TIBIAL PLATEAU

FRACTURES

MODERATOR : Dr. MAHESH D V

PRESENTER : Dr. PRASHANTH H K
 INTRODUCTION

• One of the commonest intraarticular fractures

• 1%

• Meniscal tears and ligament injuries should be

assessed
 ANATOMY OF PROXIMAL TIBIA
• Tibial plateau is the proximal
end of tibia including
metaphyseal, epiphyseal
regions as well as articular
surfaces.

• AO defines tibial plateau as

metaphysis to a distance
equal
to the width of the tibia at
the
joint line.
LIGAMENTS AROUND KNEE JOINT
 ANATOMY OF TIBIAL PLATEAU
• Tibial plateau composed of articular surfaces of medial and
lateral Tibial plateaus, on which cartilagenous menisci are
present
• Normal tibial plateau has Posterio - inferior slope of 5-7
degrees (Posterior proximal tibial angle)
 LATERAL MENISCUS
• C-shaped
• Attached to PCL via ligaments
• Humphry (anterior) Wrisberg (posterior) No attachment to
LCL

 MEDIAL MENISCUS
• Semicircular
• Covers 50 % of the plateau
• Thick posteriorly, so promoting
posterior stabilization.
• Intimately attached to MCL
BONY PROMINENCE NEAR TIBIAL PLATEAU

• ANTERIORLY-: TIBIAL TUBERCLE

Patellar tendon insertion

• ANTEROLATERALLY:- GERDY’S TUBERCLE

Insertion of Iliotibial band

• ANTEROMEDIALLY:- PES ANSERINUS

Attachment of Medial Hamstrings
Sartorius
Gracillis
Semitendinosus
 NEUROVASCULAR STRUCTURE

 COMMON PERONEAL NERVE:

• The common peroneal nerve courses around the neck of
the fibula distal to the proximal tibia-fibular joint before it
divides into its superficial and deep branches

 POPLITEAL ARTERY :
• The trifurcation of the popliteal artery into the anterior
tibial, posterior tibial, and peroneal arteries occurs
posteromedially in the proximal tibia.
 MECHANISM OF INJURY
• Strong valgus or varus forces combined with axial
loading
• Explosive severe comminuted fractures
• Fall from height on extended knee
• High energy motor vehicle accident
• Magnitude of force – degree of communition and
displacement.
• Location of fracture- degree of flexion and
extension
 MECHANISM OF INJURY
1.Force directed medially (valgus force) or laterally (varus force) or
both

Split fracture + collateral ligament tear

2. Axial compressive force

Depression fracture

3.Both axial force and force from the side

Split + depression fracture +/- collateral ligament tear

 MECHANISM
Valgus force Varus force

MCL acts as hinge LCL acts as hinge

Lateral femoral condyle Medial femoral condyle

presses over lateral plateau presses over medial plateau

Exerts shearing and axial Exerts shearing and axial

forces forces

Lateral plateau fracture Medial plateau fracture

 INCIDENCE
• 8% OF ALL ADULTS FRACTURE

TIBIAL PLATEAU
FRACTURES

LATERAL PLATEAU MEDIAL PLATEAU

( 55 – 70 % ) ( 10 – 25 % )

BICONDYLAR
( 10 – 25 % )
BUMPER FRACTURE OR FENDER FRACTURE

• Cotton and Berg -1929

• Fracture of Tibial lateral

condyle caused by a forced
valgus applied to the knee

• Combination of abduction
and compression forces
 BUMPER FRACTURE
• Lateral part of the
distal femur and lateral
tibial plateau come in
contact causing the
tibia to fracture.

