Tibial Plateau Fractures - Overview, Anatomy, Mechanism of Injury, Classification, Diagnosis and Management

1. Tibial Plateau
Fractures
Akeel Almahdaly (R1)

2. Outlines
O Anatomy
O Mechanism of injury
O Classification
O Diagnosis (History, Physical
examination and Imaging)
O Management
O Complications

3. Introduction
O The tibial plateau is one of the most
critical loadbearing areas in the human
body; fractures of the plateau affect knee
alignment, stability, and motion.

4. Anatomy
O The tibial plateau is the proximal end of
the tibia including the metaphyseal and
epiphyseal regions as well as the articular
surfaces made up of hyaline cartilage.
O AO defines tibial plateau as the
metaphysis to a distal distance equal to
the width of the proximal tibia at the joint
line.

6. The Condyles
O Medial:
o Slightly concave shape
o Larger in both width and
length.
o Cartilage thickness ~ 3 mm
O Lateral:
o Convex
o 2-3 mm superior (proximal) to
the medial.
o Cartilage thickness ~ 4
mm
O Medial proximal tibial angle
(MPTA) 85 – 90.
O Posterior slope ~ 9 degrees
(Posterior proximal tibial
angle)
O Both plateaus covered with
hyaline cartilage.

7. O ITB to Gerdy’s tubercle
O Patellar tendon to anterior tibial tubercle
O Pes Anserine tendons (S, G, ST) to AM tibia ~
7 cm below joint line
O Ant. Compartment ms.
Muscle attachments

8. O Lateral meniscus
O semicircular
O covers 50 % of the plateau
O Attached to PCL via
ligaments
O Humphry (anterior)
O Wrisberg (posterior)
O No attachment to LCL
O Medial meniscus
O C-shaped
O Thick posteriorly, so
promoting posterior
stabilization.
O intimately attached to MCL
Menisci

9. O Four subdivisions: ACL,
PCL, PM and PL corner
ligament complexes.
O ACL:
o Two bundles: AM tight in
flexion, PL tight in
extension.
o Prevents anterior
translation
o From PM corner of lateral
femoral condyle to
anterior tibial
intercondylar area.
O PCL:
o Two bundles: AL
tight in flexion, PM
tight in extension.
o Prevents posterior
translation
o From antermedial
femoral condyle to
posterior sulcus of
tibia
Ligaments

10. O PM corner:
o MCL and oblique
popliteal ligament
o MCL:
o From medial femoral
epicondyle
o Superficial and deep
components
o Deep to medial
mensicus
o Superficial to distal
plateau
o PL corner:
o Arcuate ligament
o Popliteus
o Posterolateral capsule
o LCL
o Popliteofibular ligament
o Lateral head of
gastrocnemiius
Ligaments

11. O Common peroneal
nerve:
O The common peroneal
nerve courses around the
neck of the fibula distal to
the proximal tibia-fibula
joint before  it divides
into its superficial and
deep branches
O Popliteal artery
O The trifurcation of the
popliteal artery into the
anterior tibial, posterior
tibial, and peroneal
arteries occurs
posteromedially in the
proximal tibia.
Neurovascular structures

12. O Periarticular injuries of the proximal tibia
frequently associated with soft tissue injuries
TPF

13. Epidemiology
O demographics bimodal distribution
O males in 40s (high-energy trauma)
O females in 70s (falls)
O frequency
O lateral > bicondylar > medial

14. Mechanism of Injury
1. Force directed medially (valgus
deformity) or laterally (varus deformity)
or both.
2. Axial compressive force.
3. Both axial force and force from the side.

15. O Schatzker classification
O Six types
O Hohl and Moore
O Five types
O AO/OTA
O Three types
Classification

16. O Type I:
o Split-wedge fracture of
lateral plateau without
any joint depression or
impaction
o In young patients
o Lateral meniscal
pathology may be
present
Schatzker classification

17. O Type II:
o Split fracture of the lateral
tibial condyle with
associated impaction or
depression of the
articular surface
o Greater energy than type
1
o Commonly in fourth
decade of life
o LML tear high rate
Schatzker classification

18. • Type III:
o Pure depression of
the lateral articular
surface only.
o Common in elderly
Schatzker classification

19. O Type IV:
o Split fracture of medial
plateau with associated
comminution of
intracondylar eminence
or medial plateau
articular surface.
Schatzker classification

20. O Type V:
o 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.
Schatzker classification

21. O Type VI:
o Tibial Plateau Fx with
Metaphyseal -
Diaphyseal Separation
Schatzker classification

22. Moore Classification

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

24. Posterior shear fracture
O Pure posterior fracture
fragments
O Does not fit into
Schatzker’s
classification, may be
bicondylar, or a knee
dislocation variant.
O Needs posterior
approach

25. O Usually cruciate
ligament avulsions.
Intercondylar eminence fracture

26. A study…

27. O Injury to collateral ligaments occur in 7% to 43%
O Meniscal injuries up to 50 % with  (type I or II?)
O Vascular injury commonly with  Schatzker IV
O ACL rupture up to 23 % with  (V and VI)
O Any widening of the femoral-tibial articulation
greater than 10° upon stress examination
indicates ligamentous insufficiency
Associated injury

