History

How an injury was sustained is an important clue to its severity. The surgeon should try to understand the mechanism causing the fracture. This mechanism should suggest the likelihood of significant soft tissue injury, ligament disruption, or vascular injury. For example, a lateral plateau fracture sustained by a pedestrian struck by an automobile is completely different from one caused by a misstep off a curb.

The history ideally indicates the direction of the force of injury, which is helpful in predicting soft tissue injury and guides further evaluation. For example, whereas a valgus force to the lateral knee in a football player may suggest a medial collateral ligament (MCL) injury, a witnessed hyperextension deformity may indicate disruption of cruciate ligaments and vascular injury. An axial load sustained during a MVA with the knee in extension implies a crushing mechanism that may create more articular damage or soft tissue swelling.

Some patient-related considerations are important to determine during the history-taking process. Age and bone quality are generally related, with younger patients having denser bone. A young adolescent may be skeletally immature and sustain a growth plate injury. A comminuted fracture in an elderly versus a young patient carries completely different implications when considered along with the injury mechanism. Sometimes knowing the age may tip the surgeon off to important comorbidities; for example, a 40-year-old man with osteoporotic bone and a comminuted fracture after a fall down stairs may be a malnourished alcoholic. Proximal tibial fractures, particularly the more severe ones, occur in vehicular incidents or falls from a height. The possibility of other, potentially occult, injuries must always be remembered, and the whole patient must be evaluated accordingly.

It is important to ascertain comorbidities in these patients because soft tissue considerations must guide surgical choices. As an example, smoking, diabetes, vascular disease, and congestive heart failure all negatively affect the healing capacity of surgical wounds. Last, a patient’s activity level, employment status, and recreational diversions say a lot about such issues as motivation, compliance, and physical demands after surgery.

Physical Examination

Examination of a patient with a known or possible tibial plateau fracture begins, as it should for any injured patient, with the advanced trauma life support (ATLS) routines of primary and secondary survey. Immediate attention may need to be directed to resuscitation and treatment of injuries that threaten life or limb. The possibility of a popliteal arterial injury arises with any significant knee trauma. Its rapid identification and surgical treatment are indeed limb saving and are discussed in some detail later on. Knee evaluation is part of the secondary survey unless exsanguinating local hemorrhage is present.

Frequently, the orthopaedic trauma surgeon is called to see an injured patient whose radiographs demonstrate a tibial plateau fracture. Even if the radiographic diagnosis is known, particularly if the patient is unable to communicate, attention must be paid to signs of open wounds, swelling, deformity, instability, or crepitus. Distal pulses must always be examined, as should compartmental soft tissue swelling and turgor. For high-energy injuries, a thorough vascular assessment with documentation of an arterial pressure index (API) is mandatory.

Even if the API is greater than 0.9, serial clinical examination, focused on swelling, motor function, sensation, and stretch pain, is advisable because patients with tibial plateau fractures and intact arteries may develop compartment syndrome during the first few days after injury (or surgery). If the API is less than 0.9, further vascular workup with an arteriogram is immediately necessary. We strongly recommend measurement of relative arterial pressure . Too often, physicians have focused on whether a pedal pulse is palpable or identifiable with a Doppler device. But this approach is not sensitive enough to exclude reliably a limb-threatening arterial injury. Relative arterial pressure measurement compares the Doppler-aided systolic pressure of an injured lower extremity with that in an uninjured limb, which could be the opposite lower extremity, or perhaps more conveniently an uninjured upper extremity (also referred to as ankle-brachial index [ABI] ( Fig. 62-1 ). API measurement may be inaccurate in patients with risk factors for peripheral arterial disease, such as diabetes and hypertension. Vessel calcification, as seen in elderly adults, may also increase the risk of false-positive results. It has been shown that when the API falls within the normal range, no further diagnostic screening is necessary. However, it is imperative to continue to observe the patient’s lower extremity vascular status with serial physical examinations.

Relative systolic pressure index. Doppler-assisted measurement with blood pressure cuffs on injured and uninjured extremities.

(Redrawn from Levy BA, Zlowodzki MP, Graves M, et al: Screening for extremity arterial injury with the arterial pressure index, Am J Emerg Med 23:689–695, 2005.)

If possible, a neurologic examination to assess sensation and voluntary motor function is essential and must be repeated periodically during the first day or two after injury. Both light touch and muscle strength of the tibial, superficial, and deep peroneal nerves must be assessed and documented. These signs may indicate peroneal nerve damage or a compartment syndrome, for example. Firmness of the calf muscle compartments suggests this problem. Pain with passive stretch of the foot and ankle flexors and extensors is a critical finding. Progressive deterioration of sensation or motor function must always be assumed to indicate the development of compartment syndrome. When compartment syndrome develops, surgical release of the compartments should be performed along with application of external fixation to stabilize the fractures and allow for continued evaluation and treatment of the soft tissue envelope ( Fig. 62-2 ).

In this case of a nondisplaced tibial plateau fracture, a compartment syndrome was diagnosed by a clinical examination. A fasciotomy was emergently performed to treat the compartment syndrome. Note the bulging muscle herniating through the fasciotomy wounds.

Recognition, assessment, and monitoring of soft tissue swelling are crucial to avoid missing a compartment syndrome and to help decide about the timing of surgery, as well as the possible need for temporary external fixation. The injured knee must be compared with the opposite (hopefully uninjured) side. Particularly with severe injuries and in patients who arrive in shock, the initial appearance of the wound may not suggest damage that will become evident over the next 2 to 3 days. Excessive skin mobility or subcutaneous fluctuance may be the only suggestions of significant degloving of the subcutaneous tissue from the deep fascia. Abrasions that appear superficial may progress to full-thickness eschars. Additional signs include ecchymosis, edema, and blistering (particularly if the fluid is bloody), and shiny skin that lacks normal wrinkles and is still swollen is at risk for wound slough if it is further injured by a surgical incision ( Fig. 62-3 ). Normal wrinkling is the best indication that swelling has resolved to the point that the surgeon can proceed with definitive care.

Significant soft tissue swelling with fracture blisters in a patient with a minimally displaced lateral plateau fracture.

In low-energy injuries with minimally displaced fractures, an attempt at examining for stability with both gentle varus and valgus stress at 0 and 30 degrees is advisable. Any knee radiograph demonstrating displaced fractures should obviate such an examination. A patient with minimal deformity and a stable knee usually does not need surgical treatment for a tibial plateau fracture. A Lachman examination for anterior cruciate ligament (ACL) deficiency may also be attempted. Range of motion may be assessed in a gentle fashion. A straight leg raise assesses extensor mechanism integrity; however, these aspects of the examination are frequently limited by patient discomfort.

Associated Injuries

Skeletal Injuries

Proximal Fibular Fractures.

In a recent retrospective series by Bozkurt and colleagues, 14 of 55 patients who presented with tibial plateau fractures had an associated proximal fibular fracture. The effect of these fractures on the prognosis of these patients was significant, in that patients who had such associated fractures complained of lateral hamstring tightness and persistent lateral-sided knee pain, whereas those who did not have a proximal fibular fracture did not experience these symptoms. However, treatment of proximal fibular fractures associated with tibial plateau fractures remains controversial. Options include open reduction and internal fixation (ORIF) with plates, screws, sutures, or combinations thereof depending on the fracture configuration. It is a reasonable approach to fix the tibial fracture and then examine the knee for instability. If the instability then includes a significant varus laxity in the setting of a fibular head fracture or if marked posterolateral rotatory instability is found, then formal reconstruction should be considered. This is discussed later.

