Chapter 36

Tibial Plateau
EPIDEMIOLOGY
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 lesions.
There is a wide spectrum of fracture patterns that
involve the medial tibial plateau (10% to 23%), the
lateral tibial plateau (55% to 70%), or both (11% to
31%).
From 1% to 3% of these fractures are open injuries.
ANATOMY
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 band.
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
vessels.
MECHANISM OF INJURY
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.
o Young adults with strong, rigid bone typically
develop split fractures and have a higher rate of
associated ligamentous disruption.
o Older adults with decreased bone strength and
rigidity sustain depression and split-depression
fractures and have a lower rate of ligamentous
injury.
o A bicondylar split fracture results from a severe
axial force exerted on a fully extended knee.
CLINICAL EVALUATION
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. Intra-articular instillation of more
than 120 ccs saline may be necessary to evaluate
possible communication with overlying
lacerations.
Compartment syndrome must be ruled out,
particularly with higher-energy injuries and or
fracture dislocations.
Assessment for ligament injury is essential.
ASSOCIATED INJURIES
Soft tissue injury is seen in approximately 90% of
these fractures.
Meniscal tears occur in up to 50% of tibial plateau
fractures. Medial meniscus tears highly associated
with medial plateau fractures and lateral meniscus
tears associated with lateral 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 may
be 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;
however, these are rare.
Arterial injuries frequently represent traction-
induced intimal injuries presenting as thrombosis;
only rarely do they present as transection injuries
secondary to laceration or avulsion.
RADIOGRAPHIC EVALUATION
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 PellegriniSteata
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.
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-dimensional 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.
CLASSIFICATION
Schatzker (Fig. 36.1)
1. Type I:
Lateral plateau, split fracture
2. Type II:
Lateral plateau, split depression fracture (most
common)
3. Type III:
Lateral plateau, depression fracture
4. Type IV:
Medial plateau fracture
5. Type V:
Bicondylar plateau fracture
6. Type VI:
Plateau fracture with separation of the metaphysis
from the diaphysis
Figure 36.1 Schatzker classification. (From Bucholz RW, Heckman JD, Court-Brown C, et al.,
eds
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 is extremely rare and will only
occur in older individuals or those with osteopenia
(Fig. 36.1).
Moore (Fig. 36.2)
Type 1 is a split fracture of the medial tibial plateau
in the coronal plane.
Type 2 is an entire condyle fracture with the
fracture line beginning in the opposite
compartment and extending across the tibial
eminence.
Type 3 is a rim avulsion fracture; these fractures
are associated with a high rate of associated
neurovascular injury.
Type 4 is another type of rim fracture, a rim
compression injury usually associated with some
types of contralateral ligamentous injury.
Type 5 is a four-part fracture with the tibial
eminence separated from the tibial condyles and
the shaft.
Figure 36.2 Moore classification.
OTA Classification of Tibial Plateau Fractures
(Type 43)
See Fracture and Dislocation Classification
Compendium
athttp://www.ota.org/compendium/compendium.html.
TREATMENT
Nonoperative
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.
Operative
Surgical indications
o The reported range of articular depression that
can be accepted varies from <2 mm to 1 cm.
o 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. (Fig.
36.3)Figure 36.3 Stress exam demonstrating MCL
incompetence in conjunction with a
o Open fractures.
o Associated compartment syndrome.
o Associated vascular injury.
Operative treatment principles
o Reconstruction of the articular surface, followed
by reestablishment of tibial alignment, is the goal.
o Treatment involves reducing and buttressing of
elevated articular segments with bone graft or
bone graft substitute.
o Fracture fixation can involve use of plates and
screws, screws alone, or external fixation.
o The choice of implant is related to the fracture
patterns, the degree of displacement, and
familiarity of the surgeon with the procedure.
o Adequate soft tissue reconstruction including
preservation and/or repair of the meniscus as well
as intra-articular and extra-articular ligamentous
structures should be addressed.
Spanning external fixation across the knee may be
used as a temporizing measure in patients with
higher-energy injuries and limb shortening or
significant soft tissue injury. The external fixator is
used to keep the soft tissues out to length and
provides some degree of fracture reduction until
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. (Fig.
36.4)Figure 36.4 Arthroscopic evaluation of a
Schatzker II tibial
An avulsed anterior cruciate ligament with a large
bony fragment may be repaired. If the fragment is
minimal or the ligament has an intrasubstance
tear, reconstruction should be delayed. Instability
is generally not a problem.
Surgery in isolated injuries may 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 some type
of osteoconductive material.
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 diminished 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.
Postoperative care: Patients are kept non
weight bearing with or without continuous passive
motion and active range of motion are encouraged.
Weight bearing is allowed at 8 to 12 weeks.
COMPLICATIONS
Arthrofibrosis: This is common, related to
trauma from injury and surgical dissection,
extensor retinacular injury, scarring, and
postoperative immobility. More common in higher
energy injuries.
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 infection.
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 plateau. Can be
iatrogenic.
Popliteal artery laceration (rare).
Avascular necrosis of small articular
fragments: This may result in loose bodies
within the knee.