Anatomy, Mechanism of injury , Detailed classifications , Associated injuries, physical examination , Radiological evaluation ,non operative and detailed surgical management with X-rays & diagrams.

1. Proximal tibia
Dr. Mounika
M.S Ortho

2. Anatomy
• The tibia is the larger and medial bone of the crus, or middle segment
of the hind limb.
• The articular surface at the proximal end of the tibia comprises two
concave or dished areas: the upper surfaces of the medial and lateral
condyles, and between them the intercondylar groove or fossa.
• Just distal to the lateral condyle, on the lateral surface and facing
distally, is the small, nearly oval facet for the head of the fibula.
• On the posterior surface of the tibia, between the condyles, is
the popliteal notch. A small muscle, the popliteus, lies in the notch
and is a flexor of the knee joint.
• The tibial tuberosity, for insertion of the patellar ligament, lies
anteriorly.
• The tibial crest continues distally from the tuberosity along the shaft.

3. • The tibial plateau is the proximal tibial surface on which the femur
rests. It is divided into two articular sections, one for each femoral
condyle. In life there are fibro-cartilagenous rings around the
periphery of these articular facets, the medial and lateral menisci.
• The medial intercondylar tubercle forms the medial part of the
intercondylar eminence.
• The lateral intercondylar tubercle forms the lateral part of the
intercondylar eminence.
• The anterior and posterior cruciate ligaments and the anterior and
posterior extremities of the menisci insert into the non-articular areas
between the condyles, which are just anterior and posterior to the
medial and lateral intercondylar tubercles, respectively.

6. Bony Prominences near Tibial plateau
•ANTERIORLY :- TIBIAL TUBERCLE
Patellar tendon insertion.
•ANTEROLATERALLY :- GERDY’S TUBERCLE
• Insertion of Iliotibial band
•ANTEROMEDIALY :- PES ANSERINUS
• Attachment of Medial Hamstrings
•Sartorius Gracillis
Semitendinosus

8. • Tibial plateau composed of articular surfaces of medial and lateral
tibial plateaus, on which cartilagenous menisci are present.
• Medial plateau Lateral plateau
• Larger in size smaller in size
• concave convex
• inferior 2-3mm superior
• cartilage thickness 3mm 4mm
• lesser meniscal coverage greater
• The lateral plateau is higher than the medial accounting for few
degrees of varus of tibial plateau in relation to the shaft.

10. • The proximal articular surface slopes in relation to the shaft –
Normal tibial plateau has Posterio - inferior slope ~ 5-15 degrees
(Posterior proximal tibial angle)

11. Proximal Tibia Fractures

12. 1. Tibial plateau fractures
2. Tibial spine fractures
3. Tibia tubercle fractures
4. Proximal tibial epiphyses fracture

13. Tibial plateau fractures

14. • Fractures of tibial plateau involve the articular surface of proximal
tibia
• Most common long bone fractures
• Small rim avulsions = occur in conjunction with knee dislocations and
other ligaments injury of the knee
• Assessing the associated soft tissue injuries around the knee is
critically important.
• Certain fracture patterns have high risk of limb threatening
complications such as compartment syndrome & neurovascular
damage

15. • Low energy causes = lateral plateau fractures 55-70% [more
common]
• High energy causes = medial plateau 10-20%
and bicondylar fractures 10-30%.
• Tibial plateau fractures represent 1% of all fractures
• 8% of all fractures in elderly
• Fractures in men = younger age and tend to be result of high energy
trauma
• in women = increasing incidence with advancing age [6th & 7th
decade ] -------------- indicates these occurs in osteopenic bone

16. Anatomy
• Proximal tibia
triangular
wide metaphyseal region
narrow distally
• Muscles - deforming forces
• Patellar tendon
proximal fragment into extension
fracture into apex anterior, or procurvatum
• Gastrocnemius
distal fragment into flexion
• Pes anserinus
proximal fragment into varus

18. MECHANISM OF INJURY
• Valgus and Varus forces = Split fractures + Collateral ligament tear.
• Axial forces = Local compression/Depression fractures.
• Combination of both forces = Split depression fractures + Collateral
ligament tear.
• The greater the energy absorbed by the proximal tibia = more the
severe the fracture , more the fragments are displaced and
comminuted.
• Axially loading forces are more rapid and release greater energy
than angular forces.

