At the peak: a review of current diagnostic and therapeutic concepts surrounding tibial plateau fractures

Abstract

Tibial plateau fractures are complex injuries commonly resulting from high-energy trauma in younger patients or low-energy falls in the elderly. They significantly impair knee function and overall quality of life, often leading to complications such as post-traumatic osteoarthritis and knee stiffness. This review looks at current diagnostic modalities, epidemiological data, anatomical considerations, and therapeutic strategies for managing tibial plateau fractures, highlighting advancements in treatment and outcomes. The well-established Schatzker and AO/OTA systems of classification have evolved alongside emerging frameworks like the three-column classification and ten-segment concepts that utilize three-dimensional imaging technologies. Tibial plateau fractures have an estimated incidence of 10.3 per 100,000 people, with males affected more frequently than females. The incidence increases with age, particularly among women in their seventh decade. The management of tibial plateau fractures can involve either non-operative or operative interventions. While minimally displaced fractures may be treated conservatively, more complex cases typically require surgical procedures such as open reduction and internal fixation or arthroscopically assisted techniques. Recent improvements in rehabilitation protocols and surgical techniques aim to enhance recovery and minimize complications. Long-term assessments indicate that functional deficits and complications persist in many patients following tibial plateau fractures. Factors such as age, fracture type, and soft tissue integrity significantly influence recovery trajectories. Effective management of tibial plateau fractures requires a multi-faceted approach that utilizes imaging techniques, judicious surgical intervention, and patient-tailored rehabilitation. Further research is needed to refine treatment protocols and establish standardized methods for evaluating functional outcomes.

Introduction

Tibial plateau fractures are significant injuries that often result from high-energy trauma in young patients or low-energy trauma in the elderly, such as falls from height or road traffic collisions. This can lead to morbidity due to their complex nature.

It is important to appreciate the degree of soft tissue trauma, particularly in fractures with a high-energy mechanism of injury. The tibial plateau plays a pivotal role in load-bearing and joint stability.

The Schatzker and AO/OTA are the most popular classification systems in practice, however with the advent of three-dimensional (3D) imaging, newly developed classification systems such as the three-column concept by Luo et al. and the 10-segment concept by Krause et al. are becoming more popular. These systems categorize proximal tibia fractures based on fracture patterns and associated injuries, guiding treatment decisions and prognostic outcomes. ^,

The impact of tibial plateau fractures on quality of life and function can be profound, often leading to pain and impaired mobility. Due to the disruption of normal knee biomechanics, long-term complications such as post-traumatic osteoarthritis and knee stiffness are common. As a result, the management of tibial plateau fractures has evolved significantly. Whilst minimally displaced tibial plateau fractures with no associated injuries can be safely managed non-operatively, typically this injury requires orthopaedic consultation and operative management. Advanced surgical techniques, improved imaging, and rehabilitation protocols have been developed to enhance recovery and minimize functional impairment.

This update on tibial plateau fractures will explore these topics, drawing attention to the importance of precise diagnosis, analysis of fracture patterns, and the latest advancements in treatment approaches.

Epidemiology

Globally, the burden of tibial plateau fractures is to have a yearly incidence of 10.3 per 100,000 people, with an approximate mean age of 53. Men are affected more than women with male to female ratio reported as high as 3:1. It is worth noting that the incidence increases in females with advancing age around the 7th decade of life while it reduces in males with advancing age from the age of 50. ^,

Anatomy and biomechanics of the tibial plateau

The proximal tibia has two separate condyles (termed plateaus) with their respective cartilage surfaces. The medial tibial condyle bears 60% of the knee’s weight and is a thicker structure. It is concave and located slightly more distally compared to the lateral tibial condyle. The lateral tibial condyle is convex, thinner, weaker, and more proximal than the medial tibial condyle. ^,

Each articular surface is partially covered by its corresponding meniscus. Between the two articular condyles is an area of bone not covered by cartilage (the intercondylar eminence), which is extra-articular. There is a difference in the mechanical function between the areas covered by cartilage, which serve as the weight-bearing areas and are responsible for the stability of the joint, and the intercondylar eminence and those that are simply bone and serve as points of attachment of soft tissues such as ligaments and capsule. The ligaments and menisci of the knee joint are also at risk of injury risk for injury in association with tibial plateau fractures. ^,

The tibial articular joint surface and the attached soft tissues provide two functions: (a) stability: the ability of the tibial plateau to contain and retain the femoral condyles in their normal position in their natural relation to the articular surfaces of the plateau and (b) weight transmission: the restoration of normal weight-bearing capacity. In the setting of a fracture, the articular surfaces covered by cartilage should be reduced anatomically. The bony areas that are not covered by cartilage but serve as attachment sites for the soft tissues, are not directly involved in weight transmission and do not require the same degree of reduction.

