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Tibial Plateau Fracture

Tibial plateau fractures make up 1% of all fracture types. Among these fractures, bicondylar fractures make up 10–30%, while isolated medial and lateral plateau fractures account for the rest.

Although only 3% of these fractures are classified as open injuries, a significant number of them involve closed degloving, deep abrasions, or severe soft-tissue injuries. These factors necessitate careful deliberation when determining the timing and approach to surgery.

Mechanism of Injury

In young individuals with strong bones, these fractures follow high-energy injuries and are often split fractures with associated ligamentous disruption. In elderly patients with osteopenic bone, these may occur after a simple fall (low-energy injuries). Here depression and split depression fractures are common without any ligamentous injury.

Fractures of the tibial plateau occur as a result of varus or valgus forces coupled with axial loading.

The direction and magnitude of the generated force, age of the patient, bone quality and amount of knee flexion at impact determine the size, location and displacement of the fragments.

See Also: Tibial Stress Fracture
Mechanism of Injury

Symptoms & Signs

The patient comes with a swollen and painful knee with some deformity. Haemarthrosis occurs frequently and aspiration may reveal marrow fat, indicating a fracture.

The extent of injury to the overlying soft tissues must be carefully assessed and even small lacerations must be suspected to have a communication with the joint. There may be associated meniscal tears in up to 50% and cruciate or collateral ligamentous injury in up to 30% of tibial plateau fractures.

Neurovascular injury and compartment syndrome must be ruled out, particularly with high-energy injuries. The trifurcation of the popliteal artery is tethered posteriorly between the adductor hiatus proximally and the soleus complex distally. Hence tibial plateau fractures are often associated with neurovascular injuries. Arterial injuries are usually traction-induced intimal damage presenting as thrombosis and only rarely do lacerations occur. The peroneal nerve is similarly tethered laterally as it courses around the fibular neck and can be injured due to stretching (neurapraxia).

Radiology

Anteroposterior and lateral radiographs supplemented by 40° internal and external rotation oblique projections for lateral and medial plateau visualization should be obtained.

A 10–15° 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– Steada lesion (calcification along the insertion of the medial collateral ligament) are all signs of associated ligamentous injury.

Stress views with fluoroscopic image intensification with the patient under mild sedation are useful for the detection of collateral ligament injuries.

CT scan is useful to determine the degree of fragmentation or depression of the articular surface.

MRI is useful for evaluating injuries to the menisci, the cruciate and collateral ligaments, and also the soft-tissue envelope. CT or MRI angiography is required in the setting of suspected vascular injury.

Tibial Plateau Fracture Classification

Tibial plateau fractures have been classified by Schatzker into six types:

  1. Type I Lateral plateau, split fracture.
  2. Type II Lateral plateau, split depression fracture.
  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.
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Tibial Plateau Fracture Classification

Tibial Plateau Fracture Treatment

Non-operative Treatment:

Tibial plateau fracture non-surgical treatment is recommended for low-energy tibial plateau fractures which are stable to varus–valgus stress and include undisplaced or minimally displaced fractures. Non-surgical treatment is also indicated in nonambulatory patients and those not medically fit for surgery.

Treatment includes:

  1. Hinged knee brace and mobilization.
  2. Active-assisted and passive range of motion exercises are initiated immediately
  3. Weight bearing is typically delayed for 8–12 weeks.
  4. Alternatively, an above-knee cast may be used.

Surgical Treatment:

Tibial plateau fracture surgery is indicated in the following situations:

  1. Articular depression of >5 mm or instability of >10° (because of depression or condyle subluxation) compared with the contralateral side .
  2. High-energy injuries involving the metaphyseal–diaphyseal junction or unstable bicondylar fractures.
  3. Open fractures, associated compartment syndrome and vascular injuries.
  4. Floating knees injuries with associated lower femoral fractures.

Surgical treatment includes open reduction and internal fixation (ORIF) with adjunctive techniques such as limited open reduction, arthroscopically assisted reduction and fixation, and augmented internal fixation with resorbable bone cements.

External fixation including temporary spanning fixators, hybrid and/or fine wire fixation, and combined limited ORIF are acceptable techniques, particularly for patients with significant soft tissue injury.

Peri-articular tibial plateau fixation with raft or subchondral screws
Peri-articular tibial plateau fixation with raft or subchondral screws

Guidelines for fixation according to the fracture pattern

  • Type I: Displaced uncomminuted fragments can be fixed with two transverse cancellous screws. Open reduction and fixation with a buttress or locked plate is generally done if there is a significant widening.
  • Type II: Open reduction, elevation of the depressed plateau ‘en masse’, bone grafting of the metaphysis with fixation of the fracture with cancellous screws in the subchondral region: ‘raft’ screws, and buttress plating of the lateral cortex.
  • Type III: Elevation of the articular fragments, bone-grafting, and buttress plating of the lateral cortex
  • Type IV: Open reduction and fixation with a medial buttress plate and cancellous screws.
  • Type V: Fracture reduction is similar to type II injuries. Both condyles can be fixed with buttress plates; however, dual plating has a high incidence of soft tissue healing problems and infection rates. Alternatively, the most unstable condyle (usually lateral) is selected for the buttress fixation via an anterolateral approach and the other condyle is stabilized by percutaneous screw fixation. Fractures of the posterior medial plateau may require a posteromedial incision for fracture reduction and plate stabilization.
  • Type VI: Treatment is similar to type V fractures. Alternatively, hybrid external fixation may also be used
Tibial Plateau Fracture Treatment

References & More

  1. Schatzker J, McBroom R. Tibial plateau fractures: The Toronto experience 1968–1975. Clinical Orthopaedics and Related Research 1979;138:94–104 – Pubmed
  2. Hung SS, Chao EK, Chan YS, et al. Arthroscopically assisted osteosynthesis for tibial plateau fractures. Journal of Trauma 2003;54:356–63. Pubmed
  3. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
Last Reviewed
October 7, 2023
Contributed by
OrthoFixar

Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice.

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