Tibial Tubercle Fractures.

Tibial tubercle fracture together with avulsion of the infrapatellar tendon occurs commonly in association with high-energy fracture patterns, often demonstrating a fracture through the tibial tubercle with associated posterior cortex comminution, which would prevent typical lag screw fixation of this fragment. These occur in association with Schatzker type V and VI fractures in particular, although their incidence has not been defined. This injury represents a disruption of the extensor mechanism and must be addressed at the time of definitive fixation.

These injuries may easily be missed in many cases unless the examiner is vigilant. The significance of such a fracture, if missed and left unfixed, is that the patient will rehabilitate poorly because of pain and at times displace the fragment and develop an extension lag that is unrecoverable. Additionally, the presence of such a fragment may cause skin tenting and require that external fixation be applied with the knee in full extension to prevent pressure necrosis.

Because it is an avulsion fracture in the coronal plane, a poorly performed knee lateral radiograph frequently can miss the fracture plane entirely. More commonly, however, the examiner is distracted by the more impressive displaced fragments of the medial and lateral plateaus, whose comminution blends in with a tubercle fragment. It is always wise to assess the level of the patella, as well as the integrity of the tibial tubercle, to reduce the risk of missing this component of a tibial plateau fracture. They may also be overlooked on CT when comminution may again be misleading. Sagittal plane two- and three-dimensional (3-D) reconstruction images may best demonstrate tibial tubercle fractures, so they should be reviewed carefully with this possibility in mind ( Fig. 62-4 ).

A, An axial computed tomography scan approximately 2 cm below the joint line of a comminuted tibial plateau fracture. Do you recognize the fractured tibial tubercle? B, This coronal view through the tubercle on the same patient clearly displays a displaced tibial tubercle fracture. C, Lateral radiograph of another patient demonstrating an anterior fragment that includes the tibial tubercle. D, A lateral view of the same knee after healing of the fragment. Fixation is advisable to prevent displacement and nonunion caused by tension on the patellar ligament.

Intercondylar Eminence Fractures.

There are many intercondylar eminence fractures as a component of high-energy tibial plateau fractures, in particular Schatzker types IV, V, and VI ( Fig. 62-5 ). They are usually cruciate ligament avulsions. Thus their repair should help restore long-term knee stability. Isolated fractures of the intercondylar eminence also are seen. These typically represent pure cruciate ligament avulsions and may not involve the actual articular surfaces of the tibial plateau.

Intercondylar eminence fracture, which can be best visualized on the coronal computed tomography scan.

Soft Tissue Injuries.

Many authors have now recognized the high association of meniscal, collateral, and cruciate ligament injuries. Stannard and colleagues performed MRI on 103 patients with high-energy mechanisms. They found 71% of patients tore at least one major ligament group, and 53% tore multiple ligaments. Additionally, the authors found that 49% sustained a meniscal tears. Gardner and colleagues used MRI to analyze 103 consecutive acute tibial plateau fractures. The authors found that only one patient in the entire series had no evidence of soft tissue injury. This incidence was significantly higher than previous reports in the literature, which range from 7% to 97%. Shepherd and colleagues reviewed MRI of 20 consecutive tibial plateau fractures that were deemed nonoperative based on the degree of displacement and found 90% of the patients had injuries to at least one ligament or meniscus based on MRI.

Meniscal Injuries.

Meniscal tears are common in tibial plateau fractures. Stannard and colleagues performed MRI on 103 patients with high-energy mechanisms. There were 66 patients with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 41C fractures and 37 patients with AO/OTA type 41B fractures. They found that 50 patients (49%) sustained a total of 60 meniscal tears, with 25 medial menisci and 35 lateral menisci injuries found. Whereas medial meniscus tears were most commonly found in Schatzker type V fractures (38%), lateral meniscus tears were most commonly found in Schatzker type II fractures (55%).

In a previous report by Gardner and colleagues, 103 consecutive patients with tibial plateau fractures were assessed by MRI. The authors found 91% of the patients had evidence of a torn or peripherally separated meniscus. Medial meniscal tears were found in 44% of patients. It is important to recognize that 60% of the fractures in their series were Schatzker type II fractures, of which 73% had injuries to the lateral meniscus. Another important finding is that lateral capsular separation occurred in 100% of the Schatzker type I plateau fractures seen in their series. Medial tibial plateau fractures were associated with a medial meniscal tear rate of 86%.

The incidence noted by Gardner and colleagues is higher than in previous or subsequent reports. In a study by Vangsness and associates of 36 consecutive patients with tibial plateau fractures, only 47% had associated meniscal pathology. In a study by Colletti and colleagues, lateral meniscal tears were noted in 45% and medial meniscal tears in 21% of patients in a series of 29 cases with tibial plateau fractures assessed by MRI. In another study by Bennett and Browner, 30 tibial plateau fractures were evaluated with diagnostic arthroscopy, revealing an overall meniscal pathology rate of only 20%. In a previous study, Gardner and colleagues examined 62 consecutive patients with Schatzker type II (lateral tibial plateau) fractures who underwent imaging with radiographs as well as MRI preoperatively. The authors found that depression greater than 6 mm and widening greater than 5 mm on a standard radiograph was associated with a lateral meniscal injury rate of 83% compared with 50% among fractures with less displacement. The authors suggested that in Schatzker type II tibial plateau fractures with depression or widening of at least 5 mm, surgeons should suspect concomitant soft tissue injuries. (See Video 62-1.)

It is clear by the variation in incidence among these studies that either there are different interpretations for what represents a meniscus tear or the technique or quality of the MRI examinations is different. The arthroscopist may fail to detect certain very anterior lesions, where they are likely to occur in lateral plateau fractures. Treatment of meniscal pathology is controversial because the natural clinical history of all these variants is unknown. Regardless, the critical role of the menisci has been well established. In a classic article by Walker and Erkman, contact stress analysis was performed on both medial and lateral tibial plateaus under various loads. Under no load, contact between the femoral condyles and their respective medial and lateral articulations occurs primarily on the menisci. Under loads of up to 150 kg, the lateral meniscus carried most of the load, but on the medial side, the load was shared almost equally between the meniscus and the exposed cartilage of the medial tibial plateau. In this context, it seems that the importance of the lateral meniscus in particular and its role in stabilizing the knee joint cannot be overstated. If one considers the results of total meniscectomy in the development of posttraumatic arthrosis as noted by Fairbank, it seems intuitive that preserving the lateral meniscus is of prime importance. Peripheral meniscal detachments constitute the majority of meniscal injuries. Although radial tears of the meniscus should usually be débrided, peripheral detachments, often involving the outermost portion of the meniscus or its anchorage to the joint capsule, should be repaired to the coronary ligaments or even to a plate or screws as the implants and injury may dictate. A durable nonabsorbable monofilament suture is best used for this task. Suture anchors can be helpful in the cases in which reattachment is difficult because of poor integrity of the coronary ligaments. Perhaps most important, the presence of a peripheral meniscal tear in association with a tibial plateau fracture should never be considered an indication for meniscectomy.

It is possible that simply reducing a displaced plateau fragment approximates the coronary ligaments to the peripheral meniscal detachment and allows for healing without formal repair. This could explain the disconnect between the low rate of reported late complications related to meniscal tears and the high frequency with which present-day MRI detects such injuries acutely. In any case, maintenance of the menisci is critical because one study found that removal of a meniscus during the fracture surgery resulted in secondary degeneration in 74% of the cases compared with 37% when the meniscus was intact or repaired.

