Injury 53 (2022) 1260–1267

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Injury
journal homepage: www.elsevier.com/locate/injury

Proximal tibia fracture dislocations: Management and outcomes of a

severe and under-recognized injury ✩
Lukas G. Keil a,∗, Brian H. Mullis b, Paul Tornetta III c, Maxwell C. Alley c,
Nathan P. Olszewski c, Jonathan A. Wheeler b, Ericka P. von Kaeppler d, Saam Morshed d,
Robert N. Matar e, Michael T. Archdeacon e, Tyler W. Smith f, Anna N. Miller f,
Daniel S. Horwitz g, Mirza Shahid Baig g, Zachary L. Telgheder h, Emil Azer h,
Givenchy W. Manzano i, Heather A. Vallier i, Scott A. Barnett j, Peter C. Krause j,
Troy D. Bornes k, William M. Ricci k, Patrick J. Dunne l, Seth R. Yarboro l, Alexander J. Ment m,
Andrew J. Marcantonio m, Rashed S. Alqudhaya n, Ross K. Leighton n, Robert F. Ostrum a
a
Departmentof Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, United States
b
Indiana University Department of Orthopaedics, Indianapolis, IN
c
Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, United States
d
Department of Orthopaedic Surgery, University of San Francisco, California, San Francisco, CA, United States
e
Department of Orthopaedics & Sports Medicine, University of Cincinnati Medical Center, Cincinnati, OH
f
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, United States
g
Department of Orthopaedic Surgery, Geisinger Health System, Danville, PA, United States
h
SUNY Upstate Medical University, Syracuse, NY, United States
i
Department of Orthopaedic Surgery, MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, OH, United States
j
Department of Orthopaedic Surgery, Louisiana State University, New Orleans, LA, United States
k
Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, United States
l
Department of Orthopaedics, University of Virginia, Charlottesville, VA, United States
m
Department of Orthopaedic Surgery, Lahey Hospital and Medical Center, Burlington, MA, United States
n
Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in
Accepted 17 September 2021 the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate
reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with
Keywords: bicondylar tibial plateau fractures (BTPFs).
Proximal tibia fracture dislocation Methods: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America.
Tibial plateau fracture In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified
Knee fracture dislocation using the Moore classification. These were reviewed by an adjudication board of three traumatologists
Level of Evidence to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications,
Prognostic Level III (retrospective cohort
malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data
study)
from a previous study.
Results: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures
reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%).
Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had menis-
cal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs
9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not
clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts.
Conclusions: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go un-
recognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.
© 2021 Elsevier Ltd. All rights reserved.

✩ ∗
Authorship and Contribution: All authors named above contributed substan- Corresponding author at: 130 Mason Farm Road, CB# 7055, UNC School of
tially to study design and/or data acquisition, contributed to manuscript revision Medicine, Chapel Hill, NC 27599-7055.
and final approval, and agree to be accountable for all aspects of the work. E-mail address: lukas.keil@unchealth.unc.edu (L.G. Keil).

https://doi.org/10.1016/j.injury.2021.09.035
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Fig. 1. AP and lateral radiographs and representative coronal CT sections of the three most common types of proximal tibia fracture dislocations (PTFDs): Moore type 1
(split, top), type 2 (entire condyle, middle), and type 5 (four-part, bottom).

Introduction cated repair of ligamentous and meniscal injuries commonly asso-

Proximal tibia fracture dislocations (PTFDs) are a severe subset
of tibial plateau fractures in which bony and ligamentous injuries
destabilize the knee. They were first described by Mason Hohl in
an instructional course lecture for the American Academy of Or-
thopaedic Surgeons (AAOS) in 1967 [1]. At that time, Hohl advo-
ciated with these fractures.
Fracture dislocations of the knee were later classified by Till-
man Moore in 1981 and contrasted both with tibial plateau frac-
tures without femorotibial dislocation and with knee disloca-
tions without an associated fracture [2]. Moore described knee
fracture-dislocations as type 1 (split), type 2 (entire condyle),

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Table 1
Demographics and injury characteristics of proximal tibia fracture dislocations (PTFDs) versus bicondylar tibial plateau fractures.

