Introduction

Tibial plateau fractures account for approximately 1% of all fractures with a frequency similar to the calcaneus and humeral shaft. Serial neurovascular monitoring of tibial plateau fractures is important as high-energy fractures are at risk of compartment syndrome. Goals of surgical management include restoration of the articular surface, alignment, and joint stability. Emphasis is placed on soft-tissue management with the use of staged surgeries, dual incisions, and minimally invasive surgical techniques (Video 40.1).

I. Preoperative

1. 
   

   History and physical examination

   
   
   
   
   1. 
      

      Mechanism of injury:

      
      
      
      
      1. 
         

         Low energy—twisting, slip, and fall from standing height injuries:

         
         
         
         
         • 
           

           i. Varus and valgus forces can drive the femoral condyle into the underlying corresponding tibial plateau.

           
           
         • 
           

           ii. These injuries commonly occur in the elderly population with osteoporotic bone.

         
         
      2. 
         

         High energy—falls from height, skiing/sport injuries, motor vehicle accidents:

         
         
         
         
         • 
           

           i. Axial load to the knee that can cause bicondylar tibial plateau fractures.

           
           
         • 
           

           ii. Usually occurs in younger patients with more dense bone.

      
      
   2. 
      

      Weight-bearing status:

      
      

      The patient is typically unable to bear weight.

      
      
   3. 
      

      Patient comorbidities:

      
      
      
      
      1. 
         

         Smoking status.

         
         
      2. 
         

         Medical history.

      
      
   4. 
      

      Patient employment and activity level.

      
      
   5. 
      

      Inspection:

      
      
      
      
      1. 
         

         View the soft tissues circumferentially (including posterior aspect of knee) to ensure there are no open wounds or lacerations.

         
         
      2. 
         

         Usually a significant joint effusion indicative of lipohemarthrosis (fat and blood contents from the exposed underlying bone marrow) is present.

         
         
      3. 
         

         Significant soft-tissue swelling and bruising may be present.

      
      
   6. 
      

      Palpation:

      
      
      
      
      1. 
         

         Significant tenderness to palpation about the proximal tibia.

         
         
      2. 
         

         May palpate crepitus from subcutaneous fracture fragments.

      
      
   7. 
      

      Range of motion:

      
      
      
      
      1. 
         

         Usually deferred in more severe fractures due to pain and instability from the fracture.

         
         
      2. 
         

         In minimally displaced or nondisplaced fractures, patients may have a painful arc of motion that is limited.

      
      
   8. 
      

      Neurovascular examination:

      
      
      
      
      1. 
         

         The importance of a thorough neurovascular examination cannot be overstated.

         
         
      2. 
         

         Neurological:

         
         
         
         
         • 
           

           i. Motor: Ankle dorsiflexion (deep peroneal nerve), extensor hallucis longus (deep peroneal nerve), gastrocnemius (tibial nerve), flexor hallucis longus (tibial nerve), and peroneals (superficial peroneal nerve) should be documented.

           
           
         • 
           

           ii. Sensation: Gross sensation in sural, saphenous, deep peroneal, superficial peroneal, and tibial nerves should be documented.

         
         
      3. 
         

         Vascular:

         
         
         
         
         • 
           

           i. The dorsalis pedis and posterior tibial arterial pulses should be palpated. The quality of the pulse should be compared to the contralateral extremity and documented.

           
           
         • 
           

           ii. If the pulses are unable to be palpated, a Doppler ultrasound should be used to document the presence or absence of pulses.

           
           
         • 
           

           iii. If there is any mismatch in pulses compared to the contralateral extremity, an ankle brachial index (ABI) should be obtained.

           
           
         • 
           

           iv. ABIs less than 0.9 warrant further vascular workup (angiography) and consultation.

      
      
   9. 
      

      Stability testing:

      
      
      
      
      1. 
         

         In high-energy fractures with severe comminution, this step can be skipped initially due to patient discomfort.

         
         
      2. 
         

         In minimally displaced or borderline operative fractures, the stability of the knee should be tested by applying a varus and valgus force with the knee in full extension.

         
         
      3. 
         

         This maneuver may be too uncomfortable due to fracture pain and a large joint effusion. In order to obtain a reliable examination, the hemarthrosis can be aspirated with a large bore needle (18–21 gauge) and the knee injected with approximately 10 to 20 mL of local anesthetic (1% lidocaine with or without epinephrine, 0.5% Marcaine with or without epinephrine).

         
         
      4. 
         

         Any increase in joint laxity to varus or valgus stress examination greater than 10 degrees compared to the contralateral side is deemed unstable.

      
      
   10. 
       

       Compartment syndrome monitoring:

       
       
       
       
       1. 
          

          Reported incidence up to 20% in high-energy bicondylar tibial plateau fractures.

          
          
       2. 
          

          Requires vigilant monitoring and expeditious diagnosis with subsequent surgical fascial release.

   
   
2. 
   

   Anatomy

   
   
   
   
   1. 
      

      Definition:

      
      
      
      
      1. 
         

