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Tibial Plateau

Ovid: Handbook of Fractures

Authors: Koval, Kenneth J.; Zuckerman, Joseph D.
Title: Handbook of Fractures, 3rd Edition
> Table of Contents > IV – Lower Extremity Fractures and Dislocations > 36 – Tibial Plateau

Tibial Plateau
  • Tibial plateau fractures constitute 1% of all fractures and 8% of fractures in the elderly.
  • Isolated injuries to the lateral plateau
    account for 55% to 70% of tibial plateau fractures, as compared with
    10% to 25% isolated medial plateau fractures and 10% to 30% bicondylar
  • From 1% to 3% of these fractures are open injuries.
  • The tibia is the major weight-bearing bone of the leg, accounting for 85% of the transmitted load.
  • The tibial plateau is composed of the
    articular surfaces of the medial and lateral tibial plateaus, on which
    are the cartilaginous menisci. The medial plateau is larger and is
    concave in both the sagittal and coronal axes. The lateral plateau
    extends higher and is convex in both sagittal and coronal planes.
  • The normal tibial plateau has a 10-degree posteroinferior slope.
  • The two plateaus are separated from one
    another by the intercondylar eminence, which is nonarticular and serves
    as the tibial attachment of the cruciate ligaments. Three bony
    prominences exist 2 to 3 cm distal to the tibial plateau. Anteriorly is
    the tibial tubercle on which the patellar ligament inserts. Medially,
    the pes anserinus serves as attachment for the medial hamstrings.
    Laterally, the Gerdy tubercle is the insertion site of the iliotibial
  • The medial articular surface and its
    supporting medial condyle are stronger than their lateral counterparts.
    As a result, fractures of the lateral plateau are more common.
  • Medial plateau fractures are associated
    with higher energy injury and more commonly have associated soft tissue
    injuries, such as disruptions of the lateral collateral ligament
    complex, lesions of the peroneal nerve, and damage to the popliteal
  • Fractures of the tibial plateau occur in
    the setting of varus or valgus forces coupled with axial loading. Motor
    vehicle accidents account for the majority of these fractures in
    younger individuals, but elderly patients with osteopenic bone may
    experience these after a simple fall.
  • The direction and magnitude of the
    generated force, age of the patient, bone quality, and amount of knee
    flexion at the moment of impact determine fracture fragment size,
    location, and displacement:
    • Young adults with strong, rigid bone
      typically develop split fractures and have a higher rate of associated
      ligamentous disruption.
    • P.383

    • Older adults with decreased bone strength
      and rigidity sustain depression and split-depression fractures and have
      a lower rate of ligamentous injury.
    • A bicondylar split fracture results from a severe axial force exerted on a fully extended knee.
  • Neurovascular examination is essential,
    especially with high-energy trauma. The trifurcation of the popliteal
    artery is tethered posteriorly between the adductor hiatus proximally
    and the soleus complex distally. The peroneal nerve is tethered
    laterally as it courses around the fibular neck.
  • Hemarthrosis frequently occurs in the
    setting of a markedly swollen, painful knee on which the patient is
    unable to bear weight. Knee aspiration may reveal marrow fat.
  • Direct trauma is usually evident on
    examination of the overlying soft tissues, and open injuries must be
    ruled out. Intraarticular instillation of 50 to 75 mL saline may be
    necessary to evaluate possible communication with overlying lacerations
  • Compartment syndrome must be ruled out, particularly with higher-energy injuries.
  • Assessment for ligament injury is essential.
  • Meniscal tears occur in up to 50% of tibial plateau fractures.
  • Associated ligamentous injury to the cruciate or collateral ligaments occurs in up to 30% of tibial plateau fractures.
  • Young adults, whose strong subchondral
    bone resists depression, are at the highest risk of collateral or
    cruciate ligament rupture.
  • Fractures involving the medial tibial
    plateau are associated with higher incidences of peroneal nerve or
    popliteal neurovascular lesions owing to higher-energy mechanisms; it
    is postulated that many of these represent knee dislocations that
    spontaneously reduced.
  • Peroneal nerve injuries are caused by stretching (neurapraxia); these will usually resolve over time.
  • Arterial injuries frequently represent
    traction induced intimal injuries presenting as thrombosis; only rarely
    do they present as transection injuries secondary to laceration or
  • Anteroposterior and lateral views
    supplemented by 40-degree internal (lateral plateau) and external
    rotation (medial plateau) oblique projections should be obtained.
  • A 10- to 5-degree caudally tilted plateau view can be used to assess articular step-off.
  • Avulsion of the fibular head, the Segond
    sign (lateral capsular avulsion) and Pellegrini-Steata lesion
    (calcification along the insertion of the medial collateral ligament)
    are all signs of associated ligamentous injury.
  • A physician-assisted traction view is
    often helpful in higher-energy injuries with severe impaction and
    metadiaphyseal fragmentation to delineate the fracture pattern better
    and to determine the efficacy of ligamentotaxis for fracture reduction.
  • P.384

  • Stress views, preferably with the patient
    under sedation or anesthesia and with fluoroscopic image
    intensification, are occasionally useful for the detection of
    collateral ligament ruptures.
  • Computed tomography with two- or
    three-dimensional reconstruction is useful for delineating the degree
    of fragmentation or depression of the articular surface, as well as for
    preoperative planning.
  • Magnetic resonance imaging is useful for
    evaluating injuries to the menisci, the cruciate and collateral
    ligaments, and the soft tissue envelope.
  • Arteriography should be performed if there is a question of vascular compromise.
Schatzker (Fig. 36.1)

