Tibial Plateau Fractures

Tibial plateau fractures are intra-articular fractures
of the proximal tibia that occur in adults, with the highest incidence
in the third through the fifth decades of life. Fractures in men occur
at a younger age and women have increasing incidence with advancing
age, particularly in the sixth and seventh decades, which indicates
these fractures are occurring in osteopenic bone.

Diverse patterns of tibial plateau fractures result when
the knee sustains one of a variety of mechanisms of injury. In
middle-aged or elderly patients, simple falls lead most commonly to
lateral or, less commonly, medial side fracture patterns. Split
depression fractures of the lateral plateau are most common. When the
bone is very osteopenic, insufficiency fractures in elderly patients
can occur and be missed on plain radiographs.¹²⁹
Higher-speed injuries in younger patients from sports or similar
mechanism can cause split fractures or rim avulsion fractures
associated with knee ligament injuries. Motor vehicle accidents and
falls from heights and pedestrian struck injuries often produce more
severe patterns, which may involve both condyles and have a high risk
for associated neurovascular injuries, compartment syndrome, and
communicating open wounds. In one study of severe plateau fractures
treated with external fixation, 16 of 21 injuries were motor vehicle
related, and in another study of bicondylar fractures treated with dual
approaches, 68 of 83 were motor vehicle related or caused by a fall
from a height.¹¹,¹¹¹
In contrast, a study of elderly patients with a mean age of 74 years
reported that 58% of fractures were caused by a simple fall.⁸⁷

The magnitude, type, and direction of forces that injure
the knee dictate the fracture pattern. The greater the energy absorbed
by the proximal tibia, the more severe is the fracture and the more the
fragments are displaced and comminuted. The energy of fracture results
from a combination of the forces applied and the quality of the bone.⁷
Generally, axially loading forces are more rapid and release greater
energy than angular forces. In cadavers, it is possible to produce
typical split fractures with pure valgus forces, local compression
fractures with axial forces, and split depression fractures with
combinations of both forces.⁹¹ The
intact medial collateral ligament (MCL) acts like a hinge for the
lateral femoral condyle, and in this cadaver study it needed to be
present for the lateral plateau to fracture.⁹¹ This means that clinically the MCL should not be torn in these lateral patterns.

The proximal tibia is most likely to be subjected to a
valgus force because of the normal 5 to 7 degrees of valgus alignment
of the knee and because of a propensity to be struck from the lateral
side. A valgus force loads the lateral tibial plateau to failure from
direct impact with the lateral femoral condyle. A combination of valgus
and axial compression produces lateral side depression, split
depression, or, less commonly, lateral split or total lateral condyle
fractures.¹⁰⁴ Younger patients with
good bone tend to have split fractures with less depression, and
elderly patients with osteopenic bone have a greater component of
compression with a less prominent split fragment. Most commonly in
lateral fracture patterns, there is at least a small component of both
a split fracture and depression at the peripheral margin of the
fracture. Less commonly than in lateral side fractures, varus injuries
lead to failure of the medial plateau. These injuries can involve the
entire medial plateau and, in some cases, the fracture-shearing plane
may extend well into the lateral plateau. In other cases, the fracture
involves lesser portions of the medial plateau. A posteromedial
shearing fracture of the medial plateau is a common medial side pattern
and can occur as an isolated split fracture, or in as many as one third
of bicondylar fractures, and it is part of the bicondylar fracture
pattern.¹³ The mechanism has been described as knee flexion, varus, and internal rotation of the medial femoral condyle.³⁹,¹⁶²

Tibial plateau fractures most often occur with the leg
in a weight-bearing position so axial load is typically some component
of the injuring force. Generally, the greater the axial load component,
the more energy there is at failure and the more severe is the fracture
pattern. Bicondylar patterns result when axial load predominates, with
the severity varying based on the magnitude of the axial forces.
Occasionally in a patient with a

valgus knee, an axial force may shear the medial tibial condyle and produce a medial plateau fracture or fracture dislocation.

Another type of tibial plateau fracture pattern occurs
at the metaphyseal region as a result of direct trauma and/or a
combination of axial load and bending forces. These are classic bumper
injuries or other crush, direct blow, or similar mechanisms where the
tibial shaft is separated from the condyles with proximal extensions of
fracture lines into the plateau. These severe injuries have a high risk
of complications because of both the area of the injury and the high
degree of energy transfer. Open fractures, severe closed soft tissue
injury, trifurcation injury, and compartment syndrome are all
associated with this mechanism.¹⁶⁶,¹⁷⁷

The diagnosis of a tibial plateau fracture is typically
made on plain radiographs, and 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 (Fig. 53-4). The caudal view
provides a better view of the articular surface and helps assess
displacement and depression better than the standard AP view.⁸²,¹¹⁵
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.¹¹⁵
Less frequently, oblique views are obtained to assess the location of
fracture lines or degree of displacement but are not routine. CT scans
have largely supplanted the need for these adjunctive views. When there
is substantial fracture displacement, particularly in bicondylar or
fracture dislocation patterns, radiographs in traction will better
assess the fracture anatomy (Fig. 53-5).
Traction restores the gross geometry of the proximal tibia, decreases
overlap, and better defines the fracture pattern than the original
radiographs. Manual traction may be applied solely for the purposes of
such radiographs, but in severe fractures, radiographs obtained after
applying a joint-spanning external fixator will provide the necessary
traction for assessment of fracture anatomy. When applying the fixator,
care should be taken to avoid having metal bars or clamps overlying the
proximal tibia in the plane of the important radiographic views.

Axial CT scans are routinely obtained for many or most
tibial plateau fractures. They provide excellent detail of the fracture
pathoanatomy and serve as a critically important aid to preoperative
planning for operative approaches and fixation techniques. Although CT
may be used to help decide on the need for surgery, there are no good
data to indicate that the additional detail apparent on CT helps
determine which fractures will benefit from surgery. CT typically
demonstrates more articular displacement and comminution than is
apparent on plain films.¹⁰² CT has
been shown to help surgical planning and to lead to more reliability in
classifying the fracture and deciding on a treatment plan.³²,¹⁷⁶
The location of depressed fragments, the size of articular segments,
and the location and orientation of fracture lines are important
details in planning an operative strategy, and they are best visualized
on CT. Three-dimensional reconstructions have been increasingly used
and found to demonstrate spatial relationships of fracture fragments
better than plain radiographs.¹⁸ In one study, the addition of spiral CT with three-dimensional reconstructions frequently resulted in

modifications and adjustments in operative plans compared with using plain radiographs alone¹⁰²,¹⁷⁶ (Fig. 53-6).

Current multidetector row CT provides CT datasets of the
fractured plateau that may be visualized in any two-dimensional plane
or with high-quality three-dimensional images.⁵²
Three-dimensional images from multidetector CT scans provide detail of
the fractured proximal tibia, which enables the surgeon to assess
comminution, depression, and fracture location more accurately than
previously possible.¹⁰⁰,¹⁰⁶
Similar to plain films, realigning the fracture with a spanning fixator
or other traction techniques before scanning will enhance the quality
of the information available from the study.

Three-dimensional intraoperative imaging with
multiplaner reconstruction may increasingly be part of operatively
reducing and fixing displaced tibial plateau fractures. Early reports
indicate that this imaging technology allows the surgeon to better
assess the articular surface reduction and the placement of hardware
during the operation than is possible with standard C-arm fluoroscopy.⁹⁰,⁹³
Although the future role of these devices is currently uncertain, it is
likely that better intraoperative imaging will continue to improve the
ability to accurately and minimally invasively reduce and fix tibial
plateau fractures.

MRI assesses the location of fracture lines and the
degree of articular displacement and also identifies occult fracture
areas better than plain films and has been found to be equivalent

to traditional two-dimensional CT.⁹⁴
MRI provides additional information about injuries to the soft tissue
structures of the knee that is not obtained with other imaging
modalities (Fig. 53-7). However, whether MRI
should be a routine part of evaluating tibial plateau fractures or
whether it should be used instead of CT scanning is controversial. CT
scans better visualize the fracture anatomy than do MR images but MRI
demonstrates associated soft tissue injuries, particularly those of the
menisci and ligaments, that are not visualized on CT. When tibial
plateau fractures were assessed with both techniques, CT was found to
be sensitive and specific in identifying ligament injuries because most
of them had at least small bony avulsions, but MRI was necessary to
detect meniscal injuries.¹²¹

The information present on MRI is important if the
surgeon incorporates management of these soft tissue injuries into a
treatment strategy, but whether this strategy improves patient outcome
is an area of controversy. MRI was shown to lead to higher observer
agreement for both fracture classification and treatment plan than
either plain films alone or plain films with the addition of CT.¹⁷⁸ When a proximal tibia stress fracture is suspected and plain films are negative, MRI is the imaging modality of choice.²⁶

The fracture pattern dictates the treatment plan and the
risk for complications and, to some extent, the patient outcome.
Because different fracture patterns require very different treatment
strategies, it is important to group together similar injuries and to
separate different injuries from each other. In this way, treatments
can be matched to fracture patterns to optimize outcomes. To accomplish
these goals, fracture classifications must be reasonably reliabile and
reproducibile.

For tibial plateau fractures, word descriptions of
injury patterns are frequently used substituting for formal
classification. The AO/OTA¹¹⁰,¹²²
and Schatzker classifications are both important and widely used in
current practice. Other fracture classifications are of historical
interest.

Although there are two well-accepted and commonly used
classifications of tibial plateau fractures, most surgeons still
classify fractures by describing them. Word descriptions provide more
meaning than lettered or numbered classifications, particularly because
many surgeons are not familiar with the exact numbers or letters of a
classification. Fracture descriptions in the tibial plateau work well
for management decisions and convey information necessary for patient
care but do not work for databases or for clinical research.

Fracture description in the tibial plateau must first
localize the fracture and then convey the general characteristics of
the fracture. For instance, whether the medial or lateral or both
plateaus are involved provides a reasonable start in describing the
fracture. The terms split, split depression, local compression, and bicondylar fracture
are well-accepted, commonly used terms and convey meaning that is
understood by most surgeons. These terms are incorportated in the
Schatzker classification, which is described later. Similar to other
fractures, the amount the fracture is displaced, angulated, or
comminuted and the presence or absence of subluxation or dislocation
are standard descriptions used for tibial plateau fractures. The amount
of articular surface depression, usually measured in millimeters, is a
quantitative method to assess and characterize the severity of tibial
plateau fractures. Surgical indications for local compression and split
depression fractures have been based on this measurement.
Unfortunately, this

measuremnt cannot be made very reliably between observers, significantly limiting its usefulness.¹¹⁴

The AO/OTA alphanumeric code for articular fractures is well suited to the proximal tibia (Fig. 53-8).¹¹⁰
It has several advantages over the commonly used Schatzker
classification. It identifies both articular and nonarticular fractures
of the proximal tibia, and by the use of the rule of squares, it
provides a way to distinguish proximal tibia from tibial shaft
fractures.¹²² The rule of squares
identifies a proximal tibia fracture as one where the center of the
fracture is within a square with one side along the articular surface
and the length of a side defined by the width of the metaphyseal
segment. Fractures outside of this square are tibial shaft fractures.
There is more than one category of medial plateau fracture, which is
desirable because it is clinically important to distinguish subtypes of
medial plateau fractures for treatment. For the total articular C
patterns, the degree of comminution of both the metaphysis and the
articular surface is subcategorized, providing important distinctions
for treatment and prognosis. The AO/OTA classification therefore
distinguishes ranges of severity in high-energy patterns better than
the Schatzker classification. It is well accepted for trauma databases
and has been frequently used in recent publications on tibial plateau
fractures.⁵³,¹³⁶,¹⁴²,¹⁶⁶
It is increasingly becoming a standard and well-accepted way to
classify proximal tibia fractures. The entire classification was
recently updated and republished, and there were no changes made to the
proximal tibia section.¹¹⁰

In this classification, the tibia is 4 and the proximal
tibia is 1, so the plateau region is 41. The rule of squares is used to
distinguish these fractures from tibial shaft fractures, 42. The
subtypes of 41 are similar to the ends of the other long bones:

Type A: These are
nonarticular fractures of the proximal tibia. Technically, they are not
tibial plateau fractures because the articular surface is not involved.

