Tibial Plateau Fracture Classification PDF

Tibial plateau fractures: Review of the classification
systems, management, and outcome
Poster No.: C-1752

Congress: ECR 2015
Type: Educational Exhibit
Authors: S. L. Coleman, R. Parisien, A. Guermazi, A. Murakami; Boston,
MA/US
Keywords: Trauma, Outcomes, Education and training, Education,
Conventional radiography, CT, Musculoskeletal joint,
Musculoskeletal bone
DOI: 10.1594/ecr2015/C-1752
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Page 1 of 48
Learning objectives
Classify fracture patterns of tibial plateau using Schatzker and AO

classification systems
Identify the indications for cross sectional imaging
Recognize the different indications for surgical intervention and be familiar
with surgical hardware
Become familiar with the long term outcome of the different fracture patterns
and surgical techniques
Background
Background:
The earliest attempt at tibial plateau fracture classification was based on the observation
of common themes and three fracture types were described: split of a condyle,
subchondral depression, and comminuted bicondylar involvement. (1,2)
Schatzker et al. presented their classification system in 1979, which was created based
on findings from AP radiographs. The Schatzker group created 6 groups of tibial plateau
fractures based on fracture pattern, which helped to direct operative versus non-operative
treatment. (2)
The AO system is part of a larger system of classification of bone fractures throughout

the body, meant to categorize the fracture by localization and severity and to predict
treatment and prognosis.
Radiograph Views for Evaluation of Tibial Plateau Fracture:
AP
Lateral
Two 45 degrees internal oblique views
10-15 degree caudally tilted AP view
Page 2 of 48
Fig. 1: AP, Lateral, Caudal AP, and Internal Oblique views
References: Radiology, Boston Medical Center - Boston/US
What to look for on radiograph views:
Fracture patterns
Depression
Condylar widening
Injuries to suggest ligamentous injury (i.e. Segond fracture, Pellegrini-Stieda lesion, and
fibular head avulsion)
Images for this section:
Page 3 of 48
Fig. 1: AP, Lateral, Caudal AP, and Internal Oblique views
Page 4 of 48
Findings and procedure details
SCHATZKER CLASSIFICATION: 6 types of tibial plateau fractures (3)
Fig. 2: Schatzker Classification Types I, II, and II I - Split fracture II - Split fracture with
depression III - Pure depression fracture
Type I: lateral split without depression

Type II: split-depression lateral plateau fracture
Type III: pure depression lateral plateau fracture- based on the classification
system this pattern can be separated into A and B, however, this is not
necessarily used in the clinical setting (IIIA: compression fracture of the
lateral plateau; IIIB: compression fracture of the central plateau)
Page 5 of 48
Fig. 3: Schatzker Classification Types IV, V, and VI IV - Medial plateau fracture V -
Bicondylar plateau fracture VI - Meta-diaphyseal dissociation
Type IV: medial plateau fracture

Type V: bicondylar plateau fracture
Type VI: meta-diaphyseal dissociation
Type I: (Fig.9 and 10)
Wedge shaped pure cleavage fracture with <4mm of depression or

displacement
Accurate assessment of depression/displacement; may need cross sectional
imaging to distinguish Type I and Type II
6% of all tibial plateau fractures, most frequently in young patients
Impaction injury to one side of the knee and distraction injury to the other side
-May be associated with distraction injury to anterior cruciate ligament (ACL)

or medial collateral ligament (MCL)
Page 6 of 48
Type II: (Fig.11 and 12)
Combined cleavage and compression fracture of the lateral tibial plateau

Type I fracture with depression
Depression is measured between the lowest point on the intact medial
plateau and the lowest depressed lateral plateau fracture fragment
25% of all tibial plateau fractures
Injury usually occurs in bone with underlying osteopenia
Valgus force on the knee; 20% with distraction injury to MCL and medial
meniscus
Condylar widening
Type III: (Fig.13 and 14)
Pure compression fracture of the lateral tibial plateau with depression of the
articular surface into the metaphysis
Axial loading
Bone often has underlying osteopenia
Type IV: (Fig.15 and 16)
Medial tibial plateau fracture with a split or depressed component

