), with the 95% CI in parentheses. MCL = medial collateral ligament.

Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
 8
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
C O M PA R AT I V E A N A LY S I S O F M E C H A N I S M -A S S O C I AT E D
V O L U M E 0 0-A N U M B E R 00 D E C E M B E R 19, 2 019
d d
3-D I M E N S I O N A L T I B I A L P L AT E AU F R A C T U R E P AT T E R N S

TABLE IV Morphological Characteristics of Mechanism-Associated Tibial Plateau Fracture Patterns in a 3-Dimensional Context

Injury Mechanism Primary Features* Other Features

Flexion varus A medial fragment spike located Often concomitant with posterolateral
posterior to the tibial crest articular comminution involving adjacent
rim; moderately associated with ACL avulsion
Flexion valgus Posterolateral articular depression with Seldom involves the medial column;
or without disruption of posterior wall sometimes with ACL avulsion
Extension varus A large medial fragment with its spike on the High incidence of fracture type C; often

tibial crest, or medial plateau splitting into
anterior and posterior fragments with
spikes symmetrically around the tibial crest
Extension valgus Central depression in the lateral plateau
and/or pure sagittal split fragments
LE
concomitant with posterolateral articular
comminution involving adjacent rim;
involvement of tibial tubercle is not rare
No posterolateral rim disruption; articular
split and depression are common;

C
seldom involves the medial column
Hyperextension varus Anteromedial articular depression Posterior tensile fragment containing
with adjacent rim disruption PCL insertion; moderate association

TI
with proximal fibular avulsion
Hyperextension valgus Anterolateral depression with Sometimes tensile fragment posteriorly;
adjacent rim disruption seldom involves the medial plateau
AR
*Soft-tissue injuries, including ligament ruptures and neurovascular compromise, were not described.

injury pattern between anteromedial plateau fractures and PLC
injuries. PLC avulsions were found to be moderately associated
with the hyperextension varus fractures. Moreover, the flexion
varus fractures had moderate association with ACL avulsions. The
S
setting of 3 knee positions is thought to account for the majority
of tibial plateau fractures. Finally, although the criteria adopted
to classify fractures in this study were summarized from previous
studies1,2,4-7,10,19,20 and had substantial interobserver and intra-

findings were consistent to some extent with a cadaveric study4, in observer agreement, systematic studies specifically investigating
which 19 flexed knees that sustained a varus load had 19 ACL the injury force mechanism of tibial plateau fractures, including
ES

detachment fractures and 16 posteromedial plateau fractures. It is
noted that magnetic resonance imaging (MRI) and arthroscopic
examination were not included in the present study, thereby
potentially underestimating the true incidence of fracture-
associated ligamentous injury. An awareness of the fracture
mechanism may thus increase the specificity and accuracy of
R
the force vectors and knee positions, are still needed.
In conclusion, the data represented 6 tibial plateau frac-
ture patterns with distinct, recurrent characteristics in a 3-
dimensional context. This morphological study demonstrated
the tibial plateau fracture topography on the articular surface
and its supporting metaphysis, facilitating identification of the

diagnostic examinations. principal fracture planes and common features of mechanism-

This study had limitations. First, the fracture mechanisms associated fracture patterns, including a potential association
proposed in this study may not have been exactly consistent with with subtle but important ligament avulsions. Further research
-P

the real situation. Because patients often could not accurately
recall the force direction or the knee posture at the exact
moment of the fracture occurrence, several cadaveric exper-
iments were performed to elucidate the fracture process3-6.
IN
is still needed to validate the classification reliability among
other investigators and the potential value in the diagnosis of a
ligamentous injury and the formulation of surgical protocols.

However, differences between the laboratory testing setup and Appendix

clinical cases in terms of bone quality, muscle strength, liga- Supporting material provided by the authors is posted
ment tension, force energy, and orientation variations pre- with the online version of this article as a data supplement
clude the extrapolation of these results. Although analyzing at jbjs.org (http://links.lww.com/XXXXXXX). n
injury videos may help to determine fracture mechanism33,
the extremely low recruitment rate and the restriction to
subjects involved in sport activities limited its potential appli-
cation in tibial plateau fractures. Another limitation was that less
common force vectors in the axial plane, including rotation, Xuetao Xie, PhD, MD1
Yu Zhan, MD1
translation, and direct anterior forces onto the proximal part of Yukai Wang, MD1
the tibia, were not considered in this study. According to the Justin F. Lucas, MD2
common mechanism of tibial plateau fractures suggested in Yingqi Zhang, MD3
previous studies1-9, the simplification into 2 force vectors in the Congfeng Luo, MD1

Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
 9
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 0 0-A N U M B E R 00 D E C E M B E R 19, 2 019
d d
1Department of Orthopaedic Surgery, Shanghai Jiao Tong University
Affiliated Sixth People’s Hospital, Shanghai, China
2Department of Orthopaedic Surgery, Santa Clara Valley Medical Center,
San Jose, California
3Department of Orthopaedic Surgery, Tongji Hospital, Tongji University
School of Medicine, Shanghai, China
References
1. Schulak DJ, Gunn DR. Fractures of tibial plateaus. A review of the literature. Clin
Orthop Relat Res. 1975;109:166-77.
2. Khan RM, Khan SH, Ahmad AJ, Umar M. Tibial plateau fractures. A new classi-
fication scheme. Clin Orthop Relat Res. 2000 Jun;375:231-42.
3. Kennedy JC, Bailey WH. Experimental tibial-plateau fractures. Studies of the
mechanism and a classification. J Bone Joint Surg Am. 1968 Dec;50(8):1522-34.
4. Vanek J. Posteromedial fracture of the tibial plateau is not an avulsion injury. A
case report and experimental study. J Bone Joint Surg Br. 1994 Mar;76(2):290-2.
5. Wang Y, Luo C, Zhu Y, Zhai Q, Zhan Y, Qiu W, Xu Y. Updated three-column concept
in surgical treatment for tibial plateau fractures - a prospective cohort study of 287
patients. Injury. 2016 Jul;47(7):1488-96. Epub 2016 May 2.
6. Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau
fractures. Injury. 2018 Dec;49(12):2252-63.
7. Firoozabadi R, Schneidkraut J, Beingessner D, Dunbar R, Barei D. Hyperextension
varus bicondylar tibial plateau fracture pattern: diagnosis and treatment strategies. J
AR
Orthop Trauma. 2016 May;30(5):e152-7.
8. Hirsch G, Sullivan L. Experimental knee-joint fractures. A preliminary report. Acta
Orthop Scand. 1965;36(4):391-9.
9. Zhu Y, Meili S, Dong MJ, Zhai QL, Yao L, Wang JC, Hu CF, Sun H, Luo CF.
Pathoanatomy and incidence of the posterolateral fractures in bicondylar tibial pla-
teau fractures: a clinical computed tomography-based measurement and the
associated biomechanical model simulation. Arch Orthop Trauma Surg. 2014 Oct;
134(10):1369-80. Epub 2014 Jul 31.
10. Gonzalez LJ, Lott A, Konda S, Egol KA. The hyperextension tibial plateau fracture
S
pattern: a predictor of poor outcome. J Orthop Trauma. 2017 Nov;31(11):e369-74.
11. Zhang Y, Song L, Li X, Fang J. Flexion-valgus unicondylar tibial plateau depres-
sion fracture pattern: classification and treatment. Injury. 2018 Apr;49(4):852-9.
Epub 2018 Mar 7.
ES
12. Molenaars RJ, Mellema JJ, Doornberg JN, Kloen P. Tibial plateau fracture
characteristics: computed tomography mapping of lateral, medial, and bicondylar
fractures. J Bone Joint Surg Am. 2015 Sep 16;97(18):1512-20.
13. Chen P, Shen H, Wang W, Ni B, Fan Z, Lu H. The morphological features of
different Schatzker types of tibial plateau fractures: a three-dimensional computed
tomography study. J Orthop Surg Res. 2016 Aug 27;11(1):94.
14. Molenaars RJ, Solomon LB, Doornberg JN. Articular coronal fracture angle of
R
posteromedial tibial plateau fragments: a computed tomography fracture mapping
study. Injury. 2019 Feb;50(2):489-96. Epub 2018 Oct 29.
15. van den Berg J, Reul M, Nunes Cardozo M, Starovoyt A, Geusens E, Nijs S, Hoekstra
H. Functional outcome of intra-articular tibial plateau fractures: the impact of posterior
-P
column fractures. Int Orthop. 2017 Sep;41(9):1865-73. Epub 2017 Jul 18.
16. Xie X, Zhan Y, Dong M, He Q, Lucas JF, Zhang Y, Wang Y, Luo C. Two and three-
dimensional CT mapping of Hoffa fractures. J Bone Joint Surg Am. 2017 Nov 1;
99(21):1866-74.
17. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation
IN
classification compendium-2018. J Orthop Trauma. 2018 Jan;32(Suppl 1):S1-170.