Collateral Ligament Injuries.

Several other studies have been performed to determine the incidence of collateral ligament injury associated with tibial plateau fractures. Methods of diagnosis in these different investigations vary from physical examination to operative findings to arthroscopy and MRI. The overall incidence ranges between 8% and 45%. Delamarter and Hohl reviewed 39 tibial plateau fractures and noted that ligamentous injury occurred in all types of tibial plateau fractures but most commonly in split-depression and pure depression injuries. In Schatzker type II tibial plateau fractures, Gardner and colleagues noted a fibular collateral ligament tear incidence of 18% and in 36% of the MCLs. In their report of 103 operatively treated tibial plateau fractures, 29% of patients had complete fibular collateral ligament tears, 47% had partial fibular collateral ligament tears, 33% had complete MCL tears, and 57% had partial MCL tears. In this series, 60% were Schatzker type II fractures. In the series by Colletti and colleagues, fibular collateral ligament injuries were discovered in 34% of patients and MCL injuries in 55%. These more recent studies demonstrate again that ligament injuries were underappreciated in previous reports. Bennett and Browner, in their study of 30 tibial plateau fractures, found an MCL lesion in only 20% of the patients and fibular collateral ligament lesions in only 3% based on diagnostic arthroscopy, physical examination, and stress radiographs ( Fig. 62-6 ).

Example of Schatzker type II lateral plateau fracture with medial collateral ligament (MCL) avulsion. A, Preoperative anterior-posterior (AP) radiograph. Note the proximal MCL avulsion. B, Preoperative computed tomography (CT) scan. Note that the proximal MCL avulsion is seen better by CT. C, Postoperative AP view of the MCL avulsion reattached at the time of open reduction and internal fixation of the plateau.

Cruciate Ligament Injuries.

Injuries to the ACL and posterior cruciate ligament (PCL) in the setting of tibial plateau fractures have been described in numerous series. In Stannard and colleagues’ report on 103 tibial plateau fractures that underwent preoperative MRI, the authors found ACL injuries in 45 patients (44%), most commonly in Schatzker type V variants, occurring in eight of 13 (62%). They were found in all variants, however, ranging from 15% to 62%.

In Gardner and colleagues’ previous preoperative MRI study of 103 patients with tibial plateau fractures, significant ACL injuries occurred in 57%. In contrast to the study by Stannard, Gardner found Schatzker type II fractures rather than type V had the highest rates of complete ACL tears; however, footprint avulsions were noted in 71% of bicondylar Schatzker type V fractures but were common among all tibial plateau fracture types, ranging from 42% to 71%. In a more recent study by Gardner and colleagues, in Schatzker type II fracture patterns, the overall incidence of ACL injury was 47%, most of which were footprint avulsions. In Colletti’s series of 29 patients, 41% were noted to have injuries to the ACL. In Bennett and Browner’s series of 30 patients, injury to the ACL was noted in 10%.

The incidence of PCL injury is lower. Stannard and colleagues found PCL injuries in 41 patients (40%), most commonly in Schatzker type IV variants, occurring in seven of 13 (54%). Gardner and colleagues previously reported a rate of 28%. Most of these were avulsions of the PCL. Footprint avulsions of the PCL were highest in Schatzker type I fracture patterns with an incidence of 67%. In a more recent study by Gardner and colleagues reviewing Schatzker type II fracture patterns, 25% were noted to have PCL lesions, of which most were PCL footprint avulsions. In Colletti’s series of 29 patients, 28% were noted to have PCL injuries. Gardner and colleagues reviewed the literature of the reported incidence of associated soft tissue injuries in tibial plateau fractures and noted injury to the cruciate ligaments ranging from 8% to 69%. Bicruciate injuries were most common in Schatzker type IV variants in Stannard’s series, seen in six of 13 (46%).

Posterolateral Corner Injuries.

More recently, damage to the posterolateral corner supporting structures of the knee has been defined and appreciated. In particular, popliteal fibular ligament (PFL) and popliteus tendon (PT) tears have been described in association with tibial plateau fractures ( Fig. 62-7 ). Stannard and colleagues demonstrated injury to the posterolateral corner structures in 46 of 103 (45%) patients in their series. This injury was seen most commonly in Schatzker type IV and V variants, both occurring in 62% of patients. In their previous study series of 103 patients, Gardner and colleagues reported that 68% of patients had tears of the PFL, the PT, or both.

Posterolateral corner structures. Lateral view of the left knee (cadaveric model). The hemostat on the left is pointing to the popliteus attachment on the femur. The superficial layer of the iliotibial band split (to the right) is under the fibular (lateral) collateral ligament. The arcuate complex and the popliteal fibular ligament are deeper, posteriorly.

Neurovascular Injury.

Neurovascular injury is rarely seen in most tibial plateau fractures. However, fracture-dislocations and high-energy medial condyle (Schatzker type IV) and bicondylar (Schatzker types V and VI) patterns do present an increased risk to neurovascular structures, in particular the popliteal artery and common peroneal nerve (CPN). Our current approach to vascular assessment is outlined in Figure 62-8 .

Suggested algorithm for evaluation and treatment of a patient with suspected knee-region arterial injury. “Hard signs” of vascular injury include pulsatile hemorrhage, expanding hematoma, audible bruit, or pulselessness.

(Data from Levy BA, Zlowodzki MP, Graves M, et al: Screening for extremity arterial injury with the arterial pressure index, Am J Emerg Med 23:689–695, 2005.)

Although arteriography is rarely necessary if a patient has limb-threatening ischemia associated with a single fracture or dislocation, when more than one level of injury is present, it may be necessary for the vascular surgeon to localize the arterial obstruction. In such cases, imaging should be done rapidly with whatever technique is best suited to the needs of patient and vascular surgeon and is within the institutional capabilities: angiography in the operating room (OR), rapid arteriography by a radiologist, CT arteriography, duplex ultrasonography, and so on. Harrell and associates, in a retrospective review, noted that the incidence of popliteal artery injury with fractures about the knee was 3%, but clearly this rate is fracture specific and therefore institution specific, depending on the injury profile that presents to a given emergency department.

In a study by Bennett and Browner, only one patient in 30 had injury to the peroneal nerve, for an incidence of 3%. Myint and colleagues reported on a patient who sustained a CPN palsy caused by posterolateral displacement of a fractured lateral plateau.

Fracture-Dislocations.

Tibial plateau fractures represent a spectrum of bony and soft tissue injury. Because of the high rate of associated ligamentous injuries, most high-energy tibial plateau fractures should be considered fracture-dislocations. In other words, some tibial plateau fractures have associated significant ligamentous injuries that require reconstruction, and some knee dislocations have associated rim fractures of the tibial plateau that require fixation. The Hohl-Moore classification is often more helpful than that of Schatzker in classifying these fractures and predicting concomitant injuries and guiding treatment.

Bennett and colleagues in 2003 described anterior rim tibial plateau fractures with posterolateral corner injuries of the knee in 16 knees of 15 patients who had evidence of posterolateral corner injury on physical examination and MRI. Six knees showed evidence of tibial plateau fracture on MRI. Five of those six were anteromedial rim fractures. The authors concluded that anteromedial rim fractures of the tibial plateau occur rarely but are frequently seen in the setting of a posterolateral corner knee injury ( Fig. 62-9 ).