Varus force with axial loading of the knee
Posteromedial coronal split fractures in hyperflexed knee with varus forces
and axial loading
Worst prognosis
Younger patients, high energy mechanism
Commonly associated with subluxation or dislocation --> increased
likelihood of injury to popliteal nerve or vessel --> cross sectional imaging
needed
Distraction to the lateral compartment-lateral collateral ligament (LCL) or
posterolateral corner injury, or fracture/dislocation of fibular
Type V: (Fig.17 and 18)
Wedge fracture of the medial and lateral tibial plateau, often with an inverted
"Y"
Articular depression in the lateral plateau- may be associated with
intercondylar eminence
Maintenance of the metaphyseal-diaphyseal continuity
High energy, complex mechanism
Associated with peripheral meniscal detachment and ACL avulsion injury
Condylar fractures can lead to instability by disruption of collateral ligaments
and/or cruciate ligaments
Page 7 of 48
Cross section imaging for bicondylar fractures to exclude four part fracture
Type VI: (Fig. 19 and 20)
Transverse subcondylar fracture with dissociation of the metaphysis from

the diaphysis
All types of fracture patterns of the condyles can occur
High energy injury
Complex mechanism
Can be associated with open fractures, soft tissue injury, and compartment
syndrome
AO CLASSIFICATION:(1,4)
The classification system aims to systematically classify fractures based on anatomical

location and morphological characteristics of the fracture.
The system creates a 5-element alphanumeric code, which represents: a description

of the location (bone segment), fracture type, and morphological characteristics of the
fracture.
The long bones are divided into three segments. The fractures of each segment are then
divided into three types, with a further subdivision into three groups and their subgroups.
Page 8 of 48
Fig. 4: AO Classification Types A1, A2, and A3
Type A: Extra articular fractures
A1: Avulsion
A2: Metaphyseal simple
A3: Metaphyseal multifragmentary
Page 9 of 48
Fig. 5: AO Classification Type B1 with subgroups
Page 10 of 48
Page 11 of 48
Type B: Partial articular fracture (Fig. 21)
B1: Pure split

B2: Pure depression
B3: Split-depression
Page 12 of 48
Fig. 8: AO Classification Type C1, C2, and C3
Type C: Complete articular fracture (Fig. 22)
C1: Articular simple, metaphyseal simple

C2: Articular simple, metaphyseal multifragmentary
C3: Articular multifragmentary
Example:
What is the AO Classification of the Tibial Plateau fracture shown below?
Page 13 of 48
Fig. 21: AO Classification: 41.C.3. Proximal tibia, articular, complex
metadiaphyseal and complex articular
1. Anatomical location:
Anatomical location designated by two numbers, one for the bone and one for the
segment
-Long bone = Tibia = 4
-Proximal tibia = 41
-Mid tibia = 42
-Distal tibia = 43
Answer= 41
Page 14 of 48
2. Type of fracture:
Types of fractures are coded by three letters: A, B, C
Answer=C (complete articular)
3. What group within the type of fracture?
Within the fracture types there are groups: 1, 2, 3
Answer=3 (articular multifragmentary)
Full AO Classification of above fracture = 41.C.3
CLASSIFICATION SYSTEMS AND TREATMENT:
Tibial plateau fractures are often complicated to repair surgically due to the
highly complex nature and intra articular involvement
Adequate, reliable, and reproducible pre-operative classification of fracture
patterns is essential in aiding operative treatment (5)
Comparison of systems:
One study showed substantial reliability in intra-observer assessment of both the

