1) Fractures of the tibial plateau can be complex injuries involving both bone and soft tissues. Accurate reduction of the articular surface is important but other factors like alignment, ligament stability, and meniscal integrity also influence outcomes. 2) Surgical treatment may involve open reduction and internal fixation with plates and screws or less invasive options like percutaneous plating and hybrid external fixation to minimize soft tissue disruption. 3) Patient factors like age, comorbidities, and the specific fracture pattern help determine the best treatment which can range from non-operative management to internal fixation, external fixation, or a combination approach.

1. Fractures of the Tibial Plateau
Douglas R. Dirschl, MD
Thomas Ellis, MD
Bruce French, MD

2. Outline
• Anatomy
• Mechanism of Injury
• Evaluation
• Emergency Management
• Surgical Indications
• External Fixation
• Internal Fixation
• Outcomes

3. Osseous Anatomy
• Proximal Tibia
– widens into lateral and medial tibial flares
– flares lead to medial and lateral plateau (condyles)
– intercondylar eminence
– tibial tubercle (patellar tendon)
– Gerdy’s tubercle (ITB)
– proximal tib/fib joint

4. Osseous Anatomy
• Medial Plateau VS
– larger
– concave: frontback
– sideside
– lower than lateral side
– slopes posteriorly 10°
– cartilage 3mm
– medial condyle stronger
bone
– bears 75% of weight
• Lateral Plateau
– smaller
– convex: frontback
– sideside
– higher than medial
– slopes posteriorly 7°
– cartilage 4 mm
– softer bone

5. Meniscus
• Fibrocartilage
• lateral meniscus
– more circular than medial
– covers more of articular surface than medial
– attached to PCL via ligaments
• Humphry (anterior)
• Wrisberg (posterior)
– no attachment to LCL
– bears most of joint reactive force

6. Meniscus
• Medial meniscus
– “C” shaped
– intimately attached to MCL
– bears equal joint reactive force as bone

7. Introduction/Mechanism of
Injury
• Mean age in most series of tibial plateau
fractures is about 55 years
– Large percentage over age 60
• Elderly population is increasing in numbers
– Fastest growing segment of US population
• Tibial plateau fractures comprise 8% of all
fractures in the elderly population (Hohl)

8. Mechanism of Injury
• Mechanism of injury is fall from standing
height in most patients
– MVA is increasing as % of fractures
– High energy fracture patterns increasing in this
age group!
• Most common fracture pattern is split-
depressed fracture of lateral tibial plateau
(80% of fractures)

9. Demographics of
Plateau Fractures
• 1% of all fractures
• 8% of all fractures in the elderly
• lateral plateau involved 55-70%
• medial plateau involved 10-20%
• both involved 10-30%

10. Mechanism
• Mechanism of injury is important when
considering treatment options, timing and
associated injuries
• remember… Force = Mass X Acceleration
• even if the xrays are similar, these are
completely different injuries

11. Evaluation
• Trauma Evaluation
– ABCs
– Associated Injuries
• Evaluation of Limb
– Gentle exam for knee stability
– Observation of soft tissues
– Neurovascular evaluation
– Evaluate for compartmental syndrome
• Imaging Evaluation

12. Physical Exam
• Soft Tissue Assessment
– Tscherne & Goetzen (closed injury)
• grade 0: minimal soft tissue damage/ indirect force
• grade 1: superficial abrasion/contusion via pressure from
within
• grade 2: deep, contaminated abrasion with localized
skin/muscle contusion: impending comp. syn.
• Grade 3: extensive skin contusion/crush: sobq avusion;
underlying muscle damage; decompensated cs
– Gustilo and Anderson (open injury)

13. Physical Exam
• Neurologic exam
– peroneal nerve!
• Vascular exam
– popliteal artery and medial plateau injuries
– beware the of the knee dislocation posing as a
fracture
– beware of posteriorly displaced fracture fragments
– ABI <0.9 urgent arterial study

14. Physical Exam
• Compartment syndrome
• KNEE STABILITY
– varus/valgus in full extension
– may require premedication
• aspiration of knee effusion/hematoma
• replace with lidocaine+marcaine

15. Evaluation of Soft Tissues
• Proximal and distal
tibia subcutaneous
• Soft tissue remains
compromised for at
least 7 days
• Early ORIF risks
wound
sloughexposed
hardware