• Mechanism of injury :
forced valgus of knee
when struck from side
by car bumper.
 CLASSIFICATION

 Hohl and Moore

 Moore

 AO/OTA

 Schatzker’s

 Three column classification

HOHL AND MOORE
Moore classification
 AO / OTA CLASSIFICATION

• Type A : Extra articular ( 41 - A)

• Type B : Partial Articular ( 41 - B)

B1 : Pure split
B2 : Pure depression
B3 : Split depression

• Type C : Intra-articular and Metaphyseal (41 - C)

C1 : Simple articular, Simple metaphyseal
C2 : Simple articular, Multifragmentary metaphyseal
C3 : Multifragmentary articular
AO / OTA CLASSIFICATION
SCHATZKER’S CLASSIFICATION
 TYPE I : SPLIT FRACTURE
• Typical wedge shaped
uncommunited fragment is
split off and displaced
laterally and downwards
• Common in younger patients
• No articular depression
• Lateral tibia plateau is
involved
• Low velocity injury
 TYPE II - SPLIT DEPRESSED FRACTURES

• Lateral plateau involved

• Lateral wedge split +
articular surface
depression down into
metaphysis
• Elderly patients
• Low velocity with lateral
bending force
TYPE III – PURE CENTRAL DEPRESSION WITH
LATERAL CORTEX INTACT
• Occur in osteoporotic
bone
• Low velocity injury
• Fractures may be stable
or unstable depending on
size and degree of
depression and coverage
by lateral menisci
 TYPE IV –MEDIAL CONDYLE FRACTURE
• Split wedge / communited /
depressed
• Varus+ axial loading combination
in intermediate to high energy
trauma
• Often associated with sift tissue
injuries and ligament injuries like
cruciate ligaments
collateral ligaments (usually
lateral)
peroneal nerve and vessel
injuries
 TYPE V – BICONDYLAR FRACTURE
• Both sides split
• Varying degree of depression
and displacement
• Common pattern is
medial condyle –split
lateral condyle – split
depressed or depressed
• High velocity injuries
• Evaluate neuro-vascular
injuries
 TYPE VI - PLATEAU FRACTURE WITH
METAPHYSEODIAPHYSEAL DISSOCIATION

• High energy trauma

• Explosive fracture with joint
disruption, combination ,
depression and displacement\
• Often associated with
soft tissue compromise of the
knee
compartment syndrome
neurovascular compromise
• Unstable fracture
 THREE COLUMN CLASSIFICATION
 Zero column # :- Pure articular
depression = Schatzker type III
 1 column # = Schatzker type I
and II
 2 column # = Schatzker type IV
 3 column # = Schatzker type V
and VI , Atleast 1 independent
articular fragment in each of
these 3 columns
 CLINICAL PRESENTATION
• High energy injury
• Pain
• Swelling
• Deformity
• Instability
• Fat in blood aspirated
 FEATURES OF HIGH VELOCITY INJURIES

• Fracture blisters
• Compartment syndrome
• Neurovascular injuries
• Medial plateau fracture
• Bi condylar fracture
• Metaphysio-diaphyseal dislocation
 FEATURES OF LOW VELOCITY INJURIES

• Lateral tibial condyle + articular depression

• No associated injuries
• Limited active and passive movements of knee
• Tenderness over proximal tibia and joint line
 EVALUATION OF INJURY

 Clinical Evaluation:-
• Neurovascular examination to rule out any
neurological or vascular injury (peroneal nerve
or popliteal artery injury)
• Assessment for any ligament injury
• Assessment for compartment syndrome
• Assessment for Haemarthrosis
 INVESTIGATIONS

 Plain x- ray
 CT scan
 MRI
 Angiography
 Arthroscopy
 X - RAY
• AP and lateral views
• In doubtful cases- 15 degrees AP oblique view
inclined caudally
• Internal oblique view 40 degree -> lateral
plateau
• External oblique view -> medial plateau
• Traction films and stress x rays -> efficacy of an
applied ligamentotaxis force
 X - RAY
• 10 degree caudally tilted plateau view
(articular surface)
 CT SCAN
• Extent of injury in an articular surface or in
comminuted fracture but limited information
about soft tissue status

• CT with leg in traction -> ligamentotaxis

3D CT RECONSTRUCTION
 MRI SCAN
• Better status of associated soft tissue injuries
• Traction MRI is more useful
MRI
 ANGIOGRAPHY
• Alteration of distal pulses
• Suspected arterial lesion
• High energy trauma
• Fracture dislocations
• Unexplained compartment syndrome
 ROLE OF ARTHROSCOPY
• Diagnostic
 In assessing the degree of injury to menisci,
collateral and articular surfaces.