Type B: These are partial articular fractures. Although this terminology applies well to the tibial plateau, it is not commonly

used because the verbal descriptions of split and split depression are
more common. However, these are lateral side terms and the AO/OTA
classification allows similar, although less common, medial side
injuries to be classified.

Type C: These are complete
articular fractures and, in the proximal tibia, are frequently called
bicondylar fractures. The advantage of the AO/OTA is the ability to
subclassify these fractures based on comminution.

The Schatzker classification has been the most widely
used classification of tibial plateau fractures and is familiar to most
surgeons (Fig. 53-9). Some of the categories
are similar to those of previous classifications. For instance, Hohl in
1969 classified split, split depression, and central depression
fractures.⁷¹ Many surgeons may not
be familiar with the numbers of the six types, but most are familiar
with the meaning of the verbal descriptions of each type and this is an
important advantage of the Schatzker classification. Because the six
types are typically treated differently,

the
classification fufills some of the goals of an ideal classification.
Types 1 through 3 were described as lateral and less severe. These
three categories reasonably identify the types of fractures that occur
on the lateral side of the plateau.

Unfortunately, there are some problems with this
classification with regard to types 4 through 6, which are the medial
(type 4) and the more severe higher-energy bicondylar (type 5) and
shaft dissociated (type 6) patterns. Type 4 is the only category for a
medial sided fracture, but medial plateau fractures occur in several
distinct patterns. For instance, there is no way to distinguish a
posteromedial split fracture from a medial total condylar fracture. In
reporting a series of posteromedial plateau fractures treated by
internal fixation, Bhattacharyya et al.¹⁹ point out difficulties with categorizing these fractures in the Schatzker classification.

The Schatzker 5 pattern is commonly referred to as bicondylar. In the diagram in the original publication¹⁴³
and most subsequent diagrams of the Schatzker 5 pattern, the
intercondylar eminences are intact with fractures of both condyles.
This pattern occurs only rarely if at all. The category Schatzker 6 is
important because it identifies a pattern where the diaphysis is
separated from the metaphysis with fractures proximally involving the
articular surface. Complications are frequent and treatment must be
designed to minimize risks. However, because of the problems with the
Schatzker 5 category, the 6 category is often used for any bicondylar
fracture. The common bicondylar pattern where both condyles are broken
without any intact articular surface or intercondylar eminences but the
shaft is not separated from the metaphysis is not easily classified in
the Schatzker classification. Despite these problems, the terms in the
Schatzker classification appear frequently in this chapter and in the
vernacular of most surgeons, so it is important to be familiar with
them:

Type 1: Split or cleavage fracture—Pure
split fractures have a single fracture line creating a marginal
fracture across the lateral plateau. These fractures are less common
than type 2 because any split is usually accompanied by some degree of
marginal depression along the split fracture line. They occur more
commonly in younger patients. Schatzker et al.¹⁴³ identified four of these fractures from among 70 reviewed, and Hohl⁷¹ found them in only 3% of plateau fractures (Fig. 53-10).

Type 2: Split or cleavage depression—These are the most common lateral tibial plateau fractures in most series, although Schatzker et al.¹⁴³ found that the type 3 fracture was slightly more common and Hohl⁷¹
found them to occur with equal frequency. The depression is the
marginal impaction at the edges of the split fragment. The relative
size of the split fragment and the amount of depression vary, ranging
from minimally displaced fractures to explosion fractures of the entire
lateral side of the joint and with a fractured fibular head (Fig. 53-11).

Type 3: Local compression or pure central depression—Local
compression fractures are lateral. Although it is implied that this
type of fracture does not have a split fragment, only local depression,
there frequently is a small split through the lateral cortex. However,
the split is small enough and minimally displaced and does not provide
an easy window of access to the depression. This fracture tends to
occur in an older age group¹⁴³ (Fig. 53-12).

Type 4: Medial condyle fractures—The
entire condyle is split as a single fragment or it may have a
comminuted joint depression component. The fracture line is usually
through the intercondylar region although it may be through the
opposite lateral condyle, but some portion of the lateral

condyle
is left unfractured. With large medial condyle fractures, the intact
lateral condyle displaces laterally from the femur, leading to a
fracture dislocation pattern. These severe injuries have a risk of
associated injuries, including compartment syndrome, peroneal nerve,
and vascular injury. Wahlquist et al.¹⁶⁵
found that the more the fracture line moves laterally, the greater is
the risk for these associated complications. Schatzker et al.¹⁴³ thought that these fractures had the worst prognosis. Chan et al.³¹ found a high incidence of associated anterior cruciate ligament (ACL) tears with posteromedial fracture patterns (Fig. 53-13).

Type 5: Bicondylar fracture—This
pattern was originally described by Schatzker as a fracture where both
the medial and lateral tibial plateaus are fractured. The
distinguishing feature was that the metaphysis and diaphysis remain
intact and not fractured. The intercondylar eminences may or may not be
fractured. The diagram in Schatzker et al.¹⁴³
from 1979 shows them to be intact. The type 5 fracture in this diagram
has fractures of both plateaus with the intercondylar area intact. This
is extremely uncommon, and in the original paper Schatzker et al.¹⁴³
identified only 2 of 70. There are patterns where some portion of both
condyles are fractured and some portion of one or both condyles remains
intact. For instance, there are medial and lateral partial condylar
fractures but typically the intact portion is not the area of the
intercondylar eminences. More commonly, these are posterior or anterior
fracture patterns where the fractures of the

two plateaus are mostly in the coronal plane, leaving the anterior or posterior portion of both intact²⁹ (Fig. 53-14). Barei et al.¹³
noted that approximately one third of bicondylar fractures have a
posteromedial fracture and described the characteristics of this
associated pattern. This information is important when a surgeon is
planning to treat a bicondylar fracture with laterally based locking
plates.

Type 6: Shaft dissociated from the metaphysis—In
most classic bicondylar patterns, the shaft is separated from the
condyles (there is no articular surface intact or in continuity with
the shaft below). The defining characteristic of the Schatzker 6
pattern was a diaphyseal metaphyseal dissociation with varying
comminution of the articular surface.¹⁴³ According to this definition, the distal extent of the fracture is more distal in type

6 than in type 5. Unfortunately, just when the change from 5 to 6
should occur is not precisely defined and is subject to observer
interpretation and therefore variability. The degrees of displacement
and comminution of the two articular surfaces vary, and there is no
subclassification of this pattern. The classic Schatzker 6 from the
original diagrams is a proximal shaft fracture with extension into the
joint. One of the weaknesses of this classification is the wide range
of patterns requiring different management strategies that all fit in
the 6 category. These are mostly high-energy fractures (Fig. 53-15).

Studies have assessed the observer reliability of
classifying tibial plateau fractures. Similar to many fracture
classifications, the AO/OTA and the Schatzker classifications of tibial
plateau fractures have been found to have less than excellent
interobserver reliability. In one study, the AO/OTA was found to be
more reliable than the Schatzker classification and to be more reliable
at the type than the group level.¹⁶⁶ Another study found that simple use of unicondylar versus bicondylar and split versus split depression was more reliable than either the Schatzker or the

AO/OTA classification.³⁵
One study looked at fracture characteristics that form the bases of all
plateau classifications and found that even simple terms like displaced versus nondisplaced and comminuted versus not comminuted led to significant observer disagreement.¹¹⁴
These studies indicate that the common fracture classifications and
even the terminology used for tibial plateau fractures are only
modestly reliable.

There are two frequently used surgical approaches to
reduce and internally fix tibial plateau fractures: the anterolateral
approach and the posteromedial approach. They are used in isolation for
fractures on the lateral and medial side of the knee, respectively,
and, not uncommonly, they are used together for patterns that involve
both condyles. These two approaches with common variants can be used to
treat virtually all tibial plateau fractures. In current practice, most
other approaches have become unusual or reserved for special
circumstances.

The anterolateral approach is the most common approach to surgically reduce and internally fix tibial plateau fractures (Fig. 53-16).
It is the workhorse approach for split depression fractures of the
lateral plateau. The incision is based over Gerdy’s tubercle and is
extended distally over the anterior compartment. An L-shaped incision
in the origin of the anterior compartment muscles provides access to
the anterolateral surface of the tibia. Care should be taken along the
posterolateral border of the tibia as the anterior tibial artery passes
through the interosseous membrane from back to front.

The proximal portion of the anterolateral approach is
variable based on surgeon preferences for joint exposure. For
fluoroscopic or arthroscopic reductions, the proximal exposure develops
subcutaneous access posteriorly toward the fibular head for placement
of a lateral tibial plate. The knee joint is not opened or further
exposed. Alternatively, two different exposures can be used to directly
visualize the lateral joint. In one of them, the deep dissection is
brought posteriorly along the tibial margin of the joint line, incising
the coronary ligament to create a submeniscal arthrotomy. With a long
enough inframeniscal incision, the meniscus can be retracted proximally
to expose the tibial side of the lateral joint beneath the meniscus.
Cross-joint distraction facilitates visualizing the joint through this
submeniscal arthrotomy. This approach has been credited

to the AO group.¹²⁰
The coronary ligament is repaired at the end of the procedure and has
been found to heal in a dog model of this submeniscal arthrotomy.³⁰

The second approach extends the skin incision proximally
and an anterolateral joint arthrotomy is created. In this approach,
exposure of the joint is from above the meniscus. The ability to
visualize the tibial fragments is increased by incising the anterior
portion of the coronary ligament and the intermeniscal ligament
detaching the anterior horn of the lateral meniscus that can then be
retracted laterally with the split fragment opening the joint through
the fracture. These are repaired with sutures at the end of the
procedure.¹²⁷ Arthroscopic evaluation of the anterior horn has shown that the incised meniscus heals.¹²⁵,¹²⁷

The posteromedial approach, the second most common
approach, is used to reduce and fix the medial side of the proximal
tibia and particularly the posteromedial fragment (Fig. 53-17).
It has the advantage of relatively good soft tissue cover and it is
widely separated from the anterolateral approach allowing these two
approaches to be combined when necessary. In addition, the fracture
fragments often have extra-articular fracture lines, which are not
comminuted and are relatively easy to reduce. A posteromedial plate
when optimally positioned is well suited to resist deforming forces. An
antiglide plate is placed directly over the area of maximal
displacement at the apex of the fracture.

