منو منو

Tibial Plateau Fractures


  • SUMMARY

    • Tibial Plateau fractures are periarticular injuries of the proximal tibia frequently associated with soft tissue injury.

    • Diagnosis is made with knee radiographs but frequently require CT scan for surgical planning.

    • Treatment is often ORIF in the acute setting versus delayed fixation after soft tissue swelling subsides. 

  • EPIDEMIOLOGY

    • Incidence 

      • 1-2% of all fractures

      • 10.3 per 100,000 people annually 

    • Demographics

      • mean age 52

      • bimodal distribution

        • males in 40s (high-energy trauma)

        • females in 70s (low energy falls)

    • Location

      • lateral plateau 70-80%

      • bicondylar 10-30%

      • medial plateau 10-20%

  • ETIOLOGY

    • Mechanism

      • Vector of applied load, amount of energy, and quality of bone determine type of fracture

        • valgus load 

          • lateral plateau

        • varus load

          • medial plateau

        • axial load

          • bicondylar 

        • combination

          • fracture dislocation 

          • high energy

          • usually medial-sided plateau fractures 

          • frequently associated with soft tissue injuries

        • low energy

          • usually lateral plateau fractures

    • Associated conditions

      • meniscal tears

        • lateral meniscal tear 

           

          • more common than medial

          • associated with Schatzker II fracture pattern 

             

          • associated with >10mm articular depression 

             

          • associated with >6mm condylar widening

        • medial meniscal tear

          • most commonly associated with Schatzker IV fractures 

             

      • ACL injuries

        • more common in type IV and VI fractures (25%) 

           

      • compartment syndrome

      • associated soft tissue injuries have little bearing on final outcomes  

      • neurovascular injury

        • commonly associated with Schatzker IV fracture-dislocations 

           

          • perform ABIs in suspected fracture/dislocation  

             

        • common peroneal nerve is most common nerve injury 

        • higher rates with hyperextension bicondylar injuries

  • ANATOMY

    • Osteology

      • lateral tibial plateau 

        • convex in shape

        • proximal to the medial plateau 

           

        • less dense bone 

      • medial tibial plateau 

        • concave in shape

        • distal to the lateral tibial plateau

      • alignment of proximal tibia 

        • posterior tibial slope 

          • 6-10 deg

        • varus slope 

          • 3 deg relative to mechanical axis of tibia

    • Ligaments 

      • ACL

        • inserts anteriorly between tibial spines

        • primary restraint against anterior tibial translation

        • secondary stabilizer of tibial rotation

      • PCL

        • inserts on posterior tibial sulcus below articular surface

        • primary restraint to posterior tibial translation  

      • MCL

        • two components

          • superficial MCL

            • broad insertion on proximal tibia deep to pes anserinus

            • primary stabilizer of valgus stress

          • deep MCL

            • attaches to medial meniscus 

            • secondary stabilizer to valgus stress

      • LCL

        • inserts on anterolateral aspect of fibular head

        • primary restraint to varus stress at 30 deg

    • Meniscus

      • lateral meniscus

        • covers larger portion of articular surface

        • more mobile

          • easier to assess articular surface laterally through submeniscal arthrotomy due to mobility of meniscus

      • medial meniscus 

        • less mobile due to coronary ligaments

    • Muscles 

      • 4 compartments in lower leg

        • anterior compartment

        • lateral compartment 

        • superficial posterior 

        • deep posterior 

    • Tendons

      • patellar tendon

        • inserts anteriorly on tibial tubercle 

      • iliotibial band 

        • inserts on anterolateral aspect of proximal tibia at Gerdy's tubercle

      • hamstring tendons

        • pes anserine insert on anteromedial aspect of proximal tibia

    • Neurovascular structures

      • popliteal artery runs just posterior to knee capsule and bifurcates

        • anterior tibial artery

        • posterior tibial artery 

      • tibial nerve

        • courses posteriorly along with popliteal artery 

        • sensory: plantar aspect of foot

        • motor: innervates posterior compartments which control ankle plantarflexion and inversion of foot 

      • common peroneal nerve

        • course around fibular neck 

        • two branches

          • superficial peroneal nerve

            • sensory: dorsum of foot (except first dorsal webspace) 

