This document summarizes tibial plateau fractures, including: - Common mechanisms of injury including falls and motor vehicle accidents - Classification systems including Schatzker and AO/OTA - Imaging techniques including plain radiographs, CT, and MRI - Treatment goals of restoring articular congruity, alignment, and stability - Surgical techniques including plating and minimally invasive approaches - Indications for surgery including articular displacement over 10mm or instability

1. Tibial Plateau Fractures
Dr.PONNILAVAN

2. • Tibial plateau # - intra-articular # of proximal tibia that occur in adults
• 5th decades of life
• Fractures in men - younger age
• Women - increasing incidence with advancing age( 6th & 7th decades) -
osteopenic bone.

3. • Middle-aged or elderly patients, simple falls lateral >medial side
# patterns.
• Split depression # lateral plateau –m/c
• When bone is very osteopenic, insufficiency #s in elderly patients can
occur & be missed on plain radiographs.
• Higher-speed injuries in younger pts from sports or similar
mechanism can cause split fractures or rim avulsion #s asso. with
knee ligament injuries.

4. Mechanisms of injury
-
Motor vehicle accidents
- Falls from heights
- Pedestrian struck injuries more severe patterns- involve
both condyles &
have a high risk for asso. neurovascular injuries,
compartment syndrome &
communicating open wounds.

5. M.O.I
• In one study of severe plateau #s treated with external fix,
16 of 21 injuries were motor vehicle related,
• Another study of bicondylar #s treated with dual approaches,
- 68 of 83 were motor vehicle related or caused by a fall from a height.
- In contrast, a study of elderly pts - mean age- 74 yrs - 58% of #s were
caused by a simple fall.

6. Forces Causing Injury
• Magnitude, type, & direction of forces that injure the knee dictate the
fracture pattern.
• Greater the energy absorbed by proximal tibia, more severe is the # &
the more the fragments are displaced & comminuted.
• Energy of # results from a combination of forces applied & quality of
the bone.
• Generally, axially loading forces are more rapid & release greater
energy than angular forces.

7. • In cadavers, it is possible to produce-
- typical split # s with pure valgus forces,
- local compression fractures with axial forces, and
- split depression fractures with combinations of both forces.
Proximal tibia is most likely to be subjected to a valgus force
- because of normal 5 to 7 degrees of valgus alignment of knee and
because of a propensity to be struck from the lateral side.

8. • A valgus force loads the lateral tibial plateau to fail from direct impact
with the lateral femoral condyle.
•
lateral side depression,
split depression
or less commonly, lateral split or
total lateral condyle fractures
Valgus + axial compression

9. Associated Injuries
• MCL injuries can be asso. with lateral plateau #s from valgus forces.
These asso. collateral ligament injuries were once thought to be
common because of the instability apparent on exam, but this
instability can occur because of the loss of osseous support from the
depression of lateral plateau articular surface.
• Bony failure on one side of the jt actually protects collateral ligament
on the opposite side.
• In one recent study, incidence of asso. collateral ligament injury was
only 3% each for both MCL & LCL.

10. • There are also frequent asso. intra-articular soft tissue injuries to both
the cruciate ligaments & menisci.
• Certain peripheral # s of the margins of the tibial plateau are virtually
pathognomonic of cruciate ligament injury, & in these injured knees,
it is appropriate to emphasize treating the ligament injuries rather
than the plateau # itself.
• These fractures include Segond #, reverse Segond # , anteromedial
tibial margin # s, & semimembranosus tendon insertion site #s

11. • Certain types of tibial plateau # s have a high risk for compartment
syndrome.
• In one study, 10% of all tibial plateau #s were diagnosed with an
associated compartment syndrome & the risk was particularly high in
high-energy # s, with 30% in Schatzker 6 patterns.

12. If the diagnosis is clear on physical ex, fasciotomy may be performed
without pressure measurements.
Patients who have high-energy # patterns who are not able to provide a
history & who are difficult to examine should have compartment
pressures measured at presentation, & these measurements may need to
be repeated based on the clinical findings & results of the initial
measurement.
• Tibial plateau #s may have communicating open wounds that need to
be identified on physical examination of the injured limb

13. • In lateral tibial plateau #s, assessing for valgus instability of the knee
may provide a guide to the need for surgical Rx.
• If instability is present, it is likely caused by fracture displacement &
will not resolve without reducing the #.
• However, pain from the injury often makes it difficult to examine the
knee for coronal instability, limiting the value of this assessment

14. Classification of Tibial Plateau Fractures
• AO/OTA Classification-
• In this classification, the tibia is 4 and the proximal tibia is 1, so the
plateau region is 41.
• Type A: Nonarticular #s of proximal tibia.
Technically, they are not tibial plateau #s because articular surface is
not involved.
• Type B: Partial articular #s.