The approach is based over the posteromedial border of
the tibia. The patient is most commonly positioned supine, which allows
access to the front of the knee for a second anterolateral approach or
to apply a distracter.⁶² The leg is
externally rotated, allowing easy access. Alternatively, the patient
can be positioned prone, which makes the posterior to anterior hardware
easier to place and facilitates fracture reduction by knee extension.⁴⁰
The subcutaneous dissection must avoid the saphenous nerve and vein,
and the incision must be posterior enough to allow hardware to be
placed from the posterior aspect of the tibia without the posterior
skin flap obstructing the screw paths. The deep interval is between the
posterior border of the pes anserine tendons and the medial head of the
gastrocnemius. A retractor under the medial head protects the popliteal
fossa structures. The origin of the medial head may be incised to
increase exposure, but this is rarely necessary.¹⁹,⁴⁰
To directly visualize the bone, the popliteus origin must be lifted and
retracted laterally. This often directly exposes the apex of the
fracture.

The anteromedial tibial plateau is easily accessed
through distal extension of a medial arthrotomy similar to a total knee
approach. However, it is unusual for fracture patterns to involve the
anteromedial tibia in isolation. An anteromedial approach should not be
used in conjunction with the common anterolateral approach. Usually,
medial patterns involve the posteromedial plateau, which requires a
posteromedial approach. Occasionally through the same incision, a
separate anteromedial interval in front of or between the pes tendons
can be used to reduce and fix the front of the medial joint through the
posteromedial approach.

Not infrequently, there is posterolateral comminution,
which is difficult to stabilize from an anterolateral approach with the
fibular head in the way. If the posterior plateau is comminuted far
onto the lateral side, it cannot be reached through the posteromedial
approach. In these cases, a posterolateral approach between the lateral
gastrocnemius and the biceps femoris with mobilization of the peroneal
nerve will provide access to the posterolateral tibial plateau. This
can be combined with a posteromedial approach as described by Carlson.²⁸,²⁹

Extensile approaches from the anterior portion of the knee have been used for complex tibial plateau fractures.⁵⁴,⁷⁰,¹⁴¹
The exposure obtained is similar to familiar approaches for knee
arthroplasty. They provide simultaneous access to both the medial and
lateral sides of the tibial plateau. Exposures where the extensor
mechanism is elevated with a tibial tubercle fracture or through
incision of the patellar tendon combined with anterior meniscal
incision provide an intra-articular exposure to reduce fractures that
are not possible with any other approach. Unfortunately, these
exposures, when combined with dual plating, lead to excessive soft
tissue stripping and devascularization of damaged fracture fragments,
and when they resulted in infection and/or wound breakdown, disastrous
results followed. For these reasons, alternate techniques should be
chosen if at all possible. Current opinion and data indicate that dual
plates can be reasonably safely applied to the fractured proximal tibia
but that dual approaches are safer than extensile approaches.

Posterior approaches done in the prone position through the popliteal fossa have been used to treat posterior fracture patterns¹⁶¹ but have fallen out of favor because of the need to mobilize the neurovascular bundle. Bhattachharyya et al.¹⁹ treated a series of patients with an approach that divides the medial head of the gastrocnemius tendon, and Bendayan¹⁵ described an approach where the medial gastrocnemius was split.¹⁵ Most recently, Fakler et al.⁵³
used the Lobenhoffer approach for posteromedial fractures. This
approach uses the same interval as the previously described
posteromedial approach between the pes tendons and the medial
gastrocnemius. Carlson²⁸,²⁹
described combined posteromedial and posterolateral approaches to the
back of the tibial plateau. These are efficacious for posterior
shearing patterns where direct posterior plating is mechanically
optimal. A posterior approach in the prone position has the advantage
of reducing the fracture with the knee in extension with a more direct
view of the fracture and screw paths. In addition, taking the medial
head down makes for a more extensile exposure to visualize comminuted
fractures. These advantages are offset by the more difficult
positioning compared to the supine posteromedial approach and lack of
readily available access to the lateral side for bicondylar fractures.

Fractures of both condyles are frequently treated with
combined approaches using an anterolateral approach and posteromedial
approach as described earlier.⁶²
Dual approaches provide access to complex bicondylar fractures but
strip less soft tissue attachments than extensile anterior approaches.
The patient is positioned supine and the leg must externally rotate for
the posteromedial portion of the approach. Anterolateral and
posteromedial incisions are nearly at 180 degrees from each other, so
short skin bridges are not an issue. Direct access to each injured
condyle to reduce the fracture and to place implants is obtained, which
minimizes the soft tissue dissection required.

Not all fractures of the proximal tibial articular
surface require surgery and not all displaced intra-articular fractures
need to be surgically reduced. The proximal tibial articular surface
tolerates small to modest articular displacements and, in properly
selected fractures, nonoperative treatment results in predictably
excellent outcomes despite articular irregularities. Progressive
incapacitating posttraumatic arthritis is actually very unusual.

In current practice, it is rare to attempt to obtain or
maintain a closed reduction of the proximal tibia and, for many
displaced fractures, it is impossible. Nonoperative treatment is
therefore indicated for tibial plateau fractures that will heal without
a significant deformity or for elderly patients or patients with
associated medical problems where operative intervention is high risk
or otherwise undesirable and for whom a deformity will be clinically
acceptable.

In selecting cases for nonoperative treatment,
predicting the presence or absence of a deformity after treatment is
very important (Fig. 53-18). Angular deformity
is not well tolerated by the articular surface since typically the knee
will be malaligned in a direction that increases the weight-bearing
load on the most damaged portion of the articular surface. Malalignment
increases the propensity for knee instability and is cosmetically
objectionable.

Unfortunately, predicting healing without deformity can
be difficult. To make this judgment, a surgeon must use information
about the fracture pattern, knowledge of outcomes of various types of
fractures, and the alignment both on injury radiographs and on clinical
examination. The type of fracture is critically important to choosing
nonoperative treatment and to achieving a good result. Although the
amount of articular displacement and the risk for deformity have some
relationship to each other, it is not a direct relationship. Localized
depressions of up to 10 or more millimeters of the lateral plateau may
result in stable knees and good outcomes when treated nonoperatively,
if the depression involves a small portion of the articular surface.
Depressions with associated displaced split fragments or those that
involve larger portions of the lateral articular surface will be more
likely to lead to valgus malalignment. Different from the lateral
plateau, a minimally displaced medial total condylar fracture has a
greater potential for displacement that may lead to unacceptable varus
deformity. The medial articular surface is less well protected by the
meniscus, so it is more important to minimize the amount of articular
steps or other displacements on this side of the knee.

These examples demonstrate that basing decisions on
operative versus nonoperative treatment for tibial plateau fractures on
a predetermined number of millimeters of displacement of the articular
surface is not sensible and does not account for important knowledge
about how different tibial plateau fracture patterns have more or less
propensity to lead to deformity and subsequent favorable or unfavorable
outcomes.

Bracing. Cast braces can be used to unload the injured
side of the joint. They once were commonly used to stabilize the
injured joint while permitting some degree of joint mobility.⁴²,⁴³,¹⁴⁶ DeCoster et al.⁴²
showed that alignment within 7 degrees of normal was obtained in all 30
plateau fractures treated with a cast brace. Delmarter and Hohl⁴³
used cast bracing as both a primary nonoperative treatment and as an
adjunct to open reduction and internal fixation and showed that 85%
maintained alignment in the cast brace. Currently, cast braces are not
commonly used since most unstable plateau fractures are treated
surgically and most surgical techniques achieve enough stability that a
cast brace is not necessary. Tibial plateau fractures that are
inherently stable or stabilized surgically do not need this additional
protection and a lighter, removable brace is preferred.

Although injured knees with tibial plateau fractures
tolerate up to 6 weeks of cast immobilization, most surgeons prefer
early mobilization with a hinged brace, which allows joint mobility and
provides some coronal support.

Weight-Bearing Guidelines. Most patients with
nonoperatively treated tibial plateau fractures should be kept
non-weight bearing during the initial weeks after injury. The duration
of non-weight bearing depends on the fracture pattern but is typically
4 to 8 weeks. Scotland and Wardlaw¹⁴⁶ reported that plateau fractures treated in a cast brace could weight bear early,

within a few days or weeks after injury; however, this technique is not often used in current practice.

Excellent results treating tibial plateau fractures
nonoperatively have been reported. Although there are no recent
reports, older series provide important information. Since the
indications to treat plateau fractures nonoperatively have narrowed
considerably, the older series can be considered worst case compared
with those treated nonoperatively in current practice.

Apley et al.⁸ and Moore et al.¹¹⁷ both used initial traction and joint movement to manage tibial plateau fractures and

thought early joint mobility and exercises contributed to their favorable outcomes. Jensen et al.⁸³
compared traction to surgery and found equivalent outcomes, although
not surprisingly surgery led to shorter hospital stays. On the other
hand, motion must not be critical because Drennan et al.⁴⁷
reported 85% good and excellent results with good motion at follow-up
in patients treated with closed reduction and a spica cast for 6 weeks.

Lansinger et al.⁹⁹
reported on a 20-year follow-up of nonoperatively treated patients
originally reported by Rassmusen. Surgical treatment was reserved for
patients with greater than 10 degrees of coronal plane instability in
full extension.¹³¹ The patients
achieved 90% good and excellent results, which indicate that lack of
significant instability in full extension is associated with good
results after nonoperative treatment. Although this information is
helpful in clinical decision-making in some cases, it is of limited
value since it is often difficult to reliably examine an acutely
injured knee to determine the degree of instability.

Other authors have identified other predictors of outcome after plateau fractures treated nonoperatively. Waddell et al.¹⁶⁴ found that plateau depression or widening of less than 10 mm was usually well tolerated. Honkonen⁷⁶
found that 5 mm of widening and 3 mm of step-off were well tolerated
but that any medial side displacement or tilt should be avoided.

Scotland and Wardlaw¹⁴⁵
reported excellent results for 29 patients treated in a cast brace and
emphasized early weight bearing and return to function. DeCoster et al.⁴²
followed 30 plateau fractures treated with a cast brace and found that
the outcome of the knee was less favorable for more complex bicondylar
fractures.

Duwelius and Connolly⁴⁸
reported good results after nonoperative or limited surgical approaches
and noted that excellent clinical outcomes did not correlate well with
the radiographic appearances of the knee.

These results indicate that favorable outcomes are
possible for many tibial plateau fractures without surgery, despite
articular incongruities and displacements. It is important to maintain
limb alignment, and this may require external support with a cast brace
and, for some fractures, traction or other methods. In current
practice, patients with fractures similar to those in many of the cited
studies are treated operatively, which ensures accurate limb alignment,
early motion, and better reductions with less external support.
However, the favorable results of nonoperative treatment should be
considered when a patient with a tibial plateau fracture has
significant comorbidities, is elderly with osteopenic bone, has poor
skin, or does not want an operation. An excellent outcome without
surgery is possible for many tibial plateau fracture patterns.

