Tibial Plateau

Fractures
John J. Wixted MD
Chief, Orthopedic Trauma Division
Beth Israel Deaconess Medical Center

Core Curriculum V5
Disclosure
• Clinical images provided by the author.
• Figures used with permission from Tornetta P, Ricci WM,
eds. Rockwood and Green's Fractures in Adults, 9e. Philadelphia, PA.
Wolters Kluwer Health, Inc; 2019.

Core Curriculum V5
Objectives
• Describe initial evaluation and management of tibial plateau fractures
• Identify common fracture patterns
• Apply treatment principles and strategies
• Partial articular fractures
• Complete articular fractures
• Discuss rehabilitation, complications, and outcomes

Core Curriculum V5
Objectives
• Describe initial evaluation and management of tibial plateau fractures
• Identify common fracture patterns
• Apply treatment principles and strategies
• Partial articular fractures
• Complete articular fractures
• Discuss rehabilitation, complications, and outcomes

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Plateau Fractures: Initial
Presentation
• 1-2% of all fractures
• Similar bimodal distribution to many peri-articular injuries
• 70% in young adult men, average age 43

Rockwood and Green, 9th edition Core Curriculum V5

Age and mechanism dictate
injury pattern
-Middle age and elderly with simple falls
-commonly split depressed patterns, or less common isolated medial side injuries

-Higher energy or sports related

-pure split injuries, or rim injuries with associated ligamentous
injuries to the knee and potential for instability

-High energy MVA, fall from height, pedestrians struck

-Often younger patients
-bicondylar patterns
-higher risk for neurovascular injury
-compartment syndrome and open fractures common
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 Initial presentation – mechanism
matters!
• Lower energy • Higher energy
• Simple falls, struck from side • Axial load, associated shearing
• Remain length stable • Compartment syndrome risk

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Initial Management
• Physical exam • Imaging
• Swelling – compartment syndrome • CT scan routinely obtained
• Distal pulses – vascular injury • Plain films
• ?ABIs • MRI for occult or suspected
• Valgus Instability? fractures, particularly in the
elderly
• Fracture-dislocation patterns:
• Splinting high risk for ligamentous damage,
• Knee immobilizer MRI indicated
• Compartment checks • Think about need for MRI prior to
• DVT Prophylaxsis placing ex fix! Save yourself some
phone calls!
Core Curriculum V5
Objectives
• Describe initial evaluation and management of tibial plateau fractures
• Identify common fracture patterns
• Apply treatment principles and strategies
• Partial articular fractures
• Complete articular fractures
• Discuss rehabilitation, complications, and outcomes

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Schatzker Classification

Rockwood and Green, 9th edition

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Schatzker Classification:
Injuries isolated to the lateral
plateau
• I: Younger patients, better bone
quality
• II: Higher energy, with
associated depression of the
lateral chondral surface
• III: Poor quality bone in elderly
patients
• Most common patterns

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Schatzker Classification: Isolated
medial fractures come in two
flavors
• Lower energy, elderly • Higher energy, young patients
• Simple depression • Medial shearing
• Varus loading • Higher risk for vascular injuries
• Fracture lines exit medial to • Fracture lines exit lateral to
spines spines
• Called “fracture dislocation”
variants

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 Schztzker Classification:
Bicondylar injuries
• Typically higher energy
• Compartment syndrome risk
• Vascular exam a must
• Consider ABIs
• Commonly open
• Soft tissues at risk
• Exam will progress over hours and
often worsen with time
• Includes varus hyperextension
Bicondylar variant*
Firoozabadi R, Schneidkraut J, Beingessner D, Dunbar R, Barei D. Hyperextension Varus
Bicondylar Tibial Plateau Fracture Pattern: Diagnosis and Treatment Strategies. J Orthop
Trauma. 2016 May;30(5):e152-7. Core Curriculum V5
OTA Classification
• Uniform classification
• Captures all variants
• A: Extra articular
• B: Partial Articular
• C: Complete Articular

Rockwood and Green, 9th edition

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 Important Variants – Open
injuries
Open injuries
-antibiotics: ASAP
-tetanus
-vascular exam
Present challenges for coverage
Shaft extension
Early coverage within 72 hrs
decreases late infection rate

