MAJOR TRAUMA

Tibial plateau fractures young adults prior to physeal closure and will not be discussed in
these patient groups. High energy fractures are more likely to be

e review of current associated with concurrent fractures, compartment syndrome,

neurological and vascular compromise.2,3 Given the morbidity

concepts in management associated with this injury, it is important to carefully evaluate

the fracture pattern to plan the definitive management at the
appropriate time in order to avoid soft tissue complications.
Ana Jeelani
Mateen H Arastu Relevant anatomy
The tibial plateau is divided into medial and lateral parts, sepa-
rated by the non-articular intercondylar eminences. The medial
Abstract plateau is larger and concave in the sagittal and coronal planes
Tibial plateau fractures represent a wide spectrum of injury patterns and has less thick articular cartilage compared to the lateral
and encompass degrees of severity that are challenging to treat by plateau. The lateral plateau is convex in the sagittal plane. The
even experienced orthopaedic trauma surgeons. The principles of articular surface of the proximal tibia lies in 3 of varus to the
treatment include respect for the soft tissues, restoring the congruity mechanical axis of the tibia. As a result of these anatomical dif-
of the articular surface and reduction of the anatomic alignment of the ferences the lateral plateau lies higher than the medial. This is
lower limb to enable early movement of the knee joint. There important to recognize in order to avoid screw penetration
are various surgical fixation methods that can achieve these princi- during fixation into articular cartilage during placement of
ples of treatment. Recognition of the particular fracture pattern is supporting subchondral screws. The trabecular bone pattern on
important, as this guides the surgical approach required in order to the medial aspect of the tibial plateau is denser than the lateral
adequately stabilize the fracture. and this is reflected in more medial fracture patterns being asso-
Keywords adult; fracture; tibial plateau ciated with higher energy trauma and lateral fractures occurring
more commonly in the elderly following lower energy trauma.
The normal average posterior tibial slope is approximately 9 .
It is important to recognize that in some patterns of tibial plateau
Introduction
fracture in which a hyperextension injury has occurred the pos-
Tibial plateau fractures are intra-articular fractures of the knee terior tibial slope is reversed into an anterior slope and not only
that are often associated with high energy trauma, but also does the articular congruity need to be restored but also the
commonly occur in the elderly as a result of a lower energy posterior tibial slope, in order to avoid hyperextension of the
mechanism of injury. However, despite the spectrum of possible knee during normal gait.
fracture patterns, the treatment principles remain the same with The tibial tuberosity is the site of attachment of the patella
the aim of restoring the congruity of the articular surface and tendon and can be fractured in high energy injuries yet this is
maintaining the mechanical axis of the lower limb. The severity easily missed during the initial assessment. This represents
of the fracture and an understanding of the associated soft tissue disruption of the extensor mechanism of the knee and unless
injury and its evolution influences the timing and method of addressed at the time of surgical fixation can result in an extensor
surgical reconstruction. This article reviews the relevant surgical lag of the knee. It is also important to note that a displaced tibial
anatomy, the classification systems, treatment options and sur- tuberosity fragment can cause pressure necrosis of the skin,
gical approaches that are currently available in order to try to compromising any form of surgical treatment. Temporary
optimize the outcome in this often difficult fracture. external fixation with the knee in full extension can minimize
this and the treating surgeon needs to be cognizant of this frac-
Epidemiology ture pattern.
Tibial plateau fractures account for 1e2% of all adult fractures.1
Classification
There is a bimodal distribution of incidence: high energy frac-
tures occur in the younger population, often as a result of road One of the fundamental roles of any useful fracture classification
traffic accidents or falls from height, while relatively lower en- is that it should guide the surgical approach and fixation, and
ergy osteoporotic fractures occur in the elderly, often sustained should be reliable. As for most fractures there is not a single
as the result of a simple fall. The injury is rare in children and classification that encompasses all fracture patterns and can
enable a surgeon to identify the specific approach and fixation
needed. Some knowledge of the different classification systems,
Ana Jeelani MBChB MRCS ST5 Trauma and Orthopaedics, Royal and using them in combination, can enable a surgeon to make
Lancaster Infirmary, University Hospitals of Morecambe Bay, more informed decisions on treatment. The next section sum-
Lancaster, Lancashire, UK. Conflict of interest: no conflict of interest. marizes the pertinent classification systems and highlights where
they may be useful in guiding treatment.
Mateen H Arastu MBBS BSc MSc FRCS Tr & Orth Consultant Trauma and
Orthopaedic Surgeon, Department of Trauma and Orthopaedics,
University Hospitals Coventry and Warwickshire NHS Trust, Schatzker classification
Coventry, West Midlands, UK. Conflict of interest: no conflict of Schatzker described this classification in 1979 and it is still in
interest. common use4 (Figure 1). The advantages of this classification