Operative treatment is indicated for displaced unstable
tibial plateau fractures where near-normal limb alignment cannot be
predicted based on the fracture pattern or physcial examination. In
young healthy patients, this will include almost all bicondylar and
shaft dissociated patterns, and all but minimally displaced medial
plateau fractures and lateral plateau fracture patterns where valgus
alignment will occur without surgically reducing and fixing the
fracture. For the lateral patterns, the presence of a split fragment, a
depression affecting over half of the lateral articular surface, a
fibular head fracture, valgus alignment on injury radiographs, and
clinical valgus alignment on examination are all strong indications for
surgery.

The number of millimeters of depression of the articular
surface measured on radiographs has been frequently used to indicate
surgery. Unfortunately, depression is difficult to measure accurately
and reliably on plain radiographs (Fig. 53-19). Martin et al.¹¹²
found that when observers make measurements independently of each
other, their measurements are different from each other by at least 12
mm 10% of the time. In addition, the size and location of the depressed
area all make a difference in whether a certain amount of depression
will be clinically significant. The number of millimeters is not
reliable and too simplistic to be a good way to determine surgical
indications.

In elderly persons, less active persons, or medically
unfit patients, the indications for operative treatment are narrower
and the risks and benefits of surgical intervention must be carefully
assessed on a case-by-case basis. In these patients, a deformity will
be less significant, functional demands are less, and surgery is
potentially more difficult with more osteopenic bone (Fig. 53-20). The results of surgery in elderly patients are generally less satisfactory than in young patients.¹¹,⁷⁵,⁸⁸,¹⁴⁵,¹⁷⁰

The treatment techniques that result in the most
favorable patient outcomes depend on the patient and the fracture
pattern. A variety of techniques are currently popular and have good
results reported in the literature, and new techniques continue to be
developed. However, for a given patient with a given

fracture
pattern, there is little evidence to indicate one technique is superior
to others. For instance, for one of the most common fracture patterns,
a split depression lateral plateau fracture, currently acceptable
techniques for visualizing the articular surface reduction include
fluoroscopic, arthroscopic, and joint arthrotomy with meniscal
incision. The same fracture might be stabilized with either small or
large plates and screws, or screws alone. Numerous materials to fill
the void created after reducing the fracture would be considered
acceptable choices. As another example, there has been a wave of
popularity for treating AO/OTA C fractures and Schatzker 6 patterns
with locking plates without any evidence that outcomes are better than
with previous techniques. It is even difficult to know which fractures
are benefited by surgical management.

In planning to operatively treat a tibial plateau
fracture, the fracture pattern will dictate the operative approach, the
technique of reducing the fracture, and the appropriate use of internal
or external fixation devices. In addition to assessing the fracture
pattern, the surgeon must decide how to visualize the articular
reduction and whether to assess and manage associated meniscal and
ligament injuries as part of an operative treatment plan.

Accurately reducing the displaced articular surface is
an important aspect of treating displaced plateau fractures. In
planning a surgical case, the surgeon has choices on how to assess and
visualize the reduction. The articular reduction can be assessed
indirectly by fluoroscopy, with an arthroscope, or directly through an
arthrotomy to see the articular surface. Some surgeons favor one
approach over another, and others choose different approaches based on
the fracture pattern.

If the fracture pattern permits, many surgeons prefer to
directly assess the fracture reduction through a joint arthrotomy. In
lateral side patterns, the meniscus can either be incised anteriorly or
elevated with a submeniscal arthrotomy. Both approaches allow the
articular reduction to be directly assessed under direct vision. The
meniscus and arthrotomy are repaired during closure.

Arthroscopic techniques to assess and direct fracture
reduction have been used by some surgeons for a wide range of fracture
patterns for more than two decades⁸¹ (Fig. 53-21).
With arthroscopic techniques, the fractured articular surface is
visualized less invasively than with wide arthrotomies and detaching or
elevating the meniscus. In addition to assisting with fracture
reduction, arthrosocpy has the further advantage of allowing associated
intra-articular soft tissue injuries to be directly assessed and
treated.¹⁶³ Faster rehabilitation and more accurate reductions compared to open techniques with arthrotomy have been reported.²⁴ Most authors have reported results that are similar to or better than more traditional open procedures,⁵⁶,⁷⁹,¹⁰¹,¹⁰⁵ but directly comparing the two techniques is difficult because of potential differences in case selection.⁷⁴,¹⁰⁵
Although mostly used for split, split depression, and local compression
fractures, arthroscopy has been used for higher energy fractures.³³,⁸¹ Good results have been reported for arthroscopic treatment for elderly patients, mostly for lower energy fractures.³⁷

Fluoroscopy is an integral tool in treating tibial
plateau fractures because it is used to assess the placement and final
position of hardware in relation to fracture lines and the articular
surface. Final assessment of fracture reduction is frequently by
fluoroscopy. Therefore, using fluoroscopy to assess the reduction is
frequently part of the operative plan. However, using fluoroscopy
exclusively as a guide to reducing depressed fragments is challenging
and not universally accepted. It has the advantage of being less
invasive than joint arthrotomy and does not require the extra equipment
and joint distention required for arthroscopy. Koval et al.⁹⁶
indirectly reduced 18 plateau fractures using fluoroscopy and fixed
them with screws and had 13 excellent reductions. They noted more
difficulty accurately reducing fractures with depressed fragments,
although, interestingly, all cases with incomplete reductions had
excellent outcomes. Other authors have reported similar experiences
with simple cases amenable to fluoroscopic assessment alone and more
complex cases requiring adjunctive arthrotomies or arthroscopy.⁴⁹,⁶⁷,⁹²
In a comparative study, Loebenhofer et al. found that fluoroscopic
assessment of the plateau with a C-arm was equivalent to and
technically easier than assessing it with an arthroscope. Patients
assessed with fluoroscopy alone did not have clinical problems
secondary to unrecognized soft tissue injuries.¹⁰⁴

Soft tissue injuries are frequent with tibial plateau
fractures and may or may not need to be incorporated into an operative
plan. There are two important types of soft tissue injuries. First
there are injuries to menisci and ligaments and second there is the
injury to the surrounding soft tissue envelope that increases the risks
for complications and must be considered when managing tibial plateau
fractures.

Ligament and Meniscal Injuries. There is a high
incidence of ligament and meniscal injuries associated with tibial
plateau fractures. When assessed by MRI, one study found that even
minimally displaced tibial plateau fractures indicated for nonoperative

treatment had a high percentage of these injuries (meniscal 80%, ligament 40%).¹⁵²
In another study of MRI findings in 103 patients with operatively
treated tibial plateau fractures, all but one patient had some soft
tissue injury with lateral meniscus (91%), most commonly followed by
ACL (77%), posterolateral corner (68%), and medial meniscus (44%).⁵⁸
Similarly, in knees evaluated arthroscopically during operative
treatment of a tibial plateau fractures, 71% (70 of 98) were found to
have meniscal or ligament injuries at a rate of 57% for meniscal, 25%
for ACL, 5% PCL, and 3% each for MCL and LCL.¹
The authors of this study could not demonstrate a strong association
with fracture type although ACL injuries were more common in total
condylar and Schatzker 6 patterns. In another study, the incidence of
meniscal injury in split depression patterns was found to correlate
with the degree of depression and condylar widening.⁵⁷ Looking specifically at ligament injuries using stress radiographs and intraoperative findings, Delamarter et al.⁴⁴
found that in 39 tibial plateau fractures evaluated there were 22 MCL,
8 LCL, 1 ACL, and 8 combined ligament injuries. Unfortunately, the
clinical significance of these soft tissue injuries when associated
with a tibial plateau fracture is not known.

The treatment of these associated soft tissue injuries
is controversial. Conservatively managing MCL injuries is generally
favored so most surgeons do not currently advocate diagnostic or
treatment strategies for an associated MCL injury. In addition, the
medial ligament does not present long-term problems and residual laxity
usually relates to bony depression rather than collateral ligament
laxity. At an average of nearly 3 years after injury, Moore at al.¹¹⁶
tested 208 patients with unicondylar tibial plateau fractures for varus
or valgus laxity using stress radiographs. They found that compared to
the uninjured knee, there was no increased laxity to suggest chronic
collateral ligament damage. This was despite calcification in
collateral ligaments in one of seven knees. This information suggests
that after reducing and fixing a lateral plateau fracture, a brace is
sufficient to treat the associated collateral ligament injury.

Assessing and managing other intra-articular meniscal
and ligament injuries that are frequently present is controversial.
Some authors recommend an aggressive approach to both diagnosis and
surgical repair.¹⁷,⁸¹,¹⁶³ Other authors have found that the patient’s function and outcome are excellent without addressing these injuries.²⁷,¹¹¹
The meniscus is important in preventing posttraumatic osteoarthritis
(OA), and many operative techniques stress meniscal repair.¹⁴
However, the vast majority of minimally displaced tibial plateau
fractures have excellent outcomes without addressing associated
meniscal or ligament injuries. For these minimally displaced fractures,
as for all tibial plateau fractures, it is difficult to know which soft
tissue injuries need to be managed surgically to improve patient
outcome. Many severe tibial plateau fractures have excellent outcomes
after being treated surgically with techniques that do not routinely
evaluate or repair meniscal injuries.¹¹¹
These results indicate that meniscal injuries either heal or are not
symptomatic in patients after tibial plateau fractures. Reattaching an
avulsed ACL or PCL, particularly when it is associated with a fracture
fragment, is recommended by the authors of some series of high-energy
fractures.¹⁶,³⁷
In one comparative study, better results were found in fractures where
the ligaments were surgically repaired compared to fractures treated
without ligament repair.¹⁷⁸ However, other series of high-energy fractures have reported good results without ligament repair,¹⁵⁹,¹⁷⁷ and many reports on high-energy fractures do not indicate whether ligament injuries were addressed surgically.⁵³,¹⁶⁴,¹⁶⁶
Some surgeons order MRI routinely to assess tibial plateau fractures
and the associated soft tissue injuries, and others reserve it for
cases where there is a particular concern about the status of the
ligaments or the menisci that would not be otherwise assessed through
the operative approach.

Soft Tissue Envelope. Some tibial plateau fractures have
a severe injury to the overlying soft tissues. The worst soft tissue
injuries typically occur with bicondylar fractures,
fracture-dislocations, and shaft dissociated patterns. These
high-energy patterns may require extensive surgical approaches with
substantial implants, and the risk of these procedures is increased
because of the injury to the soft tissues. Open tibial plateau
fractures may be clinically obvious, but subtle wounds or abrasions in
the zone of injury must be assessed with suspicion for being an open
fracture. When there is doubt, these suspicious wounds should be
explored. Fracture blisters occur when the soft tissue injury is severe
and may be red or white; red blisters represent a deeper dermal injury.
Tense swelling and deep contusions are additional signs of severe
fracture associated soft tissue injury. Severe closed soft tissue
injuries take many days or even weeks after the injury to recover. If
mismanaged, surgical approaches that are performed during the period of
intense swelling before recovery pose a high risk for wound
complications.