Type I: Lateral plateau, split fracture
Type II: Lateral plateau, split depression fracture
Type III: Lateral plateau, depression fracture
Type IV: Medial plateau fracture
Type V: Bicondylar plateau fracture
Type VI: Plateau fracture with separation of the metaphysis from the diaphysis
  • Types I to III are low-energy injuries.
  • Types IV to VI are high-energy injuries.
  • Type I usually occurs in younger individuals and is associated with medial collateral ligament injuries
  • Type III usually occurs in older individuals (Fig. 36.1)
OTA Classification of Tibial Plateau Fractures
See Fracture and Dislocation Compendium at
  • Indicated for nondisplaced or minimally displaced fractures and in patients with advanced osteoporosis.
  • Protected weight bearing and early range of knee motion in a hinged fracture-brace are recommended.
  • Isometric quadriceps exercises and
    progressive passive, active-assisted, and active range-of-knee motion
    exercises are indicated.
  • Partial weight bearing (30 to 50 lb) for 8 to 12 weeks is allowed, with progression to full weight bearing.
  • Surgical indications:
    • The reported range of articular depression that can be accepted varies from <2 mm to 1 cm.
    • Instability >10 degrees of the nearly
      extended knee compared to the contralateral side is an accepted
      surgical indication. Split fractures are more likely to be unstable
      than pure depression fractures in which the rim is intact.
      Figure 36.1. Schatzker classification.

      (From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)
    • P.385


    • Open fractures should be treated surgically.
    • Compartment syndrome is a surgical indication.
    • Associated vascular injury is an indication.
  • Operative treatment principles
    • Reconstruction of the articular surface, followed by reestablishment of tibial alignment, is the goal.
    • Treatment involves buttressing of elevated articular segments with bone graft or bone graft substitute.
    • Fracture fixation can involve use of plates and screws, screws alone, or external fixation.
    • The choice of implant is related to the
      fracture patterns, the degree of displacement, and familiarity of the
      surgeon with the procedure.
    • Adequate soft tissue reconstruction
      including preservation and/or repair of the meniscus as well as
      intraarticular and extraarticular ligamentous structures should be
  • Spanning external fixation across the
    knee can be used as a temporizing measure in patients with
    higher-energy injuries. The external fixator is used to keep the soft
    tissues out to length and provides some degree of fracture reduction
    before definitive surgery.
  • Arthroscopy may be used to evaluate the
    articular surfaces, the menisci, and the cruciate ligaments. It may
    also be used for evacuation of hemarthrosis and particulate debris, for
    meniscal procedures, and for arthroscopic-assisted reduction and
    fixation. Its role in the evaluation of rim disorders and its utility
    in the management of complicated fractures are limited.
  • An avulsed anterior cruciate ligament
    with a large bony fragment should be repaired. If the fragment is
    minimal or the ligament has an intrasubstance tear, reconstruction
    should be delayed.
  • Surgery in isolated injuries should
    proceed after a full appreciation of the personality of the fracture.
    This delay will also allow swelling to subside and local skin
    conditions to improve.
  • Schatzker type I to IV fractures can be
    fixed with percutaneous screws or lateral placed periarticular plate.
    If satisfactory closed reduction (<1-mm articular step-off) cannot
    be achieved with closed techniques, open reduction and internal
    fixation are indicated.
  • The menisci should never be excised to facilitate exposure.
  • Depressed fragments can be elevated from
    below en masse by using a bone tamp working through the split component
    or a cortical window. The metaphyseal defect should be filled with
    cancellous autograft, allograft, or a synthetic substitute.
  • Type V and VI fractures can be managed
    using plate and screws, a ring fixator, or a hybrid fixator. Limited
    internal fixation can be added to restore the articular surface.
  • Percutaneous inserted plating, which is a
    more biologic approach, has been described. In this technique, the
    plate is slid subcutaneously without soft tissue stripping.
  • Use of locked plates has eliminated the need for double plating bicondylar tibial plateau fractures.
  • Fractures of the posterior medial plateau may require a posteromedial incision for fracture reduction and plate stabilization.
  • P.387

  • Postoperative non–weight bearing with continuous passive motion and active range of motion is encouraged.
  • Weight bearing is allowed at 8 to 12 weeks.
  • Knee stiffness: This is common, related
    to trauma from injury and surgical dissection, extensor retinacular
    injury, scarring, and postoperative immobility.
  • Infection: This is often related to
    ill-timed incisions through compromised soft tissues with extensive
    dissection for implant placement.
  • Compartment syndrome: This uncommon but
    devastating complication involves the tight fascial compartments of the
    leg. It emphasizes the need for high clinical suspicion, serial
    neurovascular examinations, particularly in the unconscious or obtunded
    patient, aggressive evaluation, including compartment pressure
    measuring if necessary, and expedient treatment consisting of emergency
    fasciotomies of all compartments of the leg.
  • Malunion or nonunion: This is most common
    in Schatzker VI fractures at the metaphyseal-diaphyseal junction,
    related to comminution, unstable fixation, implant failure, or
  • Posttraumatic osteoarthritis: This may
    result from residual articular incongruity, chondral damage at the time
    of injury, or malalignment of the mechanical axis.
  • Peroneal nerve injury: This is most
    common with trauma to the lateral aspect of the leg where the peroneal
    nerve courses in proximity to the fibular head and lateral tibial
  • Popliteal artery laceration.
  • Avascular necrosis of small articular fragments: This may result in loose bodies within the knee.

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