            • motor: innervates lateral compartment which controls ankle eversion 

          • deep peroneal nerve

            • sensory: first dorsal webspace of foot

            • motor: innervates anterior compartment which controls ankle dorsiflexion

    • Biomechanics 

      • medial tibial condyle 

        • bears 60% of load through knee

      • lateral tibial condyle

        • bears 40% of load through knee

    • Kinematics

      • flexion-extension 0-140 degrees

        • functional ROM for walking 0-70 degrees

      • posterior femoral rollback

        • screw-home mechanism

          • medial tibial plateau is concave creating a pivot point

          • lateral plateau is convex allowing for rollback of femur during flexion

        • net effect

          • influences amount of terminal knee flexion

          • tibia externally rotates with knee extension 

  • CLASSIFICATION

    • Schatzker classification

      • Schatzker Classification

      • Type I

      • Lateral split fracture

      • young patient with strong subchondral bone

      •  
      • Type II 

         

      • Lateral Split-depressed fracture

      • most common 

      •  
      • Type III

      • Lateral Pure depression fracture

      • uncommon, elderly osteoporotic 

      •  
      • Type IV 

         

      • Medial plateau fracture

      • associated fx-dislocation

      • high rate of NV and ligamentous injuries

      •  
      • Type V

      • Bicondylar fracture

      • tibial spines remain continuous with shaft

      •  
      • Type VI

      • Metaphyseal-diaphyseal disassociation

      • significant soft-tissue injury

      •  
    • Hohl and Moore Classification

      • Useful for

        • true fracture-dislocations

        • fracture patterns that do not fit into the Schatzker classification (10% of all tibial plateau fractures)

        • fractures associated with knee instability

      • Hohl and Moore Classification of proximal tibia fracture-dislocations

      • Type I

      • Coronal split fracture

      •  
      • Type II

      • Entire condylar fracture

      •  
      • Type III

      • Rim avulsion fracture of lateral plateau

      •  
      • Type IV

      • Rim compression fracture

      •  
      • Type V

      • Four-part fracture

      •  
    • 3-column concept 

        

      • tibial plateau divided into 3 columns

        • medal column

        • lateral column

        • posterior column

      • utility 

        • includes posterior plateau fractures that are not considered in Schatzker classification

        • helps determine fixation strategy  

  • PRESENTATION

    • History

      • mechanism of injury 

        • high-energy vs low-energy

      • unable to bear weight after injury 

      • baseline functional status 

      • comorbidities 

    • Physical exam

      • inspection

        • look circumferentially to rule-out an open injury

        • assess soft-tissues for timing of operative intervention

      • palpation

        • evaluate for compartment syndrome  

      • varus/valgus stress testing

        • any laxity >10 degrees indicates instability

        • often difficult to perform or deferred in acute setting given pain

        • stability assessed in full extension 

      • neurovascular exam

        • perform ankle-brachial index if any asymmetry in pulses 

          • ABI <0.9 proceed with arteriogram 

        • assess tibial and common peroneal nerve function

  • IMAGING

    • Radiographs

      • recommended views

        • AP

        • lateral

        • oblique

          • oblique is helpful to determine amount of depression

      • optional views

        • plateau view

          • 10 degree caudal tilt to match posterior tibial slope

      • findings

        • on AP

          • depressed articular surface 

          • sclerotic band of bone indicating depression 

          • abnormal joint alignment

          • fracture plane involving medial/lateral plateau

        • on lateral

          • posteromedial fracture lines must be recognized 

             

          • abnormal tibial slope 

             

    • CT scan 

      • indication

        • negative radiographs with high index of suspicion for tibial plateau fracture

        • preoperative planning  

           

          • obtain after ex-fix if definitive fixation delayed if soft-tissues are not amenable for surgery

      • findings

        • articular depression

        • degree of comminution 

        • fracture plane and location 

          • posterior coronal split fracture best appreciated on axial and sagittal views 

        • lipohemarthrosis indicates an occult fracture 

           

        • certain fracture patterns are suggestive of associated soft tissue injury 

    • MRI

      • indications

        • not well established

        • identify meniscal and ligamentous pathology 

        • occult fractures 

  • DIFFERENTIAL

    • Distal femur fracture 

    • Knee dislocation 

    • Patella instability  

    • Patella fracture 

    • Patella tendon rupture 

    • Quadriceps tendon rupture 

    • ACL tear 

    • Meniscus tear  

  • TREATMENT

    • Nonoperative

      • closed reduction / immobilization

        • indications

          • minimally displaced split or depressed fractures

          • low energy fracture stable to varus/valgus alignment

          • nonambulatory patients

          • significant comorbidites that preclude surgical intervention

        • modalities

          • patella-tendon-bearing (PTB) cast

          • knee immobilizer

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