AO Principles of Fracture

Management—Third Edition
Tibia, Proximal
Introduction
• Proximal tibial fractures account for approximately 18.6% of all tibial fractures based on a survey of 10,234 fracture cases.
• Advances in imaging and treatment have significantly improved the management of proximal tibial fractures over the past
decade.
• Computed tomography (CT) and 3-D reconstruction are valuable tools for diagnosing and treating tibial plateau fractures.
• The treatment approach for intraarticular and extraarticular proximal tibial fractures depends on various factors, including
the patient's condition, soft-tissue considerations, fracture pattern, available resources, and surgical expertise.
Evaluation and diagnosis
Case history and physical examination
• Reviewing the case history, including the energy level and injury mechanism, is crucial for decision making in managing
fractures.
• Physical examination, including inspection of the soft-tissue envelope, helps determine if the fracture is closed or open
and assesses associated injuries.
• Clinical signs such as blisters, abrasions, contusions, and degloving injuries indicate high-energy trauma, requiring
caution in surgical exposure.
• Regular evaluation of neurological and vascular status is important to detect complications like compartment syndrome.
• Severe pain worsened by passive stretching, swelling, and tenseness in the leg are indicative of compartment syndrome.
• Compartment syndrome can have atypical presentations, and pedal pulses should always be palpated to ensure proper
assessment.
• Absent or abnormal pedal pulses indicate arterial injury or occlusion and should never be ignored.
• Good capillary return in the foot with absent pulses can be misleading, so deformity correction should be done
immediately and pulses checked again.
• If pulses fail to return, it indicates a limb-threatening vascular injury until proven otherwise, requiring an emergency
vascular surgery consult.
• Soft-tissue structures around the knee are frequently injured in tibial plateau fractures.
• Examination for knee ligament stability before fracture fixation is not helpful, but stability should be evaluated after
operative fixation to diagnose ligament injury.
• Residual instability after fixation may require further management.
Imaging
• Conventional x-rays (AP and lateral) are essential for assessing tibial plateau fractures, but additional 45°
oblique views may be helpful.
• CT scanning improves the reliability of fracture classification and is recommended for a comprehensive
analysis of tibial plateau fractures, including coronal, sagittal, and 3-D reconstructions.
• MRI is more sensitive for assessing associated soft-tissue injuries like meniscal and ligament injuries but is
not routinely recommended in the acute setting.
• Intraoperative examination of stability after fracture fixation is crucial for management decisions regarding
ligament injuries, as MRI findings may not correlate with functional deficits.
• Doppler ultrasound, CT angiography, or digital subtraction angiography should be considered when
vascular trauma is a concern, but they should not cause significant delays in revascularization.
Anatomy
• The medial plateau of the proximal tibia is larger, concave, and stronger, while the lateral plateau is smaller, convex, and
lies slightly higher.
• Fractures of the lateral plateau are more common and may involve articular depression and fragmentation.
• Medial plateau fractures occur en bloc and are associated with more severe injuries and fracture dislocations.
• The posteromedial ridge is a strong part of the proximal tibia, often used as a landmark for intraoperative reduction.
• Important bony landmarks include the tibial tuberosity, Gerdy's tubercle, and fibular head, which guide surgical incisions.
• The anterior and posterior cruciate ligaments, along with the posteromedial and posterolateral complexes, are crucial
ligamentous stabilizers of the knee.
• The menisci serve as shock absorbers and enhance femorotibial stability, and efforts should be made to repair and
preserve them during surgery.
• The common peroneal nerve and popliteal artery with its bifurcation into the posterior tibial artery and tibioperoneal
trunk are vital structures to be protected during surgery.
• The proximal tibia can be divided into three columns (lateral, medial, and posterior), aiding in understanding fracture
patterns, surgical approach planning, and placement of buttress plates to support each column.
Classification
• The AO/OTA Fracture and Dislocation Classification and the Schatzker
classification are commonly used for tibial plateau fractures.
• A CT-based, three-column classification system, combined with
knowledge of the injury mechanism, helps guide treatment decisions
for complex tibial plateau fractures.