         According to the AO/OTA classification, tibial plateau fractures encompass fractures of the proximal tibial articular surface and a portion of the tibial metaphysis equal to the width of the joint at its widest point (▶ Fig. 40.1 ).

         

      
      
   2. 
      

      Skeletal:

      
      
      
      
      1. 
         

         The skeletal anatomy includes the medial condylar articular surface, lateral condylar articular surface, and medial/lateral intercondylar eminences (also called tibial spines; ▶ Fig. 40.2a, b ).

         

         
         
         
         
         • 
           

           i. The medial condyle of the tibial plateau is larger than the lateral condyle, concave, has stronger subchondral bone, and sits lower on a lateral radiograph.

           
           
         • 
           

           ii. The lateral condyle is smaller, convex, has weaker subchondral bone, and sits higher on a lateral radiograph compared to the medial condyle.

           
           
         • 
           

           iii. The intercondylar eminence has anterior and posterior areas that serve as attachment points for the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), respectively.

      
      
   3. 
      

      Alignment (▶ Fig. 40.3 ):

      

      
      
      
      
      1. 
         

         The proximal tibia articular surface is in 3-degree anatomic varus, meaning the lateral condyle is slightly higher than the medial condyle when viewing an anteroposterior (AP) radiograph (average medial proximal tibia angle = 87 degrees).

         
         
      2. 
         

         The proximal tibia articular surface has approximately 5 to 10 degrees of posterior slope (average posterior proximal tibia angle = 81 degrees).

      
      
   4. 
      

      Soft tissue (▶ Fig. 40.4 ):

      

      
      
      
      
      1. 
         

         Meniscus:

         
         
         
         
         • 
           

           i. The medial and lateral menisci are fibrocartilaginous rings of tissue that are located on top of the medial and lateral condyles.

           
           
         • 
           

           ii. Function:

           
           
           
           
           • 
             

             Cushion the knee joint to allow for smooth articulation between the distal femur and proximal tibia.

             
             
           • 
             

             Stress distribution.

             
             
           • 
             

             Load transmission.

           
           
         • 
           

           iii. These structures are frequently torn in association with tibial plateau fractures (typically reported incidence of 40% but has been described in up to 80%), most commonly tearing off its peripheral attachment to the capsule of the knee joint (meniscocapsular avulsions).

         
         
      2. 
         

         Ligaments:

         
         
         
         
         • 
           

           i. There are four main ligaments surrounding the knee joint. These structures can be injured at their proximal or distal bony insertions while remaining attached to the bone (avulsion fracture) or can be torn in the middle of the ligament (intrasubstance tear).

           
           
           
           
           • 
             

             ACL—resists excessive anterior translation of the tibia in relation to the femur.

             
             
           • 
             

             PCL—resists excessive posterior translation of the tibia in relation to the femur.

             
             
           • 
             

             Medial collateral ligament (MCL):

             
             
             
             
             • 
               

               Function—resists excessive valgus force to the knee joint.

               
               
             • 
               

               Clinical significance—may be injured in lateral condyle tibial plateau fractures.

             
             
           • 
             

             Lateral collateral ligament (LCL):

             
             
             
             
             • 
               

               Function—resists excessive varus force to the knee joint.

               
               
             • 
               

               Clinical significance—may be injured in medial condyle tibial plateau fractures.

         
         
      3. 
         

         Tendons:

         
         
         
         
         • 
           

           i. Patellar tendon—inserts into the anterior aspect of the proximal tibia at the tibial tubercle.

           
           
           
           
           • 
             

             Function—knee extension.

           
           
         • 
           

           ii. Iliotibial band—inserts into anterolateral aspect of proximal tibia at “Gerdy’s tubercle.”

           
           
           
           
           • 
             

             Function—part of the “posterolateral corner,” a group of tendons, ligaments, and the knee capsule that stabilize the knee in extension/slight flexion.

           
           
         • 
           

           iii. Hamstring tendons—group of three hamstring tendons (gracilis, semitendinosus, sartorius), referred to as the pes anserine, insert into anteromedial aspect of proximal tibia.

           
           
           
           
           • 
             

             Function—knee flexion.

      
      
   5. 
      

      Neurovascular structures:

      
      
      
      
      1. 
         

         Common peroneal nerve—winds around the fibular neck (upper aspect of fibula) and is the most common nerve injury in tibial plateau fractures.

         
         
         
         
         • 
           

           i. The nerve most commonly is stretched due to a varus injury to the knee.

           
           
         • 
           

           ii. The resulting nerve injury usually resolves with observation.

           
           
         • 
           

           iii. Function:

           
           
           
           
           • 
             

             Deep peroneal nerve controls ankle dorsiflexion and provides sensation between the first and second web space dorsally on the foot.

             
             
           • 
             

             Superficial peroneal nerve controls ankle eversion and provides sensation to the majority of the dorsum of the foot.

         
         
      2. 
         

         Tibial nerve and popliteal artery:

         
         
         
         
         • 
           

           i. Course along the posterior aspect of the knee immediately behind the knee capsule.