19. • The medial plateau is more resistant to failure than the lateral
plateau
• Middle aged or elderly patients simple falls lead most commonly to
lateral plateau fractures.
• Younger patients high speed energy caused split fractures / rim
avulsions associated with knee ligament injuries.
• The proximal tibia is most likely to be subjected to a valgus force
because of the normal 5-7 degrees of valgus alignment of the knee.

21. CLASSIFICATION
1. HOHL AND MOORE CLASSIFICATION
1. AO / OTA CLASSIFICATION
1. SCHATZKER CLASSIFICATION

22. HOHL & MOORE CLASSIFICATION

23. AO / OTA CLASSIFICATION
• Type A – Extraarticular
• Type B - Partial Articular
• Type C - Intra-articular and Metaphyseal

26. ASSOCIATED INJURIES
• 90% of these fractures associated with soft tissue injuries
• Meniscal tears occurs in 50% of these fractures
• Associated ligamentous injuries (cruciate or collateral) occur in 30%
of these fractures
• Other associated peripheral fractures of margins of the tibia –
Segond fracture,
Reverse segond fracture,
anteromedial tibial margin fractures,
semi-membranous tendon site insertion fracture
• Others-: common Peroneal nerve
Popliteal artery injury

27. • The mechanism of injury clues to the fracture pattern.
• The fracture pattern guides treatment, decisions and determines the
risk of complications.
• The physical examination of the knee and leg is critically important to
diagnose associated injuries and complications.
• Metaphyseal-diaphyseal distraction patterns and fracture dislocations
are particular risk for vascular and neurologic injury.
• Medial condyle #s and schatzker type 6 #s have risk of compartment
syndrome.
• Tibial plateaus may have communicating open wound , to be
identified on physical examination

29. Evaluation
• Trauma evaluation
ABCs
Associated injuries
• Evaluation of limb
gentle examination of knee stability
observation of soft tissues
neurovascular evaluation
evaluation of compartment
• Imaging evaluation

30. Physical examination
• Neurological examination
Peroneal nerve especially with valgus force
Compartment syndrome with severe injuries
• Vascular exam
Palpable pulses don’t exclude injury
Popliteal artery and medial plateau injury
Knee dislocation posing as a fracture
Posteriorly displaced fracture fragments
• Soft tissue assessment
Gustilo and anderson [ open injury ]
Tscherene and goetzen [ closed injury ]
Severity of swelling, location of blisters – size, character.

31. • Hemarthrosis , Aspirate for:
.Pain relief
.Fat evaluation
• Assessment of stability after local anaesthetic.
.Valgus / Varus in full extension
• Compartment syndrome
.Pain on passive stretch
.Pain out of proportion

32. Fasciotomy

33. Radiographic evaluation
• Ap view in plane of plateau(10-15 degrees caudally) , Laterally
• Oblique view – Internal rotation view
shows posterolateral fragment.
• Traction films
restores the gross geometry of proximal tibia
Decreases the overlap and better defines the fracture fragments
two types – Manual traction
- Traction by joint spanning external fixator.
• CT scan – Demonstrates the more articular displacement and comminution
• MRI – Location of fracture lines and degree of articular displacement ,
Injuries to the soft tissues structures of the knee(Menisci and Ligaments).
MRI is the imaging modality of choice when there is a proximal tibia stress

34. TREATMENT OPTIONS
•NON OPERATIVE
•OPERATIVE

35. NON OPERATIVE
• The proximal tibial articular surface tolerates small to modest articular
displacements , therefore non operative treatment results in excellent outcomes
despite the articular irregularities.
• The minimally displaced medial total condylar # has greater potential for
displacement that may lead to unacceptable varus deformity.
• Indicated for non-displaced or minimally displaced fractures
without any ligament injury
In pts with advance osteoporosis
Small depression of lateral plateau without deformity.