Anterior-posterior ( A ) and lateral ( B ) radiographs showing an anterolateral knee dislocation. The axial ( C ) computed tomography cut shows the detail of an anteromedial rim fracture. In the sagittal slice ( D ) of the magnetic resonance image (MRI), a disruption of the anterior cruciate ligament (ACL) is appreciated as well as detachment of the popliteus and the fibular collateral ligament on the coronal view of the MRI ( E ). This tibial plateau fracture associated with multiligament knee injury required repair of the popliteus and fibula collateral ligament attachment in addition to open reduction and internal fixation with a buttress plate and multiple screws to fix the anteromedial rim ( F ). It is the authors’ preference to reconstruct the ACL in a delayed fashion.

It is important to recognize the possibility of significant soft tissue envelope compromise and the high risk of associated popliteal artery injury, compartment syndrome, and peroneal nerve injury in severely displaced, high-energy plateau fractures. These patients typically require emergent attention, including preliminary fracture reduction and stabilization, typically with application of a knee-bridging external fixator.

Compartment Syndrome.

Compartment syndrome is a devastating complication of tibial fractures, including the tibial plateau. Schatzker type VI fractures and medial plateau fracture-dislocations appear to be particularly at risk.

Park and colleagues retrospectively reviewed 414 patients and classified into three groups (proximal, diaphyseal, and distal) based on the anatomic location of the fractures (AO/OTA fractures 41, 42, and 43, respectively). The authors found the rate of compartment syndrome for 186 proximal tibial fractures was 1.6%.

As stated earlier, the risk has been found to be significantly greater than this in Schatzker type VI variants and medial plateau fracture-dislocations. Stark and colleagues retrospectively reviewed 67 patients with tibial plateau fractures and fracture-dislocations who were treated with initial external fixation within 48 hours of injury. There were 50 Schatzker type VI fractures and 17 fracture-dislocation variants. The authors found 18 compartment syndromes (27%) in 67 extremities. Compartment syndrome developed after Schatzker type VI fractures in nine of 50 (18%) and medial plateau fracture-dislocations in nine of 17 (53%). The authors recommended careful monitoring of Schatzker type VI fractures and especially medial plateau fracture-dislocations after placement of spanning external fixators.

Other authors have found no relationship between application of knee-spanning external fixation and compartment syndrome. Egol and colleagues prospectively evaluated intracompartmental pressures in all four compartments at four time points during the external fixator application. The authors found that application of knee-spanning external fixation for stabilization of high-energy proximal tibial fractures and dislocations in 25 patients and found only transient elevations of intracompartmental pressures.

Compartment syndrome in the setting of tibial plateau fracture can be managed effectively with both one- and two-incision fasciotomy surgical techniques. Placement of fasciotomy incisions should take into account plans for future incision placement during definitive fixation whenever possible.

Radiographs

Supine anterior-posterior (AP) and lateral radiographs are required for all patients with suspected or known fractures of the tibial plateau. Internal and external rotation oblique views of the knee are helpful in identifying and defining articular injuries. The internal rotation oblique displays the fibula in profile, eliminating tibiofibular overlap, because the fibula resides posterolateral to the tibia. This view demonstrates the posterolateral plateau and the anteromedial plateau. In contrast, the external rotation oblique projects the fibula more anteriorly, increasing tibiofibular overlap. This view provides better detail of the anterolateral and the posteromedial plateau surfaces ( Fig. 62-10 ).

Oblique radiographs of the tibial plateaus provide additional information by eliminating superimposition of lateral views. A, Internally rotated oblique radiograph, showing posterolateral and anteromedial features, including proximal tibiofibular joint. B, Externally rotated oblique radiograph, bringing posteromedial and anterolateral regions into profile.

The well-performed AP, lateral, and oblique radiographs of the knee typically provide the necessary information when assessed by experienced orthopaedic surgeons. As with many articular fractures, one should obtain contralateral AP and lateral radiographs so that normal anatomy, which varies, can be used for preoperative planning and intraoperative comparison. To restore the bony architecture to a preinjury state, the surgeon must have knowledge of the patient’s normal anatomy. Contralateral radiographs thus act as a template for fracture reduction, indicating tibial plateau height, condylar width and alignment in the coronal plane, and posterior slope of the tibial plateau in the sagittal plane ( Fig. 62-11 ).

Example of joint line obliquity (tibia varum), present bilaterally. A, Noninjured extremity comparison view. B, Injured extremity status after open reduction and internal fixation. Note that the joint lines are neither horizontal nor perpendicular to the tibia shaft.

In addition to the above views, the “tibial plateau view” can be obtained. As described by Moore and Harvey, an AP radiograph is obtained with the knee in full extension and the x-ray beam directed approximately 15 degrees caudally ( Fig. 62-12 ). This view parallels to the posterior slope of the tibial plateau and thus yields a better view of the joint surfaces. The exact angulation of the x-ray beam for a particular patient can be determined from the slope of the contralateral tibial plateau.

Technique for a tibial plateau anterior-posterior radiograph. The central x-ray beam is aligned tangential and parallel to the proximal tibia. X-ray beam angulation equals that of the anterior-to-posterior obliquity of the tibial plateaus.

(From Moore TM, Harvey JP Jr: Roentgenographic measurement of tibial-plateau depression due to fracture, J Bone Joint Surg Am 56:155, 1974.)

With appropriate interpretation of plain radiographs, many CT scans could be obviated. In many instances, well-done AP, lateral, and oblique views demonstrate perfectly well that there is minimal displacement of a fracture. If it is then clear that surgical indications are not met and that a patient is not an appropriate candidate given the displacement seen, then no CT scan is necessary. The examiner should obtain a CT scan if surgical consideration exists based on radiographic assessment of fracture displacement and pattern. With the advent of staged protocols using initial spanning external fixation, repeating the lateral and AP radiographs of the knee after application of the spanning external fixator is important to ensure that appropriate provisional length and alignment has been restored. Fracture fragment alignment is usually improved by ligamentotaxis during application of spanning external fixation.

In addition to defining osseous pathology, certain radiographic findings should also raise suspicion for injury to meniscal and ligamentous structures. Gardner and colleagues found that Schatzker type II fractures with greater than 5 mm of depression or condylar widening were often associated with significant soft tissue injuries. They recommended heightened vigilance and consideration of MRI evaluation preoperatively in these situations.

Computed Tomography Scanning

Several studies have demonstrated the utility of CT scans for assessing the degree of comminution and depression that is often underestimated with routine radiographs. In most cases, better alignment and elimination of fragment overlap in the posttraction setting aids interpretation of radiographs and CT scans. Thus, in cases in which staged management with an external fixator is planned, CT evaluation for the purposes of preoperative planning should not be performed until after the external fixator has been applied.

Standard two-dimensional (2-D) CT scans with standard coronal and sagittal reconstructions help to assess the degree of comminution, trajectory of fracture lines, and injury nuances, which can enhance the surgeon’s ability to develop a surgical tactic. Scout line functionality in many systems provides a better understanding of fracture characteristics. Routine 2-D axial views are now commonly supplemented by 3-D reconstructions, providing even the novice an excellent understanding of fracture morphology ( Fig. 62-13 ). However, it is unclear whether the addition of 3-D reconstructions to standard 2-D imaging improves reliability of classification of tibial plateau fractures. Hu and colleagues concluded that 3-D imaging was superior to 2-D imaging and significantly improved interobserver and intraobserver reliability, but Doornberg and colleagues found the addition of 3-D did not significantly improve reliability .