• Therapeutic
 In meniscectomy and its repair,particularly in
lateral condyle fracture.
 Removal of loose bodies
 ASSOCIATED INJURIES
• 90% of these fractures associated with Soft tissue
injuries
• Meniscal tears occurs in 50% of these fractures
• Associated ligamentous injuries (cruciate or
collateral) occur in 30% of these fractures
• Others :
 common Peroneal nerve – very rare
 Popliteal artery injury – Type IV – TYPE VI 15-20%
 TREATMENT
 AIM :
• Restore articular congruity
• Restore axial alignment
• Restore stability
• Restore early joint motion and function

 GOAL
To obtain a stable, aligned, painless mobile joint and to
minimise post traumatic OA to achieve optimal knee
function
 PRINCIPLES OF TREATMENT
• Fracture immobilised for more than 4 weeks leads to joint
stiffness
• IF + Immobilisation – more stiffness
• Regardless of treatment , knee joint should be mobilised early.
• Impacted articular fragments cannot be dislodged by traction
or manipulation alone, because there is no soft tissue
attachment to lever them up
• Depressed articular surface doesn’t fill with hyaline cartilage so
depressed fractures -> correct surgically
• Anatomic reduction and stable fixation is needed for cartilage
regeneration
• If ORIF is indicated and patient refuses surgery then fracture
should be treated with skeletal traction and early motion
 MODALITIES OF TREATMENT
 CONSERVATIVE :
• Closed reduction and pop
• Skeletal traction and mobilization
• Functional brace
• Aspiration of knee
• Guarded weight bearing

 SURGERY :
• Percutaneous cc screw fixation
• ORIF with cancellous screws and bone grafting
• ORIF with buttress plate and screws
• ORIF with buttress plate and screws and bone grafting
• External fixator / Hybrid ex fix / ilizarov ring fixator
• Arthroscopic assisted internal fixation
• MIPPO
 Conservative management
 RELATIVE INDICATIONS :

• Non displaced/ incomplete fractures

• Minimally displaced stable lateral plateau fracture
• Elderly osteoporotic pts with unstable plateau fractures
• Infected and old fractures
• Non ambulatory patients
• Anterior plateau fracture < 5 mm depression and posterior
depression < 10mm
• Patient refusal
 GOAL – Restoration of axial alignment and
knee motion
• Unacceptable if malalignment more than 7
degrees in mediolateral plane
• No varus valgus instability, greater than 5-10
degrees at any point in the arc of motion,
from full extension to 90 degrees of flexion
when compared to the opposite side
 NON-OPERATIVE TREATMENT
 INDICATIONS :
• Non-displaced or minimally displaced fractures
• Without any ligament injury
• In pts with advance osteoporosis .
 Immobilization with cast or brace for a week followed by early
range of knee motion in a hinged knee brace along with skeletal
traction
 SURGERY
Treatment of choice in Displaced , unstable,
incongruous , misaligned tibial plateau fractures

 INDICATIONS
• Displacement (joint depression > 5mm)
• Instability
• Bicondylar fractures
• Open fractures
• Compartment syndrome
 TIMING OF SURGERY
• Absolute indications mentioned previously need
emergency surgical management
• Displaced , unstable fractures that occur in blunt multiple
trauma should be stabilised asap
• In critically ill patients and in patients with soft tissue
destruction