36. Bracing Tibial Plateau Fracture
• Cast bracing used as both primary non operative treatment and adjunct to ORIF.
• It is used to unload the injured side of the joint .
• Used to stabilize the joint while permitting some degree of joint mobility.
• Immobilization with cast or brace for week .
• Injured knees with tibial fractures tolerate upto 6weeks of cast immobilization
before becoming increasingly stiff
• followed by early range of knee motion
in a hinged knee brace along with
skeletal traction

37. Weight bearing guidelines
• The duration of non weight bearing depends on fracture pattern but
typically 4 – 8 weeks.
• Isometric quadriceps exercises and progressive passive, active-
assisted, and active range-of-knee motion exercises are indicated .
• Toe touch weight bearing for 8 to 12 weeks is allowed, with
progression to full weight bearing

38. Operative
• Indicated for displaced unstable tibial plateau fractures where near
normal alignment can’t be predicted
• It includes – all bicondylar fractures
shaft dissociated patterns
lateral pattern fractures – split fragments
depression affecting ½ of lateral articular surface
fibular head fracture
valgus alignment on x rays and clinical

39. Indications
• The no. of millimetres of depression of the articular surface measured on x rays
has been used to indicate surgery.
• Acceptable articular displacement is controversial
• Some authors recommended sx --- articular stepoff > 2mm
other - articular stepoff>5mm
• If the articular depression is 5 to 8mm ,the decision for operative or non
operative t/t depends on –age of pt
- activity demand of the knee
• Instability > 10 degrees of nearly extended knee compared to the contralateral
side is an absolute indication.
• Open fractures
• Associated compartment syndrome
• Associated vascular injury

40. Modified Rasmussen’s criteria- for functional
outcome evaluation

41. AIMS OF SURGERY
• Restoration of articular congruity, joint stability and original knee axis
• Provide fracture stability allowing for early pain free movement of
knee & mobilization of the pt.
• Obtain full functional recovery as a long term goal.
• Avoidance of posttraumatic arthritis.

42. Approaches
• The fracture pattern and classification dictates the operative
approach, fixation, risk of complications, to some extent outcome.
• Two frequently used surgical approaches to reduce and internally fix
the fractures : antero-lateral approach = lateral plateau #s
postero-medial approach = medial plateau #s
• They are used together for the patterns that involve both condyles.
• Most other approaches reserved for special circumstances.
- posterior approach
- anterior approach

43. ANTERO – LATERAL APPROACH
• Most common approach to surgically reduce and internally fix tibial plateau
fractures.
• Proximal exposure develops subcutaneous access
posteriorly towards the fibular head for placement
of a lateral tibial L- shaped plate.
• Used for ORIF of lateral plateau
• S shaped incision starting approximately 3-5 cm
proximal to joint line
• Staying just lateral to patellar tendon
• incision is curved anteriorly over Gerdy’s tubercle
and it is extended distally ,1cm lateral to anterior
border of tibia.

44. POSTERO – MEDIAL APPROACH
• Used to reduce and fix the medial side of proximal tibia and
Particularly the posteromedial fragment.
• It has the advantage of relatively good soft tissue cover
• For ORIF of # Medial tibial plateau
• A 6 cm longitudinal incision over the
postero- medial border of proximal tibia is made
and then subcutaneous fat is incised and Pes Anserinus is divided and
retracted
• The subcutaneous dissection must avoid saphenous
nerve and vein
• The deep interval is btwn the posterior border of the
pes anserinus and the medial head of gastrocnemius.