Example of three-dimensional computed tomography image showing severe posterior comminution, which is hard to distinguish on standard two-dimensional views.

Computed tomography scans have led surgeons to reclassify fracture patterns and change the plan of treatment for tibial plateau fractures as shown in one study by Chan and associates. Macarini and colleagues reviewed 25 patients with a tibial plateau fracture and compared standard radiography with multiplanar and 3-D CT reconstruction. In 60% of patients, CT features led the orthopaedist to modify the treatment. The authors also noted that compared with axial CT, the 3-D reconstructions enabled a more accurate assessment of plateau depression and overall view of the fracture fragments. Although 3-D imaging may aid in determining fracture location, articular detail is lost because of volume averaging, so critical assessment of 2-D images is important for evaluation of the joint surface. Chan and colleagues reviewed 21 cases of tibial plateau fractures imaged with plain radiography and CT scans. Classification was changed in 12% of the cases with the addition of CT, and the treatment plan was changed an average of 26% of the time. The number of image slices may also be an important consideration. McEnery and colleagues performed an in vitro analysis of sensitivity and specificity of spiral CT and recommended 2-mm sections for optimal sensitivity and specificity.

Special attention must be given to the posteromedial plateau when evaluating CT. Barei and colleagues described the frequency and morphology of the posteromedial fragment on CT in 57 patients with bicondylar tibial plateau fractures. The authors found that the posteromedial fragment was present in 74% of patients and comprised a mean of 58% of the articular surface of the medial tibial plateau and 23% of the entire tibial plateau articular surface. The mean height was 42 mm. Most important perhaps, the mean sagittal fracture angle was 81 degrees. Higgins and colleagues subsequently described the morphology of the posteromedial fragment present on CT scan in 111 bicondylar fractures. They found that the fragment occurred in 59% of cases and on average accounted for 25% of the total joint surface. They found greater than 5 mm of articular displacement in 55% of cases. The posteromedial fragments exhibited vertical fracture patterns, with average sagittal angle of 73 degrees, suggestive of shear instability and vertical displacement. The presence of this fragment has significant clinical implications when deciding on reduction techniques and fixation constructs. Laterally based fixation may fail to adequately stabilize this fragment. Consideration should be given to direct reduction and fixation of this fragment through a posteromedially based approach to ensure adequate fixation.

Magnetic Resonance Imaging

The role of preoperative MRI in tibial plateau fracture management is controversial and evolving. Recent studies suggest the possible importance of MRI in assessing osseous and associated soft tissue lesions. However, neither the natural history of MRI-discovered soft tissue injuries nor the indications for surgical treatment of these injuries in the setting of a tibial plateau fracture has been established. Nonetheless, some authors recommend MRI as an adjunct imaging modality for tibial plateau fractures. It is possible, with further advances in quality and technique, that MRI could supplant CT as the imaging modality of choice if it can be found to consistently provide equivalent detail of osseous injuries.

The limitations of MRI include the difficulty of positioning claustrophobic and obese patients in an MRI scanner. Also, patients with certain implanted metal objects, such as stents or pacemakers, cannot undergo MRI. Additionally, not all spanning external fixators are suitable for MRI scanners according to one study by Kumar and associates. The degree of ferromagnetism was studied in a number of orthopaedic implants including external fixator clamps by measuring the deflection at the portals of a 0.25- and 1.0-T scanner (magnet). Although deflection was found to be significant with some ferromagnetic external fixator clamps, neither heating nor ferromagnetic force was a factor in multiple studied implants. The authors concluded that external fixator clamps exhibiting strong ferromagnetism should be avoided. Consideration should be given to applying titanium external fixator clamps for all spanning fixators to accommodate potential future studies needed by neurosurgeons as well as spine and knee surgeons. The stainless steel Schantz pins used for application of external fixators do not cause thermal problems nor do they displace. In fact, according to Kumar and associates, they are nonmagnetic. Both the orthopaedic and radiology departments must be sufficiently educated about these factors for MRI protocols to be executed without reluctance on the part of the radiology team.

Duplex Ultrasonography and Arteriography

As mentioned earlier, displaced bicondylar tibial plateau fractures and those of the medial condyle carry a significant risk of associated arterial injury. The same is true for fracture-dislocation variants. Because arterial occlusion at the knee level often results in amputation unless perfusion is restored very promptly, a high level of suspicion with rapid definitive assessment is required if limb loss is to be prevented.

It was previously thought that physical examination alone does not reliably identify the presence or absence of arterial injury. However, numerous studies have more recently been published supporting selective arteriography performed only in patients who have abnormal physical examination findings. Ten studies, including two prospective studies, have evaluated the use of selective arteriography in a total of 543 patients with knee dislocation. In each of these studies, physical examination alone was sufficient to detect all clinically significant vascular injuries . If the ABI is considered positive (<0.9), duplex ultrasonography or arteriography should be performed immediately.

Duplex ultrasonography is a fast and accurate examination. It carries no risks. Its effectiveness has been demonstrated in multiple studies ; however, the examination is operator and interpreter dependent and requires the ready availability of a skilled vascular ultrasonographer. The use of arteriography as a primary or routine screening tool for diagnosing arterial injury is cost ineffective, has a poor risk-to-benefit profile, and is therefore unwarranted. In the case of an acutely ischemic leg, if the limb is considered salvageable and the ABI is less than 0.9, formal angiography may be required. Because of the few hours available before significant tissue necrosis occurs, it is essential that a vascular surgeon be involved early in the care of patients with arterial injuries about the knee. Arteriography should never delay vascular consultation and necessary arterial repair and fracture stabilization. If additional information is required by the vascular surgeon to determine if there is a need for formal vascular repair, evaluation with standard or CT angiography can be performed in the radiology suite. However, when the need for revascularization is clear, arteriography should be performed in the OR whenever possible to prevent unnecessary delays in revascularization.

Schatzker Type I

Type I is most common in young patients with hard cancellous trabeculae and good bone density, in which case the joint does not crush, but a pure split is created. The fracture line typically occurs in the sagittal plane ( Fig. 62-16 ). For reference purposes, this is a partial articular fracture and is therefore considered a type 41B1.1 fracture in the AO/OTA system.

Schatzker type I plateau fracture. A type I fracture involves a split-wedge fracture of the lateral plateau without any joint depression or impaction. Lateral meniscal pathology may be present that may preclude closed manipulation and percutaneous treatment.

(Redrawn from Schatzker J: In Chapman MW, editors: Operative orthopaedics, Philadelphia, 1988, JB Lippincott, Fig. 35-1, p 422.)

Schatzker Type II

This fracture is typically associated with either greater energy than a type I or with poor bone quality. This split-depression fracture of the lateral tibial condyle occurs most commonly in the fourth decade of life. In this fracture pattern, the cancellous bone underlying the articular surface cannot withstand the load of the lateral femoral condyle and thus sustains a depressed articular region as well as the split component ( Fig. 62-17 ). For reference purposes, this correlates with the AO/OTA classification type 41B3.1.

Schatzker type II tibial plateau fracture. A type II fracture involves a split fracture of the lateral condyle with associated impaction and depression of the lateral articular surface. The depressed fragment is often comminuted.

(Redrawn from Schatzker J: In Chapman MW, editors: Operative orthopaedics, Philadelphia, 1988, JB Lippincott, Fig. 35-2A, p 423.)