Surgical indications
Indications for surgery include:
• Open fractures
• Fractures with vascular injury or compartment syndrome
• Fracture dislocations
• Displaced intraarticular fractures
• Articular depression causing knee instability
• Malalignment, especially varus
• Polytrauma
Preoperative planning
• Timing of surgery
Staged management with urgent closed reduction and temporary, joint-spanning external fixation
ahead of definitive fixation surgery is indicated for the following:
• Open fractures
• Acute vascular injury
• Severe, closed soft-tissue injury
• Damage control in polytrauma
• In stable conditions, a comprehensive diagnostic workup is conducted to assess the fracture
type and soft-tissue condition.
• Surgery can be safely performed once soft-tissue swelling has fully resolved, typically within
10-14 days.
• In cases of compartment syndrome or open fractures with challenges in primary skin closure,
additional interventions such as negative-pressure wound therapy, skin grafts, or rotational
flaps may be required.
• A good clinical indicator that it is safe to perform open reduction and internal fixation (ORIF)
is skin wrinkling indicating regression of edema
Implant selection
• External fixation with radiolucent rods is suitable for staged care or patients with soft-tissue complications.
• Lag screws (3.5 or 4.5 mm) are used to fix articular fragments, and they can be placed as a raft to support the subchondral
bone in complex articular fractures.
• Plate fixation involves the use of locking compression plates (LCP) (3.5 or 4.5 mm) for buttressing or bridging.
• Nonlocking plates, such as low-contact dynamic compression plates, can be utilized for B-type fractures with good bone
quality when buttress fixation is needed.
• Smaller locking plates (2.4 or 2.7 mm) can be used as reduction plates, tension band plates, or for fragment-specific
fixation.
• Screw fixation alone (raft technique) is suitable for pure depression fractures (Schatzker III).
• Intramedullary (IM) nails with proximal interlocking screws can be considered for type A fractures.
Operating room set-up
• The patient is positioned in the supine position.
• A thigh tourniquet is applied, but only inflated if necessary.
• Light manual traction is maintained on the limb during preparation.
• The exposed area from mid thigh to the foot is disinfected.
• The limb is draped with a single-use U-drape or extremity drape.
• A stockinette is used to cover the foot and lower leg and is secured with tape.
• The surgeon, assistant, and operating room personnel are positioned on the side of the injury.
• The image intensifier is positioned on the opposite side of the injury, with the screen in full view of the surgical team and
the radiographer.
Surgery
Approaches

Anterolateral approach
• The most commonly used approach involves a lateral arthrotomy.
• A transverse incision is made at the meniscotibial attachment, allowing for lifting of the meniscus and inspection of the
lateral joint surface.
• Important landmarks for this approach include the joint line, Gerdy tubercle, tip of the fibula, and lateral femoral
epicondyle.
• The incision begins near the epicondyle, curves slightly, and ends between the fibula and Gerdy tubercle.
• The incision can be extended proximally and distally if more exposure is required.
• Deep dissection involves splitting the fibers of the iliotibial tract, taking care not to disrupt other displaced structures,
such as the meniscus.
• The meniscus is palpated, and the knee joint may be opened below the meniscus, which is lifted using a stay suture.
Posteromedial approach
• The supine position with a bump under the opposite hip is used for this approach.
• It is recommended for fractures involving the medial column and/or medial part of the
posterior column.
• The approach is directed towards the posteromedial ridge of the proximal tibia.
• The pes anserinus may be retracted anteriorly or incised and repaired during closure.
• Caution should be taken not to damage the posteromedial complex, an important knee
stabilizer, when exposing the meniscus and joint.
• Posterolateral approach
• The surgeon must have a thorough understanding of knee anatomy for this approach, as the common peroneal nerve is at
risk.
• The approach involves a single skin incision but two separate windows of dissection to expose both the anterior and
posterior parts of the lateral plateau.
• The patient is positioned in the lateral position.
• A longitudinal skin incision is made along the line of the fibular head, starting 3 cm above the joint line and extending
distally along the fibula.