Schatzker and AO classifications. The AO system was mildly more reliable in regards to
inter-observer assessment. (5)
As the AO classification becomes more specific (i.e group and subgroup) the
reliability of classification breaks down due to the complexity of the system.
Better reliability is seen in assessing AO type of fracture pattern. (5)
CT imaging may be indicated when classification is not clear to increase accuracy of

classification.
AO classification inter-observer reliability improved to "good" with CT

imaging, compared to "moderate with radiograph assessment.
Fellowship trained orthopedic surgeons and skeletal radiologists showed
better intra-observer reliability overall. With CT imaging, only skeletal
radiologists showed significant improvement in reliability.
Page 15 of 48
Observers noted extreme difficult distinguishing between certain types of
AO fractures with radiographs, however, they had no difficulty classifying the
same types with CT imaging. (6)
Schatzker classification inter-observer reliability improved to "good" with

use of CT imaging, compared to "moderate" with radiograph assessment.
Intra-observer reliability of the Schatzker classification was "good" with
radiograph assessment and did not change with use of CT imaging.
Certain fracture patterns were difficult to classify with radiographs (type I
vs II and type V vs type VI), however, the same observers had no difficulty
classifying these same fractures with CT imaging. (6)
Additional studies have supported improved classification with CT imaging over

radiographs (1)
At our institution CT imaging is utilized for pre-operative management of split depression,

bicondylar, and meta-diaphyseal fractures identified on radiographs.
In our opinion radiologists should recommend CT imaging for the following indications:
Unclear classification that may change management

Condylar widening
Articular incongruity
Depression/compression of the articular surface
Treatment:
Non-operative treatment is usually indicated in non-displaced or mildly depressed plateau

fractures (7)
Partial weight bearing in a hinged brace for 8-12 weeks with regular
radiographs is recommended(3, 8)
Goals of surgical treatment of intra-articular fractures to avoid or postpone posttraumatic

arthritis(8):
restoration of the articular surface

axis
meniscal integrity
stability
Range of acceptance for articular depression varies from 2mm to 1cm
Page 16 of 48
Some degree of joint depression can be tolerated.
Despite an average of >3 mm of residual tibial joint line displacement, Weigel and Marsh
demonstrated a low rate of posttraumatic arthrosis at long-term follow-up(9)
Treatment based on Schatzker Classification:
Type I, II, III (8)
-Lower energy injuries
-Goal is to restore: Joint congruity, length, alignment, stability
-meniscal and/or ligamentous repair
Type I (low energy) (3)
-Open reduction and internal fixation (ORIF) with or without arthroscopy
-Hardware: Screw osteosynthesis with lag technique; lateral locking or buttress plate
Page 17 of 48
Fig. 24: Schatzker Type I fracture repaired with open reduction and fixation using a
lateral plate and screws.
Type II (low energy) (3, 10)
-ORIF for all unstable fractures
-Articular elevation
-Meniscal repair (reduces incidence of degenerative changes)
-Bone grafting: cancellous bone chips; bioresorbable calcium phosphate cement;

aoralline hydroxyapatite; autogenous iliac bone graft
-Hardware: Rafting screw to support impacted joint surface; lateral locking or buttress
plate
Page 18 of 48
Fig. 25: Schatzker Type II fracture status post open reduction and internal fixation with
a lateral plate and screws.
Type III (low energy) (3)
-If extent of articular depression is small and joint is stable = non-operative
-May result in joint instability -->elevation of the depressed portion of the plateau via sub-
metaphyseal cortical window
-Athroscopic reduction of type III is possible although not standard practice
Page 19 of 48
Fig. 26: Schatzker Type III fracture status post open reduction and internal fixation
with a lateral plate and screws.
Type IV (high energy) (3)
-Tend to angulate into varus position
-ORIF
-Hardware: medial buttress plate and cancellous screws
Soft tissue injuries dictate management in Types V and VI (3)
-Severe soft tissue impairment may benefit from primary external fixation with secondary
ORIF
Type V (high energy) (3, 11)
Page 20 of 48
-Initial management depends on soft tissue integrity
-Temporary external fixation
-Wait for soft tissue inflammation and edema to decrease before definitive fixation
-Secondary ORIF
-Hardware: Buttress plating, locked plating, dual plating, circular fixator
Fig. 27: Schatzker Type V fracture pattern with internal fixation using a longer lateral
plate and screws.
Type VI (3)
-No traction secondary to meta-diaphyseal dissociation
-Hardware: If extra-articular --> tibial intramedullary nail may be used.
Page 21 of 48
Fig. 29: Schatzker Type VI fracture treated with external fixation only.
Treatment based on AO Classification: (4)
Non-displaced stable fractures are treated non-operatively:
Put in brace to prevent displacement

