Update management of tibial plateau fracture

1. Rizqi D Rosandi
Orthopaedi-Traumatology FK Univ. Brawijaya
April 2020
Pengampu: Dr. dr. Edi Mustamsir, Sp. OT (K)
Management of Tibial Plateau
Fracture

2. Epidemiology
(burden of disease/cost to society)
• Tibial Plateau
– Articular surface proximal tibia
– +/- metaphyseal /diaphyseal extension
• Account for 1.2% of all fractures
• Lateral Plateau: 55-70% of fractures
• Medial Plateau: 10-20% of fractures
• Bicondylar Plateau: 10-30% of fractures

3. Epidemiology
(burden of disease/cost to society)
• Bimodal distribution
– Young adults: high energy mechanism
• Highest in 5th decade
• Male > Female
– Elderly: low energy mechanism
• Osteoporotic bone
• Female > Male
• Significant functional impairment
– Joint incongruity, malalignment, instability
– Post-traumatic arthritis

4. Anatomy
• Consist of medial and
lateral plateau
– Medial larger
– Medial lower (concave)
– Medial bone harder
(thus less likely to
fracture)
– Lateral higher (convex)
– Lateral cartilage thicker (3
vs 4 mm)
MedialLateral

5. Anatomy
Medial
concave
Lateral
convex

6. Mechanism of Injury
• Valgus producing force
– Lateral plateau
• Varus producing force
– Medial plateau
• Axial compressive force
– Bicondylar plateau
• Combination
– High energy
– Bicondylar plateau

7. Mechanism of Injury
• Low energy
– Split depression
– Increasing age
– Poor bone quality
• High energy
– Pedestrian vs car (bumper)
– Fall from height
– Motor vehicle accident
– Axial load (knee extended)
– Bicondylar fracture
– Associated injuries

8. Clinical presentation
• History
– High energy trauma in young
– Low energy trauma in elderly
• Assessment
– Open or closed fracture
– Compartment syndrome
– Instability
– Neurovascular
– ATLS

9. Imaging • Radiographs
– Knee AP/LAT
– Oblique ( subtle plateau depression)
– Plateau view ( 10 caudal tilt)
• Knee CT
– Articular involvement comminution
– Schatzker IV V VI
– Pre op planning
• Knee MRI
– Schatzker I II III
– Assesment meniscus and ligament
• Angiography

10. Personality of fracture
• Soft tissue damage
• Degree of dislocation
• Degree of comminution
• Degree of join involvement
• Osteoporosis
• Nerve / blood vessel injury

11. Personality of the fracture

12. Classification
• Schatzker classification
• AO/OTA
• Hohl & Moore
• Three column classification

13. Schatzker classification

14. AO/OTA classification

16. The three column classification

17. Management
• Non operative
• Operative

18. Goals of treatment
• Decompression and preservation of soft tissues
• Reconstruction of joint surfaces
• Reconstruction of normal mechanical axis
• Early motion

19. Nonoperative treatment
• No joint step > 2 mm
• No axial instability
• Severe osteoporosis
• General and local contraindications

20. Nonoperative treatment
• Traction may be of use in short term
• Early active movements in a cast brace
• Touch weight-bearing if patient’s condition allows
• Weight-bearing to tolerance at 6 weeks
• Nonoperative treatment does well in low-demand elderly
patients

21. Emergency operative treatment
• Vascular injury
• Compartment syndrome
• Open fractures
• Gross dislocation
• Floating knee
• Polytrauma

22. Operative treatment—timing
• Rarely as an emergency, unless:
- Open fracture, dislocation, vascular injury …
• Delayed surgery to allow soft tissue recovery and
adequate investigations
- (spanning external fixation may be required)

23. Timing of Surgery
Low Energy:
Fixed electively and early
High Energy: Be patience

24. Delayed surgery
• The use of a temporary spanning external fixator will
allow
• Optimal recovery of soft tissues while preserving length
and axis

25. Decision-making
• Surgical approaches can be open or arthroscopic

26. Approach
• Straight anterior
• Posteromedial
• Lateral
• Miniopen

27. Approach
Anterolateral approach Posteromedial approach

28. Intraoperative procedure
•
•
•
•
•
Expose ligamentous and meniscal structures
Reconstruct the joint surface usually with anatomical
reduction and interfragmentary compression using lag
screws
Support the joint surface with bone or substitute
Buttress with plate (conventional)
Repair of the ligaments or menisci to achieve joint
stability

29. ORIF
• Fixation based on fracture type
• Type I, II, III: Buttress plates with raft
screws
• Type IV: Medial plate (buttress)
– Be cognizant of any impaction of lateral joint
line
• Type V, VI:
– Important to understand plate function
– Pattern dictates fixation
– Single lateral base fixed angle implant
– Dual plating (lateral and posteromedial)

30. ORIF

31. ORIF

32. Rehabilitation
• Postoperative Care
• Antibiotic x 24 hours
• +/- drain
• Knee brace
– For comfort until able
to do straight leg raise
(SLR)
– Associated ligamentous
injuries
• Elevate leg
• NWB 10-12 weeks

33. Rehabilitation
• Physical therapy
• Early ROM
• CPM
• Strengthening
– Isometric quad sets
– Heel slides
– SLR
• Gait training
– Crutches
– D/c crutches when able
to walk without limp and
pain

34. Complications
• Infection
– Surgery timing is important
– Careful soft tissue handling
– Prolong operative time
• Nonunion
– Aseptic
• Metadiaphyseal junction
– Septic
– Opened fracture
Aseptic Nonunion Revised with ICBG

35. Complications
• Contractures
– Arthrofibrosis
– Encourage early ROM
and physical therapy
– May require knee
manipulation
– Arthroscopic lysis
of adhesion
• Post Traumatic
Osteoarthritis

36. Outcomes
• 90% excellent or good results
– Despite some incongruity
• 10% fair or poor
– > 10mm depression persisted
• Conclusion
– Instability (lateral or medial with knee extended)
– Should be operative
Lansinger et al. JBJS Am 1986

37. Outcomes
• Risk factors for post-traumatic arthritis
– Increase age
– Removal of meniscus
– Articular incongruity
– Instability
– Malalignment
Honkonen JOT 1995

38. Summary
• Anatomical reduction and rigid fixation of joint surface—
absolute stability
• Functional reduction and stable fixation of metaphysis—
relative stability
• Restoration of joint stability by appropriate soft-tissue
reconstruction
• Early active movement

39. Thank You
Malang, 07 April 2020