• The anterolateral arthrotomy is performed first, with incision and detachment of the iliotibial tract from Gerdy tubercle.
• The meniscotibial ligament is incised, and the meniscus is elevated to expose the joint surface.
• The second window is posterior to the tendon of biceps femoris, where the common peroneal nerve is exposed and
marked for protection.
• Dissection is performed posterior to the nerve, biceps femoris tendon, and lateral collateral ligament to expose the
posterolateral corner of the tibial plateau.
• While this approach allows for joint exposure and screw fixation, fixation with a posterolateral plate is difficult and risky
due to limitations in distal dissection imposed by the common peroneal nerve and tibioperoneal trunk/anterior tibial
artery.
Posterior, inverted L-shaped approach
A posterior, inverted L-shaped approach is recommended for fractures involving the posterior column or in combination
with the medial column.
• The procedure is performed with the patient in a floating position or prone.
• A transverse incision is made in the skin crease of the popliteal fossa, turning distally at the medial corner to form a
vertical limb parallel to the posteromedial border of the tibia.
• A fasciocutaneous flap is raised, protecting the sural nerve and short saphenous vein.
• The tendon of the medial head of the gastrocnemius is visualized and the deep fascia over gastrocnemius is incised close
to the posteromedial border of the tibia.
• The popliteus muscle is identified at the posteromedial border of the tibia, and the fascia is incised to elevate the muscle
from medial to lateral, retracting it laterally.
• This protects the popliteal vessels and exposes the fracture, the posterior column, and the posterior knee capsule.
• Care should be taken to avoid overdissection laterally toward the fibula to prevent injury to the bifurcation of the
popliteal artery and the common peroneal nerve.
Reduction
• Single condylar injuries are approached through longitudinal incisions.
• Direct joint reduction is performed followed by the placement of lag or raft screws and subchondral bone
support with bone graft or substitute.
• Buttress plating is done to provide additional stability.
• Reduction of the intraarticular portion usually requires direct inspection of the joint via an arthrotomy.
• The lateral plateau can be rotated laterally with its soft-tissue attachments to facilitate inspection of the
joint impaction.
• The depressed area and fragments are gently elevated and directly reduced using a bone tamp from below.
• The femoral condyle serves as a template for the reduction.
• Assessment of the intercondylar area and cruciate ligaments should be performed during this process.
Reduction
• The femoral distractor or external fixator can be used for indirect reduction.
• Ligamentotaxis can be employed to correct alignment, rotation, and length in cases of diaphyseal extension of the
fracture.
• Nonlocking reduction screws and plates can aid in the final adjustment of reduction.
• In bicondylar fractures, reducing the medial plateau fragment is a key step, often accomplished by pushing the fragment
proximally and buttressing it with an antiglide plate.
• Perfect reduction of the joint surface can be achieved without opening the joint in cases of simple metaphyseal fractures.
• Reduction of the articular surface is a priority in cases of metaphyseal comminution, followed by fixation of the articular
block to the shaft.
• Careful preoperative study of x-rays is crucial to identify anatomical landmarks and plan the surgical approach.
Fixation
• Fixation should be determined based on the injury mechanism and 3-D pathomorphology.
• Identifying the compression side and tension side of the fracture helps guide the choice of
fixation.
• The compression side requires a buttress plate to provide support.
• The tension side, opposite to the compression injury, may require a smaller plate or no plate
depending on the situation.
• Reduction of impacted metaphyseal bone can lead to bone defects, which may need to be filled
with bone autograft, allograft, or bone substitutes to enhance support for the reduced joint
surface.
Extraarticular fractures (41A1)
• Extraarticular proximal tibial fractures are complex with significant soft-tissue damage and often exhibit specific fracture
patterns.
• The surrounding muscles and tendons contribute to malalignment, leading to valgus and extension deformities of the
proximal fragment.
• Understanding the mechanism of injury is crucial for guiding reduction and fixation.
• Operative stabilization is typically recommended for these fractures, even if they are not grossly displaced or unstable.
• Plates providing angular stability are preferred due to the short proximal segment and biomechanical challenges.