16. Evaluation
• Plain radiographs
– AP, lateral, ? oblique of knee on 17-inch
cassettes
– AP and lateral of entire tibia
– Traction radiographs
• Very helpful for complex fractures
• Traction can be applied by temporary spanning ex-
fix
– CT scan indications
• Fractures for which you are considering nonsurgical
care
• Complex fractures to assist in surgical planning
• Always obtain CT after applying traction

17. AP and Lateral Radiographs

18. AP and Lateral Radiographs

19. AP and Lateral Radiographs

20. Pre-traction

21. Post-traction

22. Tomography

23. Computed Tomography
• Indications
– Fracture in an active patient for which you are
considering nonsurgical care
– Complex fracture
– To aid surgical planning of approach,
technique, screw position, etc.
• Indications for 3-D reconstructions
– Rare
• Rapid prototyping?

24. Computed Tomography

25. Computed Tomography

26. Classification:
Schatzker
I
II
III

27. Classification:
Schatzker
IV
V
VI

28. Classification:
AO/OTA

29. Classification:
AO/OTA

30. Classification:
AO/OTA

31. Urgent Management
• Rule out compartmental syndrome
• Provide temporary external stabilization
– Relieves pain
– Stabilizes bone and soft tissues
• Consider spanning external fixation if:
– Complex fracture pattern
– Large amount of shortening
– Soft tissue conditions or other injuries make
immediate ORIF unsafe

32. Compartmental Syndrome

33. Spanning External
Fixation

34. Spanning External Fixation

35. Surgical Indicatons
• Open Fracture – I&D, spanning ex-fix
• Extensive soft tissue contusion – spanning
ex-fix
• Closed fracture
– Varus/valgus instability of the knee
– Varus or valgus tilt of the proximal tibia
– Meniscal injury/previous mensicectomy
– Articular displacement or gapping???

36. Should You Operate on These
Fractures?
• “The objective of treatment of tibial plateau
fractures is precise reconstruction of the
articular surface and stable fragment
fixation allowing early motion”
• Do outcomes data support these objectives?

37. Should You Operate on These
Fractures?
• Tenet: patient outcome will vary directly
with the accuracy of the articular reduction
• The literature seems to indicate that
articular incongruity is tolerated fairly well
and that other factors may be more
important in determining outcome

38. Lucht et al (Acta Orthop Scand 1971; 42:366)
• 109 fractures treated op and non-op
• 3-10 mm articular depression
– 78% acceptable functional result
• > 10 mm articular depression
– 79% acceptable functional result

39. Ramussen (JBJS 1973; 55A:1331-1351)
• 183 patients followed for 7.3 years
• Functional outcome no different in 40
patients with > 5 mm articular depression
than in those with < 5 mm
• No correlation between residual articular
depression and arthrosis

40. Lansinger et al (JBJS 1986; 68A:13-19)
• 102 of Rasmussen’s 183 patients followed
for 20 years
• No change in functional outcomes from the
original study
7 yrs: 87% G or E 20 years: 90% G or E
• All 20 patients with 5-10 mm incongruity
had excellent results (including 9 with
instability of the knee)

41. Lansinger et al (JBJS 1986; 68A:13-19)
• All 5 patients with > 10 mm incongruity and
stable knees had G or E result
• Poor outcome occur only with combination
of:
– Central depressed condylar fragment
– > 10 mm articular incongruity
– Mediolateral instability of the knee

42. Koval et al (J Orthop Traum 1994; 6:340-346)
• 18 patients followed 16 months
• Clinical results no different for patients with
anatomic (< 2 mm) or nonanatomic (> 2 mm)
reductions
• 5 nonanatomic reductions:
• 2 excellent, 3 good results

43. Blokker et al (Clin Orthop 1984; 182:193-199)
• 60 patients followed for 39 months
• Adequacy of articular reduction strongly
associated with outcome
• Satisfactory results:
– Anatomic reduction 86%
– 1-4 mm step-off 75%
– > 5 mm step-off 0%

44. Blokker et al (Clin Orthop 1984; 182:193-199)
• To attain “satisfactory” rating
• Satisfactory clinical result AND
• Satisfactory radiographic result
– Criterion for satisfactory radiographic result
was < 5 mm articular incongruity
• Patients with > 5 mm incongruity were
assigned an unsatisfactory result, regardless
of clinical outcome

