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