           
           
         • 
           

           ii. Can suffer stretch injuries due to the mechanism of injury, displaced bony fragments, or knee dislocations in association with fracture.

           
           
         • 
           

           iii. Rarely, the popliteal artery can be transected.

   
   
3. 
   

   Imaging assessment

   
   
   
   
   1. 
      

      Radiographs:

      
      
      
      
      1. 
         

         High-quality AP and lateral radiographs of the knee and tibia—Visualize the joint above and below the fracture.

         
         
      2. 
         

         Tibial plateau view:

         
         
         
         
         • 
           

           i. X-ray beam angled similarly as an AP radiograph of the knee but with 10 degrees of caudal tilt. This is due to the approximately 10-degree slope of the proximal tibia articular surface.

      
      
   2. 
      

      CT scan:

      
      
      
      
      1. 
         

         Usually obtained for operative fractures to measure displacement and/or precisely define fracture fragments for preoperative planning.

         
         
      2. 
         

         Aids the surgeon in identifying occult fractures that would otherwise be missed on plain radiographs:

         
         
         
         
         • 
           

           i. Lipohemarthrosis visualized on CT scan is a clue that an occult fracture is present.

           
           
         • 
           

           ii. Especially helpful in identifying posteromedial shear fractures that could require an additional incision and surgical fixation in the operating room (▶ Fig. 40.5 ).

           

         
         
      3. 
         

         If there is significant soft-tissue injury or fracture displacement and external fixator placement is planned, the CT scan should be obtained after placement of the external fixator to aid in fracture pattern recognition (see ‘External Fixation’ section later in this chapter).

      
      
   3. 
      

      MRI:

      
      
      
      
      1. 
         

         The role of MRI in tibial plateau fractures is controversial.

         
         
      2. 
         

         Identifies soft-tissue injuries that are not visible on X-ray or CT (meniscus and ligament tears).

         
         
      3. 
         

         Oftentimes, the lateral meniscus is routinely visualized during surgery (see “Open reduction internal fixation”). However, during the posteromedial approach, the medial meniscus is not routinely visualized.

   
   
4. 
   

   Classification

   
   
   
   
   1. 
      

      OTA-AO classification:

      
      
      
      
      1. 
         

         The fracture can be subdivided into either type A, B, or C.

         
         
         
         
         • 
           

           i. Extra-articular (type A)—the articular surface is not fractured, but there is a fracture of the proximal tibia metaphysis that is a distance equal to or less than the width of the joint at its widest point.

           
           
         • 
           

           ii. Partial articular (type B)—there is a fracture of the articular surface of the tibia, but a portion of the articular surface remains in continuity with the metaphysis/diaphysis.

           
           
         • 
           

           iii. Complete articular (type C)—there is a fracture of the articular surface, and no portion of the articular surface remains attached to the underlying metaphysis/diaphysis.

      
      
   2. 
      

      Schatzker’s classification (▶ Fig. 40.6 ):

      

      
      
      
      
      1. 
         

         This classification is the most commonly used to describe the general characteristics of a tibial plateau fracture.

         
         
      2. 
         

         The classification is intended to describe increasing severity of fractures with each number.

         
         
         
         
         • 
           

           i. Schatzker I—isolated split fracture of the lateral tibia plateau; often occurs in young patients with strong subchondral bone.

           
           
         • 
           

           ii. Schatzker II (▶ Fig. 40.7 )—split fracture of the lateral tibia plateau with associated depression of the articular surface; most common tibial plateau fracture.

           

           
           
         • 
           

           iii. Schatzker III—pure depression fracture of the lateral tibial plateau:

           
           
           
           
           • 
             

             Relatively uncommon fracture pattern.

             
             
           • 
             

             Usually occurs in the elderly population and/or those with osteoporotic bone.

             
             
           • 
             

             Be aware of the difference between a lateral tibial plateau split fracture with displacement versus a lateral tibial plateau fracture with depression as they can be easily confused radiographically.

           
           
         • 
           

           iv. Schatzker IV (▶ Fig. 40.8 )—split fracture of the medial condyle often with extension into the intercondylar eminence:

           

           
           
           
           
           • 
             

             These fractures tend to be highly unstable as they can be associated with a fracture dislocation.

             
             
           • 
             

             Have the highest rate of associated neurovascular and ligamentous injuries.

             
             
           • 
             

             Require a high level of vigilance to avoid devastating complications.

           
           
         • 
           

           v. Schatzker V—fracture of the medial and lateral condyles of the tibial plateau (“bicondylar fracture”) typically with the tibial spines remaining in continuity with the diaphysis. This pattern is relatively uncommon.

           
           
         • 
           

           vi. Schatzker VI (▶ Fig. 40.9 )—fracture of the medial and lateral condyles of the tibial plateau (“bicondylar fracture”) with no remaining attachment of the articular surface to the diaphysis:

           

           
           
           
           
           • 
             

             Usually associated with significant soft-tissue injury.

             
             
           • 
             

             Medial and bicondylar tibial plateau fractures (Schatzker IV–VI) have the highest rates of compartment syndrome.