 Percutaneous / limited approach and fixation of the joint

surfaces combined with temporary joint bridging external
fixation
 Simple joint bridging external fixation or distal tibial pin
traction is favoured
 SURGICAL APPROACHES
 Anterior
 Anterolateral
 Minimal access Anterolateral
 Posteromedial
 Combined posterior and anterolateral
 ANTERIOR APPROACH
• A longitudinal incision
on anterior surface of
leg parallel to anterior
border of tibia and 1 cm
lateral to it is made
 ANTERO – LATERAL APPROACH

• Used for ORIF of lateral plateau

• S shaped incision starting
approximately 3-5 cm proximal
to joint line
• Staying just lateral to patellar
tendon
• Incision is curved anteriorly
over Gerdy’s tubercle and it is
extended distally ,1cm lateral to
anterior border of tibia.
 MINIMAL ACCESS ANTERO – LATERAL APPROACH

• 2 incisions are made

• Proximal incision start just
proximal and lateral to Gerdy’s
tubercle and extended distally in
a curvilinear fashion for 5-6 cm
• Distal incision is 5-6 cm
longitudnal incision, 2 cm lateral
to tibial crest
• Then an epiperiosteal plane is
developed to connect the two
incisions running along the
lateral border of tibia
 POSTERO – MEDIAL APPROACH

• For ORIF of fracture

Medial tibial plateau
• A 6 cm longitudnal
incision over the postero –
medial border of proximal
tibia is made and then
subcutaneous fat is incised
and Pes Anserinus is
divided and retracted
POSTERO - MEDIAL APPROACH
 COMBINED POSTERIOR AND ANTERO -
LATERAL APPROACH
• Used primarily for three
column fixation.
• Reverse L shaped
incision combined with
antero lateral approach.
• Safe and effective in
treating complex
Schatzker V and VI tibial
plateau fractures.
 IMPLANT OPTIONS
• Choice of implant is related to the fracture pattern,
degree of displacement and the familiarity of surgeon
• Plate and screw
• Buttressing against shear forces or neutralizing
rotational forces
• Screw alone
• Simple split
• Depressed fracture elevated percutaneously
• External fixator
• Thinner plates
 EXTERNAL FIXATORS

1. BRIDGING EXTERNAL FIXATOR

2. HYBRID EXTERNAL FIXATOR
3. RING EXTERNAL FIXATOR
 BRIDGING EXTERNAL FIXATOR
 INDICATION:
• Open fracture with severe soft
tissue injury
• Joint instability
• Polytrauma
• Severe soft tissue compromise
• Serious medical co-morbidity

 Contra indication
osteoporosis
 BRIDGING EXTERNAL FIXATOR
 ADVANTAGES :
• Soft tissue friendly
• Fast procedure
• Restore and maintain length
• Restore axial alignment
• Improves position of bone fragment by ligamentotaxis

 DISADVANTAGES:
• Risk of pin tract infection Risk of knee stiffness
• Technique :
Two 5-mm half-pins in distal femur, two in distal tibia
axial traction applied to fixator
fixator is locked in slight flexion
 HYBRID EXTERNAL FIXATOR

• Indication
• Severe open fracture
• Major joint instability
• Severe soft tissue
compromise, not permitting
definitive internal fixation
• Post-operative care
• weight bearing should be
allowed only when callus is
visible on radiographs
HYBRID EXTERNAL FIXATOR
 HYBRID EXTERNAL FIXATOR
• With increasing soft tissue injury and communition –
lateral buttress plate with a simple half pin ex fix
medially provides substitution for medial buttress plate
• One or two percutaneous half pins are placed proximally
and parallel to the articular surface of the knee joint
medially and are connected with simple monolateral
frame to one or two distally placed half pins.
• Ex fix is maintained for 6-10 weeks
• As severity of soft tissue injury increases -> hybrid ex fix
• Small diamter tensioned wires placed proximally and
half pins placed distally
 HYBRID EXTERNAL FIXATOR
 ADVANTAGES :
• Minimal devitalisation
• Maintain length and alignment
• Allows secondary correction of angular and rotational
deformities
• Allows partial weight bearing
• Range of movements can be initiated immediately