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 Fracture Dislocation patterns
• High energy
• Frequently with medial
displacement and shortening
• High association with vascular
injury
• Subluxation or dislocation thru the
fracture causes traction injury to
the vessels
• Don’t always “fit” Schatzker
• Hohl and Moore Classification may
be more descriptive

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 Posterior Shear Patterns

• Commonly posteromedial
patterns
• “B-type” partial articular injury
to the medial plateau
• Often associated with
bicondylar patterns and less
commonly isolated fracture;
lateral side seen as well

Rockwood and Green, 9th edition

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Three Column Concept of
Plateau Fractures
• Evolution of the Schatzker
Classification
• Better incorporates fractures
involving posterior plateau
• Help with determining
appropriate fixation strategy

Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma.
2010 Nov;24(11):683-92. doi: 10.1097/BOT.0b013e3181d436f3. PMID: 20881634
Core Curriculum V5
Objectives
• Describe initial evaluation and management of tibial plateau fractures
• Identify common fracture patterns
• Apply treatment principles and strategies
• Partial articular fractures
• Complete articular fractures
• Discuss rehabilitation, complications, and outcomes

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General Principles for Plateau
Treatment
• Fracture location and classification generally dictate approach
• Anterolateral, posteromedial, direct medial most common
• Visualization of the fracture – key for articular reduction
• Direct visualization; ie anterolateral with submeniscal approach
• Fluroscopic; ie minimally invasive reduction and plating
• Arthroscopic; in conjunction with fluoroscopic
• Use of temporary external fixation may be considered
• Fractures which are length stable can be safely delayed with bracing
alone

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Nonoperative treatment: Indications and
contraindications

Rockwood and Green, 9th edition

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 Nonoperative management
• Valgus instability – 5-10 degrees
• Articular step-off threshold is
controversial
• Isolated medial injuries: late varus
collapse
• In general, small isolated lateral
injuries without valgus instability
• Early ROM, limited wb x 8-12
weeks, +/- bracing
• Angular malalignment poorly
tolerated

Rockwood and Green, 9th edition

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Goals of Surgical Fixation –
plateau fractures
• Restore alignment
• Coronal
• Sagittal
• Slope
• Normal Condylar width
• Fully stable knee
• Congruent Articular Surfacte

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Lateral Plateau Fixation
• Most common fracture pattern
• Anterolateral approach
• Key steps: Click below for video link
• Anterolateral approach
• Submeniscal arthrotomy
• +/- distractor if needed
• “book open” the split portion
Anterolateral Approach for the Treatment of Tibial
• Reduce the depressed articular Plateau Fractures
segment and provisionally stabilize Mark Hake, Rajbir Hundal, Jacob Kirsch, Michael Yee
with K-wires
• Fill voids as necessary
• Reduce the split portion
• Apply rafting screws and/or lateral
plate Core Curriculum V5
 Lateral Plateau Fixation
• Healthy, active 48 year old
woman fell off scooter

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CT Imaging – axial cuts
demonstrate approach

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Anterolateral approach –
visualize + reduce

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 Postoperative Care

• Early ROM – trust your fixation

• Protected WB
• 8 weeks tdwb, then adv to wbat
over weeks 8-12
• Bracing?
• DVT prophylaxis

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Isolated medial injuries
• Much less common
• Posteromedial approach
• Key steps:
• Generally buttress at the apex
• Prone vs supine?
• Supine – simple, allows for anterolateral
approach, also adds significant rotation
and varus often thru the fracture in
bicondylar injuries
• Posterior – inconvenient, but fewer
deforming forces, simplifies fixation
• Direct approach to apex
• Indirect reduction at joint line
• Fluroscopic reduction key
• With Medial surface impaction – can
perform submeniscal arthrotomy to
visualize the surface

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Isolated medial injuries –
prevent late varus

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Lobenhoffer approach – interval between
hamstring and medial head of the gastroc

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More complex injuries…
bicondylar plateau
-Neurovacular checks
are crucial
-Exam can evolve
-applying external
fixation can change the
vascular exam
-restoring length can
increase compartment
pressure as well