Bicondylar Plateau
PTFD(n = 187∗ ) Fracture(n = 1297∗ ) p-value†

Age at injury in years, mean 48 (16) 50 (14) 0.056

(SD)
Sex, n (%) 0.186
Female 82 (44) 541 (46)
Male 105 (56) 647 (54)
Body mass index in kg/m2 , 29 (7) 30 (7) 0.914
mean (SD)
Injury Severity Score, mean 10.3 (6.8) 10.5 (7.0) 0.508
(SD)
Mechanism of injury, n (%) <0.001
Fall from height 73 (39) 418 (32)
Fall from standing 12 (6) 205 (16)
MVC 31 (17) 230 (18)
MCC 29 (16) 255 (20)
Pedestrian vs auto 10 (5) 94 (7)
Other 32 (17) 80 (6)
Laterality, n (%) 0.115
Left 98 (52) 662 (51)
Right 89 (48) 634 (49)
Condylar involvement, n (%) N/A
Lateral only 8 (4) 1297 (100)
Medial only 53 (28)
Bicondylar 126 (67)
Open fractures, n (%) 7 (4) 123 (9) 0.009
Compartment syndrome, n (%) 18 (10) 166 (13) 0.255
Ipsilateral bony injury, n (%) 24 (13) 245 (19) 0.042
Preoperative neurologic deficit,
n (%)‡ 7 (4)
Peroneal nerve 4 (2)
Tibial nerve
Vascular injury requiring repair, 2 (1)
n (%)‡
∗
Missing data in some cells, percents reflect individual denominators.
†
Chi-squared test for categorical variables, Wilcoxon rank sum (Mann-Whitney U) test for continuous variables.
‡
Data not collected in the bicondylar plateau fracture study.

type 3 (rim avulsion), type 4 (rim compression), or type 5
(four-part).
Moore Type 1 (split) fractures may be mistaken for Schatzker 4
fractures, but rupture of the lateral collateral ligament allows the
lateral femoral condyle to dislocate and become impacted into the
fracture (Fig. 1). Medial or lateral Type 2 (entire condyle) fractures
are characterized by displacement of an entire condyle including
the tibial spines with rupture of the opposing collateral ligament,
permitting dislocation (Fig. 1). Type 5 (four-part) fractures may be
mistaken for Schatzker VI fractures, but with separation of the tib-
ial eminence from the shaft and from both condyles (hence four-
part), separating all major stabilizing ligamentous structures of the
knee from one another (Fig. 1). The hallmark of many PTFDs is dis-
placement of the entire lateral tibial articular surface lateral to the
lateral femoral condyle.
Moore noted that (as for tibial plateau fractures) the primary
goal of surgical treatment is restoration of stability to the knee.
However, unlike in plateau fractures without dislocation, in PTFDs,
restoring stability may require repair of ligamentous structures in
addition to fixation of osseous injuries, which may a separate sur-
gical approach.
While Schatzker [3] and Orthopaedic Trauma Associa-
tion/Arbeitsgemeinschaft für Osteosynthesefragen (OTA/AO)
[4] remain the most commonly used classification systems,
neither takes into account femorotibial dislocation or associated
ligamentous injuries [5]. As many as one third of proximal tibia
fractures have been shown to be unclassifiable by experienced
traumatologists using either system [6,7,8,9].
We hypothesized that PTFDs are inconsistently recognized even
by traumatologists and although PTFDs often affect the articular
surface of only one condyle, that their clinical outcomes of align-
ment, range of motion and complications would be comparable
to or worse than bicondylar tibial plateau fractures (BTPFs). This
study was approved by Institutional Review Boards at all sites.
Materials and methods
This was a retrospective cohort study conducted at 14 level 1
orthopedic trauma centers throughout North America. No funding
was obtained for this study. All proximal tibia fracture dislocations
available in the medical records at each site from 2001 through
2019 were included; there were no exclusion criteria. All proximal
tibia fractures were identified via search for Current Procedural
Terminology (CPT) codes 27535 and 27536 for open treatment of
unicondylar and bicondylar tibial plateau fractures, respectively, as
well as review of trauma registries at participating institutions. The
Moore classification was provided to each center to ensure that all
reviewers were using the same classification. orthopedic trauma
surgeons at each site reviewed imaging for all proximal tibia frac-
tures to identify PTFDs, defined as the injuries described in the
Moore classification. Those fractures identified by these centers as
possible PTFDs were then independently reviewed by an adjudica-
tion board composed of two attending traumatologists with a third
as a tie-breaker in cases of discrepancy. All injuries determined by
the adjudication board to represent PTFDs as defined by the Moore
classification were included and composed the study sample. Data
collected via chart review included demographics, injury character-
istics, management, complications, and functional outcomes. De-
mographics included age at time of injury, sex, and BMI. Injury
characteristics included injury severity score (ISS), mechanism of
injury, laterality, condylar involvement (medial, lateral, both), open
fracture diagnosis, compartment syndrome diagnosis, any ipsilat-

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Table 2
Management and outcomes of proximal tibia fracture dislocations (PTFDs) versus bicondylar tibial plateau fractures.