Exceptions include: fractures of the medial tibial plateau because of high risk
of secondary displacement and associated complications requiring surgical
treatment
Operative treatment is indicated for:
Joint instability
articular surface incongruity
Page 22 of 48
axial deformity
PROGNOSIS:
Outcome depends on knee stability, joint congruity, meniscal integrity and correct axis.
Favorable outcomes have been reported for surgically treated low-energy

tibial plateau fractures (12)
Adequate surgical techniques for Split (Type-I) and Split-Depression (Type-
II) fractures yield more than 90% good and excellent results (13)
Studies have shown that operative treatment with a fracture that disrupts
the articular surface leads to good functional results 2-10 years post injury,
possibly due to early mobilization (7), particularly for elderly patients
Maintaining meniscal and ligamentous stability is important (14)
Posttraumatic arthrosis is related to initial chondral injury or result of residual joint

incongruity (14, 15)
Images for this section:
Page 23 of 48
Fig. 9: Schatzker Type I Fracture: Vertically oriented intra articular fracture through the
lateral tibial plateau with less than 4 mm of depression of the lateral tibial plateau.
Page 24 of 48
Fig. 10: CT imaging of Type I fracture in Fig. 9. Coronal and sagittal CT images in bone
algorithm that more accurately demonstrates a Type I from Type II fracture, with less than
4 mm of depression of the lateral tibial plateau.
Page 25 of 48
Fig. 11: Schatzker Type II Fracture- Intra articular vertical fracture of the lateral tibial
plateau with depression and mild distraction, consistent with a Type II fracture pattern.
Page 26 of 48
Fig. 12: CT imaging of the Type II fracture in Fig. 11. Coronal and sagittal CT reformats in
bone window demonstrating a Type II fracture of the lateral tibial plateau. An intra articular
split fracture of the lateral tibial plateau with depression (>4mm) and condylar widening.
Page 27 of 48
Fig. 13: Schatzker Type III Fracture - Pure depression fracture of the lateral tibial plateau
without displacement (split) of the fracture fragment.
Page 28 of 48
Fig. 14: CT imaging of Type III fracture in Fig. 13 - Coronal and sagittal images in bone
algorhitm better demonstrating the depression of the articular surface of the lateral tibial
plateau into the metaphysis.
Page 29 of 48
Fig. 19: Schatzker Type VI Fracture - Shows a transverse fracture of the tibial diaphysis
with a depressed split fracture of the lateral tibial plateau and a split fracture of the medial
tibial plateau.
Page 30 of 48
Fig. 20: CT Imaging of Type VI fracture in Fig. 19 - Transverse tibial diaphyseal fracture
causing metaphyseal-diaphyseal dissociation. There is a displaced split fracture of the
lateral tibial plateau with depression of the articular surface and a minimally distracted
longitudinal fracture of the medial plateau with less < 4mm of articular depression.
Page 31 of 48
Fig. 22: AO Type B3 fracture - split depression fracture of the lateral tibial plateau
Page 32 of 48
Fig. 23: AO Classification Type C3 fracture - Comminuted, multifragmentary, intra
articular fracture of the bilateral tibial plateaus with extension to the metaphysis.
Page 33 of 48
Fig. 18: CT Imaging of Type V fracture in Figure 17 demonstrating a bicondylar split
fracture with mild depression of the articular surfaces.
Page 34 of 48
Fig. 17: Schatzker Type V Fracture - Bicondylar spit fracture with mild depression of the
articular surfaces.
Page 35 of 48
Fig. 28: Surgical repair of Schatzker Type V fracture with bicondylar plates.
Page 36 of 48
Fig. 16: CT imaging of Type IV fracture in Fig.15. Coronal and sagittal images in bone
algorithm better demonstrating depression of the articular surface of the medial tibial
plateau into the metasphysis.
Page 37 of 48
Fig. 15: Schatzker Type IV Fracture - Depression fracture of the medial tibial plateau only.
Page 38 of 48
Fig. 2: Schatzker Classification Types I, II, and II I - Split fracture II - Split fracture with
depression III - Pure depression fracture
Page 39 of 48
Fig. 3: Schatzker Classification Types IV, V, and VI IV - Medial plateau fracture V -
Bicondylar plateau fracture VI - Meta-diaphyseal dissociation
Page 40 of 48
Fig. 4: AO Classification Types A1, A2, and A3
Page 41 of 48
Page 42 of 48
Page 43 of 48
Page 44 of 48
Fig. 8: AO Classification Type C1, C2, and C3
Page 45 of 48
Fig. 21: AO Classification: 41.C.3. Proximal tibia, articular, complex metadiaphyseal and
complex articular
Page 46 of 48
Conclusion
CONCLUSIONS:
Classification systems can be useful to standard fracture pattern

