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TRAUMA

Review Article
Trauma
13(3) 181–187

Tibial plateau fractures: A review ! The Author(s) 2011


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DOI: 10.1177/1460408610396422
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P Fenton1 and K Porter2

Abstract
Tibial plateau fractures are uncommon injuries of the proximal tibia which vary in severity from minimally
displaced stable injuries to high energy complex fractures with significant articular and metaphyseal
comminution and severe associated soft tissue injuries. Following initial assessment and appropriate
investigation a number of management options are available to the treating surgeon. We discuss the
presentation, initial management and investigation as well as outlining the various treatment options
with an emphasis on operative treatment. We further discuss the common complications and outcomes
following tibial plateau fracture.

Keyword
Tibial plateau fracture

Introduction alone were put across the knee bicondylar frac-


The tibial plateau consists of a pair of concave tures were produced (Kennedy and Bailey,
condylar articular surfaces, which allow articu- 1968). They postulated that lateral plateau frac-
lation with the menisci and femoral condyles. tures were produced when the medial collateral
On the medial side the surface is oval in shape ligament was intact although with the advent of
while on the lateral side the surface is more cir- MRI scanning it has become apparent that soft
cular. Between the condyles is the elevated inter- tissue injuries are often associated with plateau
condylar eminence. fractures (Bennett and Browner, 1994).
Fractures of the tibial plateau are reported as
accounting for 1% of all fractures and up to 8%
of fractures in the elderly (Hohl, 1991). Most
Initial management
injuries affect the lateral plateau with isolated Patients may present with a history of a valgus
medial plateau injuries accounting for 10–23% strain to the knee such as being struck by a car
of fractures and bicondylar fractures accounting
for 10–30% (Hohl, 1991).
1
Tibial plateau fractures are produced by a Walsall Manor Hospital, 87 Russell Bank Road, West
combination of axial loading together with Midlands, UK.
2
Department of Clinical Traumatology, Selly Oak Hospital,
either a varus or valgus force. In their cadaveric Raddlebarn Road, Birmingham, UK.
study Kennedy and Bailey found that applying
Corresponding author:
valgus and compressive forces across the knee Paul Fenton, Walsall Manor Hospital, 87 Russell Bank Road,
produced recognisable patterns of tibial plateau West Midlands, UK
fractures. When significant compressive forces Email: fenton1977@hotmail.com

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182 Trauma 13(3)

bumper, being tackled playing football or rugby separation of the metaphysis and diaphysis
or falling from a height. Often the mechanism of of the tibia.
injury is not clear from the history. Initial assess- The AO group also use six classifications
ment in patients with a significant mechanism of for these fractures. 41-B fractures are partial
injury or multiple injuries should follow ATLS articular injuries. 41-B1 is a pure split, 41-B2
guidelines. In assessing the injured limb atten- pure depression and 41-B3 split depression.
tion must be given to the condition of the soft The 41-C injuries are complete articular injuries
tissues and relationship of any open wounds to with 41-C1 being simple articular and simple
the fractures site. The state of the muscle com- metaphyseal, 41-C2 simple articular and multi-
partments about the knee should be assessed as fragmentary metaphyseal and 41-C3 multi-
well as the presence of distal pulses and neuro- fragmentary articular.
logical status of the limb with particular respect It has been suggested that there is a high
to peroneal nerve function. interobserver variability with both the AO and
Following initial assessment the limb should Schatzker classification. Some recommend
be rested in a splint, most often an above knee describing fractures as either unicondylar or
backslab, to provide pain relief and protect the bicondylar and either pure split or depression
injured soft tissues. þ/ split (Charalambous et al., 2007).

Investigations Conservative treatment


Imaging begins with AP and lateral views of the The management of a tibial plateau fracture will
knee joint, supplementation with oblique views depend on many factors including the fracture
of the knee may aid diagnosis where clinical sus- pattern, joint displacement or depression, extent
picion is high. CT with axial, sagittal and coro- of soft tissue injury, the comorbidities and func-
nal reconstructions can provide information tional demands of the patient as well as the skills
regarding the degree of comminution and artic- of the surgeon.
ular involvement and thus aid surgical planning. The indications for operative treatment of
MRI has come to play an increasing role in the tibial plateau fractures are not absolutely
assessment of the soft tissue injuries associated defined. Koval suggested that minimally dis-
with these fractures. In their study comparing placed, stable fractures could be treated conser-
the assessment of soft tissue injuries with CT vatively (Koval and Helfet, 1995). In his paper,
or MRI, Miu et al. (2007) found that although Honkonen advised that lateral fractures with an
CT was useful in the diagnosis of bony ligament articular step of 3 mm or over, valgus tilt of over
avulsions MRI was required to detect ligament 5 or condylar widening over 5 mm should be
and meniscal injuries. treated operatively. Medial condyle fractures
with any displacement and all bicondylar frac-
tures should be treated operatively (Honkonen,
Classification
1994). Low energy fractures of the lateral condyle
The most commonly used system to classify with minimal joint displacement and a stable
tibial plateau fractures is that of Schatzker. knee are most amenable to conservative treat-
He divided fractures into six groups. A type I ment. This involves treatment in a cast brace
fracture is a split of the lateral plateau; type II for 8–12 weeks with the brace initially locked in
involves a split and depression of the lateral extension and then adjusted to allow a progres-
plateau; type III is a pure depression of the sive range of motion up to 90 by 4 weeks.
lateral plateau; type IV fractures involve Regular radiographs are required to ensure the
only the medial plateau; type V are bicondylar fracture position is maintained. Weight bearing is
fractures; and type VI are bicondylar with generally commenced at between 4 and 6 weeks.

