Evaluation and Management

As with most fractures, multiple factors play a role when deciding on operative versus nonoperative management of tibial plateau fractures. Important considerations include fracture pattern, knee stability, soft tissue condition, other skeletal injuries, medical comorbidities, and patient expectations. Prior to determining the ideal treatment protocol for a patient with a tibial plateau fracture, a thorough examination of the knee should be performed, and appropriate diagnostic studies obtained. During the physical examination, particular attention should be placed on the neurovascular status, degree of swelling, condition of the compartments of the lower leg, and condition of the skin.

If the fracture is closed, it should be classified using Tscherne′s system for grading closed fractures (see Chapter 2).12 The condition of the soft tissue is critical, and developing the habit of classifying the soft tissue status will ensure a careful assessment.

Appropriate imaging studies are crucial for determining the treatment plan for a patient with a tibial plateau fracture. Initial radiographs should include good-quality anteroposterior and lateral views of the knee and tibia. Additional views that can be very helpful include two obliques and a 10-degree caudal radiograph.3,10,12 Stress radiographs or traction views are helpful but may not be tolerated by the patient without sedation. An axial CT scan with sagittal and coronal reconstructions is used to evaluate the degree of articular depression and detailed anatomy of the fracture (Fig. 32.5).40 The CT scan can change the treatment plan up to 26% of the time40 and is a must for preoperative planning to better determine the surgical approaches and the reduction and fixation strategies. If closed reduction and external fixation is planned, as will be discussed later, the CT scan should be obtained afterward to enable improved visualization in situations entailing ligamentotaxis.

Abbreviations: ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; PLC, posterolateral corner; PMC, posteromedial complex.

As an alternative to the CT scan, the role of magnetic resonance imaging (MRI) in patients with tibial plateau fractures has been controversial.3,10 Several studies have found that up to 99% of patients with tibial plateau fractures have associated soft tissue injuries of the knee.41–44 The addition of an MRI to plain radiographs and CT scan can lead to a change in fracture classification and management41,44 and improves interobserver agreement.41 As expected, MRI increases the recognition of associated soft tissue injuries (ligament, meniscus, articular cartilage). MRI may also show minimally displaced fractures that are not noted on CT scan by demonstrating the surrounding bone edema.44 Gardner et al42 reported that only one patient (1%) of 103 with operatively treated plateau fractures had no soft tissue injury on preoperative MRI42; 77% had a cruciate or collateral ligament injury, 91% had lateral meniscal pathology, and 68% had posterolateral corner injuries. Our protocol over the past 10 years for high-energy mechanism tibial plateau fractures has included obtaining MRI scans as part of the patient′s diagnostic evaluation (Fig. 32.6). Our published experience with the diagnosis of associated injuries is very similar to that of Gardner et al when MRI was used instead of CT for advanced imaging of tibial plateau fractures.43 Many of these associated injuries are very difficult to detect with physical examination alone in patients with unstable tibial plateau fractures, but may impact the clinical outcome. Although it is well accepted that these injuries occur in association with tibial plateau fractures, determining which ones require surgical treatment is controversial given the lack of information about how they impact clinical outcomes.

Indications

Both patient and injury factors should determine definitive management. Patient factors to consider include age, functional demands, associated injuries, and medical comorbidities. Important injury factors include the fracture pattern, comminution, displacement, joint impaction, mechanism of injury, soft tissue condition, and knee stability. Surgeon factors also play a role and include the surgical team′s experience and the operating room environment and equipment. If the patient and the injury meet the criteria for operative management, but the surgeon does not feel comfortable doing the procedure, the patient should be referred to a fracture care specialist.

Absolute indications for surgery include open fractures and those associated with a compartment syndrome or a vascular injury.15 Relative indications include most displaced bicondylar and medial condyle fractures, lateral plateau fractures that result in joint instability or condylar widening that exceeds 5 mm, fracture-dislocations of the knee, and fractures in the polytraumatized patient that will prevent early mobilization of the patient if the knee is treated nonoperatively.2,3,10,12,15

The status of the surrounding soft tissue determines when surgery should be performed and may modify the surgical approach and method. Severe damage to the soft tissue envelope is the most common contraindication to early surgical treatment of tibial plateau fractures.34,51,52 Delaying definitive surgical treatment until optimal soft tissue conditions exist minimizes complications.10,51,52

Surviving the Night (Fig. 32.7)

The primary concerns during the initial presentation of a patient with an isolated tibial plateau fracture are the following:

1. 
   

   Neurovascular status

   
   
2. 
   

   Compartment syndrome

   
   
3. 
   

   Open fracture

   
   
4. 
   