descriptions, but may need to be updated or revised as imaging standards
change.
Classification systems that are simple for both radiologists and orthopedic
surgeons to understand are the most useful. The more complex the system
the more inaccuracy that occurs in classifying the fracture pattern.
Radiographs, particularly with tibial plateau views, are often sufficient to
classify tibial plateau fracture patterns.
Cross sectional imaging can improve more accurate classification and
address soft tissue injuries, which may change management.
CT imaging should be recommended when radiographs show condylar
widening, articular incongruity, and depression/compression of the articular
surface.
The goal of treatment is to restore joint stability and functionality.
Stability dictates operative management in low energy fracture patterns.
Additional soft tissue injuries can influence surgical approach in high energy
fracture patterns.
Long-term prognosis is dependent on how well joint stability is preserved
with treatment.
Personal information
References
1. Gicquel T., Najhi N., Vendeuvre T., Teyssedou S., Gayet L.E., Huten D.
Tibial Plateau fractures: Reproducibility of three classifications (Schatzker,
AO, Duparc) and a revised Duparc classification. Orthopaedics and
Traumatology: Surgery and Research. 2013; 99:805-816.
2. Zeltser D.W., Leopold S.S. Classifications in Brief: Schatzker Classification
of Tibial Plateau Fractures. Clin Orthop Relat Res. 2013; 471:371-374.
3. Markhardt K.B., Gross J.M., Monu J.U.V. Schatzker Classification of Tibial
Plateau Fractures: Use of CT and MR Imaging Improves Assessment.
Radiographics. 2009; 29:585-597.
4. Hansen M., Pesantez R., Raaymakers E., Schatzker J. Proximal Tibia.
AO Foundation.https://www2.aofoundation.org/wps/portal/surgery?
showPage=diagnosis&bone=Tibia&segment=Proximal. 5.15.2010
Page 47 of 48
5. Walton N.P, Harish S., Roberts C., Blundell C. AO or Schatzker? How
reliable is classification of tibial plateau fractures? Arch Orthop Trauma
Surg. 2003; 123:396-398.
6. Brunner A., Horisberger M., Ulmar B., Hoffman A., Babst R. Classification
systems for tibial plateau fractures; does computed tomography scanning
improve their reliability? Injury. 2010 Feb; 41(2):173-178.
7. Hoube PF., van der Linden ES., van der Wildenberg FA., Stapert JW.,
Functional and radiological outcome after intra-articular tibial plateau
fractures. Injury. 1997 Sep; 28(7):459-62.
8. Kobbe P, Pape HC. Lateral Tibial Plateau Fractures. Operative Techniques
in Orthopaedic Surgery:Editor Weisel SW, 2011; Vol 1:p623-628
9. Weigel DP, Marsh JL: High-energy fractures of the tibial plateau: Knee
function after longer follow-up. J Bone Joint Surg Am 2002;84:1541-1551
10. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto
experience 1968-1975. CORR 1979;94-104
11. The Canadian Orthopaedic Trauma Society. Open Reduction and Internal
Fixation Compared with Circular Fixator Application for Bicondylar Tibial
Plateau Fractures. J Bone Joint Surg 2006
12. Stevens DG, Beharry R, McKee MD, et al. The long-term functional
outcome of operatively treated tibial plateau fractures. J Orthop Trauma
2001;15:312-320
13. Lobenhoffer P, Schulze M, Gerich T, et al. Closed reduction/percutaneous
fixation of tibial plateau fractures: arthroscopic vs fluoroscopic control of
reduction. J Orthop Trauma 1999;13:426-431
14. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop
Trauma 1995;9:273-277
15. Saleh KJ, Sherman P, Katkin P, et al. Total knee arthroplasty after ORIF of
fractures of the tibial plateau: a minimum five-year follow up study. J Bone
Joint Surg am 2001;83A:1144-1148
Page 48 of 48