45. Principles of surgical procedures
• Seven surgical procedures commonly utilized.
• No. 1 – limited approach technique with arthroscopic or fluoroscopic assessment
of reduction = OA / ATO B1 or schatzker 1.
• No. 2 – Reduction and buttress plate fixation and void filling
=OTA / AO B2 or B3 or schatzker type 2.
• No. 3 – Limited approach technique with arthroscopic or fluoroscopic assessment
of reduction and screw or plate fixation and void filling.
= schatzker type 3.
• No. 4 – Medial anti-glide plating via posteromedial approach.
= OTA / AO B1,2,3 or schatzker type 4.
• No. 5 – Dual plating ; Lateral locking plating ; and External fixation.
= OTA / AO 41C or schatzker 5 & 6.

46. 1. Limited approach technique with fluoroscopy
assisted percutaneous reduction- split lateral
plateau #s

47. 2. Reduction & buttress plate fixation & void filler –
split depression #s of lateral plateau.

48. Intra-op fluoroscopy assisted reduction, provisional & definitive fixation
&void filler

49. 3. Limited approach technique with fluoroscopy
assisted reduction & screw/ plate fixation & void
filling – local compression #s

50. 4. Medial anti-glide plating via posteromedial
surgical approach – isolated medial side patterns

51. 5,6,7. Dual plating; lateral locking plate & ex-
fixation - bicondylar or metaphyseal-diaphyseal
dissociation.

54. Management of soft tissue
• The worst soft tissue injury occur with bicondylar fractures, fracture
dislocations, shaft dissociated patterns.
• Fracture blisters occur when soft tissue injury is severe.
• Severe closed soft tissue injuries take many days or even weeks after
the injury to recover.
• Open soft tissue injuries should be urgently debrided.
• Soft tissue coverage may be needed – like rotational flaps [from
medial or lateral heads of gastrocnemius ]
• Surgical timing, temporary spanning external fixation, and
recognizing the risk of compartment syndrome = optimize the
outcomes due to soft tissue injury.

55. Principles of external fixator
• External fixation is now frequently used as a temporary treatment by
spanning the knee
• It restores the length & aligns the fracture during soft tissue
recovery prior to definitive treatment with IF .
• Indications
severe soft tissue injury / open wounds [best indicator ]
delay in the time for surgery
bicondylar #s
• The frame and bone fixation elements must come over the
deforming muscle forces.
• The tibial pins should be placed in a way not to interfere with
subsequent procedures of internal fixation.

56. • The external fixator spans both the fracture and knee & pins avoid the entire
zone of injury.
• The joint spanning frames = severe #s with marked displacement, shortening,
subluxation.
• The ex-fix will span the metaphyseal area of fracture and stabilize the tibial
condyles to tibial shaft.
•EXTERNAL FIXATORS
• Bridging external fixator
• Hybrid external fixator
• Ring external fixator

57. Schatzker ty-6 [high energy] Rxd with spanning
ex-fix and then with nailing.

58. • If pin fixator, hydroxyapatite coated pins provide longer lasting
purchase.
• Pins are placed medially, antero-medial, antero-lateral.
• Pins and wires should be kept as far away from articular surface to
minimize the chance of septic arthritis.
• In severe cases with soft tissue injury, fracture instability and small
peri-articular fragments = cross-knee spanning frame used to
neutralize the cross- joint forces.
• External fixator helps in early weight bearing.

59. Principles of void filling
• Reducing the depressed tibial articular fragments, leads to empty
areas in bone or voids beneath the reduced fragments
• They don’t present a risk for healing process.
• They are an area that lack support for reduced articular fragments
increasing re-displacement despite internal fixation.
• Materials used :
grafting [ iliac crest ]
interporous coraline hydroxyapatite
beta tricalcium phosphate
phase changing cements – calcium phosphate [ Ca-P ]
rafting screw technique [ support the reduced fragment ]

60. Adverse Outcomes & Complications
• Loss of reduction in tibial plateau fractures.
• Wound infection and breakdown.
• Septic arthritis after external fixation.
• Knee stiffness.
• Painful prominent hardware.
• Tibial non union.
• Post traumatic arthritis.