Schatzker Type III

Type III fractures are associated with poor bone quality and can be caused by very low-energy mechanisms. This fracture pattern is amenable to the arthroscopically assisted fixation technique described later in this chapter. Type III is a pure depression fracture of the lateral plateau commonly diagnosed in elderly adults and can be considered a fragility fracture. In older patients with osteoporosis in whom the cancellous bone underlying the articular surface is more porous than normal, the bone crushes rather than splits ( Fig. 62-18 ).

Schatzker type III tibial plateau fracture. A type III fracture involves a pure depression of the lateral articular surface only. There is no associated metaphyseal condylar fracture line. Instability may not be present when the depressed area is small or centrally located.

In a recent paper by Gardner and colleagues, 103 MRIs on consecutive tibial plateau fractures were performed, and the authors found no true cases of pure depression type III fractures. In every case considered to be a type III fracture by plane radiographs, a peripheral split was noted on MRI. These findings suggest simply that occult fracture lines cannot always be detected on plane radiographs. The clinical significance may therefore be that one should not assume the lateral cortical envelope is stable and will not displace, and thus treatment may need to include lateral cortical support. Schatzker’s classification, based on radiographs, does not seem to be upstaged by these MRI findings, which merely complement our understanding of the pattern. For reference purposes, this fracture correlates to the AO/OTA classification types 41B2.1 and 41B2.2.

Schatzker Type IV

These fractures of the medial condyle may not violate the medial articular surface. They typically pass more laterally, through or lateral to the intercondylar eminence, and separate the medial plateau from the remainder of the tibia. Medial plateau fractures involve higher energy mechanisms and shearing (transverse plane) displacement and are usually unstable. In fact, they represent a variant of knee dislocation. Typically, whereas the MCL and cruciate ligaments stay attached (or partially attached) to the medial condyle, the lateral plateau and shaft displace laterally away from the femur and medial plateau fragment. The fracture may be a pure sagittal split but more commonly is oblique to the frontal plane, with the apex of the fracture occurring posteromedially ( Fig. 62-19 ).

Schatzker type IV tibial plateau fracture. A type IV fracture involves a split fracture of the medial plateau with associated comminution of the intracondylar eminence or medial plateau articular surface.

An important clinical implication of medial tibial plateau fractures is their tendency toward subluxation or dislocation. Associated arterial, peroneal nerve, and ligamentous injuries are relatively frequent. They should be seen as quite different from partial articular (type B) fractures involving the lateral plateau, which are usually less unstable and the result of lower energy injuries.

Although medial tibial plateau fractures only account for approximately 10% of all tibial plateau fractures, this is the fracture pattern that has the highest association of injuries to the neurovascular structures and cruciate ligaments. ACL and PCL injuries and bony avulsions are common in Schatzker type IV fractures. Bear in mind that radiographs are static images, which do not reveal the maximal displacement that occurred at the time of injury. Thus, even less displaced medial plateau fractures are at higher risk of neurovascular injury. These fractures also carry an increased risk of compartment syndrome and therefore warrant close observation and critical vascular assessment. Rarely, medial plateau fractures may be stable, but even these may surprise the surgeon with late displacement. For reference purposes, medial tibial plateau fractures correspond to the AO/OTA classification types 41B1.3, 41B2.3, 41B3.2, and 41B3.3.

Schatzker Type V

The type V is a total articular injury that involves wedge fractures of both medial and lateral plateaus. The intercondylar area may remain more or less intact, with the intercondylar fracture line passing through it but usually not crossing the weight-bearing articular surface. Schatzker recognized a typical “inverted-Y” pattern and classified his type V plateau fractures as 41C1.1, 0.2, or 0.3—noncomminuted total articular fractures in which both the medial and lateral condyles are detached from each other and from the underlying metaphysis. Occasionally, the combination may include a split or split-depression fracture of the lateral plateau in addition to a separate medial plateau fracture. Because the cruciate ligaments typically remain attached to the intercondylar eminence and one plateau, there is usually less femorotibial instability and through ligamentotaxis traction often achieves a reasonably congruent reduction, but without surgical stabilization, loading results in distal displacement of the condyles and often with widening of the intercondylar gap. This pattern is unlikely to be associated with a knee dislocation. CT or high-quality traction radiographs may be needed to demonstrate clearly their bicondylar, total articular pattern ( Fig. 62-20 ).

Schatzker type V tibial plateau fracture. This is a total articular fracture in the configuration of an inverted “Y,” with both plateaus separated from each other and from the distal tibia. The nonarticular intercondylar eminence region remains largely intact. There is less comminution and displacement than in the Schatzker VI category. Traction may be necessary to demonstrate clearly all fracture planes.

Schatzker Type VI

The Schatzker type VI tibial plateau fracture is a bicondylar fracture that involves both medial and lateral tibial plateaus but has the distinction of having more comminution and obvious complete separation of the articular surface (including the eminence) from the diaphysis ( Fig. 62-21 ). These are usually high-energy injuries commonly associated with severe articular involvement and soft tissue injury. Multifragmentation comminution of at least one plateau is common. Meta­physeal comminution may be extreme and extend into the diaphysis as well. These displaced, comminuted bicondylar proximal tibial fractures typically have severe soft tissue injury, whether they are closed or open. They carry a significant risk of wound slough if operated on early, particularly through extensile midline incisions. This pattern should serve warning for possible compartment syndrome and neurovascular injury, and thus, serial neurologic and vascular assessment should be performed. For reference purposes, these fractures correspond to the AO/OTA classification types 41C2, and 41C3.

Schatzker type VI tibial plateau fracture. The feature in this fracture pattern is the complete dissociation between the articular surface and the diaphysis. Impaction of the articular surface is common in this fracture pattern, usually involving the lateral plateau.

Type I: Coronal Split

These fractures account for 37% of tibial plateau fracture-dislocations. The fracture involves the medial side and is apparent on the lateral view. The fracture line is typically in an oblique coronal-transverse plane at a 45-degree angle to the medial plateau. The fracture may extend to the lateral side, and avulsion fractures of the fibular styloid, insertion of the cruciates, and tubercle of Gerdy are common. Capsular disruption and ligamentous injuries are common.

Type II: Entire Condyle

This fracture-dislocation may involve the medial or lateral plateau and is distinguished from the type IV fracture by a fracture line extending into the opposite compartment beneath the intercondylar eminences. The opposite collateral ligament is involved in half of fractures, resulting in fracture or dislocation of the proximal fibula. This type constitutes 25% of all fracture-dislocations, and 12% result in neurovascular injuries. Stress testing is necessary to determine occult ligament injury.

Type III: Rim Avulsion

Constituting 16% of fracture-dislocations, this type involves almost exclusively the lateral plateau, with avulsion fragments of the capsular attachment, the Gerdy tubercle, or plateau. Disruption of the ACL or PCL is common. Although meniscal injury is rare, neurovascular injuries occur in 30% of fractures. Type III fractures are almost invariably unstable.

Type IV: Rim Compression

This injury accounts for 12% of all fracture-dislocations. Akin to type III fractures, these are almost invariably unstable as well. The opposite collateral ligament complex and usually (75% of patients) the cruciate ligaments are avulsed or torn, allowing the tibia to sublux to the extent that the femoral condyle compresses a portion of the anterior, posterior, or “middle” articular rim.