   Knee/fracture stability

If any of the first three exist, urgent or emergent action must be taken, as follows:

• 
  

  If the patient has a neurovascular injury and an obvious deformity exists, an emergent closed reduction should be performed to see if the neurovascular status improves. If vascular status does not improve, a vascular surgeon should be consulted and the patient should undergo an emergent vascular evaluation and management. If vascular repair is indicated, fracture reduction and placement of a knee-spanning external fixator in the operating room should be performed. Controversy exists regarding whether the vascular repair should be performed first or after the fracture length is restored.53 This decision should be based on the individual patient′s situation.

  
  
• 
  

  If a neurological injury is evident and there continues to be obvious deformity or fracture fragment causing continued or progressive neurologic injury, operative intervention for closed versus open fracture reduction with external fixation should be considered. If the neurologic injury is not progressive, the patient may be followed nonoperatively for nerve recovery.

  
  
• 
  

  If a patient has compartment syndrome (see Chapter 4), the patient should undergo emergent fasciotomies in the operating room with closed reduction and external fixation if the fracture pattern is length unstable or the knee is grossly unstable.18

  
  
• 
  

  If an open fracture is present, urgent debridement of the open fracture in the operating room and external fixation should be performed as the patient′s overall medical status allows.

If the fracture is associated with knee instability or the fracture is grossly unstable and the soft tissue injury precludes early definitive management, early closed reduction and knee-spanning external fixation should be considered to prevent continued soft tissue injury and to improve patient comfort.52

Indications and Techniques for Temporary Knee-Spanning External Fixation

As discussed previously, the soft tissue component of the tibial plateau fracture is more important initially and should guide the timing of definitive surgical management of tibial plateau fractures. Indications for temporary knee-spanning external fixation include length or angular unstable fractures, including fracture dislocations, that will undergo delayed definitive management. Other indications include polytraumatized patients or fractures that require close soft tissue monitoring such as patients with an associated compartment syndrome. External fixation also enables overall fracture length and alignment to be restored and can improve visualization of fracture fragments through ligamentotaxis. Delaying getting a CT scan or MRI until after closed reduction and knee-spanning external fixation can aid in planning for the definitive surgery. It is important to place the external fixator clamps proximal to the tibial articular surface to avoid interfering with imaging the fracture. It should be verified that the external fixator is MRI-compatible if MRI is utilized.

When placing a knee-spanning external fixator, Schanz pins should be placed well outside of the zone of injury. Femoral pins can be placed either anteriorly through the quadriceps or laterally through the iliotibial band. Pins should be placed in the tibia anteriorly or anteromedially. It is helpful to draw the eventual surgical incisions on the leg prior to placing the pins to ensure that pin placement will not compromise the surgical approaches for definitive surgery.52 However, there does not appear to be an increased risk of infection if the definitive plating construct overlaps previous external fixator pin sites for high-energy tibial plateau fractures.54 Other authors have found an increased risk of infection when definitive plates overlap external fixator pin sites when pilon and plateau fractures are combined, but they did not differentiate between risk of infection for open versus closed injuries or fracture (pilon vs plateau) type.55

Relevant Surgical Anatomy

The medial and lateral plateaus vary in shape and size. The medial plateau is concave, and larger and stronger than the convex lateral plateau. This is important to remember when placing subchondral or rafting screws from the lateral side, to avoid articular penetration. The lateral meniscus covers a much larger portion of the articular surface than the medial meniscus.56 Meniscotibial (coronary) ligaments attach the menisci to the periphery of the tibial plateaus and must be repaired following either peripheral meniscal tears or submeniscal arthrotomies. It is wise to place stay sutures in the peripheral meniscus for later repair prior to fracture reduction because they are easier to place with the added room the depressed fracture provides (Fig. 32.8).

Important landmarks around the proximal tibia include the tibial tubercle, Gerdy′s tubercle, the pes anserinus, and the proximal tibiofibular joint. Due to the constant and powerful tension the extensor mechanism places on the tibial tubercle, it is critical to adequately stabilize tibial tubercle fragments to enable early knee motion. The fibular head provides attachments for numerous ligaments and tendons of the posterolateral corner (PLC), and also acts as a buttress for the proximal lateral portion of the tibial plateau.

Surgical Approaches

The primary surgical approaches for managing tibial plateau fractures include midline, lateral parapatellar, antero-lateral, posteromedial, and direct posterior approaches to the knee. A submeniscal arthrotomy improves articular visualization for all approaches.

The midline and lateral parapatellar incisions are very similar, and they facilitate visualization of the anterior aspect of the tibial plateau. Great care must be taken to avoid excessive stripping of the deep tissue, which can be associated with infection and wound dehiscence. The incision should be long enough to provide adequate exposure and enable placement of a lateral plate without excessive soft tissue retraction.