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 MAJOR TRAUMA

Figure 1 Schatzker classification.

system are that it is simple, reliable and offers guidance for a shear fracture, often with the fracture line exiting proximally
treatment. Schatzker (types IeIII) are unicondylar fractures of either on the lateral tibial plateau or at the level of the inter-
the lateral plateau and are often lower energy injuries, while condylar eminences. The fracture is usually unstable and re-
types IVeVI represent higher energy injury patterns. Schatzker quires surgical stabilization. These fractures have a significantly
(types V and VI) are bicondylar fractures. higher rate of associated neurovascular and cruciate ligament
The Schatzker type I fracture is a pure split in the sagittal injury than other patterns of fracture. There is also a risk of
plane, not associated with joint depression and tends to occur in compartment syndrome with this injury pattern.
younger patients with denser bone. Lateral meniscal pathology Schatzker type V injuries involve both the medial and lateral
(peripheral tear) can prevent reduction of this fracture pattern as plateaux, often with preservation of the intercondylar eminence
it becomes incarcerated in the fracture. and cruciate ligament attachment. The pattern is often an ‘inver-
The Schatzker type II fracture is a split depression and is ted Y’ fracture and rarely associated with knee dislocation. This is
either associated with higher energy injury patterns in younger often caused by a pure axial load with the knee in full extension.
bone or is secondary to poor bone quality and is a common Schatzker type VI injuries involve fractures of both the
fracture pattern in the elderly. The mechanism of injury is similar medial and lateral tibial plateaux but there is metaphyseal
to a type I injury with a valgus and axial load to the knee. ediaphyseal dissociation. The high energy mechanism of injury
The Schatzker type III fracture is a very rare pattern of that causes this fracture pattern will often cause multi-
injury and is a pure depression fracture, classed as a fragility fragmentary fractures that extend into the diaphysis of the tibia.
fracture in the elderly, and is a result of bone crushing rather Often one or both tibial plateaux are highly comminuted and
than splitting. It is likely that most fracture patterns presumed tibial tuberosity involvement is also often present. The soft tissue
to be type III are type II fractures with an occult split fracture injury with this pattern is significant.
not visible on plain radiographs. A review of the MRI scans of
103 patients with tibial plateau fractures found no cases of type AO/OTA
III fractures but an associated extension of the fracture line in The AO/OTA classification, published in 1996, has been shown
lateral depression fractures technically making these fracture to have good interobserver agreement and is commonly used in
patterns type II.5 scientific publications (Figure 2). Type A fractures are extra-
Schatzker type IV fractures are higher energy injuries and are articular and type A1 fractures represent avulsion injuries
akin to a variant of knee fractureedislocation. The fracture in- (A1.1 e fibula avulsion, A1.2 e tibial tubercle avulsion and A1.3
volves the medial tibial plateau and can be regarded as more of e intercondylar eminence avulsion).

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 MAJOR TRAUMA

Figure 2 AO/OTA classification. Copyright by AO Foundation, Switzerland. Source: AO Surgery Reference, www.aosurgery.org.