• Minimally invasive techniques, such as the less invasive stabilization system plate and locking compression plate, have
shown excellent outcomes in terms of fracture union, infection rate, and maintaining reduction.
• Severe comminution or defects in the medial cortex may require an additional medial plate to prevent secondary loss of
alignment and varus deformity.
Extraarticular fractures (41A1)
• Unstable fractures with severe soft-tissue damage may require temporary stabilization with external fixation to minimize
the risk of wound-healing problems.
• External fixation can be used as a definitive management option or as a bridge to internal fixation.
• Hybrid external fixators or ring fixators following Ilizarov principles may be utilized for proximal fracture fixation.
• IM nailing with specialized nails and multiple proximal locking options is recommended for certain cases.
• Reduction of the proximal fracture is crucial before nail insertion to prevent malalignment.
• Additional tools such as forceps, Poller screws, or LCP plates may be necessary to maintain reduction during nail
insertion.
• Suprapatellar nail insertion technique with knee extension helps avoid malalignment and offers good clinical results,
including improved tibial alignment, union, knee movement, and reduced anterior knee pain.
• Careful application of this surgical technique has shown no significant damage to the articular cartilage of the
patellofemoral joint, as confirmed by arthroscopy and MRI scans.
Partial articular fractures (41B)
Lateral column fracture: pure split fractures (41B1.1, B1.3), split-depression/total depression fractures
(41B3.1, B3.3).
• Lateral column fractures result from a valgus-extension force and require buttress fixation after reduction to prevent recurrent valgus deformity.
• An anterolateral approach is recommended for surgical access.
• Split fractures (41B1.1) can be treated with buttress plate fixation, lag screw fixation, or a combination of both.
• Split-depression fractures (41B3.1) involve a lateral column fracture with impaction of the articular surface. Preoperative assessment, such as
CT scan, is crucial to evaluate the extent of articular damage.
• Provisional K-wire fixation can stabilize the impacted fragment(s) of the articular surface before definitive fixation.
• Fixation with a plate is typically the preferred method, with the option of inserting lag screws independently or through the plate.
• Buttress plates are used for split fractures, while lateral locking plates or plates allowing screw rafting beneath the subchondral bone provide
angular stability and support for the impacted joint surface.
• Displaced meniscal tears should be addressed and repaired once the articular surface is reconstructed to achieve anatomical reduction.
Medial column fractures (41B1.2, 41B1.3, 41B2.2, 41B3.2)
• Medial column tibial plateau fractures, often caused by a varus extension force, may involve associated
vascular, nerve, and ligament injuries.
• Treatment includes the use of a medially placed buttress plate to prevent varus deformity.
• Assessment of knee stability is crucial after fracture fixation, and any findings should be documented in the
operation note.
• Associated posterolateral corner soft-tissue injuries with instability should be repaired early in the
treatment process.
• Medial column fractures commonly occur in combination with posterior column fractures, requiring a
different approach to management compared to isolated medial column injuries.
Posterior column fractures (41B2.3, 41B3.2)
• Fracture dislocation involving the medial part of the posterior column is a common type of posterior column fracture.
• It is often associated with a posterior-central or posterior-lateral articular depression and is caused by a varus-flexion
injury mechanism.
• Early reduction is important and can be achieved by maintaining the knee in extension-valgus with axial traction.
• The dislocation should be reduced and fixed using a posteromedial buttress plate.
• Accessing the depressed articular surface may require different approaches, with an inverted L-shape approach being a
reasonable option.
• Associated injuries such as anterior cruciate ligament avulsion and lateral meniscus tear are common and may require
repair.
• Managing the lateral part of the posterior column is challenging, and the optimal treatment approach is still uncertain.
• Surgical access to this area for reduction and fracture fixation is difficult, even for experienced surgeons.
Depressed articular fractures (41B2)
• Lateral plateau injuries are common and often involve circumscribed impactions.
• CT scan is necessary for accurate assessment as regular x-rays may not reveal the full extent of the impaction.
• Restoring the height of the affected joint compartment is crucial to prevent secondary collapse and valgus deformity.