The anterior midline incision should be avoided with high-energy bicondylar tibial plateau fractures because of the biological cost of the significant amount of soft tissue stripping that is required to appropriately address fracture fragments and place both medial and lateral hardware. This approach yields up to an 87.5% deep infection rate.14 The use of an anterior midline incision to plan for future arthroplasty incisions has been unnecessary and may be a self-fulfilling prophecy because the ability to reduce and stabilize fractures through this approach is compromised.

The anterolateral or hockey-stick approach is used most commonly. It can be extended posteriorly and proximally to access the PLC (Fig. 32.8). Distally, the incision starts distal to Gerdy′s tubercle and lateral to the tibial crest over the anterior compartment. As the incision is extended proximally, it should curve posteriorly just distal to the joint line, following the anterior insertion of the tibialis anterior muscle. It can be extended proximally to access the posterior corner by dividing the iliotibial band. It is helpful to identify the joint line with fluoroscopy to use as a reference as the surgical incision is drawn. The origin of the anterior compartment muscles is released to enable sub-muscular plating or elevation of an impacted fragment.

Medial fractures (either type IV or those associated with bicondylar fractures) are best approached through a separate posteromedial incision. We do not recommend attempting to place a medial plate through a midline approach because of the excessive stripping necessary to address the posteromedial fragment. A posteromedial approach enables creating a large skin bridge when used with an anterolateral approach and is associated with a low incidence of complications.51 The patient is positioned supine, and the incision is placed along a line from the medial epicondyle to the insertion of the medial collateral ligament, continuing approximately 1 cm posterior to posteromedial border of the tibia (Fig. 32.9). The saphenous vein and nerve should be identified and protected above the fascia. Once the posterior compartment fascia is incised, the posterior aspect of the pes anserinus tendon insertions are elevated and retracted anteriorly. Although transection of the tendons with later repair has been described, in our experience this is unnecessary and may compromise function by creating more scar tissue and risk of hamstring compromise. The medial head of the gastrocnemius muscle is then identified. The remainder of the surgical approach remains anterior to the gastrocnemius directly on the proximal tibial and medial femoral condyle. All retractors must remain anterior to the medial gastrocnemius to avoid injury to the popliteal vessels, and the medial head is not routinely released. Keeping the knee flexed relaxes the posterior neurovascular bundle, creating added safety.

As the desire to address posterior fragments has increased, alternative approaches have been described. Carlson57 described simultaneous posterolateral and posteromedial approaches utilizing the posteromedial interval described above with proximal extension and a posterolateral interval between the lateral head of the gastrocnemius and lateral compartment. A posterolateral approach incorporating a fibular osteotomy has been described to address posterolateral comminution.58 Based on the three-column concept of the tibial plateau, Luo et al38 described an alternative posteromedial approach that provides access to the entire posterior plateau (Fig. 32.10).38 This can be performed with the patient in either the semilateral or prone position. The semilateral position enables a simultaneous anterolateral approach, whereas the fully prone position usually requires the patient to be repositioned supine.

Operative Reduction and Fracture Fixation Techniques

A variety of surgical techniques are available for operative management of tibial plateau fractures. To be successful in addressing the wide variety of fractures and associated soft tissue injuries, the surgeon should become comfortable with most, if not all, of these techniques. The primary factors we consider, when deciding on a specific surgical technique, are soft tissue condition, fracture pattern, surgeon skill, and bone quality. Although there may be other techniques available, we will discuss the techniques we most commonly use.

Patient Positioning and Operating Room Setup

The majority of tibial plateau fractures are addressed with the patient in the supine position (Fig. 32.11). Indications for utilizing the prone position are discussed below (see Bicondylar Tibial Plateau Fractures). An operating room table that is radiolucent from the hip to the foot should be used. A bump should be placed under the ipsilateral hip to help keep the limb in neutral rotation (i.e., patella straight anterior) when addressing the lateral tibial plateau. Inflatable bumps under the buttock may be useful when lateral and medial surgical approaches are being performed because they can be inflated or deflated based on the surgical approach being utilized. It is helpful to have the operative limb on an elevated platform either using blankets or a commercially available ramp to avoid limb overlap on the lateral fluoroscopic view (Fig. 32.11a).

The fluoroscopy unit should be positioned on the opposite side of the more complex column fracture. The fluoroscopy monitor is typically placed near the head of the patient if space allows. This is particularly helpful when the medial tibial plateau is being addressed because the surgeon avoids having to completely turn around to visualize the monitor.