Moore column concept’.10 This classification system divides the tibial

This fractureedislocation classification system of five types does plateau into lateral, medial and posterior columns in order to
not fit with the Schatzker classification.6 This classification sys- improve surgical decision-making. The identification of
tem highlights the importance of recognizing that a tibial plateau posterolateral and posteromedial coronal shear fractures has
fracture may also be a consequence of a knee dislocation and the been documented.9,11 Although, medial and laterally applied
associated soft tissue injury means that supporting structures of plates have had good clinical and biomechanical results, there is
the knee are significantly compromised. an increasing tendency to consider posterior fixation for this
fracture pattern.8,12 However, tibial tuberosity and intercondylar
Chertsey classification eminence fractures are not incorporated into this classification
This is a mechanistic classification system and is divided into system. Agreement between observers has been reported to be
Chertsey types C1e3 injuries that correspond to valgus, varus significantly better for the Schatzker classification than the three-
and axial loading, respectively.7 column classification. The use of 3D CT reconstructions did not
improve agreement in this classification system.
The “Three-Column” concept
The Schatzker, AO/OTA and Moore classification systems are Clinical evaluation
predominantly based on the AP radiographic appearances and
fail to identify more recently identified posterior shear (coronal) History
fracture patterns.8 The “Three-Column” classification was pub- The mechanism of injury often highlights the severity of injury
lished by Luo et al in 2010 and is based on axial CT scans which, pattern observed. Medical comorbidities increase surgical risk
in addition to the aforementioned classifications, can aid surgical and the incidence of wound healing complications. Extensive
planning to address posterior fracture patterns (Figure 3).9 This medical comorbidities often can preclude safe surgical interven-
has subsequently been updated and termed the ‘updated three- tion and non-operative management may be required.

Assessment
Tibial plateau fractures are often high energy injuries and
therefore an Advanced Trauma Life Support (ATLS) approach to
initial evaluation should be adopted. Once life-threatening in-
juries have been excluded, attention can be paid to extremity
injuries. Initially, it is important to assess the knee circum-
ferentially to rule out an open injury.
The soft tissue envelope around the proximal tibia, apart from
the posterior aspect, is thin. Displaced bone fragments can
damage this fragile envelope of tissue as can the mechanism of
injury, for example direct impact from a car bumper. The soft
tissue trauma often results in oedema, local venous compromise,
dermal hypoxia and additional soft tissue compromise. Soft tis-
sue swelling, bruising and blister formation evolve rapidly over a
24e72 hour period and at initial assessment in the resuscitation
room the soft tissue damage may appear benign. Excessive skin
mobility or fluctuance can be a marker of a significant degloving
of the skin from the deep fascia. If there is a high energy multi-
fragmentary fracture pattern the soft tissue envelope will need
repeated assessment in order to determine the safe timing of
Figure 3 The 3-column concept. surgical intervention, which in the vast majority of cases should

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 MAJOR TRAUMA

be deferred and consideration given to temporary spanning There are several configurations of spanning knee external
external fixation. Normal wrinkling of the skin is often the best fixators (Figure 4). Two 5 mm Schanz pins are positioned in the
clinical indicator that it is safe to perform definitive care safely. femur and two in the tibia, outside the zone of injury if possible.
It is vital to perform a thorough neurological and vascular The femoral pins can either be placed anterolateral (between
assessment, as there is a risk that there has been a knee dislo- rectus femoris and vastus lateralis) or direct anterior via rectus
cation resulting in a tibial plateau fracture that has spontaneously femoris and vastus intermedius. The tibial pins are sited 1 cm
reduced. Use of the ankle-brachial index should be adopted in posterior to the tibial crest on the medial aspect of the tibia. The
cases where there is suspicion of a vascular injury and trauma CT bars are positioned in the mid sagittal plain to resist extension
scans with contrast may assess the vascular tree additionally. A and flexion forces and also control varus and valgus deforming
careful examination of the lower limb motor and sensory function forces. A rectangular construct is made with medial and lateral
should be undertaken, with particular focus on common peroneal longitudinal bars (often a pair on each side) to improve stability.
nerve function. Compartment syndrome should be considered in Manual traction and varus/valgus correction is performed in
all patients who sustain a tibial plateau fracture. It is however order to obtain reduction and the clamps are tightened. An
more common in Schatzker types IVeVI patterns. Acute alternative to this configuration is a diamond shaped construct. A
compartment syndrome necessitating urgent fasciotomies has ‘kickstand’ to offload the heel can be added to the frame in order
been reported in 14.5% of high energy tibial plateau fractures. to protect the soft tissues if necessary.