45. Importance of Factors Other Than
Articular Congruity on Outcome
• The literature clearly indicates that other
factors are critically important to outcome:
– Angular malignment of the proximal tibia
– Resection of the meniscus
– Ligamentous instability

46. Angular Malalignment of the
Proximal Tibia
• Rasmussen (Acta Orthop Scand 1972; 43:566-572)
– Incidence of arthrosis:
• Valgus < 10o
14%
• Valgus > 10o
79%
– Any amount of varus angulation was bad
– Independent of articular congruity

47. Meniscectomy
• Jensen et al (JBJS 1990; 72B:49-52)
– Higher rate of arthrosis in patients who had
undergone meniscectomy at surgery
• Honkonen (J Orthop Traum 1995; 4:273-277)
– 70% arthrosis in patients who had undergone
meniscectomy
– results were independent of the amount of
articular incongruity

48. Ligamentous Instability
• Rasmussen (Acta Orthop Scand 1972; 43:566-572)
– 46% arthrosis in patients with mediolateral
instability (17% incidence in all others)
• Lansinger (JBJS 1986; 68A:13-19)
– Mediolateral instability a necessary condition
for a poor functional outcome
• Honkonen (J Orthop Traum 1995; 4:273-277)
– 69% arthrosis in patients with mediolateral
instability > 10o

49. Surgical Indicatons
• Open Fracture – I&D, spanning ex-fix
• Extensive soft tissue contusion – spanning
ex-fix
• Closed fracture
– Varus/valgus instability of the knee
– Varus or valgus tilt of the proximal tibia
– Meniscal injury/previous mensicectomy
– Articular displacement or gapping

50. 90 yo Male Injured in MVA
Non-op
Care!

51. Surgical Treatment
Depressed Fractures (Schatzker 3)

52. Surgical Treatment
Depressed Fractures (Schatzker 3)

53. Surgical Treatment
Depressed Fractures (Schatzker 3)

54. Surgical Treatment
Depressed Fractures (Schatzker 3)

55. Surgical Treatment
Depressed Fractures (Schatzker 3)

56. Surgical Treatment
Split Fractures (Schatzker 1)

57. Surgical Treatment
Split Fractures (Schatzker 1)

58. Surgical Treatment
Split Fractures (Schatzker 1)

59. Surgical Treatment
Split Fractures (Schatzker 1)

60. Surgical Treatment
Split Depression Fractures (Schatzker 2)

61. Fixation Lateral Plateau
Fractures
• Traditional
– large fragment “L” or “T” buttress plate
– 6.5mm subchondral lag screws
– 4.5mm diaphyseal screw
• Current Recommendation
– small fragment fixation
– pre-contoured peri-articular plates
– clustered sudchondral k-wires
•

62. Biomechanics: Subchondral
Fixation
• 3.5 mm raft construct allowed significantly less
displacement than 6.5 mm screw with axial load (2954
vs. 968 newtons/mm) Twaddle et al AAOs, 1997
• no difference in pull out strength between 6.5mm screws
and 3.5mm screws in subchondral bone Westmoreland
et al J Ortho Trauma 2002
• Subchondral clustered K-wires signicantly enhance load
tolerance depress articular surface Beris et al Bull Hosp
Joint Dis 1996

63. Large or Small Fixation for the
Lateral Plateau?
• No significant difference between fixation strengths
small vs large frament (Hubbard et al. A J Ortho, 1999)
• Karunaker et al. J Ortho Trauma 2002
– No significant difference in overall stiffness between: large
fragment; periarticular small fragment plate; 3.5 mm
subchondral screws with separate 1/3 semitubular anti-glide
plate
– local depression stiffness > with 3.5 mm vs 6.5 mm screws

64. Clinical Example
• 57 female
• ped struck

65. Instability

66. • Arrows (left right)
– depressed joint
– lateral wall
– meniscus

67. • Elevation of joint
• temporary fixation
• bone graft defect

68. Fixation

69. Lateral Split Depression Plateau
Clustered K-wires

70. Surgical Treatment
Medial Fractures (Schatzker 4)

71. Operative Management
High Energy Fractures
• Soft tissue envelop more of an issue
• treatment aimed at minimizing iatrogenic,
surgically induced complications
– limited ORIF with external fixation
• hybrid
• monolateral half pin
– composite fixation
– open reduction joint with perc. locked plate (LISS)
– temporary knee spanning external fixation with delayed
double plating/ locked plate

72. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)

73. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)

74. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Hybrid Ex-Fix

75. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Hybrid Ex-Fix

76. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Hybrid Ex-Fix

77. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Hybrid Ex-Fix

79. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Hybrid Ex-Fix

80. Hybrid External Fixation
Results
• Duration external fixation 12-16 weeks
• ROM: 100-120°
• knee score average 80-90 on 100 point scale
• complications
– nonunion 5%
– angular malunion 10%
– deep infection 5%
– PIN TRACT INFECTION COMMON

81. Hybrid External Fixation
Pin Tract Infections
• Generally respond to antibiotics + pin care
• may result in septic joint (10%)
• Ways to avoid septic joint:
– stable fracture reduction (impact metaphysis)
– keep pins >15mm from joint
– beware cavity communicating metaphysis joint
– gentle post op ROM to avoid pin irritation
– aggressive investigation post op knee effusion
– consider cross joint adjunct fixation

82. Temporary Knee Spanning External
Fixation with delayed ORIF
• Acute: femur tibia external fixation
– reduction via ligamentotaxis
– pins in tibia at least 5cm from distal fracture line
• CT scan
• ORIF when soft tissue recovers
– up to 3 weeks!!!
– Double plating
– unilateral locked plate

83. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Percutaneous Plating

84. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Percutaneous Plating

86. Posteromedial Approach

87. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Percutaneous Plating

88. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Locking Plates

89. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Locking Plates

90. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Locking Plates

91. Surgical Treatment
Bicondylar Fractures (Schatzker 5 and 6)
Locking Plates

92. Locked Plate
Pitfalls
Hole # 13 12 11 10
Distance
Ant. Nv bundle
to drill sleeve
(mm)
0 3 6 8
Distance sup
peroneal n. to
drill
sleeve(mm)
7 6 9 12

93. Locked Plate- Results
• 52 proximal tibia fractures
• 31/52 bicondylar plateau
• 18/52 open injuries
• 1 nonunion
• 4 malunion
• average range of motion 2-116°
• 2 infections (both grade 3B)
Stannard et al. OTA 2001

94. Locked Plate- Results
• 75 bicondylar plateau fractures
• 16/75 open injuries
• 6 delayed unions: 4/6 union with bone graft
• 1 deep infection
• 9 loss of fixation: 8/9 technique related
• 78% good/excellent results (Rasmussen)
Gosling, Krettek et al. OTA, 2002

95. Can I Synthesize this Information
into Clear Guidelines?
• Articular incongruity 5 mm or less
• Stable knee in full extension
• Normal varus/valgus alignment
• Non-operative Care!

96. 90 yo male injured in MVA
Non-op
Care!

97. Can I Synthesize this Information
into Clear Guidelines?
• Articular displacement > 5 mm AND
• More than 10 degress varus/valgus
instability to exam in full extension
• Operative Care!

98. Can I Synthesize this Information
into Clear Guidelines?
• Articular displacement > 5 mm AND
• Knee stable to varus/valgus stress in full
extension
• Favor non-operative care

99. Can I Synthesize this Information
into Clear Guidelines?
• Varus or valgus tilting of proximal tibia
more than 5 degrees
• Operative Care!

100. Postoperative Management
• Immediate PROM/AROM of knee
• Shower beginning 48 hours after surgery
– Ok to shower with ex-fix in place
• Routine Pin site care (if ex-fix)
• TDWB for 8-12 weeks
• Sutures out in 2 weeks
• Xrays in 4-6 weeks

101. Outcomes
• See slides 27-39 in this presentation
• Outcome depends on:
– Varus valgus stability of the knee
– Varus/valgus alignment of the proximal tibia
– Presence of an intact meniscus
– Articular congruity (to a lesser extent)

102. Treatment Goals
• Focus on restoring stability and proximal
tibial alignment to the knee, rather than
restoring anatomic alignment of the
articular surface at all costs
• Use minimally invasive techniques, when
possible
• Other techniques are preferable to hybrid
ex-fix
• Move the knee early in all patients!

103. Thank You!
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