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Fenton and Porter 183

Operative treatment comminution (Duwelius et al., 1997). In a bio-


The options in operative management of plateau mechanical study Parker et al noted that in
fractures includes internal fixation with percuta- Scatzker I fractures the addition of a third
neous techniques, conventional or locking screw or an antglide plate conferred no benefit
plates, external fixation with or without limited (Parker et al., 1999).
internal fixation and staged management with There has been a trend toward treating pure
external fixation followed by internal fixation. depression fractures (Schatzker III) with a raft
The choice of treatment will depend upon both screw construct. This involves elevating the
the personality of the fracture and the expertise depressed fragment and supporting it with a
of the operating surgeon. raft of screws beneath the articular surface.
In low energy injuries surgery can usually be Patil et al. reported that using four 3.5 mm
performed once adequate imaging has been screws gave a statistically significantly stronger
performed and the patient’s condition repair than using two 6.5 m screws (Patil et al.,
allows. In high energy injuries associated vis- 2006). The depressed articular fragments can be
ceral injuries may require attention before the elevated via a cortical window distal to the joint
limb can be definitively treated. These injuries surface, any residual defect may require grafting
often have a significant soft tissue component (see below).
and limb swelling may prohibit early internal In Schatzker type I, II and IV fractures with
fixation. In these situations a temporary span- significant comminution or in osteoporotic bone
ning external fixator provides fracture stabil- a buttress plate can be applied to maintain the
ity and allows the soft tissues to recover. reduction and neutralise axial forces across the
Egol et al. treated 49 high energy fractures fracture. When a depressed component is pre-
according to their protocol with spanning sent a raft construct can be used in conjunction
external fixation on day one followed by with plate fixation. In a cadaveric study
conversion to internal fixation or circular fixa- Kurankar et al. compared plateau fractures
tor when the soft tissues allowed. They repaired with L-buttress plate with or without
reported a low complication rate although bone graft, antiglide plate with 4 subchondral
they acknowledged that significant knee stiff- raft screws or periarticular plate with 4 subchon-
ness developed in 4% of their patients (Egol dral raft screws. They found constructs using
et al., 2005). raft screws were more resistant to depressive
Internal fixation remains the mainstay of loads (Karunakar et al., 2002).
operative treatment of tibial plateau fractures. Bicondylar fractures require reconstruction
The principles of anatomical reduction of the of the joint surface followed by reduction of
joint surface should be rigorously applied. the metaphyseal component. Reduction can be
Ebraheim et al. (2004) treated 117 fractures of aided by the use of femoral distractors. The joint
all classifications with internal fixation. They surface can then be elevated and the joint stabi-
reported good to excellent results in 94, fair in lised with cannulated screws. Fixation can
13 and poor in 10 cases. then be achieved by dual plating or with a
Some fractures, particularly Schatzker I (AO fixed angle plate.
B1) or low energy type IV fractures are amena- Locking plates are increasingly used in the
ble to percutaneous lag screw fixation. This treatment of proximal tibial fractures. Implants
involves indirect reduction of the fracture and such as the Less Invasive Stabilisation
fixation with two cancellous screws across the System (LISS) allow a minimally invasive tech-
fracture. Several studies have reported good nique to be employed with less disruption of the
results with this technique (Keogh et al., 1992; soft tissues. Boldin et al. (2006) reported good
Koval et al., 1992) although it is less suitable for functional outcomes and a low complication
fractures with significant joint depression or rate in 26 patients with proximal tibia fractures

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184 Trauma 13(3)