Imaging Principles of treatment and indications

Plain AP and lateral radiographs usually confirm the diagnosis. The effect that intra-articular fractures have on articular cartilage
The complexity of fracture patterns is often underestimated. CT injury, the outcome of surgical intervention and residual joint
scanning is recommended for pre-operative planning in order to function are to date relatively poorly defined. It is likely that
fully evaluate the fracture pattern. The degree of articular different joints respond differently and the reasons for this are
depression is often better appreciated on CT scans than on ra- multifactorial. The tibial plateau is part of a major weight bearing
diographs. If there is gross axial malalignment, significant joint but the articular cartilage is thick and has some protection
comminution, shortening and deformity then CT scanning after afforded by the menisci. There is no consensus about the
the application of a spanning external fixator is recommended acceptable degree of articular step-off in the literature to date,
and provides more useful information to plan surgery.
Associated knee ligament and meniscal injures are not un-
common in higher energy patterns (single major ligament e 71%,
multiple major ligaments e 53% and meniscal injuries e 49%).13
Clinical assessment for this is not possible due to the underlying
fracture. The majority of meniscal injuries appear to be peripheral
rim detachments. However, reducing the fracture may allow pe-
ripheral meniscal separations to repair, as there is a low rate of
delayed presentation of meniscal pathology after tibial plateau
fractures. The role for MRI to determine the soft tissue injury is
controversial in the acute setting, as the natural history is un-
known in the context of tibial plateau fractures.

Treatment options
Temporary spanning external fixation
This allows the soft tissue envelope to recover, provides more
skeletal stability than a plaster, improves the usefulness of im-
aging (CT) in complex fracture patterns and facilitates nursing
care, especially after polytrauma. The primary reason to perform
this is as part of a staged management protocol for high energy
and axially unstable tibial plateau fractures in order to decrease
the future risk of wound complications.14 It utilizes liga-
mentotaxis in order to reduce metaphyseal/diaphyseal segment
shortening secondary to comminution. Urgent indications for its
use are: open fractures, knee fractureedislocations, compart-
ment syndrome and vascular injuries. For stable and lower en-
ergy injury patterns temporizing spanning external fixation is not
necessary. The duration of time the soft tissues take to improve is
variable and often can range from 7 to 21 days. If the soft tissue Figure 4 Spanning external fixator of the knee in a case of an open
injury does not resolve within this time frame then, rather than tibial plateau fracture with associated knee dislocation to allow soft
planning internal fixation, the use of external fixation as defini- tissue injury to be treated appropriately and fracture stabilization until
tive management becomes a more favourable option. definitive combined orthoplastic treatment is performed. Note the pin
sites are not in the zone of injury and positioned in the distal tibia.