Bicondylar Plateau
PTFD(n = 187∗ ) Fracture(n = 1297∗ ) p-value†

Ankle brachial index (ABI) 57 (30)

documented‡ 7 (4)
Abnormal (<0.9)
Postoperative neurologic deficit,
n (%)‡ 5 (3)
Peroneal nerve 1 (1)
Tibial nerve
Meniscal injury requiring repair, 72 (39)
n (%)‡ 67 (36)
Medial 3 (2)
Lateral 2 (1)
Both
Ligamentous repair performed, 11 (6)
n (%)‡ 9 (5)
Medial collateral ligament 2 (1)
Posterolateral corner
Temporary ex-fix used, n (%) 149 (80) 813 (63) <0.001
Plating, n (%) <0.001
Medial only 57 (31) 129 (10)
Lateral only 35 (19) 457 (37)
Dual plating 89 (49) 648 (53)
Wound dehiscence, n (%) 17 (9) 72 (6) 0.070
Wound infection, n (%) 26 (14) 118 (9) 0.038
Duration of follow-up in years, 1.0 (1.1) 1.5 (1.6)
mean (SD)
Time to radiographic union in 6 (7) 6 (8) 0.671
months, mean (SD)
Malunion, n (%)‡
Articular surface step-off 28 (15)
>3 mm 15 (8)
Articular surface gap >5 mm 12 (6)
Condylar widening >3 mm 6 (3)
Metadiaphyseal angulation >5° 2 (1)
Femorotibial subluxation
Range of motion at last
follow-up, mean (SD) 3° (5) 2° (4) <0.001
Extension 112° (19) 116° (39) 0.017
Flexion
Time to return to work in 7 (7) 9 (14) 0.195
months, mean (SD)
Knee limiting function at last 39 (24) 277 (24) 0.851
follow-up, n (%)
Need for assistive device at last 43 (24)
follow-up, n (%)‡
∗
Missing data in some cells, percents reflect individual denominators.
†
Chi-squared test for categorical variables, Wilcoxon rank sum (Mann-Whitney U) test for continuous variables.
‡
Data not collected in the bicondylar plateau fracture study.

eral bony injury, preoperative tibial or peroneal neurologic deficit,
and vascular injury requiring repair. As proximal tibia fracture dis-
locations are not included in the OTA/AO or Schatzker classifica-
tions, the Moore classification was used. Management characteris-
tics included documentation of ankle brachial index (ABI), meniscal
repair other than sub-meniscal arthrotomy and/or ligamentous re-
pair described in the operative note, use of temporary external fix-
ation, and medial/lateral/dual plating. Outcomes included wound
dehiscence and/or infection noted in any clinical documentation,
time to radiographic union, malunion (defined as articular surface
step-off >3 mm, articular surface gap >5 mm, condylar widen-
ing >3 mm, metadiaphyseal angulation >5°, and/or any femorotib-
ial subluxation), range of motion as documented at last follow-
up by the treating surgeon, time to return to work in months,
knee pain limiting function at final follow-up, and need for an as-
sistive device at final follow-up. All data were collected and ra-
diographic outcomes assessed by trained orthopedic surgeons and
researchers.
Study data were collected and managed using HIPAA-compliant
REDCap electronic data capture tools hosted at the primary site
[10,11]. Data from PTFDs were compared to data from a related
study on BTPFs collected from 18 institutions in the same format
[12]. The 18 institutions involved in the prior BTPF study were in-
vited to participate in the current study, but not all elected to do
so. Missing data points were omitted from statistical analysis; no
data imputation was used. Descriptive statistics, kappa for inter-
rater agreement, Chi-squared tests, and Wilcoxon rank-sum tests
were used for analysis. Significance was set at p<0.05.
Results
At 14 level 1 trauma centers 4771 proximal tibia fractures were
reviewed and 278 cases were identified by site reviewers as pos-
sible PTFDs. After adjudication board review, 187 were determined
to be PTFDs as described by Moore (4% of all proximal tibia frac-
tures reviewed, 67% of the cases submitted as possible PTFDs). The
remaining 91 injuries were determined to be proximal tibia frac-
tures without dislocation as described by Moore and were not in-
cluded in the study sample. Inter-rater agreement by the adjudica-
tion board was good (83%, kappa 0.6415).

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Fig. 2. AP and lateral radiographs of a proximal tibia fracture dislocation treated with dual plate fixation. Final radiographs show anatomic alignment and radiographic union.