61. Tibial spine injuries

62. • Tibial spine also called intercondylar eminence.
• The term tibial spine refers to area btwn the medial and lateral tibial
plateaus, on the proximal tibia
• It consists of lateral tibial spine and medial tibial spine.
• The ACL inserts on the medial tibial spine.
• Tibial spine fractures occur at the base of the medial tibial spine and
are ACL equivalent injuries.
• The fracture may extend into medial & lateral articular surfaces.
• These injuries can occur during sporting endeavors.
• They are more common in skeletally immature patients btwn ages
8-14yrs.

63. • Mechanism of injury = hyperextension to knee [ classical ], rotation,
ab/aduction.
• The injury creates traction on ACL and causes avulsion of tibial spine.
• ACL STRONGER THAN TIBIAL SPINE. The immature tibial spine is
weaker than ACL
• They should be operatively manages if displaced. But the meniscus
and intermeniscal ligament can be the barriers for reduction.
• Although ACL laxity occurs commonly due to ligamentous stretch
during the injury, this laxity is rarely clinically significant if the fracture
is properly treated.

64. CLASSIFICATION – MEYERS AND
McKEEVER• TYPE – 1
incomplete avulsion with no / minimal displacement.
• TYPE – 2
fractures are displaced anteriorly with intact posterior hinge.
• TYPE – 3
fractures are displaced completely from proximal tibia.
• Modified by ZARICANYJ as
• TYPE – 4
comminuted fractures.

66. Treatment
• Based on the magnitude of displacement of fracture and the presence of
additional intra articular injury.
• GOALS OF SURGERY :
anatomic reduction of the fracture
preservation of motion.
• TYPE -1 : Non displaced and minimal displaced fractures = treated non
operatively with either casting or bracing . In full extension or slight flexion for
approx. 6weeks.
• TYPE -2 : managed with immobilization of knee extension +/- arthrocentesis if a
near anatomic reduction can be achieved.
• TYPE – 3 : either arthroscopic or ORIF with screws and wires. Sx allows the
removal of barriers of reduction and anatomic fixation of fracture & to restore
normal function of ACL.

68. Complications
• Laxity
• Non union
• Mal union with extension block
• Growth plate disturbances
• Arthrofibrosis

69. Tibial tubercle fractures

70. Anatomy
• Proximal tibia has two ossification centers
• Primary ossification center (proximal tibial physis)
• Secondary ossification center (tibial tubercle physis or apophysis)
insertion of patellar tendon
• Physeal closure occurs from posterior to anterior and proximal to
distal, with the tibial tubercle the last to fuse
• Places distal secondary center at greater risk of injury in older
children
• Extensor mechanism exerts great force at secondary ossification
center

71. • These are common fractures that occur in adolescent boys near the
end of skeletal growth during athletic activity.
• Concentric contraction of quadriceps during jumping
• An eccentric contraction of quadriceps against a flexed knee.
Epidemiology :
• Less than 1% of paediatric fractures.
• Males >> females .
• Age 12-15yrs [ approaching skeletal maturity ]
Associated conditions
compartment syndrome (4%)
meniscal tears with Type III injuries

72. Ogden Classification (modification of Watson-Jones)
• Based on level of fracture and presence of fragment displacement
• Type III most common
• Type I- fracture of the secondary ossification center near the insertion
of the patellar tendon
• Type II- fracture propagates proximal between primary and secondary
ossification centers
• Type III- coronal fracture extending posteriorly to cross the primary
ossification center
• Type IV- fracture through the entire proximal tibial physis
• Type V- periosteal sleeve avulsion of the extensor mechanism from
the secondary ossification center