 DISADVANTAGE :
• Relies on ligamentotaxis , usually doesn’t reduce impacted
articular surface
 TREATMENT
 SCHATZKER’S TYPE 1

• Preop - evaluate with MRI or intraoperative arthroscopy

• If peripheral tear with incarceration of menisci into
fracture site - ORIF with repair of menisci
• If menisci intact - closed reduction and percutaneous
fixation with cc screws
• Reduction achieved by varus stress on the knee
manually or by applying a femoral distractor. Reduction
maintained by large pointed reduction forceps.
Reduction achieved by 6.5 to 7mm cannulated screws
 SCHATZKER’S TYPE I
• Closed reduction with
6.5mm cancellous lag
screw with washer to
gain compression
• In young patient, screw
fixation is adequate
• In elderly, buttress plate
is required
 SCHATZKER’S TYPE II
• Depression anterior or central

• Approach : straight or lateral parapatellar incision

• Anterior compartment muscles elevated
• Joint exposed by sub meniscal approach
• Impacted fragments accessed
• Fracture fragments disimpacted elevated and supported
with bone graft
• Joint reduced
• Intact minimally communited lateral condyle
• Cancellous screw fixation with or without washer
 SCHATZKER’S TYPE II
• Via anterolateral approach ,
open reduction and elevation
of the depress fragment
• Bone graft is placed to support
the elevated fragment
• Temporarily held with k- wire
• Fixed with lateral buttress plate
& cancellous screws
 SCHATZKER’S TYPE III
• Less invasive method
• Depressed surface is visualised with c arm or
arthroscopy
• Small anterolateral incision is made to open a
bone window and surface is elevated from below
and is supported by bone graft
• Fracture reduced and 6.5 to 7mm lag screws or
multiple 3.5 mm screws inserted parallel to
articular xurface to prevent collapse
 SCHATZKER’S TYPE III

• Elevation of depressed
articular fragment through
a metaphyseal window
• Bone grafting to support
the fragment
• Fixation Subchondral
plate/ screws
 SCHATZKER’S TYPE IV
• Type IV A:
Closed reduction and percutaneous screw fixation

• Type IV B:
ORIF with buttress plate and cannulated screws

If intercondylar eminence with cruciste ligaments avulsed ->

lag screw
-> loop wire
-> suture and secured through drill hole in the
anterior cortex
 SCHATZKER’S TYPE IV

• These fractures tend to

angulate in varus , these are
fixed with medial butress
plate and cancellous screws
 SCHATZKER’S TYPE V AND VI
• In patients with good bone stock and moderate soft
tissue damage -> lateral buttress plate extraperiosteally

• If medial condyle fragment is not communited at its

base , it usually reduces with ligamentotaxis and
fragments can be controlled using lag screw from the
laterally placed plate

• If medial condyle is communited at its base a small

plate is used extraperiosteally on the posteromedial
tibial surface to prevent varus malalignment
Treatment based on Schatzker’s
 THREE COLUMN FIXATION
• Multiplanar complex tibial
plateau fractures, specially
posterior column- difficult
to manage.
• This technique – stresses
on posterior column
fixation.
• Uses combination
approach – posterior and
anterolateral approach
 THREE COLUMN FIXATION
• Pt.is placed in floating
position.

• Safe and effective approach

for management of
Schatzker’s type V and type
VI tibial plateau#
• Three column fixation
(Graphic representation)
ARTHROSCOPICALLY ASSISTED REDUCTION AND
FIXATION OF TIBIAL PLATEAU FRACTURE

• Arthroscopically assisted reduction and fixation

techniques are being used with increased
frequency, for treatment of Schatzker‘s type I ,II,
III Tibial plateau fractures.