28. O History :
• Age
• Comorbidities
• Patient activity level, employment,
recreational …
• Mechanism of injury
• Direction of force
Diagnosis

29. O Physical exam
O ATLS!
• Inspection – circumferentially to r/o an
open injury
• Palpation – r/o compartment syndrome
when compartments are firm
• varus/valgus stress testing – any laxity >10
degrees indicates instability
• neurovascular exam – any differences in
pulse exam between extremities should be
further investigated with ABI
Diagnosis

30. O Plain X-Ray:
• Supine AP and lateral view for all patients
• Internal and external oblique view
• Obtain contralateral AP and Lateral (compare)
• Tibial plateau view: AP with knee extended and beam
directed 15 degrees caudally
• CT scan:
• increases the diagnostic accuracy
• indicated in cases of articular depression
• shown to increase the interobserver and intraobserver
agreement on classification in tibial plateau fractures
• excellent adjuncts in the preoperative planning
Radiology

31. • MRI:
• alternative to CT scan or arthroscopy
• osseous as well as the soft tissue
components of the injury
• cost prohibitive for use in standard
situations
• Duplex US and Arteriography:
O To evaluate associated arterial injury.
Radiology

32. O Non-operative management:
O Indicated for non-displaced or minimally
displaced fractures
- Method:
O Protected weight bearing and early range-of-
knee motion in a hinged fracture brace.
O Isometric quadriceps exercises and progressive
passive, active-assisted, and active range-of-
knee motion exercises.
O Partial-weight bearing (30-40 Ib) for 8 to 12
weeks with progression to full weight bearing.
Management

33. O Indications:
O Accepted range of articular depression
varies from < 2 mm to 1 cm
O Instability > 10 degrees of nearly extended
knee compared to the contralateral side
O Open fractures
O Associated compartment syndrome
O Associated vascular injury
Operative treatment

34. O Goals of treatment:
O reconstruction of the articular surface
O re-establishment of tibial alignment
O Treatment involves reducing and buttressing
of elevated articular segments with bone graft
O Soft tissue reconstruction including menisci
and ligaments
O Spanning external fixator as a temporizing
measure in patients with high-energy injuries
or significant soft tissue injury.
O Arthroscopy
Principles of management

35. O Plates and screws, screws alone or external
fixation. (The choice of implant is related to the
fracture patterns, degree of displacement, and
familiarity of the surgeon).
O Plates and screws:
O Functions: buttressing against shear forces or
neutralize rotational forces
O Thinner plate
O Percutaneous plating
O Double plating
O Screws alone:
O Simple split fractures, or depressed that are elevated
percutaneously
Implant options

36. O External fixation:
O Advantages of external fixation include
O minimal soft tissue dissection
O ability to alter frame stiffness and thus control
compression across comminuted fracture fragments.
O can be dynamized during fracture healing, which
may help if delayed or nonunion occurs in the
metaphyseal regions.
O provides excellent stability in cases where there is
severe soft tissue or bony defect.
O allows for correction if there is a malalignment or
deformity.
O spanning external fixators
Implant options

37. O Type I:
O Closed reduction then stabilized cancellous
lag screws with washers to gain
compression.
O Type II:
O OR and elevation of depressed fragment
O Bone graft is placed to support the
elevated fragments
O Screws are placed across the reduced split
fracture fragments in lag mode
Operative treatment

38. O Type III:
O elevation through cortical fenestrations
O supported with subchondral screws and
bone graft
O Type IV:
O requires a medial buttress plate to
counteract the shear forces acting on the
medial plateau
O lag screws alone are not sufficient to
stabilize these fractures
Operative treatment

39. • Type V:
– locking plates, laterally placed plates with
screws that lock to the plate creating a fixed
angle construct provide enough stability to
counteract forces seen by the medial tibial
plateau.
Operative treatment

40. Operative treatment
O Type VI:
O Following articular reconstruction, the
articular segment has historically been
stabilized to the tibial shaft using a single
plate, double plates, a single plate and a
contralateral two-pin external fixator, or a
thin-wire fixator. If the fracture is
transverse, a single plate will suffice.
Oblique fracture lines exiting the opposite
cortex require a second plate or external
fixator to resist shearing forces.

41. O Early:
O most commonly is infection (3 – 38 %)
O Superficial
O Deep
O Thromboembolic complication (DVT, PE)
O Late:
O Painful hardware
O Loss of fixation
O Posttraumatic arthritis
O malunion
Complications

42. O Handbook of Fractures, Zuckerman
O Rockwood and Green's Fractures in Adults
O Netter’s Concise Orthopedic Anatomy
O Gray’s Anatomy
O
http://emedicine.medscape.com/article/124987
2-overview
O
https://radiopaedia.org/articles/meniscofemora
l-ligament
O
References

43. Thank you for your attention!