Open soft tissue injuries should be urgently debrided in
the operating room. Soft tissue coverage may be needed, and this can
frequently be accomplished with a rotational flap from the medial or,
less commonly, lateral head of the gastrocnemius.

Plates and Screws. Plates and screws are the most
frequent implants used to stabilize tibial plateau fractures, and all
major manufacturers have recently developed precontoured periarticular
plates and locking plates, resulting in more plate choices than have
ever been available in the past. The simplest implants are lag screws
used to compress simple fracture lines in isolation or in conjunction
with other fixation devices. For compression, partially threaded screws
are most common and 6.5-mm screws work well for major plateau fracture
lines, although smaller screws may work equally well.

Plates serve different functions depending on the
fracture pattern and where they are anatomically placed. A common plate
application is for the anterolateral proximal tibia where it is used as
a buttress and to substitute for the damaged lateral cortex that occurs
with lateral split depression plateau fractures. These plates are
precontoured for this anatomic region, which makes obtaining an
accurate fit for buttressing the lateral tibial condyle much easier.
The 3.5-mm implants and screws are the most common size, having largely
supplanted the 4.5-mm implants that were common in the past. The 3.5-mm
implants are less bulky and easier to fit on the bone, and the smaller
3.5-mm screws allow more screws to be placed closer to the articular
surface to support reduced fragments. In cancellous bone, 3.5-mm screws
have been shown to have equivalent pullout strength in comparison to
6.5-mm and 4.5-mm screws.¹⁷⁴ Multiple holes in the head of the plate allow 3.5-mm screws to be placed parallel and close to the articular surface to support

the reduced articular surface and minimize the chances for
postoperative settling. This technique has been called “rafting screws.”⁸⁵,⁹⁵ It is similar to a technique that used multiple K-wires beneath a lateral fragment as a way to prevent secondary displacement.¹⁸
The high incidence of some loss of the articular reduction after
surgically treating lateral plateau fractures, reported in 31% of cases
in one series, means that newer techniques not used in this series,
such as rafting screws, should be very seriously considered.⁴

Posteromedial plates serve a different mechanical
function than anterolateral plates. In this area, the plate must
function as an antiglide device to resist shearing forces. Again,
3.5-mm implants are most common and specially contoured plates are
becoming available from several manufacturers. In this area, the plate
position in relation to the apex of the fracture is more important than
the exact placement of screws.

Precontoured plates for fractures of the proximal tibia
have several advantages. They decrease time spent for intraoperative
plate contouring, facilitate limited approaches when the bone is not
completely visualized to allow contouring, and may assist with
reduction by fitting the fractured bone to the precontoured plate.
However, Goyal et al.⁶⁵ have shown
that there is significant normal variation in the shape of the proximal
tibia leading to suboptimal fit of precontoured plates to cadaver
specimens, even in ideal laboratory settings. The relevance of this
finding to maintaining fracture reduction is uncertain, but surgeons
can be certain that perfect plate contact with the bone will not
frequently be obtained.

Lateral plates used for bicondylar and Schatzker 6
fractures must resist axial, rotational, and bending forces. Locking
screws to the plate has been a great advance in resisting these
mechanical forces, and these implants are currently very popular. They
are larger and use larger screws than those used for unicondylar
fractures based on the need to resist substantial deforming forces.
From their lateral position, they must prevent the tendency of bending
forces to create a varus deformity. By resisting varus collapse, they
have decreased the need for dual plates and for definitive external
fixation.

These plates have been designed to be inserted through a
limited approach with external targeting of the distal screws. They can
now be used with either locked or nonlocked screws. So-called hybrid
techniques use nonlocked screws to pull the bone to the precontoured
plate, and then locked screws are added to resist angular deviation.
Some manufacturers now offer polyaxial designs with flexibility in the
direction of screw insertion combined with fixed angle stability.⁶⁶
Although many manufacturers have made locking technology for many of
their implants, the use of locking screws for unicondylar tibial
plateau fractures where the plate functions as a buttress (lateral
plateau) or for antiglide (posteromedial plateau) is of uncertain value.

External Fixation. The way in which external fixation is
used for tibial plateau fractures has dramatically changed in the past
decade. The advent of locking plates applied through limited approaches
has significantly decreased the amount of external fixation used for
definitive treatment of shaft dissociated and bicondylar patterns.
However, external fixation is now frequently used as temporary
treatment by spanning the knee. This noninvasively restores length and
aligns the fracture during soft tissue recovery before definitive
treatment with internal fixation.

Definitive external fixation still has a role in complex
tibial plateau fractures based on surgeon preference or in cases with
severe soft tissue injury, when, despite delay, internal fixation is
not thought to be safe. Most data indicate that external fixation is
equally as effective or more so than plate fixation.¹⁷⁰
One recent randomized study of bicondylar fractures by the Canadian
Orthopaedic Trauma Association found that patients treated with
external fixation had similar or better outcomes with less
complications than those treated with dual plating.²⁷
Definitive external fixation can be performed using a variety of
different frames and both wires and pins have been effective. The frame
and the bone fixation elements must be designed to overcome the
deforming forces. Some fixator constructs may be as effective at
resisting deforming forces in bicondylar fractures as dual plates⁵ (Fig. 53-22).

Temporary spanning frames should be simple and can be
easily applied. Pin bar frames are most common, allowing pin spread and
frame geometry to be designed based on the needs of the fracture and
associated soft tissue injury (Fig. 53-23). The
tibial pins should be placed in a way so not to interfere with
subsequent procedures for internal fixation, keeping potentially
contaminated pin sites away from future incisions and internal fixation
devices. Radiolucent carbon bars facilitate imaging after the frame is
applied. The major goal is to restore and then maintain length and
align the fracture and knee joint. This may require significant
distraction forces. Spanning frames need to be used only for severe
fractures with marked displacement, shortening, or joint subluxation.
They are rarely necessary for routine lateral plateau fractures and
usually are not needed for medial plateau and bicondylar fractures that
are only minimally displaced. Widely displaced fractures with soft
tissue injuries such as tense swelling, fracture blisters, compartment
syndrome, or open wounds are the best indications for temporary
spanning frames. The use of a staged protocol has been reported to
decrease the wound complication rate, but there are no comparative
studies.⁵¹

Nails. Intramedullary nails have been and can be used for select tibial plateau fractures by surgeons using special techniques (Fig. 53-24). The indications for and complexities associated with nailing very proximal tibia fractures are covered in Chapter 55.

Void Filler. More than with any other fracture patterns,
reducing depressed tibial plateau articular fragments, typically those
of the lateral plateau, leads to empty areas in bone or voids beneath
the reduced fragments. The cancellous trabeculae are compressed by the
injury resulting in loss of substance after the articular fragments are
reduced. Given the excellent healing potential of these cancellous
fractures, these voids do not present a risk for failure of healing.
Rather, they are an area that lacks support for the reduced articular
fragments, increasing the risk that the articular fragments will
redisplace despite internal fixation. To minimize this risk, it has
been a principle of lateral plateau fracture surgery to fill the void
to increase stability and prevent redisplacement. Classically, the most
common material for “grafting” the void has been autograft, most
frequently from the iliac crest.⁹⁸,¹⁴⁰,¹⁶⁴ In severe cases, tricortical iliac graft has been recommended¹⁴⁷ and, where support of reduced fragments is not possible, replacement of the lateral plateau with a patellar graft.⁸⁰,¹⁷⁷
For many surgeons, allograft has supplanted autograft. It has the
advantage of being readily available in unlimited quantities and offers
similar handling properties to autograft without donor site morbidity.¹⁴⁹

Investigators have assessed a variety of commercially
available graft substitutes in mechanical and clinical studies. The
optimal material is currently uncertain, but this is an area of
changing practice. Since subsidence after surgically reducing and
fixing lateral plateau fractures is a real problem, new methods to
support the reduced articular surface are important. Interporous
coralline hydroxyapatite has excellent bone in growth properties⁷² and, in 1989, Bucholz et al.²⁵
found it to be equivalent to autograft in patients with tibial plateau
fractures. In goats, 3 months after creating a cylindrical defect and
filling it with beta tricalcium phosphate, investigators found less
collapse and more new bone than in similar defects filled with
autograft.¹⁷⁵

Most recent work has focused on phase-changing cements,
which have been shown to have better rather than equivalent mechanical
properties to bone grafts. In a split depression fracture model in
cadavers, a calcium phosphate (Ca-P) cement was significantly stiffer
in compression to cancellous bone.¹⁶⁰
In a goat lateral plateau model without internal fixation, Ca-P cement
augmentation led to less secondary displacement than cancellous bone.¹⁷³

Ca-P cement for tibial plateau fractures has been
reported in several level 4 studies, and the results have been
generally favorable.⁷⁸,⁸⁹,¹⁰³,¹⁵³
However, in all of these studies, there remains a small but persistent
rate of subsidence of the lateral articular surface. For instance,
Lobenhoffer et al.¹⁰³ noted partial
loss of reduction 4 to 8 weeks after surgery in 2 of 25 patients
treated with Ca-P cement. In a randomized controlled trial, Russel et
al.¹³⁹ found that Ca-P cement
resulted in less articular subsidence than autograft. In a
metaanalysis, fractures in metaphyseal regions treated with Ca-P cement
maintained the reduction better than those treated with autograft and
patients treated with Ca-P cement had less symptoms than control
subjects treated without graft.¹⁰
Further clinical investigation will be necessary to confirm these
results, and it will be challenging to prove that outcomes are
improved. However, the potential for better support for the reduced
articular surface should be welcomed because loss of reduction remains
one of the problems with surgery for these fractures.

In fractures of the tibial plateau, the fracture pattern
dictates the operative approach, fixation technique, risk for
complications,

and,
to some extent, outcome. These differences stratify nicely based on the
AO/OTA and Schatzker classifications. There is some variability in the
procedures recommended in the literature for each of these patterns,
but the general principles are similar enough to allow a pattern-based
discussion. For details of surgical approaches, assessment, and
management of meniscal and ligamentous injuries; techniques to assess
reduction; and void fillers, see the previous sections. The following
sections will outline the general range of surgical techniques and
implants used for each of these basic patterns and the fracture
specific results reported in the literature.

AO/OTA type B-1 or Schatzker 1—Split Fracture of the
Lateral Plateau—Limited Approach Techniques With Arthroscopic or
Fluoroscopic Assessment of Reduction. Simple split fractures of the
medial and lateral plateau are the strongest indications for limited
approach techniques that assess the reduction with arthroscopy or
fluoroscopy (Fig. 53-25). These fracture
patterns do not have large depressed fragments, and reducing the split
fragment will accurately align and stabilize the joint and restore the
congruity of the articular surface. The fracture can often be fixed
with percutaneous applied cannulated screws alone. The location and
orientation of the fracture lines can be accurately determined
preoperatively with a CT scan. This information can guide the surgeon
to apply reduction forceps and direct screw paths to optimally reduce
and securely fix the split fracture. Large reduction forceps with a
span to extend between the two plateaus are helpful.