Surgical Technique

Percutaneous Reduction and Fixation of Schatzker Type I Fractures

Type I or split lateral plateau fractures may be amenable to percutaneous screw fixation if an acceptable fracture reduction is obtained. Reduction is achieved either by applying manual traction with a varus force or by using a laterally based universal distractor or external fixator. If an anatomic reduction is achieved, compression is obtained with a percutaneously placed, large, pointed or periarticular fracture reduction clamp. Reduction should be verified on multiple fluoroscopic views including oblique projections to avoid malreduction. If an anatomic reduction is not achieved, the percutaneous technique should be abandoned for either open or arthroscopic reduction techniques. Articular displacement of as little as 1.5 mm at the joint is associated with significantly increased contact pressure.45 Once fracture reduction is achieved, it is stabilized with two or three 4.5-mm or larger solid or cannulated screws with or without washers, based on the bone quality (Fig. 32.12). Alternatively, the reduction can be temporarily stabilized with several 1.6-mm Kirschner wires (K-wires) (Fig. 32.14b), followed by several 3.5-mm “rafting” screws just below the articular surface (Fig. 32.13). This technique is used in patients with good bone quality and avoided in the setting of osteoporosis because screws alone in poor bone quality has a high risk of hardware failure. In osteoporotic patients, a buttress plate and screws is recommended.

Open Reduction and Internal Fixation of Lateral Plateau Fractures

Open reduction and internal fixation is necessary for most Schatzker type II and III fractures that require surgical stabilization (Fig. 32.5). We prefer the anterolateral surgical approach. A transverse incision of the lateral meniscotibial (coronary) ligament enables performing a submeniscal arthrotomy. Varying degrees of patient knee flexion aids visualization of the articular surface. Additional tricks that can improve visualization include placing several small traction sutures in the meniscus and the use of the universal distractor (Fig. 32.14). The location of the articular impaction can be directly visualized in most cases. The depressed articular fragments can be elevated through either the fracture site or a cortical window utilizing a bone impactor. If the lateral fracture line ends within the surgical exposure, it is easier to wedge open the fracture like opening a book, which enables the articular depression to be elevated with an impactor. Although there are often multiple fragments, care should be taken when elevating the fragments to avoid additional iatrogenic comminution. This may require initial disimpaction with a freer elevator or osteotome. The impactor should be used to gently tap the articular fragment back into an anatomic reduction under direct visualization made possible with the submeniscal arthrotomy.

If the plateau fracture line extends beyond the surgical exposure, a cortical window should be created laterally at the metaphyseal flare (Fig. 32.15). The window can be created using a small (2-mm) drill to make four holes in the shape of a 1-cm square. A small osteotome is then used to connect the dots and create a window. The window can be used to place the impactor and elevate the articular surface under direct visualization and fluoroscopic assistance. A more recent technique that can be used is an inflatable bone tamp (IBT) (see Reduction Adjuncts, below). The potential benefit of this technique is to elevate the surface in its entirety in a more controlled fashion that minimizes fragmentation. Once reduced, with either technique, a bone void filler of the surgeon′s choice may be placed and a periarticular reduction forceps should be used to reduce the fracture and maintain the reduction with K-wires.

The final stage of ORIF involves fixation with a plate (Fig. 32.5). Although nonspecialty plates can be used, the most commonly used implants are either a 3.5- or 4.5-mm anatomically precontoured nonlocking or locking plate. The 3.5-mm plates enable the use of smaller implants that help decrease prominence, as well as additional screw options in the periarticular area for comminuted fractures. Because these are all AO/OTA B-type fractures and require buttress plating, locking plates should only be considered in a severely osteoporotic patient due to their significantly higher cost and lack of buttress plate function when only locking screws are used.

For minimally invasive plating techniques, the plate is passed submuscularly along the lateral surface of the tibia through the proximal anterolateral incision. A second incision is made distally where the end of the plate is identified fluoroscopically to help center the plate. Once the plate is verified to be centered proximally and distally on the lateral fluoroscopic view and well positioned on the anteroposterior (AP) view, provisional K-wire fixation is done proximally and distally to maintain plate position. Depending on the plate length, neurovascular structures may be at risk (Fig. 32.16).59 A periarticular reduction forceps is placed proximally to compress the plate to bone. A nonlocking screw is placed just distal to the fracture exit point in the metadiaphyseal region to create a buttress. Periarticular lag screws or position screws (if there is comminution) are placed to fix the articular surface. Typically two more screws are placed in the shaft of the plate below the fracture exit point to create a balanced fixation construct.

Related posts:

Treatment of Fractures in Geriatric Patients Care of the Soft Tissue Envelope Musculoskeletal Infection Associated with Skeletal Trauma Hip Dislocations and Associated Fractures of the Femoral Head Knee Dislocations and Ligamentous Injuries Pelvic Ring Injuries

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