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 MAJOR TRAUMA

ranging between 2 and 10 mm.15 Instability of the knee is if performed early, delaying surgery is often essential to reduce
strongly associated with a poor outcome16 and can be the result wound complications if internal fixation is planned. Historically,
of articular depression, displacement of the tibial plateau or medial and lateral plate application for severe tibial plateau
ligamentous disruption. Restoration of a ‘height stable’ tibial fractures through a single anterior incision has been associated
plateau is important to restore bony stability. Failure to with an unacceptable rate of wound complications and extensive
adequately restore mechanical alignment of the lower limb and soft tissue stripping of fracture fragments. The evolution of a
non-retention of the meniscus are associated with the develop- staged approach allowing the soft tissue injury to resolve then
ment of post-traumatic arthritis. Tibial plateau articular in- enables a dual approach technique in order to minimize further
congruity appears better tolerated than in most other joints. complications. The most commonly used incisions are antero-
Anatomical reduction of the joint surface when possible should lateral and posteromedial if treating a severe bicondylar fracture
remain one of the goals of surgical fixation. In highly commi- pattern. Posterior approaches may be necessary if there is a
nuted fracture patterns this is sometimes not possible. posterior coronal shear fracture that needs to be buttressed.
The indications for surgical intervention are:
 Open fractures Generic considerations for surgical planning
 Tibial plateau fracture associated with a vascular injury or A radiolucent table that allows unimpeded radiographic access is
compartment syndrome recommended. Caudal tilt of the X-ray beam by 15 when per-
 Joint instability e often termed ‘pseudolaxity’, as the forming an AP radiograph ensures the view is parallel to the
instability is a result of loss of tibial condylar height rather posterior slope of the tibial plateau and allows better radio-
than ligamentous deficiency graphic assessment of articular congruity. A tourniquet is
 Angular deformity in the sagittal or coronal plane required to aid visualization in the surgical field. The use of a
>5 resulting in instability radiolucent triangle and block that can be wrapped in a sterile
 Intra-articular incongruity fashion, and which can be interchanged throughout the proced-
ure to aid limb positioning, assists obtaining lateral radiographs
Non-operative of the knee. A sandbag under the ipsilateral hip is used to prevent
The role of non-operative management is in low energy fractures. external rotation of the lower extremity for lateral fractures and
It is most often used in medically unfit, non-ambulatory patients under the contralateral hip in isolated medial fractures. If dual
and those with minimally or undisplaced fractures. Stability is anterolateral and posteromedial incisions are planned no
important in determining outcome and non-operative manage- sandbag is used, or it is be removed at the appropriate time
ment in cases where there is less than 10 of instability in varus during surgery. Spanning external fixator pin sites are thoroughly
or valgus should be adopted. Similarly less than 10 of instability debrided along with their skin margins and the limb should then
in the frontal plane is acceptable in the cases of posterior fracture be re-draped after this step in a sterile fashion before performing
patterns. This form of treatment should allow early full range of definitive surgery.
motion to prevent stiffness. Hinged knee bracing for a mean Useful instruments are large ball-spiked peri-articular clamps
period of 8e12 weeks and touch weight bearing to prevent that do not compress skin margins when applied, ball-spike
further displacement, usually for the first 6e8 weeks, is often pusher, bone tamps for elevation of depressed articular frag-
successful. In patients with significant comorbidities the criteria ments, small curettes and a dental pick to manipulate small bone
for considering non-operative management are naturally adhered fragments. Double ended K-wires are also useful in order to
to less strictly to prevent further harm. reduce fracture fragments from within the fracture site under
direct vision and extract on the contralateral aspect of the knee to
Surgery allow closure of the fracture site and plate application. A femoral
Surgery remains the mainstay of treatment as the majority of distractor or monolateral external fixator using 5 mm Schanz
tibial plateau fractures fall into one of the indications listed pins perpendicular to the mechanical axis (femoral metaphysis
above. and tibia distal to desired plate length) can be useful in order to
distract the tibiofemoral joint in order to aid reduction and
Surgical options visualization of the joint surface and free the surgical assistant
A recent Cochrane review has stated that intra-articular fractures for other tasks. The advantage of the femoral distractor is that the
of the tibial plateau are often difficult to treat and treatment has a axis can be positioned posteriorly, away from the surgical field.
high complication rate. Surgical fixation is usually necessary in Intra-operative assessment of the mechanical alignment of the
complex fractures and bone void fillers are often used to treat lower limb can be easily checked, especially in cases of meta-
residual bone defects following elevation of depressed articular physeal comminution. These zones of comminution are often
fractures. Currently there is no consensus on either the best treated with bridge plating. An intra-operative image of the knee
method of fixation or bone void filler.17 and a diathermy cable passed over the centre of hip and ankle
joints with the patella facing the ceiling provides an approxi-
Open reduction and internal fixation (ORIF) and relevant mation of the mechanical axis. This can be compared to the
surgical approaches contralateral limb to determine whether this has been restored.
Examination of the knee under anaesthesia after fixation of a
The decision on which approach is utilized is based on fracture fracture has been completed is also important, as occult liga-
morphology. The soft tissue envelope must be ready to withstand mentous injuries can be diagnosed with relative ease at this
further traumatic insult. Although reduction of fractures is easier stage.