(intra and extra-articular) treated with the Kumar and Whittle, 2000; Chin et al., 2005;
LISS plate. Kataria et al., 2007).
When treating bicondylar fractures locking More recently external fixation has been
plates allow the fracture to be fixed from the combined with limited internal fixation to
lateral side only without the need for dual plat- improve reduction and fixation of the articular
ing. However, in their study Jiang et al. (2008) surface, a number of studies have advocated this
noted a higher incidence of malalignment fol- approach (Marsh et al., 1995; El Barbary et al.,
lowing fixation with a LISS plate compared to 2005; Katsenis et al., 2005; Catagni et al., 2007).
conventional double plating. In situations where the joint surface is
Arthroscopy has been used in conjunction severely unstable or the fracture or soft tissues
with the treatment of Schatzker types I, II and prevent optimal pin placement some authors
III fractures. It is used to assess soft tissue inju- recommend spanning the knee joint (Katsenis
ries within the knee and to ensure adequate et al., 2006; Catagni et al., 2007). In their
reduction of the joint surface. Several case study Katsenis et al. (2005) found no significant
series have reported good results with the tech- difference in outcome between fractures treated
nique (Scheerlinck et al., 1998; van Glabbeek with joint spanning or joint sparing frames.
et al., 2002). Ohdera et al. (2003) compared The Canadian orthopaedic trauma society
arthroscopically assisted surgery with conven- performed a randomised controlled trial com-
tional open surgery in finding patients in the paring open reduction and internal fixation
arthroscopy group regained knee movement with circular external fixation with or without
quicker and had improved joint reduction com- limited internal fixation. They found that the
pared with the open surgical group. outcomes between the two groups at 2 years
The role of arthroscopy is extending to were similar however the circular fixator group
include more complicated fractures, Chan et al had a shorter hospital stay, an earlier return of
reported good or excellent results in 16 of 18 function and a reduced number and severity
patients with Scatzker V or VI fractures treated of post-operative complications (Canadian
with arthroscopically assisted surgery (Chan Orthopaedic Trauma Society, 2006).
et al., 2003). In fractures with a depression of the articular
External fixation can be used as a temporary surface which has been elevated the resulting
fixation before definitive internal fixation or as a defect in the bone often requires bone grafting.
method of definitive fixation. Fixators can be This is usually achieved with autologous cancel-
monolateral, circular or hybrid, in some cases lous bone. Biomechanical and animal studies
span the knee joint and can be used in conjunc- have suggested that the use of calcium phos-
tion with limited internal fixation. phate cements may have improved ability to
Hybrid and circular fixators can be used prevent subsidence of the articular surface com-
for high energy, complex fractures. Their ben- pared to conventional bone graft (Yetkinler
efits over internal fixation are preservation et al., 2001; Welch et al., 2003; Trenholm
of soft tissues and early commencement of et al., 2005). Several clinical studies have
knee motion. This is weighed against the risk reported favourable results in treating lateral
of pin site infection and septic arthritis. Several tibial plateau fractures with the use of cal-
studies have shown good outcomes with hybrid cium phosphate cements (Lobenhoffer et al.,
fixators in Schatzker V and VI fractures 2002; Horstmann et al., 2003; Simpson and
(Stamer et al., 1994; Gaudinez et al.,1996; Ali Keating, 2004).
et al., 2001). A number of studies have shown Post-operatively the emphasis is on early pas-
similarly encouraging outcomes in complex sive range of movement exercises to regain
fractures treated with circular fixators joint motion and nourish articular cartilage.
(Dendrinos et al., 1996; Mikulak et al., 1998; Weight bearing will depend on the fracture

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Fenton and Porter 185

pattern, method of fixation and surgeon prefer- Lobenhoffer, 1993), peroneal nerve injury and
ence. It will be guided by serial radiographs. avascular necrosis of articular fragments.
In certain situations some surgeons advocate
supplementing fixation with a cast brace.
Outcomes
Long term data on outcomes after tibial plateau
Complications
fractures is limited. Rademakers et al. (2007)
Complications following tibial plateau fractures studied 109 patients with a mean of 14 years
can be secondary to the initial injury or the sub- follow up. All patients were treated operatively.
sequent treatment. Mean range of movement was 135 , secondary
Knee stiffness can be a significant problem; arthritis developed in 31% with an increased
factors that contribute to its development incidence in those with over 5 of malalignment.
include initial injury, surgery, scarring and Results were better in monocodylar compared to
immobilisation. The risk of stiffness developing bicondylar fractures.
is reduced by early fixation with attention to soft
tissue handling and early post-operative mobili-
sation of the joint.
Summary
Infection rates are reported between 2% Tibial plateau fractures though uncommon can
(Wadell et al., 1981) and 11% (Muller et al., present a significant challenge to the operating
1992). Barei et al. (2004) reported an 8.4% surgeon. Following initial management and
deep infection rate in 83 patients with high identification of associated injuries judicious
energy bicondylar fractures treated with dual use of appropriate imaging allows the extent of
incision plating. Attention to the timing of sur- the injury to be defined. Treatment will be
gery, site of incision in relation to soft tissue guided by the fracture personality, patient
injuries, meticulous soft tissue handling and comorbidities and operative experience of the
use of percutaneous techniques where appropri- surgeon. Management can vary from conserva-
ate can reduce the risk of infection. tive therapy in cast brace for minimally dis-
Secondary osteoarhritis can result from chon- placed stable fractures to complex joint
dral damage at the time of the initial injury, reconstruction utilising internal fixation, circular
residual articular discontinuity or disruption frames or both. In cases with significant joint
of the mechanical axis post-operatively. depression bone graft is often required.
Honkonen (1995) reported a rate of secondary Following surgery knee stiffness and secondary
arthritis of 44% at a mean of 7.6 years post- osteoarthritis can be significant problems. To
injury. The incidence of arthritis was increased date long-term data regarding outcomes follow-
in patients who underwent meniscectomy com- ing tibial plateau fractures is limited.
pared to those with intact or repaired meniscus.
Malunion can result from inadequate ini-
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