Type V: Four Part

Constituting 10% of all fracture-dislocations, this injury is also nearly invariably unstable. Neurovascular injury occurs in 50% of fractures. The popliteal artery and the peroneal nerve are injured in more than one third of cases. Both collateral ligament complexes are typically disrupted with the bicondylar fracture, and the stabilization provided by the cruciates is lost because the intercondylar eminences are separate fragment(s).

Emergent and Urgent Stabilization

Technique.

A variety of external fixators have been proposed for the treatment of tibial plateau fractures. There are two different major roles for this treatment modality. First is the use of provisional, joint-bridging external fixation for temporary stabilization of a severe knee injury. The second is the use of external fixation as a part of the definitive fixation for a proximal tibial fracture, usually in company with open reduction and interfragmentary screw fixation for displaced fractures that involve the articular surface. Definitive treatment that includes external fixation is discussed in the section Definitive External Fixation.

Two 5- or 6-mm threaded half-pins with a mechanically stable connecting rod are placed into the femur, with a similar pair in the tibia. Stainless steel pins are stiffer. Hydroxyapatite coating is unnecessary if the fixator will only be used for days to a few weeks. If plans include conversion to definitive external fixation, hydroxyapatite pins are useful. Each pair of pins should be spread apart to improve stability but if possible kept out of the fracture site and the path of future surgical incisions. The simplest stable connection that can be made with available frame components is used to bridge the knee. The use of radiolucent connecting rods and placement of metal clamps away from the knee and fracture zone improves imaging ( Fig. 62-24 ). Traction and realignment are achieved manually, and the frame clamps are tightened. Usually, no attempt is made to reduce articular fracture fragments or to fix them, although occasionally this might be considered as part of preliminary reduction when the fixator is used for stabilizing an open proximal tibial plateau fracture. After applying sterile dressings with antibiotic medication if desired, alignment and stability are confirmed. We usually apply a lightly compressive dressing, typically including a well-padded prefabricated posterior splint to offload the heel. Maintaining the foot in a plantigrade position is important to avoid equinus contractures. Alternatively, a “kickstand” can be constructed as part of the external fixator to offload soft tissue injuries or the heel.

A and B, Knee-spanning uniplanar external fixator. A connected pair of half-pins (Schanz screws) has been placed in anterolateral femur and another in the anteromedial tibia. They are connected with a radiolucent rod while the knee is held in alignment.

Because of an anecdotal fear of infection, it has classically been taught that all temporary external fixation pins should be placed out of the zone planned for definitive internal fixation. Laible and colleagues sought to determine whether overlap between temporary external fixator pins and definitive plate fixation correlated with infection in high-energy tibial plateau fractures. They performed a retrospective review of 79 patients with unilateral high-energy tibial plateau fractures treated initially with knee-spanning external fixation followed by delayed internal fixation. The authors found no significant difference in rate of infection in patients whose pin sites overlapped with the definitive internal fixation compared with those whose pin sites did not overlap. The authors stated that fears of contamination and infection from overlapping pin sites do not appear to be clinically grounded. We continue to advocate for placement of pins out of the zone of planned future internal fixation whenever possible because there is little to lose with this approach. However, when required to provide adequate reduction and stability to fracture fragments and more important stability to soft tissues, we agree that pin placement should be performed wherever it is required, regardless of plans for future surgery.

Indications for Operative Management

The goals of treatment for any intraarticular fracture are to preserve joint mobility, joint stability, articular surface congruence, and axial alignment. Additional goals are to provide freedom from pain and to prevent posttraumatic osteoarthritis.

Most investigators would agree that four primary factors ultimately contribute to the prognosis of proximal plateau injuries: (1) the degree of articular depression, (2) the extent and separation of the condylar fracture lines, (3) the degree of diaphyseal–metaphyseal comminution and dissociation, and (4) the integrity of the soft tissue envelope. When considering operative treatment, all four of these factors must be evaluated to determine the best course of treatment.

Nonoperative Treatment

Nonoperative treatment is indicated for many tibial plateau fractures. Some fractures that occur after a low-energy injury are incomplete or nondisplaced. Other injuries that may be treated successfully in a nonoperative fashion include a displaced lateral plateau fracture without articular instability and some unstable lateral plateau fractures in osteoporotic patients. Another relative indication for nonoperative treatment is the presence of significant cardiovascular, pulmonary, neurologic, or metabolic compromise (e.g., severe diabetes with occlusive vascular disease or significant venous stasis ulceration).

Nonoperative treatment of these injuries does require early motion and subsequent prevention of displacement. Schatzker and McBroom found that patients with tibial plateau fractures treated nonoperatively in a plaster cast for 1 month or longer experienced marked stiffness of the knee. In most instances, fracture displacement is prevented by restricting weight bearing, and stiffness is prevented by instituting early controlled motion in a hinged knee fracture brace. Depending on fracture stability, the knee may be locked in full extension for 1 to 2 weeks, after which the hinges are adjusted to begin a gradual increase in range of motion. Frequent clinical and radiographic follow-up is required early in the course of treatment to guard against unrecognized loss of metaphyseal reduction. The goal is to achieve at least 90 degrees of flexion by 4 weeks after injury. Unlimited motion may be encouraged from the outset for stable fractures. Weight bearing is delayed until there is radiographic appearance of early fracture line consolidation. Usually, by 6 to 8 weeks the patient has progressed to 50% partial weight bearing, and by 12 weeks, the patient is allowed to ambulate with full weight bearing.

A fracture is considered stable if it does not exhibit, on varus or valgus stressing, any more than 10 degrees of instability at any point in the arc of motion, from full extension to 90 degrees of flexion. The degree of instability that is acceptable within this range must also be viewed in terms of the personality of the injury. In evaluating a partial articular fracture for stability, it must be remembered that a peripheral wedge fragment, if it involves the posterior part of the plateau, does not contribute to instability in the frontal plane, and the joint may appear to be perfectly stable on varus and valgus stressing. However, the fragment does create instability in the sagittal plane and is an absolute indication for surgical reduction and stabilization. Because small degrees of malalignment and instability may have adverse long-term effects on the knee joint, no more than 10 degrees of instability in the frontal plane should be accepted. If more than 10 degrees of instability is noted on stressing, the fracture is deemed unstable ( Fig. 62-25 ).

The decision to operate or to proceed with nonoperative management is sometimes aided by the use of stress radiographs. Instability with greater than 7 to 10 degrees of motion in the coronal plane is usually managed with surgery. A, Anterior-posterior (AP) radiograph of a lateral tibial plateau fracture. B, AP stress radiograph of same knee.

If the fracture is unstable but is not suited for ORIF because of excessive comminution, advanced osteoporosis, or other patient-related factors or if it is decided that the fracture should be treated openly but the treatment must be delayed, the patient may be treated with skeletal traction and early motion. As long as joint mobility is preserved, secondary reconstructive joint salvage procedures such as intraarticular osteotomies are possible. These procedures are usually much less successful in the presence of joint stiffness.

When skeletal traction is used for comminuted or unstable fractures, a distal supramalleolar tibial pin should be inserted. Ten to 15 lb of traction usually reduces the condylar fragments by ligamentotaxis. As stated previously, however, impacted articular fragments are not reduced with manipulation or traction alone because there are no soft tissue attachments with which to pull them upward. If skeletal traction has been used, a Thomas splint and Pierson knee attachment can often be used to initiate early active knee flexion. A radiograph should be obtained with the leg out of traction at 4 to 6 weeks after the injury to see whether there is any subsequent displacement. If the fracture shows early signs of union or reveals no further displacement, the traction pin can be removed, and a fracture brace or hinged knee brace should be placed at this time. With this method of treatment, the patient should remain strictly without weight bearing for at least 12 weeks, after which progressive weight bearing is allowed as healing is determined radiographically.