• Arthroscopic techniques require minimal soft

tissue dissection , afford excellent exposure of
articular surface and can be used to diagnose and
treat concomitant meniscal and ligament injury.
 OPEN FRACTURES
• Uncommon although subcutaneous
• Wound almost always anterior with exposure of extensor
mechanism

• Irrigation and debridement

• Broad spectrum antibiotics
• Primary closure
• No primary closure in : exposed joint
exposed patellar tendon

• In patient’s with multiple injuries - > Bridging half pin external

fixator
• Subsequent surgery -> Hybrid external fixator
 VASCULAR INJURIES
• Common in Schatzker’s Type IV, V, VI
• Direct laceration or contusion of the artery or
vein by fracture fragment or indirectly
stretching leading to intimal damage
• Indications of arteriography
 Absent or diminished pulses
 Expanding hematoma or bruits
 Progressive swelling
 VASCULAR INJURIES
 Treatment of arterial injury depends on
Severity of ischemia
Time elapsed since injury

 If arterial compromise is severe and the time

elapsed since injury is more than 6 hrs
Circulatory establishment
Bridging external fixator
Fasciotomy
 LIGAMENTOUS INJURY
• Commonly :
MCL injuries
Meniscal tears
ACL disruption
• In presence of fracture , diff for primary
ligament repair ,ligament augmentation and
formal reconstruction
• Prolong operation time and chance of infection
 LIGAMENTOUS INJURY
• Initially non operative treatment is
recommended
• Protected motion in hinged knee brace with
rehabilitation
• In patients with persistent functional disability
late ligament reconstruction once the fracture
heals and the hardware is safely removed.
 POST OPERATIVE CARE
1. Antibiotic administration is confirmed.
2. Drain is removed after 48hrs.
3. Posterior above knee slab or hinged knee brace for 3 to 4
days.
4. If fixation is stable , a continuous passive motion
machine is recommended.
5. This enchances
 Knee motion
 Decreased limb swelling and
 Improved cartilage nutrition.
 FOR SCHATZKER TYPE I, II AND III FRACTURES

1. Non weight bearing - 4 to 8wks until there is

radiographic evidence of healing & graft
incorporation

2. Partial weight bearing – another 4 to 6 wks

3. Full weight bearing – at 3 months

 IN PATIENTS WITH SOFT TISSUE INJURY :

1. Timing and degree of knee motion is delayed

2. CPM machine is used even if motion is set to
only 20 – 30 degree flexion
3. Alternatively a hinged knee brace that
permits controlled motion can be used.
4. Weight bearing delayed for 8 to 12 wks until
there are radiographic evidence of fracture
consolidation
 COMPLICATIONS
 EARLY :

1. Bleeding
2. Infection
3. Compartment syndrome
4. Nerve injury
5. Vascular injury
6. Pain
7. Swelling
8. Loss of reduction
9. Arthrofibrosis
 COMPLICATIONS
 LATE :
1. Non union
• Most common in Schatzker type IV
• Severe Communition
• Unstable fixation
• Failure to bone graft
• Infection

TREATMENT
 Aseptic non union - bone grafting
 Infected non union – antibiotic impregnated beads,
rotational flaps or external fixator
 LATE COMPLICTAIONS

2. Post traumatic arthritis

• Due to articular incongruity
• Malalignment

TREATMENT :
 Unicompartmental – alteration in mechanical
axis with corrective osteotomies
 Bi / tricompartmental – arthrodesis or Total
knee replacement ( TKR)
 LATE COMPLICTAIONS

3. KNEE STIFFNESS
• Due to damage to extensor retinaculam
• Joint surface incongruity
• Arthrofibrosis of the knee or patella femoral joint
• Prolonged immobilization

TREATMENT:
 Aggressive ROM exercise
 Arthroscopic lysis of adhesions and gentle manipulation
 OTHER LATE COMPLICATIONS

4. Implant breakage

5. Mal-union

6. Knee instability
Thank you