This document discusses the classification, treatment principles, and surgical techniques for tibial plateau fractures. There are two main subgroups - high-energy fractures in young patients and low-energy fractures in elderly osteoporotic patients. Treatment goals are to decompress soft tissues, reconstruct the joint surface and mechanical axis, and allow early motion. Surgical approaches include anterior, medial, and lateral. Fixation methods depend on the fracture but may include plates, screws, hybrid fixators, or less invasive systems like LISS. Good outcomes can be achieved with anatomical reduction, rigid joint fixation, and functional stabilization of the metaphysis while restoring soft tissue stability.

1. AOTrauma Principles Course
Tibial plateau fractures
Felix Bonnaire, DE
Ian Harris, AU

2. Fracture mechanisms
• Fractures of the tibial plateau can be caused by a variety
of forces
• Valgus/varus deformation
• Axial compression
• Flexion/extension
• Direct trauma
• Kennedy JC and Bailey WH, 1968, Experimental tibial
plateau fractures. JBJS

3. Fracture mechanisms
Two subgroups exist:
• Young patients with good bone stock—high-energy
• Elderly patients with osteoporosis—low-energy

4. Classification of proximal tibial fractures
(41-)
A = extraarticular:
A1 = avulsion
A2 = metaphyseal simple
A3 = metaphyseal multifragmentary

5. B = partial articular:
B1 = pure split
B2 = pure depression
B3 = split-depression
Classification of proximal tibial fractures
(41-)

6. C = complete articular:
C1 = articular simple, metaphyseal simple
C2 = articular simple, metaphyseal multifragmentary
C3 = articular multifragmentary
Classification of proximal tibial fractures
(41-)

7. High-energy trauma
High-energy trauma always involves:
• Extensive damage to the soft tissues
• Contusions
• Open injuries
• Compartment syndrome
• Peroneal, tibial nerve
• Popliteal artery

8. Low-energy trauma
• Axial trauma
• No contusions
• Closed injuries
• No soft-tissue problem
• Axis deviation
• Fixation problem (osteoporosis)

9. Low- and high-energy trauma
• In low-energy trauma the problem is mechanical—
fixation in osteoporotic bone
• In high-energy trauma the problem is biological and
associated with damage to the soft tissues

10. Investigations
• X-ray in two planes
• 45° oblique
• CT (computed tomography)
• MRI (magnetic resonance imaging)
• Angiography

11. Investigations

12. Personality of the fracture
• Soft-tissue damage
• Degree of dislocation
• Degree of comminution
• Degree of joint involvement
• Osteoporosis
• Nerve/blood vessel injury

13. Personality of the fracture

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

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

16. 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

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

18. 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)

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

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

21. Approach
• Straight anterior
• (Postero)medial
• Lateral
• Mini-open

22. Approach
Anterolateral approach Posteromedial approach

23. Operative treatment—Planning
• Bone graft/bone substitute
• Stabilization:
- Distractor?
- Screws
- Plate(s) or
- Hybrid fixator
- Joint fixation?

24. 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

25. Clinical cases

26. Clinical cases

27. Hybrid fixator for severe soft-tissue
injuries
• Reconstruction of the joint surface
• Reconstruction of stable axes
• Early motion
• Excellent results

28. Locked internal fixators
• Tibial locked internal fixators are available
• Locking head screws provide better support than
conventional screws in a short metaphyseal fragment
• Percutaneous insertion preserves soft tissues

29. 24-year-old man, 41-C3 IC2

30. 14 weeks

31. LISS-PLT (less invasive stabilization
system) proximal lateral tibia

32. LISS-PLT
• Reduction of joint
• Fixation using lag screws
• Restoration of mechanical axis
• Fixation of metaphysis using a LISS

33. Results
• Depend on fracture type
• Depend on soft-tissue management
• Depend on realization of goals
• Can be excellent even in high-energy trauma:
- average ROM 0/3/120° (87%)
- no deterioration in the 2nd 5 years
- good prognosis

34. Operative options
Technique for stabilization of the metaphysis depends on:
• Fracture/injury factors
• Patient factors
• Surgeon factors
• Institutional factors

35. 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