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 MAJOR TRAUMA

Anterolateral approach with valgus stress. Some posteromedial fractures can be

This is the most common approach, used for most tibial plateau buttressed using this approach, often using an under contoured
fractures. The incision is centred over Gerdy’s tubercle and either 3.5 mm small fragment plate (LC-DCP, Synthes, Oberdorf,
a lazy ‘S’ or ‘hockey stick’ incision is made. The centre of the Switzerland) and distal cortical screws, with the plate overlying
incision crosses the joint line at the mid-axial point and should the apex of the fracture. Often, shorter locked screws can be
extend distally 1e2 cm lateral to the tibial crest. Proximally the positioned in the proximal fracture fragment to prevent rotation
iliotibial band is incised in line with its fibres and the fascia over of this fragment if it is part of a bicondylar fracture pattern. In
tibialis anterior divided and elevated bluntly from the tibia this situation the medial posteromedial buttress plate is often
distally. A sterile needle can be used to locate the joint and positioned first in order to provide a stable medial column onto
dissection performed anteriorly and inferior to the meniscus to which the lateral tibial plateau is reduced via an anterolateral
perform the submeniscal arthrotomy. Stay sutures are place in approach, as described in the previous section.
the meniscus (usually 2) and can be used to retract the meniscus
to visualize the joint surface to aid reduction. Often the meniscus Posterior approach
will have detached from the coronary ligament at the periphery This approach is useful for posterior coronal shear fractures that
and be trapped in the fracture site; if so it should be removed to need a posterior buttress.8,9,12 The patient is positioned prone. A
enable anatomic reduction. If possible a rim of tissue should be posterior inverted ‘L’ shaped incision (having flexed the knee to
left on the margin of the tibia to reattach the meniscus to the position the incision in the flexor crease) is made and extended
coronary ligament at the end of the procedure. Depressed artic- distally along the medial border of the calf. For added exposure the
ular fragments can be reduced under direct vision by opening the incision can be extended proximally at the lateral end of the flexor
fracture site by hinging the lateral cortex and using bone tamps to crease incision but this is not normally required. Full thickness
elevate. A bone substitute can be used to pack the residual void. fasciocutaneous flaps are developed and the sural nerve and short
The elevated joint fragments are then held reduced with sub- saphenous vein are located and protected. The medial head of
chondral K-wires. If newer generation pre-contoured locking gastrocnemius is located and laterally retracted. Retraction should
plates are used it is important to reduce the joint surface with a be performed once subperiosteal dissection under popliteus has
peri-articular reduction clamp to generate external compression been completed. Popliteus runs in a supero-lateral direction and is
before definitive locking screw fixation performed. Pre-contoured incised on its medial margin of insertion on the tibia. This protects
plates do not provide as much of a buttress effect as more con- the neurovascular bundle in the popliteal fossa. Variations of this
ventional, straighter plates. A distal cortical screw can be placed approach include transecting the medial head of gastrocnemius
first to maximize the buttress effect and draw the plate to the close to its origin on the femur and dissecting the neurovascular
bone, more proximal cortical screws then being used towards the structures of the popliteal fossa. The posterior recurrent tibial ar-
apex of the fracture, sequentially tightening all screws to maxi- tery (branch of the anterior tibial artery) is at risk if dissection is
mize the buttress effect. This should be performed before performed too far towards the lateral aspect of the tibia. The soleal
inserting locking screws in the proximal portion of the plate. line marks the distal extent of the exposure nearer the midline and
There is no requirement, normally, even in elderly patients with sometimes a more lateral plate needs to be positioned obliquely
osteoporotic bone, to use locking screws in the diaphyseal region towards the posterolateral proximal tibia: a longer posteromedial
of the tibia. If there is space superior to the plate, separate lag buttress plate can easily be applied in addition. With this approach
screws can be used to maintain articular compression and even the posterolateral aspect of the tibia can be visualized but
reduction. A raft of subchondral locking screws is positioned in over-retraction in the region of the fibula neck puts the common
order to maintain elevation of the articular surface. The periph- peroneal nerve at risk. Any retraction should be performed over
eral meniscus can then be reattached to the coronary ligament or the fibular head if necessary. The risk of this exposure is to the
to small holes in the superior aspect of the plate. neurovascular structures as described, and also developing a fixed
flexion contracture of the knee. Reduction of fracture fragments is
Posteromedial approach performed with the knee in full extension and the ball-spike
This approach, often referred to as the Lobenhoffer approach, is pusher is useful for this. An under contoured 3.5 mm small frag-
useful for isolated medial fractures or in combination with an ment plate (LC-DCP, Synthes, Oberdorf, Switzerland) can be used,
anterolateral approach. The patient is positioned supine. A as described for the posteromedial approach.
straight incision over the posterior aspect of the tibial crest is
made, which can be extended across the joint line to the medial Other approaches
femoral condyle, but this extension is usually not required. The Posterolateral approaches, with or without a fibular osteotomy,
saphenous nerve is at risk in the subcutaneous tissue. Dissection have also been described.18,19 Some fracture patterns involve the
is performed posterior to the medial collateral ligament and the posterolateral aspect of the fibula that cannot be reduced using
pes anserinus is exposed. Invariably the fracture apex lies an anterolateral approach. The soft tissue tension of the popliteal
beneath the pes anserinus and the latter often needs to be divided corner structures can prevent reduction.
and repaired at the end of the procedure. An attempt can be made
to position implants either posterior to, or underneath it. A Case examples
submeniscal arthrotomy can be performed in a similar manner to
the lateral side, but normally is not required as there is usually Clinical cases highlight some of the treatment principles and
less comminution, especially in isolated medial fracture patterns. pertinent points related to the surgical technique required for
The reduction manoeuvre for medial fractures is often extension each case (Figures 5e9).