74. EvaluationSymptoms
• sudden onset of pain
generally occurs during the initiation of jumping or sprinting
• inability to immediately ambulate
• knee swelling/hemarthrosis with Type III injuries
Physical exam
• inspection & palpation
knee effusion
tenderness at the tibial tubercle
evaluate for anterior compartment firmness
ROM & instability
• extensor lag or extensor deficiency in Type II or III injuries
• retinacular fibers may allow for active extension

75. Imaging
• Radiographs
AP
Lateral
• Findings widening or hinging open of the apophysis
• Fracture line may be seen extending proximally and variable distance posteriorly
• Anterior swelling may be the only sign in the setting of a periosteal sleeve
avulsion (type V injury)
• Patella alta
• CT - can be useful to evaluate for intra-articular or posterior extension
• MRI - generally not indicated
useful for determining fracture extension in a nondisplaced Type II injury or
type V injury

76. Treatment
• Nonoperative
• long leg cast in extension for 6 weeks
• Indications
Type I injuries or those with minimal displacement (< 2 mm)
acceptable displacement after closed reduction/cast application
• Operative
• Open reduction internal fixation with arthrotomy +/- arthroscopy, +/-
soft tissue repair
• Indications
Type II-IV fractures - need to visualize joint surface for perfect
reduction and evaluate for intra-articular pathology
soft tissue repair for Type V (periosteal sleeve) fracture

77. Complications
• Recurvatum deformity
more common than leg length discrepancy
growth arrest anteriorly and posterior growth continues
leading to decrease in tibial slope
• Compartment syndrome
related to injury of anterior tibial recurrent artery
• Stiffness
• Bursitis most common complication following surgical repair
due to prominence of screws and hardware about the knee, resolved
upon hardware removal
• Vascular Injury to popliteal artery as it passes posteriorly over distal
metaphyseal fragment

78. Proximal tibial
epiphyses fracture

79. • Physeal considerations
general assumptions
• leg growth continues until
• 16 yrs in boys
• 14 yrs in girls
• growth contribution
• leg grows 23 mm/year, with most of that coming from the knee
(15 mm/yr)
proximal tibia - 6 mm/yr (1/4 in)
• closure of proximal tibial epiphysis occurs in a predictable pattern
• sagittal plane - posterior to anterior
• coronal plane - medial to lateral
• axial plane - posteromedial to anterolateral

80. • Uncommon , 3% of epiphyseal injuries of lower extremity
• Proximal tibia epiphyses
55% of the length of tibia
25% of the entire length of the limb
• Popliteal artery : lies close to the epiphyses in popliteal fossa , at risk
of injury with displaced fracture
• Classification : Salter – Harris classification.

83. Presentation
• Symptoms
inability to bear weight
• Physical exam
Inspection
pain and swelling
tenderness along the physis
may see deformity or have palpable step-off if displaced
• Motion may see varus or valgus knee instability on exam
• Neurovascular exam
important to perform thorough neurovascular exam
physis is at same level of trifurcation of vessels and there is a
risk of vascular compromise with displacement

84. Treatment
• Nonoperative- immobilization in long leg cast
• indications
• non-displaced (< 2mm) fractures
• stable Salter-Harris type I and type II fractures
• techniques
• reduce with traction and gentle flexion
• cast in slight flexion for 6 weeks
• outcomes
• redisplacement is common without fixation

85. • Operative
1. CRPP [closed reduction and percutaneous pinning ]
• indications
unstable Salter-Harris type I and type II fractures
redisplacement following closed treatment
2. ORIF
• indications
irreducible fractures
usually due to diaphyseal periosteal flap blocking reduction
displaced (> 2mm) Salter-Harris type III and type IV fractures
vascular injury

86. ORIF WITH CC SCREWS

87. Complications
• Loss of reduction
• Growth disturbances (25%)
can lead to limb length discrepancy and/or angular deformities
more common in open fractures
• Compartment syndrome
• Ligamentous instability