1. Tibial plateau fractures
Published: August 2013
Brian Bernstein, ZA
AOT Basic Principles Course

2. Learning outcomes
Specify classification of tibial plateau fractures according to AO and Schatzker
Differentiate fractures with and without ligamentous injuries
Describe the management of tibial plateau fractures with soft-tissue injuries
Outline the principles of the management of proximal tibial fractures as intraarticular injuries
Discuss advantages and disadvantages of available implants
Teaching points:
Utilizing a management concept for each patient and planning each surgical procedure avoids complications and gives the orthopedic surgeon security in contemplating each step of treatment for which he or she is totally responsible.

3. Objectives Understand complexity Appreciate mechanics Classify
Achieve a rational treatment plan
Articular
Metaphyseal
Soft tissues

4. Tibial plateau Articular fracture by definition Aim for:
Perfect reduction of articular surface
Absolute stability (compression)

5. Fracture mechanisms Caused by a variety of forces:
Valgus/varus deformation
Axial compression
Flexion/extension
Direct trauma
References:
Kennedy JC, Bailey WH. Experimental tibial-plateau fractures. Studies of the mechanism and a classification. J Bone Joint Surg Am Dec;50(8):

6. Fracture mechanisms 1% of all fractures: Lateral plateau: 60%
Medial plateau: 25%
Bicondylar: 15%
Two subgroups exist
Young patients with good bone stock—high- energy
Elderly patients with osteoporosis—low-energy

7. Classification of proximal tibial fractures (41-A)
A: extraarticular
A1: avulsion
A2: metaphyseal simple
A3: metaphyseal multifragmentary

8. Classification of proximal tibial fractures (41-B)
B: partial articular
B1: pure split
B2: pure depression
B3: split-depression

9. Classification of proximal tibial fractures (41-C)
C: complete articular
C1: articular simple, metaphyseal simple
C2: articular simple, metaphyseal multifragmentary
C3: articular multifragmentary

10. Schatzker Classification
Schatzker I
Split of the lateral tibial plateau without depression

11. Schatzker Classification
Schatzker II
Split and depressed fracture of the lateral tibial condyle

12. Schatzker Classification
Schatzker III
Isolated depression of the lateral tibial plateau

13. Schatzker Classification
Schatzker IV
Fractured medial plateau

14. Schatzker Classification
Schatzker V
Bicondylar fracture

15. Schatzker Classification
Schatzker VI
Bicondylar fracture and diaphyseal/metaphyseal dissociation

16. Etiology: high-energy trauma
Extensive damage to the soft tissues:
Contusions
Open injuries
Compartment syndrome
Peroneal and tibial nerve injury
Popliteal artery injury

17. Etiology: low-energy trauma
Axial trauma
No contusions
Closed injuries
Less soft-tissue problems
Axis deviation
Fixation problem (osteoporosis)

18. Etiology In low-energy trauma the problem is:
Mechanical—fixation in osteoporotic bone
In high-energy trauma the problem is:
Biological and associated with damage to the soft tissues

19. Investigations X-ray AP and lateral views 45°oblique views
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Angiography

20. Personality of the fracture
Soft-tissue damage
Degree of fracture displacement
Degree of comminution
Degree of joint involvement
Osteoporosis
Neurovascular injury
Complex ipsilateral injuries and polytrauma

21. Goals of treatment Decompression and preservation of soft tissues
Reconstruction of joint surfaces
Reconstruction of normal mechanical axis
Early motion

22. Nonoperative treatment
No joint step > 2 mm
No axial instability
Severe osteoporosis
General and local contraindications (eg, medical illness)
Selected gunshot wounds

23. Schatzker’s principles of treatment
Immobilization > 4 weeks: residual stiffness
ORIF and immobilization: even more residual stiffness
Regardless of treatment: mobilize early
As long as mobility is preserved a secondary reconstructive procedure is possible

24. Schatzker’s principles of treatment
Impacted fractures cannot be dislodged by traction or manipulation
Depressed articular surfaces remain permanent defects

25. Nonoperative treatment
Traction may be of use in the short term
Early active movements in a cast brace
Touch weight bearing if patient’s condition allows
Weight bearing to tolerance at 6 weeks
Nonoperative treatment does well in the elderly with low demands

26. Operative treatment ?

27. Emergency operative treatment
Vascular injury
Compartment syndrome
Open fractures
Gross dislocation
Floating knee
Polytrauma

28. Delayed surgery (damage control surgery)
Use of a temporary spanning external fixator will allow:
Optimal recovery of soft tissues
Preserve length and axis
Further imaging and preoperative planning

29. Surgical approach Minimally invasive versus ORIF
ORIF: anterior, (postero)medial, lateral
Prepare for bone grafting
Knee flexed position
Tourniquet
Fluoroscopy

30. Surgical approach
Images courtesy of AO Surgery Reference.

31. Intraoperative procedure
Expose ligamentous and meniscal structures
Reconstruct the joint surface!
Support the joint surface with bone or substitute
Buttress with a plate (conventional)
Repair the ligaments and menisci to achieve joint stability

32. Percutaneous screw and washer fixation
In certain cases, simple percutaneous screw fixation is feasible
Washers are advised to help with lag screw compression and buttress effect

34. Preoperative
Postoperative

36. Locked internal fixators
Tibial locked internal fixators are available
Locking head screws provide better support than conventional screws in a short metaphyseal fragment
Percutaneous insertion preserves soft tissues

39. Anatomical reduction
Lag screw fixation
Locking head screws for angular stability
Improved pull-out resistance

42. The screws indicated should probably be omitted in line with current bridging osteosynthesis practice. Lecturer can choose to challange participants on this point prior to showing this slide.

43. Fine wire fixator for severe soft-tissue injuries
Reconstruction of the joint surface
Reconstruction of stable axes
Early motion
Excellent results
(Schatzker IV, V, and VI)

45. Fine wire/Hybrid Exoskeleton allows: Problems:
Attention to soft tissues
Application of relative stability to the metaphyseal/diaphyseal component
Problems:
Fine wire irritation
Intracapsular portals
Must get articular reduction first!
Patients unhappy!

46. Fine wire/Hybrid

47. Results of ORIF on tibial plateau in general
Depends on the fracture type
Depends on soft-tissue management
Depends on realization of goals
Can be excellent even in high-energy trauma:
Average range of motion 0–120°(87%)
No deterioration in the second 5 years
Good prognosis

48. Take-home messages
Anatomical reduction and rigid fixation of joint surface—absolute stability
Functional reduction and stable fixation of metaphysis—relative stability
Restoration of joint stability by appropriate soft-tissue reconstruction
Early active movement
Respect the soft tissues!!!