• Rafting screws and plates are the preferred treatment approach for these fractures.
• Intraoperative arthroscopy can be beneficial in assisting with the surgical procedure.
Complete articular fractures (41C)
• Bicondylar tibial plateau fractures involve the medial and lateral columns, or all three columns, and are often caused by
high-energy trauma.
• Fractures extending into the shaft pose a risk of compartment syndrome and severe soft-tissue damage, requiring initial
joint-spanning external fixation.
• Percutaneous reduction may be attempted for simple articular fractures with a single fracture line.
• Medial fragment fixation is usually done through a separate posteromedial incision with a buttress plate.
• The medial condyle can often be anatomically reduced without opening the joint, while the lateral plateau can be reduced
onto the medial condyle through an anterolateral or parapatellar incision.
• Disimpaction and reconstruction of the articular surface follow similar principles as described for other fracture types.
• Lag screw fixation and locking plates are used for anatomically reduced articular blocks, while comminution can be
bridged with long locking plates.
• Bicondylar fractures with a separate tibial tubercle fragment require secure fixation to preserve the extensor mechanism.
• Type C fractures involving the posterior column may benefit from a posterior approach like the inverted L-shaped
incision for precise reduction.
Challenges
• Three-column fractures involving the lateral part of the posterior column are highly challenging tibial plateau fractures.
• An inverted L-shaped posterior approach combined with an anterolateral approach can be used for these fractures.
• Soft-tissue care and timely surgery are crucial for optimal outcomes.
• Compartment syndrome must be suspected and treated aggressively to prevent morbidity.
• Fixation in the presence of open fasciotomy wounds is difficult, and circular frame management should be considered.
• Ipsilateral tibial plateau fractures combined with shaft fractures are uncommon, often resulting from high-energy
mechanisms.
• Prioritizing fixation of the articular fracture allows for subsequent insertion of an intramedullary (IM) nail for the shaft
fracture.
• Aftercare
• Isometric quadriceps exercises are started early after surgery for rehabilitation.
• Some surgeons immobilize the knee in extension for 2 weeks to promote wound healing and
prevent flexion contractures. Alternatively, a continuous passive motion device may be used.
• Toe-touch weight bearing is typically recommended for 6-8 weeks, depending on fracture
healing and soft-tissue recovery.
• Fractures caused by high-energy trauma may require toe-touch weight bearing for 10-12
weeks, with active flexion exercises during the last 10 weeks of this period.
Complications
• Wound complications can be minimized by careful evaluation of soft-tissue condition, precise timing of
surgery, appropriate surgical approaches, and minimal soft-tissue stripping.
• Correction of mechanical axis and significant articular depression is important to prevent malunion and
joint deformity.
• Stable fracture fixation that allows early joint mobilization is a key goal of surgery to achieve better
outcomes.
• Prolonged immobilization can lead to arthrofibrosis with severe stiffness and flexion deformity, so
attention should be given to knee extension exercises and addressing other major joints in the leg during
physical therapy.
• Arthroscopic lysis of adhesions and gentle manipulation under anesthesia may be necessary for patients
who do not achieve 90° of flexion within the first 12 weeks.
Complications
Major causes of posttraumatic arthritis are:
• Axial malalignment
• Ligamentous instability
• Primary damage to the articular cartilage Meniscectomy
• Articular incongruity
• Infection
Prognosis and outcome
• Surgical treatment of low-energy tibial plateau fractures in younger patients generally leads to good results.
• Elderly patients with osteoporosis present challenges in the treatment of tibial plateau fractures due to a higher incidence
of severe joint depression, secondary joint surface impaction, and valgus deformity.
• Total knee replacement arthroplasty is being explored as a potential treatment option for these fractures in elderly
patients, but the indications and outcomes are not yet clear.
• High-energy bicondylar tibial plateau fractures treated with dual plating through two incisions may have a higher risk of
nonunion and deep infection.
• Restoring bone alignment, ligamentous stability, and preserving the menisci are important factors in achieving favorable
outcomes.
• Knee stability is considered a crucial factor for long-term patient outcome.