Copyright Ó 2019 by The Journal of Bone and Joint Surgery, Incorporated. Unauthorized reproduction of this article is prohibited.
C O M PA R AT I V E A N A LY S I S O F M E C H A N I S M -A S S O C I AT E D
3-D I M E N S I O N A L T I B I A L P L AT E AU F R A C T U R E P AT T E R N S
Email address for C. Luo: congfengl@outlook.com
ORCID iD for X. Xie: 0000-0003-2159-0030
ORCID iD for Y. Zhan: 0000-0002-7551-5039
ORCID iD for Y. Wang: 0000-0003-3842-7942
ORCID iD for J.F. Lucas: 0000-0001-6226-3525
ORCID iD for Y. Zhang: 0000-0002-4616-6888
ORCID iD for C. Luo: 0000-0001-5876-5266
LE
18. Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial
plateau fractures. J Orthop Trauma. 2010 Nov;24(11):683-92.
19. Streubel PN, Glasgow D, Wong A, Barei DP, Ricci WM, Gardner MJ. Sagittal
plane deformity in bicondylar tibial plateau fractures. J Orthop Trauma. 2011 Sep;
25(9):560-5.
20. Zhang BB, Sun H, Zhan Y, He QF, Zhu Y, Wang YK, Luo CF. Reliability and
C
repeatability of tibial plateau fracture assessment with an injury mechanism-based
concept. Bone Joint Res. 2019 Sep 3;8(8):357-66.
21. Landis JR, Koch GG. The measurement of observer agreement for categorical
data. Biometrics. 1977 Mar;33(1):159-74.
TI
22. Millar SC, Arnold JB, Thewlis D, Fraysse F, Solomon LB. A systematic literature
review of tibial plateau fractures: what classifications are used and how reliable and
useful are they? Injury. 2018 Mar;49(3):473-90. Epub 2018 Jan 31.
23. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto
experience 1968–1975. Clin Orthop Relat Res. 1979 Jan-Feb;138:94-104.
24. Krause M, Preiss A, Müller G, Madert J, Fehske K, Neumann MV, Domnick C,
Raschke M, Südkamp N, Frosch KH. Intra-articular tibial plateau fracture charac-
teristics according to the “ten segment classification”. Injury. 2016 Nov;47(11):
2551-7. Epub 2016 Sep 6.
25. Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma. 2005
Feb;19(2):73-8.
26. Chang SM, Zheng HP, Li HF, Jia YW, Huang YG, Wang X, Yu GR. Treatment of
isolated posterior coronal fracture of the lateral tibial plateau through posterolateral
approach for direct exposure and buttress plate fixation. Arch Orthop Trauma Surg.
2009 Jul;129(7):955-62. Epub 2009 Feb 14.
27. Cuéllar VG, Martinez D, Immerman I, Oh C, Walker PS, Egol KA. A biomechanical
study of posteromedial tibial plateau fracture stability: do they all require fixation? J
Orthop Trauma. 2015 Jul;29(7):325-30.
28. Sun H, Zhu Y, He QF, Shu LY, Zhang W, Chai YM. Reinforcement strategy for
lateral rafting plate fixation in posterolateral column fractures of the tibial pla-
teau: the magic screw technique. Injury. 2017 Dec;48(12):2814-26. Epub 2017
Oct 31.
29. Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach
without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop
Trauma. 2010 Aug;24(8):515-20.
30. Luo CF. Tibia, proximal. In: Buckley RE, Moran CG, Apivatthakakul T, editors. AO
principles of fracture management. 3rd ed. Stuttgart: Thieme; 2018. p 877-98.
31. Zhang W, Luo CF, Putnis S, Sun H, Zeng ZM, Zeng BF. Biomechanical analysis of
four different fixations for the posterolateral shearing tibial plateau fracture. Knee.
2012 Mar;19(2):94-8. Epub 2011 Apr 8.
32. Zeng ZM, Luo CF, Putnis S, Zeng BF. Biomechanical analysis of posteromedial
tibial plateau split fracture fixation. Knee. 2011 Jan;18(1):51-4. Epub 2010 Feb 8.
33. Kwon JY, Chacko AT, Kadzielski JJ, Appleton PT, Rodriguez EK. A novel meth-
odology for the study of injury mechanism: ankle fracture analysis using injury videos
posted on YouTube.com. J Orthop Trauma. 2010 Aug;24(8):477-82.