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Extensile posteromedial
approach
• Standard Lobenhoffer
approach with an
extended proximal limb
• Isolate the medial head of
the gastroc at its femoral
insertion
• Release the medial head
• Provides access to a
portion of the
posterolateral plateau as
well
Orapiriyakul W, Apivatthakakul T, Phornphutkul C. Posterolateral tibial plateau fractures, how to buttress?
Reversed L posteromedial or the posterolateral approach: a comparative cadaveric study.
Arch Orthop Trauma Surg. 2018 Apr;138(4):505-513. doi: 10.1007/s00402-018-2875-3. Epub 2018 Jan 19 Core Curriculum V5
Extensile posteromedial
approach - prone

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Second approach – anterolateral
supine

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 Bicondylar plateau – medial
decision making
• Medial side
• ? Posterior shear = posterior
buttress
• ? Unstable medial column = direct
medial plating
• Axial CT scans helpful
• Fixing from medial or lateral alone
may entirely miss posteromedial
fragments! Think three columms!
• Buttress posterior fractures – at
the apex!

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External fixation and 4
compartment fasciotomies
required

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Bicondylar plateau – medial decision making: CT
scan after external fixation applied

Requires bicondylar plating – with direct medial

plating, not posteromedial!
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Medial side – limited proximal
exposure and bridging distally
• Medial first
• Established length
• Anterolateral
• Clamp the two
plates together
-Axial alignment
-condylar width
-joint congruity
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 Bridge plating techniques
• It the fracture a plateau, that extends
into the shaft – or is it a shaft that
happens to extend into the plateau? Click below for video link
• Simple fracture lines call for anatomic
reduction
• Percutaneous bridge plating used for
more comminuted diaphyseal Bridge Plating of Proximal Tibia Metaphyseal Fracture by
fractures with proximal extension Limited Open Technique
Michael Gardner, Benjamin Pulley
• Can the joint be reduced without a
direct approach?
• Is an IM nail in conjunction with
plating beneficial?

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Associated shaft and plateau –
combining techniques
• Presents in extremis
• Bilateral open tibias
• Associated bicondylar
plateau on the left
• Emergent ex fix and
VAC
• Returns for fixation HD
2 in anticipation of
free flap HD 3

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Limited anterolateral approach,
percutaneous medial fixation,
suprpatellar nailing

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Limited plating, nail inserted,
screws added

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3 year f/u

*cement retained in diaphyseal fracture, shaft treated with posterolateral bone grafting Core Curriculum V5
Bicondylar plateau –
hyperextension mechanism
from trampoline
HIGH RISK FOR NEUROVASCULAR INJURY!

Hyperextension causes
anterior slope
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Plan for bicondylar plating,
direct medial
• External fixator applied
• “Travelling traction”
• Anterolateral approach
• Medial extension deformity
corrected with elevator from the
anterolateral side
• Second posteromedial approach
allows for correction of the
posterior translation of the
plateau
• Dual plating lateral and medial

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Elevate slope! Final correction

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Core Curriculum V5
Objectives
• Describe initial evaluation and management of tibial plateau fractures
• Identify common fracture patterns
• Apply treatment principles and strategies
• Partial articular fractures
• Complete articular fractures
• Discuss rehabilitation, complications, and outcomes

Core Curriculum V5
Rehabilitation
• Post op protocols :
• Can vary by fracture severity
• Goal of surgery – allow for complete ROM immediately postop
• Unlocked hinged knee brace commonly used
• Consider appropriate DVT prophylaxis
• Touch down WB 8 weeks
• Advance after 8 weeks depending on severity
• Quad sets, isometrics important

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 Complications
• Pre or postop compartment
syndrome (increases with
complexity of injury)
• Can release anterior
compartment easily from
anterolateral approach
• Infections more common after
compartment release
• Medial plating prevents late
varus collapse
• Residual valgus common with
isolated lateral injuries

Rockwood and Green, 9th edition

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Conclusions
• Systematic approach to initial presentation
• Evaluate neurovascular exam
• Consider compartment syndrome
• Evaluate in light of age and mechanism
• Operative goals
• Axial alignment, condylar width, joint congruity
• Key Steps
• Plan the approach, reduce the articular block, fill voids as necessary, re-
establish length and alignment
• Medial fixation: Direct medial or posteromedial buttress?
• Bicondylar fixation: Bridge plating helpful for comminuted metaphyseal
or diaphyseal extension injuries

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