The major area of controversy in this fracture type is
the optimal technique to assess the accuracy of the reduction (see
techniques to visualize the articular reduction). Arthroscopic
techniques directly visualize the articular fracture through a
minimally invasive approach, but fluoroscopic techniques, when used
well, may be equally as effective. To fix the fracture with screws
only, the split fragment needs to be compressed to prevent
displacement. Plate fixation requires an open approach and applies more
bulky hardware. A mechanical study in cadavers has shown no difference
between pure split fractures fixed with 6.5-mm interfragmentary screws
alone and those fixed with screws with the addition of a buttress plate
or the addition of an antiglide screw and washer at the apex of the
fracture.⁹⁵

A major exception to reducing and fixing a split
fracture through percutaneous techniques is an isolated oblique
shearing fracture of the posteromedial condyle. A split fracture in
this area is less amenable to percutaneous techniques because of more
difficult posterior access and relatively higher deforming shearing
forces. These fractures will more often be handled by a posteromedial
open approach and an antiglide plate.

Results. Numerous authors
have reported satisfactory results after closed reduction and screw
fixation alone for split fractures and combinations of split and split
depression fractures and even for relatively minimally displaced
bicondylar fractures.⁴⁹,⁶⁷,⁹²,⁹⁶
The results of treatment of Schatzker type 1 or AO/OTA type B-1
fractures in isolation are difficult to report with great precision
because they are combined with other lateral side patterns. However, in
most series, these fractures seem to have close to or the best outcomes
of all plateau fracture types studied. For instance, Honkonen,⁷⁵
in a study of seven types of tibial plateau fractures treated with
various operative and nonoperative techniques and followed an average
of 7.6 years, found the least incidence of secondary arthritis in
lateral split fractures. In Schatzker’s orginal report, which described
the six fracture types, the only type that had all satisfactory results
was the type 1 lateral split fracture.²² Koval et al.⁹⁶
treated 18 displaced fractures by closed reduction and percutaneous
screw fixation; the seven type 1 fractures had four excellent, two
good, and one fair result.

AO/OTA type B-2 or B-3 or Schatzker 2—Split Depression
Fractures of the Lateral Plateau—Reduction and Buttress Plate Fixation
and Void Filler. This is the most common operation for displaced tibial
plateau fractures. In this fracture pattern, lateral split fragments
are associated with varying amounts of articular depression. The split
fragment may be large and the depression small, or a small split
fragment may be part of a large

joint
depression fracture. An associated fibular head fracture increases the
degree of knee instability and may be a negative factor for prognosis.²³
By accurately reducing the lateral plateau, the goal of preventing or
minimizing the valgus alignment that would occur without surgical
treatment is realized.

Although the treatment approach for lateral split
depressed tibial plateau fractures is fairly straightforward and
familiar to most surgeons, the tendency to postoperative settling of
the articular fragments is significant, leading to a knee aligned in
valgus despite surgery⁴ (Fig. 53-26).
The more severe the split depression fracture and the more osteopenic
the bone, the greater are the risk and severity of this problem. To
avoid these problems, surgical techniques need to accurately and
completely reduce the fracture, the implant needs to be placed to
support the reduced fragments, and the void must be filled with the
optimal material. Newer techniques with 3.5-mm plates, multiple
“rafting screws,” and Ca-P cements to fill the void may be better than
the previous techniques.

The patient should be supine on a radiolucent table and
the C-arm should be on the medial side, leaving the lateral side free
for the surgeons to work while the knee is assessed fluoroscopically.
The anterolateral approach is used and the anterior compartment fascia
is incised proximally and anteriorly to allow a buttress plate to be
applied to the anterolateral tibia. The lateral split fragment will be
exposed and partially reflected during the approach, but care should be
taken to minimize the stripping of soft tissues from this fragment,
particularly posteriorly. When the split fracture is reduced, the
capsule and iliotibial band that remain attached to the fragment will
likewise be restored to their normal position and tension.

If the surgeon chooses to directly visualize the joint
to assist in reducing the fracture, it is accomplished through the
anterior fracture line in the lateral split fragment augmented with a
proximal anterolateral arthrotomy with incision of the anterior lateral
meniscus or a posteriorly directed horizontal arthrotomy beneath the
lateral meniscus. Either approach allows the depressed lateral
articular surface to be directly visualized. A cross-joint distractor
or external fixator may be used to further open the joint.

Opening the fracture through the split fragment allows
the depressed fragments to be manipulated and directly reduced to align
with the margins of the intact areas of the plateau. Care should be
taken to work from below, with tamps and elevators keeping as much of
the cancellous bone beneath fragments intact as possible. Generally
speaking, the more fragments that can be elevated in situ from below
and the less they are completely freed and placed on the back table,
the more favorable the eventual reduction will be. The surgeon must
carefully assess for and reduce marginal impactions of the articular
surface remaining attached to the split fragment. Otherwise, the
depressed central fragment will be incompletely elevated, to match a
marginally depressed area, leading to an unsatisfactory reduction. The
fragments may be temporarily fixed with K-wires. When assessed with
fluoroscopy, the lateral side needs to be restored to its normal
position, slightly higher than the medial side. Overreduction is better
than underreduction, given a tendency to postoperative settling.
Comparative images of the opposite side may be helpful.

The fracture is fixed with a laterally based buttress
plate positioned over the split fragment. Current practice favors
3.5-mm plates with 3.5-mm screws. Screws are placed close to the
articular surface to help support the reduced articular fragments.
Three or four of these so-called rafting screws may be used. AP and
lateral fluoroscopy assists in obtaining optimal implant position.
Mechanically, multiple smaller screws provide better support to reduced
articular fragments than a smaller number of larger screws.¹²⁶ Precontoured plates facilitate implant fit to the bone, but they must be carefully positioned

to optimally achieve this. The proximity of the plate to the
subchondral bone partially dictates the screw support for the articular
fragments.

The use of locking screws is controversial. Nonlocked
screws facilitate compressing the plate to bone, enhancing its buttress
effect and narrowing the condylar width. Fixation in firm uninjured
bone on the medial side prevents the screws from settling. They do not
have to resist the bending and rotational forces as do lateral plates
used to treat bicondylar fractures. Some surgeons might advocate that
optimal support for the articular fragment is obtained by locking a
rafting screw to the plate.

Void filler is frequently necessary as part of this
operative approach. After reducing but before internally fixing the
fracture or after both of these steps, the void created by the fracture
and the reduction process can be filled with one of several materials
to support the articular fragment. If Ca-P cements are used, the screws
should be placed before the cement to avoid fracture of the material,
which is brittle when it is set. If graft is used, it should be firmly
impacted beneath the reduced fragments.

Results. Of the three types
of lateral plateau fractures, split depression fractures have slightly
poorer outcomes than split or local compression fractures partially
because of the likelihood of these occurring in elderly patients and
partly because some very severe lateral plateau injuries are in this
category. In elderly patients, Keating⁸⁸
found that split depression had worse outcomes than all other types
except the shaft dissociated pattern. To a certain extent, the results
depend on the ability to reduce and maintain the articular reduction of
the lateral plateau and for some fractures, and in patients with
osteopenic bone, this can be difficult. Ali et al.⁴ reported a high percentage of patients who lost reduction after surgical treatment, particularly elderly patients.

Despite these concerns, most authors report generally favorable outcomes. Savoie et al.¹⁴⁰ reported 18 of 21 and Lachiewicz⁹⁸ reported 16 of 17 good or excellent results in operatively treated split depression fractures.

Schatzker 3—Local Compression—Limited Approach
Techniques With Arthroscopic or Fluoroscopic Assessment of Reduction
and Screw Fixation or Plate Fixation and Possible Void Filler. The
issues that this lateral side fracture pattern present are intermediate
to the previous two. Usually, substantial lateral joint depression
fractures are accompanied by at least a marginal split fragment and the
appropriate operative techniques are described above. Very small
isolated depressions of the lateral articular surface may or may not
need to be treated operatively. To reduce a local depression fracture
without a significant split fragment, the lateral wall should be left
intact, which then requires a technique to access the depressed area.
This can be accomplished with a cannulated drill system where a
guidewire is placed into the depressed cavity from the exterior surface
of the tibia (Fig. 53-27). Once the position is
confirmed either arthroscopically or fluoroscopically, the cortex can
then be opened over the wire, providing access for tamps or awls to
reduce the articular fragments. The cortex can be opened either
anterolaterally or anteromedially depending on the direction of
displacement of the articular fragment. The reduction is judged either
fluoroscopically or arthroscopically. The reduced fragment is supported
with subchondral screws targeted to the correct location beneath the
fragment and void filler can be used to fill the resulting cavity. This
entire procedure can be accomplished using minimally invasive
techniques.

Results. Local compression
fractures are less severe injuries than most of the other plateau
patterns and for this reason have generally favorable outcomes. Keating⁸⁸ found that in elderly patients split and local compression fractures had better outcomes than all other types. Lachiewicz⁹⁸ found that all the local compression fractures treated surgically had excellent outcomes. Savoie et al.¹⁴⁰
found all good and excellent outcomes in surgically treated patients
with local compression fractures. In one series, better results were
reported with arthroscopic treatment than with open reduction.

Isolated Medial Side Patterns—AO/OTA type B1, B2, or B3,
Schatzker 4, Total Condylar—Posteromedial Surgical Approach Antiglide
Plate. In these patterns, at a minimum, the far side of the lateral
plateau is intact and will serve as the fixation point for the
displaced medial side. The fracture line may be through the medial
plateau only or may extend to the intercondylar eminences or into the
articular surface of the lateral plateau. Fractures may be minimally
displaced or present as fracture dislocations where the forces that
fracture the medial condyle are continued and dislocate the lateral
plateau from the lateral femoral condyle. Comminution at the margin of
the fracture is common and may be severe in medial fracture dislocation
patterns and involve the lateral plateau.

The treatment principles are fairly straight forward,
but these fractures are difficult to accurately reduce and small errors
may lead to significant articular step-offs or angular malalignment.
Nondisplaced or minimally displaced fractures may be stabilized with
cannulated screws to prevent displacement. When the fracture needs to
be reduced, the forces on these large fragments are significant and the
fracture needs to be fixed with plates (Fig. 53-28).

