Open Reduction and Internal Fixation of Tibial Plateau Fractures

Introduction

Patient Selection

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  Careful examination of injured extremity is mandatory
  
  
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  Vascular injury, compartment syndrome, and open injuries should be treated emergently
  
  
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  Note knee stability and soft-­tissue conditions and image appropriately

Indications

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  Absolute, for open treatment—Open fractures, compartment syndrome, vascular injury
  
  
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  Relative—Joint instability or malalignment, medial condylar fractures, lateral plateau fractures with displacement greater than 3 mm, condylar widening greater than 5 mm, patient with multiple traumatic injuries
  
  
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  Consider closed treatment for fractures with less than 2 mm of joint surface displacement, normal alignment, and stable knee in extension

Contraindications

Alternative Treatments

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  For bicondylar fractures—Alternative technique uses small-­wire ringed external fixator
  
  
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  For minimally displaced lateral split fractures with minimal joint surface comminution—Closed reduction with percutaneous fixation is an option; rule out lateral meniscus injury or incarceration preoperatively with MRI
  
  
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  For some fractures with intact or restorable cortical envelope—Arthroscopically assisted reduction and fixation

Classification

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  Two classification systems describe fracture pattern but do not consider ligamentous or soft-­tissue injury or predict outcomes
  
  
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  Schatzker classification
  

  
  
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    Six types
    
    
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    Types I, II, III—Low-­energy mechanism; involve lateral plateau
    
    
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    Types IV, V, VI—Higher-­energy mechanism; involve medial plateau or bicondylar injury
  
  
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  AO/Orthopaedic Trauma Association classification
  

  
  
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    Classified as extra-­articular, partial articular, and complete articular
    
    
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    Further subdivisions based on fracture severity

Preoperative Imaging

Radiography

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  AP, lateral, and internal/external oblique views of knee
  
  
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  AP with beam directed 10° caudal shows articular surface displacement

Computed Tomography