Glaucoma

A tibial plateau fracture involves the articular surface of the proximal tibia and ranges from a simple low energy lateral split to severe bicondylar comminution with metaphyseal dissociation, compartment syndrome and major soft tissue injury.

The treatment objectives are:

• Restore a stable, congruent knee joint
• Restore coronal and sagittal alignment
• Restore condylar width
• Preserve meniscal tissue
• Address ligamentous instability where clinically significant
• Preserve soft tissue biology
• Permit early knee motion

Perfect reconstruction of every small articular fragment is less important than restoring the major weight bearing surface, mechanical axis and joint stability.

High energy plateau fractures must be viewed as soft tissue injuries with an associated fracture, not simply a radiographic bone problem.

Schatzker classification

Type I

Pure lateral plateau split fracture.

Usually occurs in younger patients with relatively strong cancellous bone.

Type II

Lateral split plus articular depression.

Common pattern, particularly in middle aged or older patients.

Type III

Pure lateral or central articular depression without a major cortical split.

Usually occurs in osteoporotic bone.

Type IV

Medial plateau fracture, either split or split depression.

Typically higher energy and more unstable than lateral plateau injuries.

Associated with greater risk of:

• Popliteal artery injury
• Common peroneal nerve injury
• Ligament disruption
• Compartment syndrome

Type V

Bicondylar fracture involving both medial and lateral plateaus while metaphyseal continuity with the tibial shaft is preserved.

Type VI

Plateau fracture with complete metaphyseal diaphyseal dissociation.

This is a high energy injury frequently associated with severe soft tissue trauma and compartment syndrome.

Schatzker IV, V and VI patterns should immediately raise the threshold of concern for associated soft tissue, vascular and compartment injury.

AO/OTA classification

Proximal tibial fractures are coded 41.

41A: Extraarticular

The articular surface is intact.

41B: Partial articular

Part of the articular surface is fractured while another part remains connected to the tibial shaft.

Broadly includes:

• B1 pure split
• B2 pure depression
• B3 split depression

41C: Complete articular

The entire articular surface is separated from the tibial shaft.

• C1 simple articular and simple metaphyseal fracture
• C2 simple articular fracture with metaphyseal comminution
• C3 multifragmentary articular fracture

Modern CT based assessment adds important information regarding posteromedial and posterolateral fragments, which are inadequately represented by a purely AP radiographic classification.

Patients present with knee pain, swelling, inability to bear weight and often a large haemarthrosis.

High energy injuries may produce gross deformity.

Inspect for:

• Open wounds
• Fracture blisters
• Skin tenting
• Severe swelling
• Ecchymosis
• Compartment tension

Document distal pulses and capillary refill.

Assess:

• Common peroneal nerve function, particularly ankle dorsiflexion and first web space sensation
• Tibial nerve function
• Motor and sensory status of the entire foot

A medial plateau fracture or knee dislocation type mechanism should increase concern for popliteal arterial injury.

Compartment syndrome

Tibial plateau fracture is an important cause of acute compartment syndrome, particularly in high energy bicondylar injuries.

Warning features include:

• Pain disproportionate to apparent injury
• Increasing analgesic requirement
• Pain with passive toe movement
• Tense leg compartments
• Progressive paraesthesia
• Motor weakness

Normal distal pulses do not exclude compartment syndrome.

If the patient is obtunded or examination is unreliable, compartment pressure monitoring should be used liberally.

Ligament and meniscal injury are common.

Lateral plateau fractures can be associated with medial collateral ligament injury.

Medial plateau fractures may coexist with posterolateral corner or cruciate ligament injury.

A displaced meniscus can become trapped beneath a depressed articular fragment and must be identified during reconstruction.

Obtain:

• AP knee
• Lateral knee
• Oblique views where useful
• Full length alignment imaging later when coronal alignment is uncertain

CT knee: obtain for most displaced fractures being considered for surgery. It defines depression, comminution, posterior fragments and surgical approaches far better than plain radiography.

For a severely displaced high energy fracture requiring temporary external fixation, reduction and spanning fixation can be performed first, followed by CT for definitive planning once gross alignment has been restored.

MRI is not routinely required before fixation because most clinically important meniscal and ligament abnormalities can be evaluated intraoperatively or after fracture stabilisation.

Obtain CT angiography when vascular injury is suspected.

Immediate management

Provide analgesia, elevate the leg and apply a well padded splint.