A posteromedial approach is preferred. The patient is
positioned supine or prone based on surgeon preference. When
substantially displaced, reducing the fracture is difficult and using
aids such as large and small reduction forceps, awls and elevators, and
intraoperative distraction techniques manually or with fixed skeletal
distraction is often necessary. The primary shearing fracture line may
be associated with locally depressed fragments. Depending on their size
and location, their reduction may need to be incorporated into the
operative plan. Usually, this can be accomplished with the
posteromedial approach through the major posterior fracture line even
when the depressed fragments are in the lateral plateau. As with all
plateau fractures, the techniques to visualize and ensure accurate
reduction should be planned ahead and executed intraoperatively.
Despite accurately reducing an extra-articular fracture line, large
medial plateau fractures may have residual tilts or other joint
malreductions that need to be assessed and corrected because they will
lead to limb malalignment. Fluoroscopic techniques are usually
necessary because visualizing the joint through the posteromedial
approach is difficult unless important posterior soft tissue structures
are incised.¹⁹ Fixing the fracture
with an antiglide plate will supplement interfragmentary screws that,
depending on the plate configuration, may be applied through proximal
portions of the plate. Most commonly, 3.5-mm plates will be strong
enough to provide the antiglide effect necessary. If the plate is
narrow, two plates may be used to support a total

condylar fracture (Fig. 53-29).
Placing the plate at the apex of the fracture is mechanically optimal.
Mechanical studies and common sense would indicate that the temptation
to try to stabilize a displaced medial plateau fracture with a lateral
side locking plate should be resisted.¹³²

Results. Unfortunately,
there are few results reported for these difficult and less common
fractures when they occur in isolation. In many series, there are too
few medial patterns to meaningfully report results. Schatzker et al.¹⁴³ thought that the medial side patterns had the worst prognosis of the six types. Honkonen⁷⁵
found less satisfactory outcomes and a high percentage of posttraumatic
OA in medially tilted fractures and bicondylar patterns with a medial
tilt. Both Bhattacharyya et al.¹⁹ and Carlson²⁹ warned of the possibility of flexion deformities, particularly after posterior approaches for these fractures.

AO/OTA type 41-C Fractures or Schatzker 5 and
6—Bicondylar or Metaphyseal Diaphyseal Dissociation—Lateral Locking
Plate; Adjunctive Medial Plate Based on Characteristics of Medial Side
Injury or External Fixation. These are the most difficult and complex
fracture patterns and have a wide range of injury severity. All AO/OTA
type 41-C and Schatzker 5 and 6 patterns are presented together in this
section because distinguishing between them is not clear enough to
merit separate discussions of treatment and results. The advent of
locking plates has brought new information and controversy and
increased the variety of operative strategies for these complex
fracture patterns. Without a

plate
with fixed angle stability from the lateral side, surgeons had two
choices: (a) a lateral plate combined with a medial plate or
occasionally combined with a medial external fixator¹³⁶
or (b) an external fixator with enough stability to support the entire
fracture. Many of these fracture patterns are now effectively
stabilized with a laterally based locking plate as the only major
implant. The shift to this technique has been rapid and dramatic.
However, there are issues to be considered in planning and executing
this strategy. Important decisions that require good judgment include
knowing which patterns are amenable to a lateral locking plate alone
and which need to be fixed on both sides with two plates and which
would be safer with an external fixator. Case selection is critical and
new information and new generations of locking implants may continue to
change which fractures can be stably fixed with a lateral locked plate
only. The currently available information on these fractures will be
presented in the following categories: mechanical studies, soft tissue
injury and management, definitive external fixation, dual plates,
lateral locking plates, and comparative studies.

Mechanical Studies.
Mechanical studies have compared lateral locking plates alone to dual
plates in bicondylar tibial plateau fracture models and the results
have been mixed. In paired cadaver models, Gosling et al.⁶³ and Muellar et al.¹¹⁹ found no significant difference with vertical loading between dual plates and lateral locking plates. Egol et al.⁵⁰
found that dual plates were better at resisting displacement but did
not think the differences were likely to be clinically important. In a
matched-pair cadaver model of bicondylar fracture, Higgens et al.⁶⁹ found that that subsidence was sufficiently greater with lateral locked

plates compared to dual plates to raise clinical concerns about using
lateral locked plates alone for these fractures. In a medial plateau
fracture model, medial buttress plating was found to be stronger than a
lateral locked plate.¹³²
One study demonstrated that bone quality was the most important
parameter in determining fixation strength regardless of the technique
to stabilize the fracture.⁶ The
clinical relevance of these types of studies is predicated on knowing
how stiff and how much deforming force must be resisted to promote
healing while not allowing secondary displacement.

Soft Tissue Injury and Management.
The soft tissues must be carefully assessed and managed with respect to
minimize soft tissue complications from the substantive implants
required for these fractures. Surgical timing, temporary spanning
external fixation, and recognizing the risk for compartment syndrome
are all important to optimizing outcomes. In addition, these fractures
are effectively and relatively safely managed with definitive external
fixation, so when a surgeon chooses a locking plate, he or she must be
confident that the risk for severe complications can be minimized.

Temporary joint-spanning external fixation has an
important role for initially managing some of these fractures. The
external fixator spans both the fracture and the knee, and as much as
possible the pins avoid the entire zone of injury. Frames are most
commonly constructed from pin to bar components. When placing pins, the
location of future incisions and implants should be considered. The
goal is to maintain length and alignment in the days or weeks after
injury while the soft tissue injury recovers and the definitive
procedures can be planned. However, careful attention to technique is
required to achieve these goals. A knee-spanning fixator applied with
pins in poor position and the fracture short and/or malaligned may
cause more harm than benefit. Case selection for this technique is
important because not all of these fractures require a joint-spanning
external fixator. Proximal tibia fractures that have the greatest
potential to benefit have one or more of the following: significant
displacement and shortening, open fracture, a severe closed soft tissue
injury, compartment syndrome, a fracture-dislocation, and/or a long
anticipated delay to definitive surgery.

Treatment With Dual Plates.
In some bicondylar patterns, the fracture needs to be fixed on two
sides based on the characteristics of the medial side injury. A medial
plate is necessary when the medial condyle is comminuted, is very
displaced, or is a relatively small fragment. If the medial condyle is
split coronally, creating a posteromedial fragment, this may need to be
separately fixed with a posteromedial plate. The choice between a
lateral locking plate alone and dual plates is largely driven by these
characteristics of the medial side injury. The exact fracture pattern
must be carefully assessed, and the correct choice does not easily
divide along classic classification categories or subcategories.

When dual plates are planned to treat a tibial plateau
fracture, the first important factor is the associated soft tissue
injury. Periods of joint spanning external fixation are frequently
chosen, and delays of 3 weeks or longer before definitive surgery are
not uncommon. The fixator should be placed so pins avoid the region of
the subsequent dual plating approach.

In these fracture patterns, two separate operations are performed—one on the medial and one on the lateral side of the plateau (Fig. 53-30).
Although each side must take into account the other side, they are
modestly separate techniques. The medial side is typically approached
first. Reducing and fixing the medial side restores this section of the
plateau and the lateral side will then be reduced and buttressed
against it. Additional points to consider in planning this dual
approach include the following: (a) the incisions should be nearly 180
degrees from each other anterolateral and posteromedial; (b) this is a
lot of surgery—be prepared with enough time; (c) the initial stages of
the operation on the medial side must be accurate or the final result
will be unsatisfactory; (d) medial side screws must account for the
lateral side injury—they can usually be targeted anteriorly, avoiding
the lateral fracture zone; (e) limit the number of screws early in the
case—there will be a lot of screws in the end and the lateral screws
can be used to lock in the provisionally fixed medial side, decreasing
the need for excessive medial-to-lateral screws; and (f) consider that
access is required to both sides when positioning the patient.

Results of Dual Plates. Dual
plating of fractures of the proximal tibia has been reported in
numerous case series and was compared to external fixation in one
randomized controlled trial. In the 1980s and early 1990s, this
technique developed a bad reputation because of a high incidence of
wound breakdown and devastating infections when dual plates were
applied via a single midline incision with medial and lateral
dissections. The term “dead bone sandwich” was used as a way to
criticize this technique. A variety of advances have decreased the
complication rates. One of the most important of these is adopting a
staged protocol, which initially manages the fracture with a
joint-spanning external fixator, allowing a delay to the dual plating
procedure for soft tissue recovery. This staged technique is the most
valuable in the most severe fractures with the highest risk for the
soft tissues.⁵¹ Another important change has been the use of dual approaches rather than a single anterior extensile approach.

Surgeons should still be wary that these severe
fractures treated with modern medial and lateral plating techniques
have reported deep infection rates of between 8.4% and 18%.¹²,²⁷,¹⁵⁰ Multiple surgical procedures are often necessary after a patient develops a deep infection. Shah and Karunaker¹⁵⁰
noted that the risk might be particularly high in cases where a
fasciotomy had been necessary. These infection rates are still not
trivial and every effort should be made to minimize these complications.

Although recent authors have not stressed healing rates,
the general sense of the literature is that the healing rate after dual
plating is high. With a careful technique, alignment is usually
satisfactory. Barei et al.¹²
reported 91% and 72% satisfactory coronal and sagittal alignment,
respectively. The accuracy of reducing the articular surface is hard to
measure or judge. The COT study demonstrated a significant proportion
of articular malreductions despite dual approach open reductions. The
authors did not believe the outcome was compromised by these malreduced
articular surface.²⁷ However, Barei et al.¹¹ found that the accuracy of articular reduction correlated with outcome.

Treatment With Lateral Locking Plates.
When the timing is optimal for the definitive procedure, the techniques
for either a laterally based locking plate or a definitive external
fixator are similar. Obtaining length and alignment during the
procedure is important, and this may be accomplished by a preexisting
joint spanning external fixator. Alternatively, a fixator or femoral
distracter may be applied at the time of the surgery or an able
assistant may be able to apply the necessary traction forces.

The first step is to accurately restore the proximal
tibial articular surface and fix the medial and lateral condyles to
each other, building a proximal articular block. The techniques
required depend on the intra-articular fracture pattern. In AO/OTA type
A fractures, the proximal tibia is not fractured. In cases with
nondisplaced or minimally displaced articular extensions, cannulated
screws to fix the split are satisfactory. As the fracture becomes more
complex, there is an increased need to incorporate other previously
described techniques of joint reduction and fixation (Fig. 53-31). Void filler may occasionally be necessary when significant joint depressions have been reduced.⁶⁶
The severity of these injuries and the risks for complications should
lean the cautious toward approaches that are more limited than those
for isolated medial and lateral injuries.

Once a proximal block has been restored, that block and
the tibial shaft must be reduced and fixed to each other restoring
length and alignment. This is facilitated by distraction, a
fluoroscopically compatible table, and careful implant position on the

proximal
and distal fragment. To decrease complications and to speed healing,
the area of the metaphyseal injury should be largely skipped and
treated with a no-touch technique spanned by the locking implant.

There is a wide selection of proximal tibial locking
plates made by different manufacturers. The technique is fairly similar
for all of them. An incision over the anterolateral tibia must be long
enough and appropriately positioned to accommodate the head of the
tibial plate and the insertion of the proximal screws into the plate
head. The top of the plate will be just below the joint line, and in
the sagittal plane it must be in line with the shaft and avoid being
too anterior. A small incision in the fascia at the top of the anterior
compartment is necessary to allow the plate to slide along the
anterolateral tibia. Care should be taken to keep the plate directly on
bone. This can be felt as the plate is inserted and assessed
fluoroscopically.

The plate must be accurately positioned both proximally
and distally. If the fracture is reduced, the implant may just be
placed on the bone using it to secure the reduction. If the implant
will be used to assist in reducing the fracture, each step in fixing
the implant proximally and distally must be sequentially assessed.
Accurate plate position proximally and distally will reduce the
fracture. If the plate will extend farther distal than the middle of
the tibia, care must be taken to not injure the superficial peroneal
nerve or the anterior tibial neurovascular bundle when inserting the
distal screws.⁴¹ Final fixation will be with locked screws in the head of the tibial plate and either locked or nonlocked screws distally.