Some of the major factors in determining the fracture patterns seen in the tibia plateau include the angulation of the knee at the time of the injury, the energy of the trauma, and the bone density. The position of the knee at the time of impact, whether flexed or extended, determines which part of the articular surface of the tibial plateau is loaded. If the deforming force is applied in flexion, as is most common, the posterior quadrants of the knee will be fractured. If the knee is in extension the fractures will be in the anterior quadrants, whereas varus and valgus forces determine which of the condyles is fractured. A varus force disrupts the medial column while a valgus force disrupts the lateral column.

Clinical presentation and diagnosis

Clinical manifestations of tibial plateau fracture include knee pain, swollen knee, skin, and soft tissue injuries, and difficulty in bearing weight, mostly following a high-energy trauma. Other features could include neurovascular deficits, overt open fractures, and features of compartment syndrome. Although the evaluation of patients with a suspected tibial plateau fracture begins with a history and physical assessment, the mainstay of the diagnosis remains imaging modalities due to the detailed information that can be obtained, hence they are also the basis of the classification of tibial plateau fractures. Typically, every patient being assessed for the possibility of a tibial plateau fracture should have a plain radiograph (X-ray) with anteroposterior (AP), lateral, and oblique views, however identifying the respective pieces of the fracture is limited on the X-rays, which accounts for a lower sensitivity in recognizing Tibial plateau fractures as compared to more advanced like imaging like Computed tomography (CT) scan. Identifying the presence of communications and depressed articular surface is done through a CT scan. Furthermore, features such as the pattern of the fracture, and size of the respective fragments can also be appreciated on a CT scan. ^, Magnetic resonance imaging (MRI) also has a role in the evaluation of patients, especially in identifying injuries to ligaments. Figure 1 illustrates the clinical and radiological presentation of a patient who present with a tibial plateau fracture.

Classification of tibial plateau fractures is majorly based on the patterns of the fracture as identified on the imaging. The well-publicized Schatzker classification described six types (Type I-VI) of tibial plateau fractures based on the pattern of fractures on plain radiographs with advancing numbers corresponding to the severity of the fracture (Schatzker et al. 1979). The AO/OTA classification of proximal tibia fracture further classifies the fracture patterns based on articular involvement which includes extra-articular (a), partial articular (b), and complete articular (c) fractures (Müller et al., 1990). Luo et al. (2010) used the more detailed features from CT scan to explain another classification known as the three-column classification. This classification is based on the involvement of the three columns of the tibia plateau (lateral, medial, and posterior column; shown in Figure 2 ). The three-column classification describes an independent articular depression with a break of the column wall as a fracture of the relevant column. Some aspects of this classification fit into the Schatzker classification. One column has three variations; a pure split or split depression of the lateral tibia plateau is equivalent to Schatzker I and II, respectively. However, an isolated one posterior column fragment does not fit into the Schatzker classification.

The two-column fracture with a pure split or split depression of the medial plateau and a separate posteromedial fragment corresponds to a Schatzker IV, while the lateral equivalent was not included the Schatzker classification.

Three-column fractures describe the traditional bicondylar Schatzker IV and V combined with a separate posterolateral articular fragment. Pure depressions (Schatzker type III) are defined as zero column fractures.

The centre of intercondylar eminence, anterior tibial tuberosity, the posteromedial ridge of the proximal tibia, the most anterior point of the fibular head, and posterior sulcus of the tibial plateau were the landmarks used in this classification in dividing into the columns. The medial and lateral columns are anterior and posterior components respectively. The number of columns affected determines the nomenclature as outlined above. The significant feature of the three-column classification is that it recognizes the importance of the posterior tibia plateau (posterolateral and posteromedial fragments), which on its own account for 5–10% of all tibial plateau fractures and the need for surgical fixation when affected. Malalignment, impaired function, and failed fixations are some of the complications of failure to stabilize the fragments of the posterior column which has been documented in recent studies. It is worth noting that there are other classifications of tibial plateau fractures such as the Hohl and Moore classification (shown in Table 1 ) which are useful especially when there is a dislocation or instability of the associated knee. Overall, there is no consensus on the ideal classification of tibial plateau fractures, however, the three-column classification gives more details when planning surgical management of tibial plateau fractures.

Table 1

Hohl and Moore classification

Type I	Coronal split fracture
Type II	Entire condylar fracture
Type III	Rim avulsion fracture of the lateral tibial plateau
Type IV	Rim compression fracture
Type V	Four-part fracture