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Tibial plateau fractures: Review of the classification

systems, management, and outcome

Poster No.: C-1752

Classify fracture patterns of tibial plateau using Schatzker and AO

The AO system is part of a larger system of classification of bone fractures throughout

Radiograph Views for Evaluation of Tibial Plateau Fracture:

Two 45 degrees internal oblique views

10-15 degree caudally tilted AP view

What to look for on radiograph views:

Images for this section:

SCHATZKER CLASSIFICATION: 6 types of tibial plateau fractures (3)

Type I: lateral split without depression

Type IV: medial plateau fracture

Type I: (Fig.9 and 10)

Wedge shaped pure cleavage fracture with <4mm of depression or

-May be associated with distraction injury to anterior cruciate ligament (ACL)

Combined cleavage and compression fracture of the lateral tibial plateau

Type III: (Fig.13 and 14)

Type IV: (Fig.15 and 16)

Medial tibial plateau fracture with a split or depressed component

Type V: (Fig.17 and 18)

Type VI: (Fig. 19 and 20)

Transverse subcondylar fracture with dissociation of the metaphysis from

The classification system aims to systematically classify fractures based on anatomical

The system creates a 5-element alphanumeric code, which represents: a description

Type A: Extra articular fractures

Type B: Partial articular fracture (Fig. 21)

B1: Pure split

Type C: Complete articular fracture (Fig. 22)

C1: Articular simple, metaphyseal simple

What is the AO Classification of the Tibial Plateau fracture shown below?

-Long bone = Tibia = 4

Types of fractures are coded by three letters: A, B, C

Answer=C (complete articular)

3. What group within the type of fracture?

Within the fracture types there are groups: 1, 2, 3

Answer=3 (articular multifragmentary)

Full AO Classification of above fracture = 41.C.3

CLASSIFICATION SYSTEMS AND TREATMENT:

One study showed substantial reliability in intra-observer assessment of both the

CT imaging may be indicated when classification is not clear to increase accuracy of

AO classification inter-observer reliability improved to "good" with CT

Schatzker classification inter-observer reliability improved to "good" with

Additional studies have supported improved classification with CT imaging over

At our institution CT imaging is utilized for pre-operative management of split depression,

Unclear classification that may change management

Non-operative treatment is usually indicated in non-displaced or mildly depressed plateau

Goals of surgical treatment of intra-articular fractures to avoid or postpone posttraumatic

restoration of the articular surface

Range of acceptance for articular depression varies from 2mm to 1cm

Treatment based on Schatzker Classification:

Type I, II, III (8)

-Lower energy injuries

-Goal is to restore: Joint congruity, length, alignment, stability

-meniscal and/or ligamentous repair

Type I (low energy) (3)

-Open reduction and internal fixation (ORIF) with or without arthroscopy

Type II (low energy) (3, 10)

-ORIF for all unstable fractures

-Meniscal repair (reduces incidence of degenerative changes)

-Bone grafting: cancellous bone chips; bioresorbable calcium phosphate cement;

Type III (low energy) (3)

-If extent of articular depression is small and joint is stable = non-operative