Many investigators have identified the most common fracture pattern in the elderly population as the split depression (Schatzker type II). In general, these and other low-energy fracture patterns maintain their overall reduction * when treated with a short period of traction followed by fracture brace application. The fracture patterns that have been shown to lose their reduction when treated in a conservative fashion include type 4 (medial condyle) fractures and those (type 6) with diaphyseal dissociation. The results of nonoperative treatment of displaced tibial plateau fractures in the elderly population are usually mediocre.

* References .

Surgical Treatment

Definitive surgical repair of displaced tibial plateau fractures has evolved significantly over the past two decades. The goals are to repair the knee by restoring its anatomy to as nearly normal status as possible while avoiding the potential complications of injury and treatment. Atraumatic reduction, absolutely stable articular fragment fixation, metaphyseal repair (although possibly with indirect reduction and relative stability), early motion, and progressive rehabilitation as fracture fixation and healing permit are the essential goals. Our understanding of normal anatomy has improved and can be applied intraoperatively to assess and guide the surgeon’s progress with repair. High-quality image intensification fluoroscopy with precise positioning is necessary for this. Complications of surgery, particularly related to wound slough, can be made less frequent by delaying definitive repair or using compromise approaches that avoid badly injured tissue while perhaps accepting a less than perfect reduction. Not only is reassembly of the joint surface important, but restoration of the lower extremity mechanical axis is key to treatment of this injury. The latter can be accomplished without extensive surgical approaches.

Arthroscopy has been applied successfully to certain tibial plateau fractures. It permits assessment and treatment of intraarticular soft tissue and joint surface injuries. Fluoroscopy is usually required as well, and open, but perhaps less extensive, incisions might be needed to provide stable fixation after an arthroscopically assisted reduction.

External fixation can be an effective alternative to internal fixation for some tibial plateau fractures. However, it must be used with understanding and care. By itself, external fixation does not reduce comminuted or depressed articular fragments, which need direct visualization and reduction. Only limited interfragmentary compression is possible without supplementary internal fixation. Stability may be inadequate unless a properly designed and applied external fixator is used. Pin tract infections, which may involve the fracture site or knee (or both), are possible, particularly when the fixator is placed close to the joint and into comminuted areas for optimal fracture stability. Patients sometimes have difficulty tolerating external fixators. However, these devices do not require significant soft tissue exposure and can provide excellent fixation to achieve fracture healing with satisfactory alignment, particularly with regard to limb axis. In combination with well-executed internal fixation, external fixation may be part of a combination treatment that reduces the frequency of wound healing problems while achieving the desired goals of fracture repair. However, unless a patient has severe soft tissue injury or local resources and expertise have developed strongly in the direction of external fixation instead of modern internal fixation, the latter is typically selected for most tibial plateau fractures. External fixation, as just mentioned, may be invaluable for temporary use while a patient’s soft tissues recover before internal fixation or while he or she is transferred to an appropriate center for definitive care.

The challenge for the surgeon is to assess the patient and the patient’s injuries, considering the possible treatment modalities, and to develop and execute an appropriate care plan that takes into account the patient’s circumstances, injury, and available resources.

Surgical Anatomy.

Tibial plateau fractures are complex injuries that involve both bone and soft tissue. Relevant anatomy must therefore be thoroughly understood from both a skeletal and a soft tissue standpoint. A discussion of the most relevant cartilage, ligamentous, and bony anatomy in this section is followed by clinical applications of surgical anatomy in the sections thereafter.

Skeletal Anatomy.

The tibial plateau refers to the proximal end of the tibia, including the metaphyseal and epiphyseal regions as well as the articular surfaces made up of hyaline cartilage. Following the AO/OTA classification, the tibial plateau includes the metaphysis to a distal distance equal to the width of the proximal tibia at the joint line. The proximal tibia is divided into medial and lateral plateaus as well as the tibial eminence. This tibial eminence is further divided into prominent medial and lateral tibial spines, adjacent to which attach the ACL and PCL as well as medial and lateral menisci ( Fig. 62-26 ).

Skeletal anatomy of the proximal end of the tibia. Anterior ( A ) and posterior ( B ) views (cropped).

(From Standring S (ed): Gray’s anatomy, 39th ed, Philadelphia, 2007, Elsevier, pp 1490, 1491.)

The fibular head lies along the posterolateral border of the lateral tibial plateau and articulates with the tibia at the proximal tibiofibular joint, which begins just distal to the knee joint line. The fibular head serves as the attachment for several important knee posterolateral corner stabilizers, including the fibular collateral ligament, PFL, and biceps femoris tendon. The Gerdy tubercle is found on the anterolateral aspect of the proximal tibia and serves as the distal insertion site for the iliotibial band. The tibial tubercle serves as the main attachment site for the patellar tendon, which has a broad flat insertion of approximately 3 cm in width.

One of the most important anatomic distinctions related to the proximal end of the tibia is the size and shape of the medial and lateral condyle. The medial condyle with its articular surface has a slightly concave shape and is larger in both length and width than the lateral condyle, which has an articular surface slightly convex in shape. Understanding the size and shape differences between the two condyles aids interpretation of radiographic landmarks and knee pathology.

Another important anatomic distinction is the difference in height of the lateral and medial condyles. The lateral tibial plateau lies approximately 2 to 3 mm superior (proximal) to the medial plateau. There is a slight varus alignment of the proximal tibia (medial proximal tibial angle, 87 degrees [range, 85–90 degrees]). Understanding the difference between medial and lateral plateau heights is critical for reestablishing normal alignment and height to the fractured or malaligned proximal tibia.

The lateral epicondyle of the femur lines up with the lateral rim of the tibial plateau, and the medial epicondyle with the medial rim of the tibial plateau. Although restoration of the normal intercondylar width may be difficult during repair of some tibial plateau fractures, it is important for recreating normal contact pressures between the distal end of the femur and proximal end of the tibia.

It is also important to recognize that the proximal end of the tibia has a posterior slope of approximately 9 degrees (posterior proximal tibial angle, 81 degrees [range, 77–84 degrees]). Variability in posterior slope as well as other anatomic variables of the tibial plateau anatomy can be inferred from opposite knee radiographs when attempting to assess pathology or postreduction accuracy. These radiographs of the opposite, normal proximal tibia are thus valuable for proper preoperative planning. In the case of bilateral injuries, the surgeon must occasionally revert to use of the normal values mentioned earlier while attempting to achieve similar alignment and a neutral mechanical axis for both lower extremities.

Soft Tissue Anatomy

Cartilage and Menisci.

Both medial and lateral plateaus are covered by hyaline articular cartilage. The lateral plateau cartilage is slighter thicker (4 mm) than the medial plateau cartilage (3 mm). The anatomy of the medial and lateral menisci differ quite significantly as well ( Fig. 62-27 ).

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

The History of Fracture Treatment Diagnosis and Treatment of Complications Medical Management of the Orthopaedic Trauma Patient Private: Fractures and Dislocations of the Clavicle Femoral Shaft Fractures Private: Open Fractures

Stay updated, free articles. Join our Telegram channel

Join