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 hinged knee brace Operative ORIF indications articular depression > 5-10 mm condylar widening > 5mm varus/valgus instability >10 deg medial plateau fractures bicondylar fractures timing acute ORIF lower-energy fractures with mild swelling staged ORIF temporizing knee-spanning external fixation w/ delayed ORIF indications significant soft tissue injury/swelling polytrauma outcomes restoration of joint stability is strongest predictor of long-term outcomes postoperative infection after ORIF associated with male gender smoking pulmonary disease bicondylar fracture patterns intraoperative time over 3 hours timing of definitive fixation (before, during or after) relative to fasciotomy closure does not increase the risk of infection worse results with ligamentous instability meniscectomy alteration of limb mechanical axis > 5 degrees external fixation +/- limited fixation indications severe open fracture with marked contamination highly comminuted fractures where internal fixation not possible technique limited fixation of the articular fragment may be internal or percutaneous outcomes higher malunion rates arthroplasty indications consider in patients >65-years-old with osteoporotic bone outcomes earlier time to weight bearing improved outcomes for primary TKA compared to TKA for failed ORIF Techniques Closed reduction & Immobilization technique NWB or PWB in a hinged-knee brace for 8-12 weeks early passive ROM is important to maintain motion Provisional External Fixation technique place pins outside area of planned definitive fixation two 5-mm half-pins in femur and two in tibia shaft axial traction applied to fixator indirect reduction of fracture through ligamentotaxis fixator is locked in slight flexion to avoid tensioning posterior NV structures advantages allows soft tissue swelling to decrease before definitive fixation decreases rate of infection and wound healing complications restores length and alignment which helps to better characterize fracture on preop CT findings transient increase in leg compartment pressures during external fixator placement not been shown to increase risk of compartment syndrome External Fixation with Limited Internal Fixation technique reduce articular surface either percutaneously or through small incisions stabilize reduction with percutaneous lag screws or wires must keep wires >14mm from joint to avoid intracapsular pin placement pros minimizes soft tissue insult cons pin site complications arthrofibrosis incidence as high as 15% after temporizing external fixator high malunion rates Open reduction internal fixation (ORIF) goals restore alignment coronal sagittal tibial slope normal condylar width congruent articular surface stable knee minimize additional soft tissue trauma approach anterolateral approach (most common) supine lazy S or hockey stick incision centered over Gerdy's tubercle elevate anterior compartment musculature and IT band submeniscal arthrotomy to assess articular surface and meniscus tear posteromedial approach supine with leg in figure-4 or prone interval between pes anserinus and medial head of gastrocnemius can be extensile and access posterolateral column release medial head of gastrocnemius off femur elevate soleus and popliteus articular surface not routinely visualized directly fluoroscopically or arthroscopically posterolateral approach prone or lateral biceps and peroneal nerve retracted lateral lateral gastroc and soleus retracted medial fibular neck osteotomy posterolateral access infrequently used due higher risk of NV complication posterior can be used for posterior shearing fractures midline incision (if planning TKA in future) can lead to significant soft tissue stripping and should be avoided dual surgical incisions with dual plate fixation indications bicondylar tibial plateau fractures reduction assess reduction submeniscal arthrotomy fluoroscopically arthroscopically depressed fragments open fracture split and elevate ("open the book") create cortical window and elevated with bone tamps fill metaphyseal void three main options autograft (ICBG - rare) allograft (cancellous chips) bone graft substitutes calcium phosphate cement high compressive strength for filling metaphyseal void less subsidence than ICBG osteoconductive biodegradable highly porous internal fixation absolute stability constructs should be used to maintain the joint reduction screws can be used in isolation but often used in conjunction with plate fixation isolated depression simple split fracture options raft screws placed in subchondral bone parallel to joint surface to support elevated articular fragments lag screws placed perpendicular to plane of split fractures plate fixation conventional non-locking plates buttress plates best indicated for partial articular fractures posteromedial fractures simple split peri-articular locking plates fixed angle mitigates risk of varus collapse comminuted fractures osteoporotic bone postoperative hinged knee brace with early passive ROM gentle mechanical compression on repaired osteoarticular segments improves chondrocyte survival NWB or PWB for 8 to 12 weeks Complications Post-traumatic arthritis incidence 25-35% 3-7% undergo TKA at 10+ years risk factors for arthritis meniscectomy malalignment > 5 deg instability risk factors for future TKA age bicondylar fracture increasing comorbidities Compartment syndrome incidence 7-20% risk factors Schatzker type IV high-energy mechanism associated fibula fracture fracture length associated plateau-shaft injury young age treatment emergent fasciotomy Infection incidence 2-11% risk factors poor surgical timing based on swelling open fractures longer operative time treatment irrigation and debridement + IV abx removal of hardware if loose or grossly infected ex-fix and staged revision ORIF retain hardware if fracture still healing and implant still providing stability Nonunion/malunion incidence 2-4% uncommon due to rich blood supply of cancellous bone risk factors Schatzker type VI (metaphyseal-diaphyseal junction) comminution unstable fixation treatment revision osteosynthesis augmented with bone graft Knee stiffness incidence 10-25% generally all bicondylar tibial plateau fractures have similar long term ROM risk factors increasing age higher BMI severity of fracture prolonged immobilization involvement of tibial eminence polytrauma treatment arthroscopic lysis of adhesions with MUA indicated if unable to achieve 90 deg of flexion within 4 weeks Loss of reduction incidence 5-30% risk factors inadequate fixation severity of fracture osteoporosis treatment revision ORIF to address inadequate fixation i.e. posteromedial buttress plate for coronal fracture not captured with lateral plate only Deep vein thromobosis incidence nonoperative 9% operative 6% Prognosis Mortality rate 5% at 1 year Return to work 70-90% at 1 year residual dysfunction or reduced work load is common Mean ROM 10-145 degrees at 1 year