The final sample of 187 PTFDs included 82 females (44%) and
105 males (56%) whose average age was 48 years (SD 16). Mean
BMI was 29 kg/m2 (SD 7). Mean injury severity score (ISS) was 10
(SD 7). These 187 PTFDs were compared to 1297 BTPFs from 18
sites. Mean age, sex, BMI, and ISS did not differ between PTFDs
and BTPFs (Table 1). PTFD mechanisms of injury included fall from
height (73, 39%), fall from standing (12, 6%), MVC (31, 17%), MCC
(29, 16%), pedestrian vs auto (10, 5%), and other (32, 17%). Mecha-
nisms of injury of PTFDs and BTPFs differed significantly (p<0.05),
with slightly more MVC, MCC, and pedestrian vs auto in the BTPF
group and more falls from height in the PTFD group (Table 1).
According to the Moore classification, there were type I (49,
27%), type II (71, 39%), and type V (63, 34%) fracture-dislocations.
Open fractures were less common among PTFDs than BTPFs (4% vs
9%, p = 0.009) although rates of compartment syndrome were sim-
ilar (10% vs 13%, p = 0.255). Ipsilateral lower extremity bony injury
was less common among PTFDs than BTPFs (13% vs 19%, p = 0.042,
Table 2).
Temporizing external fixation was used more commonly in
PTFDs than BTPFs (80% vs 63%, p<0.001). Plating techniques dif-
fered between PTFDs and BTPFs, with more medial-only plating
of PTFDs, while more lateral-only and dual plating was seen with
BTPFs (p<0.001, Fig. 2).
Repair of one or more ligamentous structures was performed at
the time of fixation in 11 PTFDs (6%), including 9 medial collat-
eral ligament repairs (5%) and 2 posterolateral corner repairs (1%).
Meniscal injury requiring repair occurred in 72 PTFDs (39%), in-
cluding 67 (36%) lateral meniscal injuries, 3 (2%) medial, and 2 (1%)
both. Ankle brachial index (ABI) was documented in only 57 PTFDs
(30%) and was concerning for vascular injury (ABI <0.9) in 7 of 57
(12%). Vascular injury requiring repair occurred in 2 PTFDs (1%).
Preoperative neurologic deficit was documented in 8 PTFDs (4%),

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Fig. 3. AP and lateral radiographs of a proximal tibia fracture dislocation treated by an orthopedic traumatologist with medial plate fixation. Final radiographs show malunion
with an articular surface gap >5 mm and step-off >3 mm.

including 7 peroneal palsies (4%) and 4 tibial nerve palsies (2%).
Some of these improved postoperatively with 5 persistent peroneal
palsies (3%) and 1 persistent tibial palsy (1%).
Mean follow-up postoperatively was 1.0 years (SD 1.1) among
PTFDs and 1.5 years (SD 1.6) among BTPFs. There was a trend to-
wards more wound dehiscence among PTFDs than BTPFs (9% vs 6%,
p = 0.070). Wound infection was more common among PTFDs (14%
vs 9%, p = 0.038). Time to radiographic union was similar with
mean 6 months (SD 6 months) in each group. Malunion occurred
in 25% of PTFDs (Fig. 3); objective measurement of malunion was
not performed in the BTPF cohort. PTFD malunions included ar-
ticular surface step-off >3 mm in 28 patients (15%), articular sur-
face gap >5 mm in 15 (8%), condylar widening >3 mm in 12 (6%),
metadiaphyseal angulation >5° in 6 (3%), and femorotibial sublux-
ation in 2 (1%). None of the collected injury or management data
predicted malunion.
Range of motion (ROM) was statistically worse among PTFDs
(3–112° vs 2–116°, p<0.001 for extension and 0.017 for flexion),
but this 5° difference in arc of motion is of unclear clinical sig-
nificance. Time to return to work was similar between groups (7%
vs 9%, p = 0.195). The rate of knee pain limiting function at fi-
nal follow-up was the same between groups (24% in both cohorts,
p = 0.851), and 43 PTFDs (24%) continued to require an assistive
device at last follow-up.