Results of Lateral Locking Plates.
Treating tibial plateau fractures with lateral locking plates is still
a relatively new treatment concept, so assessing the results and
comparing them to previous techniques is important. The results
reported in case series have been generally satisfactory but there have
been some concerns with loss of alignment and with hardware problems
related to either the position of the proximal portion of the implant
or to cold welding of the locked screws. There has been some
variability in the reported incidence of infection.

The LISS (Less Invasive Stabilization System) was the
first locking plate system that began to popularize this technique, and
most of the results for the proximal tibia have been reported with this
implant. Infection has been reported in between 0% and 22% of cases,
postoperative malalignment in 0% to 23% of cases, and hardware
irritation in 5% to 18%.²²,³⁸,⁵⁰,⁶⁴,¹²⁸,¹³⁵,¹⁴⁴,¹⁵⁵ Gosling et al.⁶⁴
reported a 23% malreduction rate and noted the challenges of limited
approach surgery for complex proximal tibia fractures, particularly
with less experienced surgeons. Postoperative compartment syndrome was
reported in two series, accounting for 3% to 5% of cases.¹²,¹³⁶ Peroneal nerve injury has been a rare complication.³⁸,¹²⁸ Cold welded screws during hardware removal was reported in 4 of 94 screws in one series³⁸ and in 2 of 88 screws in another series.¹²⁸ Phistikul

et al.¹²⁸
stressed the risk for complications such as deep infection which
occurred in 22% of fractures in their series. The risk of infection of
a lateral locking plate was thought to be particularly high in patients
with compartment syndrome with open fasciotomy wounds.

Clinical studies do not provide a definitive answer to
whether lateral locked plates are strong enough to prevent varus
displacement in bicondylar fractures. Some authors have found no loss
of alignment,⁵⁰,¹⁴⁴,¹⁵⁵ where Gosling et al.⁶⁴ and Phisitkul et al.¹²⁸
reported 14% and 8% loss of alignment, respectively. Watson indicated
that if the medial column was not comminuted and could be accurately
reduced, then a lateral locking plate would suffice but otherwise dual
plating was necessary¹⁶⁸ (Fig. 53-32).

More recently, other authors have reported results of different locking plate designs. For instance, Haidukewych et al.⁶⁶

reported the results of 24 type 41-A or -C and 7 type B proximal tibia
fractures treated with a polyaxial locked plate, which allows variable
trajectories of the screws before locking. Seven patients had
adjunctive posteromedial plates. The authors found no loss of
alignment. Two patients developed deep infections. Hardware removal was
not reported.

Treatment With Definitive External Fixation.
When definitive treatment is with an external fixator, the first step
in the procedure uses the same preliminary steps of reducing and
internally fixing the two condyles to each other as described for
lateral locking plates. Occasionally proximal fixation can be
supplemented by direct incisions over the area of joint involvement and
adjunctive antiglide plating.¹⁶⁷
Similar to a locking plate, the external fixator will span the
metaphyseal area of the fracture and stabilize the tibial condyles to
the tibial shaft. The metaphyseal fracture is reduced indirectly. A
wide variety of frames can be used to accomplish this. These include
circular external fixators, monolateral fixators, and hybrid fixators.
Many of these fixators have an adjustable frame to facilitate
accurately aligning the limb because this is one of the most important
technical aspects of the procedure.

Attention must be paid to the basic principles of
constructing a frame and securing the frame to the bone proximal and
distal to the fracture, to ensure stability is optimized.¹⁶⁹
Because of the limited extent of proximal tibia available for fixation
and because of the presence of fracture lines and relatively small
fracture fragments and the proximity of capsular reflections from the
knee, securing adequate proximal fixation is the most difficult
challenge. Adequate preoperative planning for frame application is very
important and should include a CT scan. If a pin fixator is used,
hydroxyapatite-coated pins provide longer lasting purchase to the
metaphyseal bone than standard noncoated pins.¹¹⁸
Pins may be placed medial, anteromedial, or anterolateral. The patellar
tendon must be avoided. Fluoroscopy should be used to assist in placing
pins in the best bone, avoiding fracture lines to the extent possible,
and to ensure that they are placed deeply through the bone without
being prominent on the opposite side. There must be two or preferably
three proximal pins to have adequate purchase in the proximal tibia. If
a circular wire frame is used, maximum wire spread is facilitated by
using a fibular head wire combined with a
posteromedial-to-anterolateral wire. Fluoroscopy is also important for
accurate wire placement. Three tensioned wires are typically used and
they may be augmented by a single half-pin. The use of olive wires
increases the stability of proximal fixation and may be used to
compress major fracture lines. Both pins and wires should be kept as
far from the joint as possible to minimize the chances of septic
arthritis, but the fracture pattern also has a role in the proximal
distal location of pins and wires.

The advantages of external fixation are accurate
alignment with stable fixation with less soft tissue dissection and
without a bulky implant.¹⁷¹ With
some frame constructs using tensioned wires and circular frames,
earlier weight bearing than with other techniques may be possible.²

The bone can be fixed to the frame with pins or tensioned wires. Although many prefer wire fixation in these areas, Marsh et al.¹¹¹
reported satisfactory results using an all-pin fixator. Pins or wires
should be kept as far away from the articular surface as possible to
minimize the chances of septic arthritis that has been reported after
both pins and wires.⁵⁵,¹¹¹,¹²³
In severe cases with soft tissue injuries, fracture instability, and
small periarticular fragments, a cross-knee-spanning frame may be used
to augment the primary frame and removed after a few weeks of
neutralizing the cross-joint forces. In one series of fine wire
external fixation for bicondylar tibial plateau fractures, the knee was
bridged as part of the frame in 63% of cases without adverse outcomes.
Neutralizing the forces across the knee may decrease the risk for
proximal pin- or wire-related septic arthritis.

Results of Definitive External Fixation.
Definitive external fixation as treatment for high-energy tibial
plateau fractures has been reported in the literature since the early
1990s.¹¹¹,¹²³,¹⁵⁴,¹⁷¹
Case selection for these techniques have been biased toward the
high-energy bicondylar or shaft dissociated patterns with a high
incidence of open fractures and compartment syndrome. For instance, in
three recent series treated by definitive external fixation, the
percentage of open fractures ranged between 33% and 100%.³⁶,⁸⁷,¹⁵⁸
Most of the results are reported in case series, and most authors have
found satisfactory results considering the severity of the fractures
treated. The union rate without additional procedures has been high,
ranging between 85% and 100% in recent series.³,³⁶,⁴⁵,¹⁵⁸,¹⁶⁷,¹⁷⁰
Although stable fixation leading to good alignment is usually achieved,
one author reported 4 of 15 open plateau fractures lost reduction
during treatment and recommended limited internal fixation as an
adjunct to prevent this problem.¹¹¹ Another author reported loss of reduction into valgus in 3 of 11 elderly patients treated with a hybrid fixator,³ and in another, 3 of 16 healed fractures had a varus deformity.⁶⁰ The knee range of motion is generally good; Kateria et al.⁸⁶ reported an average of 132 degrees in 48 patients with Schatzker 5 and 6 fractures. Marsh et al.¹¹¹
reported that patients averaged 138 degrees of flexion. Most patients
have achieved knee scores averaging 85 to 90 on 100-point scales.¹¹¹,¹⁶⁹ Weigel and Marsh¹⁷⁰
found that the initial results were maintained at longer follow-up. All
patients with sequential follow-up to 5 to 11 years after injury were
found to improve with longer follow-up. Pin tract infections are common
and septic arthritis is an unusual but feared complication of external
fixation for tibial plateau fractures.⁶⁰,¹¹¹

Comparative Studies of Fixation Techniques.
The treatment of tibial plateau fracture patterns has been extensively
reported in the literature. Despite this, the optimal technique for a
given fracture is uncertain. With the complexity of these fractures and
the difficulty of the techniques, there clearly is room for treatment
to be based on the personal preferences and experiences of the surgeon.
In addition, in most of the literature there is overlap between
bicondylar patterns treated with dual plates and shaft dissociated
patterns treated with locking plates alone or external fixation, which
makes it hard to compare the treatment methods.

Hybrid external fixation has been compared to dual plate
fixation for AO/OTA type C fractures (Schatzker 5 and 6) in a
randomized controlled trial performed by the Canadian Orthopaedic
Trauma Association.²⁷ They found
that dual plating resulted in a greater incidence of deep infection
(18%) and repeat operations, longer hospitalization, and a marginally
longer return to function. The reductions and patient outcomes were
similar in the two groups, both of which had decreased general health
status compared to age-matched control groups. In another

study, Jiang et al.⁸⁴
found that the LISS lateral locking plate and dual plating resulted in
similar outcomes. There was a trend to a slightly higher malalignment
rate and more symptomatic hardware with the LISS.⁸⁴
A metaanalysis compared fractures fixed with plates to those fixed with
external fixators and found that there was not enough evidence to
distinguish between the two techniques.¹⁰⁷

The postoperative care of tibial plateau fractures has
not been the subject of many studies. The optimal postoperative program
should minimize complications and loss of reduction of the fracture and
maximize knee motion while speeding recovery and return to function.

A period of non-weight bearing or minimal weight bearing
is necessary to minimize the chances of displacing the reduced
fracture. The duration depends on the fracture pattern and the strength
of the fixation but it probably takes 6 to 12 weeks for any meaningful
increase in resistince to displacement from fracture healing, so most
surgeons will not progress weight bearing until sometime in this range.
One paper recommended early weight bearing for operatively and
nonoperatively treated lateral plateau fractures with a cast brace to
unload the lateral side and demonstrated little secondary displacement.¹⁴⁸
Although cast braces are less commonly used in current practice, this
information should be considered when poor patient compliance with
weight-bearing restrictions is anticipated.

Mobilizing the knee postoperatively is the second issue
that is potentially important in the postoperative care of tibial
plateau fractures. Fractures treated nonoperatively can regain
excellent knee motion after being immobilized for up to 6 weeks.⁴⁷,⁶¹
However, because most fractures treated nonoperatively in current
practice can be safely moved postinjury, most surgeons will recommend
knee motion immediately or within a few weeks, usually in a hinged
brace.

Gausewitz and Hohl⁶¹
thought that that early motion was much more important after operative
treatment, because knees immobilized for longer than 2 weeks tended to
be stiff. In current practice, surgeons strive to fix fractures in a
way that will allow motion during the early weeks of recovery sometimes
in a hinged brace. In recent years, temporary periods of immobilizing
injured joints with a spanning fixator have been used with increased
frequency for some severe tibial plateau fractures. Marsh et al.¹¹¹
have shown that the knee can recover excellent motion (range of flexion
greater than 130 degrees) after up to 6 weeks of immobility using
spanning fixation. Other investigators have also found that cross-joint
external fixation does not seem to be a frequent obstacle to regaining
motion.⁵¹