15. • B1—Simple articular split
• B2—Split depression
• B3—Comminuted split depression
• Type C: These are complete articular fractures and, in the proximal
tibia, are frequently called bicondylar fractures.
• C1—Noncomminuted total articular fractures
• C2—Metaphyseal comminution with simple articular fracture lines
• C3—Total comminuted articular fractures including the articular
surface

16. Hohl and Moore

17. Hohl and Moore classification of proximal
tibial fracture-dislocations.

18. SCHATZKER FRACTURE CLASSIFICATION

19. • Diagnosis of a tibial plateau # is typically made on plain radiographs,
& for some fractures this may be the only imaging necessary.
• Anteroposterior (AP), lateral, and an AP view in the plane of the
plateau (10- to 15-degree caudal view) are the standard
examinations.
• Caudal view provides a better view of articular surface & helps assess
displacement & depression better than the standard AP view.

20. • Hohl found that the standard AP view could not reliably determine the
amount of articular depression but that a 14-degree caudal view
accurately estimated central and posterior displacement but could
overestimate anterior displacement and depression.
• Less frequently, oblique views are obtained to assess the location of
fracture lines or degree of displacement but are not routine.
• CT scans
• MRI

21. Goals of treatment
• restoration of articular congruity,
• axial alignment,
• joint stability, and functional motion.
• If operative treatment is chosen, fixation must be stable enough to
allow early motion and the technique should minimize wound
complications.

22. • The degree of acceptable articular displacement is controversial.
• If depression or displacement exceeds 10 mm, surgery to elevate and
restore the joint surface is indicated. If the depression is less than 5
mm in stable fractures, nonoperative treatment consisting of early
motion in a hinged knee brace and delayed weight bearing usually is
satisfactory.

23. • If the depression is 5 to 8 mm, the decision for nonoperative or
operative treatment depends to a great degree on the patient’s age
and the activity demands on the knee.
• If a patient is elderly and sedentary, nonoperative treatment usually
is suitable. If a patient is young or active, attempts at surgical
reconstruction of the joint surface are justified.

24. • Long-term follow-up studies have shown that posttraumatic arthritis
is associated with residual instability or axial malalignment and not
the degree of articular depression.
• Instability is another indication for operative treatment.
• Instability may result from ligamentous disruption, osseous
depression of the articular surface, or translational displacement of a
fracture fragment. Ligament injuries occur in 10% to 33% of tibial
plateau fractures

25. • .The major indication for surgery is not the measure of depression of
the fragment or articular surface but the presence of varus or valgus
instability of 10 degrees or more with the knee flexed less than 20
degrees

26. • Treatment methods proposed for fractures of the tibial condyles
include
• - extensile exposure with arthrotomy and reconstruction of the joint
surface with plate and screw fixation ,
-arthroscopy or limited arthrotomy and percutaneous screw fixation
or –
external fixation with pin or wire fixators;
closed manipulation and casting, especially with a cast brace; and
traction with early motion.

28. • Newer plating techniques are capable of fixation with less
iatrogenic soft tissue elevation and employ minimally invasive
approaches. If more than one incision is used, a large soft tissue
bridge is left between them.

29. • In undisplaced fractures, after the integrity of the collateral
ligaments is established, treatment should consist of a few days of
splinting followed by early active knee motion.
• Weight bearing should be delayed until fracture healing is evident,
generally at 8 to 10 weeks.

30. • Lateral split fractures can be reduced open or percutaneously using
traction and reduction forceps under arthroscopic or fluoroscopic
control.

31. SCHATZKER FRACTURE CLASSIFICATION

32. Type IV. Medial condyle is split off as wedge (type A) as illustrated, or it can be crumbled and depressed (type B), which is characteristic of older patients with osteoporosis (not illustrated).

34. THANK U
• Campbell
• Rockwood And Green's, 7th Edition