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L.G. Keil, B.H. Mullis, P.T. III et al.
Discussion and conclusions
Fracture-dislocations of the knee have been mentioned infre-
quently in publications since 1981. The term fracture-dislocation is
not often used to describe knee injuries, unlike other large joints
such as the shoulder, elbow, wrist, hip, and ankle. To our knowl-
edge this is the largest series of PTFDs investigating their inci-
dence, management, and outcomes as compared to other tibial
plateau fractures. To our knowledge, the largest series previously
published included 137 PTFDs among 279 tibial plateau fractures,
and PTFD diagnosis was noted to be a risk factor for numerous
complications [13].
In this study we found that PTFDs represent approximately 4%
of all proximal tibia fractures. The 67% inclusion rate, only 187 of
278 cases submitted by orthopedic traumatologists, suggests that
there is some disagreement with respect to the radiographic find-
ings of this injury. The fact that each center was given the Moore
classification to use and still only 2/3 of submitted cases were in-
cluded based on consensus may mean that the classification is
hard to apply, even by experienced surgeons, or that there are
cases that are transitional patterns between fractures and fracture-
dislocations. We found only 83% (good) inter-rater agreement be-
tween 2 orthopedic traumatologists with a particular interest in
these injuries. An important step in managing PTFDs appropriately
will be improving understanding and recognition of these destabi-
lizing injury patterns.
The few papers that have been published on the topic have pro-
posed alternative approaches and fixation strategies for these in-
juries. In a series of 42 patients Luo et al. proposed double me-
dial plating [14]. Galla and Lobenhoffer described a direct poste-
rior approach for the treatment of three Moore type 1 fracture
dislocation [15]. Lin et al. later published results of this type of
approach for the treatment of 16 patients (including 10 fracture-
dislocations) [16]. Fakler et al. later described two cases of a pos-
terior “Lobenhoffer” approach requiring less dissection than other
posterior approaches [17]. Lobenhoffer also described posterome-
dial and transfibular posterolateral approached for fixation of cer-
tain fracture patterns [18]. Of note, Moore stated that a direct pos-
terior approach was not performed for any patient in his origi-
nal series published in 1981. Finally, in a series of 29 type 2 (en-
tire condyle) fracture dislocations, Potocnik et al. advocated medial
fixation with a separate medial parapatellar mini-arthrotomy for
trans-osseus suture fixation of the eminence [19]. One series on
high energy tibial plateau fractures showed that patients treated
with double plating had a higher incidence of unplanned outcome
or post-operative complication [13].
In our cohort osseus fixation strategies varied widely, which
seems appropriate given the variety of injury patterns than can
constitute a PTFD. Medial-only plating is more common for PTFDs
than for BTPFs, likely due to the fact that type 1 and medial type
2 injuries are amenable to this fixation. Although posterior ap-
proaches have been advocated by several authors, none were per-
formed in this cohort.
Additionally, we found that the type of ligamentous repair ad-
vocated by Hohl and Moore was performed in only 6% of these
injuries in our series. It is possible that with modern osseus fixa-
tion strategies ligamentous repair may not be as critical, but it is
perhaps more likely that ligamentous repair was not performed in
many cases because the injuries were treated reflexively like other
proximal tibia fractures without dislocation. In addition, as with
lateral tibial plateau fractures with stretching of the medial collat-
eral ligament, it is possible that osseus fixation alone (medial in
many PTFDs) may allow the lateral ligamentous complex to heal
without clinical significance.
One third of PTFDs in this cohort affected the articular surface
of only one condyle, and they tended to occur from lower en-
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Injury 53 (2022) 1260–1267
ergy mechanisms and carry lower rates of open fracture and ip-
silateral injury than BTPF’s. However, they resulted in higher rates
of wound dehiscence and infection and slightly poorer ROM. De-
spite modern fixation techniques, the 25% rate of malunion and
24% need for an assistive device at one year in our series demon-
strates the severity of these injuries.
This study has a number of limitations. The unavailability of
certain data due to loss-to-follow-up is a weakness inherent to ret-
rospective studies. To avoid compromising the integrity of our data,
missing data points were omitted from statistical analysis; no data
imputation was used. No patient reported outcomes were collected
prospectively, limiting the ability of this study to evaluate injury-
related functional status postoperatively. Additionally, the relatively
short mean follow-up in these cohorts is a weakness common to
many orthopedic trauma studies in part due to the poor clinical
follow-up often observed in the populations at risk for these in-
juries. The multi-site nature of the study is both a limitation and
a strength. Comparison of data collected by different researchers
from different medical records can introduce bias, but the incor-
poration of subjects from 14 sites across the U.S. substantially im-
proves external validity, and the large number of patients allows
for more reliable conclusions.
In conclusion, traumatologists and other orthopedic providers
should take care to recognize injury patterns that constitute prox-
imal tibia fracture dislocations and differentiate these from pure
tibial plateau fractures. These injuries may necessitate ligament or
meniscal repair via a separate approach from that dictated by the
osseus injury pattern alone. Patients should be counseled about
the severity of these injuries and the incidence of wound complica-
tions, malunion, and persistent difficulty with ambulation. Further
study should focus on improving PTFD recognition and collecting
postoperative knee stability and patient reported outcomes so that
optimal fixation and ligament repair strategies can be determined.
Declarations of Competing Interest
None
Funding
None
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