Urgently reduce gross deformity or fracture dislocation when:

• Skin is threatened
• Perfusion is compromised
• Severe displacement is worsening soft tissue tension

Repeat neurovascular examination after reduction.

Do not repeatedly manipulate a swollen high energy fracture.

Nonoperative treatment

Appropriate for:

• Minimally displaced stable fractures
• Stable articular injuries without clinically significant depression or widening
• Patients whose operative risk exceeds likely benefit
• Selected low demand patients

A hinged knee brace permits early controlled knee motion.

Weight bearing is restricted initially, commonly for approximately 6 to 8 weeks, and advanced according to radiographic healing and fracture stability.

Nonoperative treatment requires serial imaging because secondary displacement can occur.

Operative indications

Common reasons for fixation include:

• Articular depression roughly above 5 to 10 mm
• Condylar widening above approximately 5 mm
• Varus or valgus instability above approximately 10°
• Medial plateau fracture
• Bicondylar fracture
• Metaphyseal diaphyseal dissociation
• Open fracture
• Associated vascular injury
• Compartment syndrome requiring fasciotomy
• Fracture displacement producing an unstable knee

These numerical thresholds guide rather than replace assessment of stability, limb alignment and patient function.

High energy fracture with poor soft tissue envelope

Do not place large definitive plates through tense swollen skin simply because the fracture requires surgery.

Use staged management:

• Restore length and alignment
• Apply a knee spanning external fixator
• Allow swelling and fracture blisters to resolve
• Obtain CT after provisional reduction
• Perform definitive fixation when skin mobility and wrinkling have returned

Emergency fasciotomy takes priority over fixation when compartment syndrome is present.

If fasciotomy is performed, place incisions so they remain compatible with later fixation and soft tissue reconstruction.

Schatzker I

A displaced lateral split can often be reduced with direct or minimally invasive techniques and fixed using lag screws with or without a lateral buttress plate.

The plate prevents lateral shear and recurrent condylar widening.

Schatzker II

Elevate the depressed articular surface.

The resulting metaphyseal void can be supported using:

• Autologous cancellous bone
• Allograft
• Calcium phosphate or another structural bone substitute

Restore the subchondral surface and stabilise the lateral split using a lateral plate.

Inspect and preserve the lateral meniscus.

Schatzker III

Pure depression requires elevation of the impacted joint surface and support of the resulting subchondral defect.

Raft screws beneath the elevated articular surface reduce recurrent subsidence.

Schatzker IV

Medial plateau fractures require strong medial or posteromedial buttress fixation because the fragment experiences substantial shear.

A posterior medial fragment should not be expected to remain reduced by a lateral plate alone.

Schatzker V and VI

Bicondylar fractures often require separate fixation of the medial and lateral columns.

Common strategies include:

• Medial plus lateral plating
• Posteromedial buttress plate plus lateral locking plate
• Selected hybrid or circular external fixation

Avoid excessive stripping of already compromised soft tissue.

The medial side frequently provides the key buttress to prevent varus collapse.

Reduction priorities

Restore:

• Mechanical axis
• Tibial slope
• Condylar width
• Articular surface
• Knee stability

Do not accept residual varus because varus malalignment markedly increases medial compartment load and promotes post traumatic arthritis.

Meniscus

Repair a detached peripheral meniscus when possible rather than resecting it.

Meniscal preservation improves load distribution across an already injured articular surface.

Ligaments

Not every ligament injury needs immediate reconstruction.

The fracture should generally be anatomically stabilised first. Persistent ligamentous instability can then be assessed after bony healing unless the ligament injury itself prevents stable fracture reconstruction.

Postoperative management

Begin knee range of motion early when fixation permits, commonly within the first postoperative days.

Prolonged immobilisation markedly increases knee stiffness.

Weight bearing is generally restricted for approximately 8 to 12 weeks in major articular fractures, then advanced according to healing, alignment and construct stability.

Major complications include:

• Acute compartment syndrome
• Infection
• Knee stiffness
• Malunion, particularly varus
• Nonunion
• Articular subsidence
• Post traumatic osteoarthritis
• Meniscal dysfunction
• Chronic ligamentous instability
• Peroneal nerve injury

Severe bicondylar fractures can progress to post traumatic arthritis despite technically satisfactory fixation because the initial cartilage injury itself may be irreversible.