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 MAJOR TRAUMA

Figure 5 Schatzker 1 type fracture in a 45 year old illustrated on the AP radiograph (a), 3D CT scan (b) and axial CT scan (c). Intra-operative
reduction via an anterolateral approach was performed and large peri-articular reduction clamp was used to reduce the fracture and buttressed
with a pre-contoured locking plate with distal cortical screws positioned first, AP and lateral intra-operative fluoroscopy images shown (d and e).
Two 3.5 mm lag screws were positioned above the plate (d and e). Intra-operative stress testing reveals an isolated medial collateral ligament
complete disruption that did not require surgical intervention (f). Uneventful recovery at 4 months (AP and lateral radiographs), (g and h).

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 MAJOR TRAUMA

Use of bone substitutes collapse of elevated fragments (>2 mm) can occur and the
incidence of this with biological substitutes (allograft, deminer-
There is a lack of consensus regarding the use of bone graft
alized bone matrix and xenograft) has been reported as 8.6%;
substitutes to fill fracture voids after elevating depressed artic-
5.4% with hydroxyapatite; 3.7% with calcium phosphate and
ular fragments (Figure 10). There is some evidence supporting
11.1% with calcium sulphate.20 Donor site morbidity is also an
their use but a lack of high quality Level 1 evidence. Secondary

Figure 6 Schatzker type II fracture illustrated on AP and lateral radiographs in an elderly lady who sustained a low energy fall (a and b). The joint
depression is more significant on the CT scan and she had pseudovalgus instability on clinical assessment (ced). Intra-operative fixation involved
elevating the depressed articular surface with a bone tamp and was held with a K-wire through a lateral locking plate (e and f). The distal plate was
secured with a cortical 3.5 mm screw to act as a buttress (g). Proximal locking screws were used following application of external compression
with a peri-articular clamp (h). No bone graft or substitute was used and there was minimal subsidence with a good clinical outcome (i).

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 MAJOR TRAUMA

Figure 7 Schatzker type IV fracture in a young male following an assault showing an isolated medial tibial plateau fracture on the AP and lateral
radiographs and axial CT scan (aec). This was treated with a posteromedial approach and medial buttress plate positioned over the apex of the
fracture (d). In this example it is not necessary to use such a long plate and ideally a cortical screw just distal to the apex of the fracture and one
additional distal screw would suffice to stabilize this fracture pattern. A straight under contoured 3.5 mm plate would also have achieved this
reduction. Proximal screws are necessary to give fixation rotational stability. Consolidation at the fracture line is evident at 4 months post injury on
the AP and lateral radiographs (e and f).

issue with iliac crest autograft. The principle of its use when the wires are then connected to the frame in a tensioned fashion.
there are large voids is reasonable but more robust evidence is Transverse stability is created by the wire-bone interface friction
needed, as there are so many products available with differing and an approximately 70 crossing angle of the wires. The Ili-
biomechanical properties. The risk of infection however is not zarov frame works through a biomechanical principle of beam
increased with their use. loading whereas the Taylor Spatial Frame (TSF; Smith and
Nephew, Memphis, Tennessee), which often but not always uses
half pins, changes the biomechanics to a cantilever type mech-
External fixation
anism. The theoretical advantages of a frame are relative pro-
Bicondylar tibial plateau fractures are often associated with sig- tection of the soft tissues and early weight bearing but the
nificant soft tissue injuries and ORIF in these situations may lead obvious disadvantage is the fact that it is an external device and
to further compromise. Tensioned fine wire ring fixators offer not always well tolerated.
another option for fixation (Figure 11). Fine wire frames should Ahearn et al reported that the treatment of complex bicon-
only be performed by a surgeon who has experience in this mode dylar tibial plateau fractures by experienced trauma surgeons
of fixation. The joint line is often stabilized first with screws in a using modern surgical techniques either using a TSF or a locking
raft fashion, and this can be performed in an open or percuta- plate gave similar clinical and radiological outcomes.21 A recent
neous fashion, depending on the fracture. Wires are then posi- systematic review concluded that functional outcome is no better
tioned just below the joint line to further support the tibial at 12 or 24 months comparing external ring fixators with internal
plateau. Olive wires can be used to aid reduction if necessary and fixation.22 One of the drawbacks of ring fixators is the inability to

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 MAJOR TRAUMA

Figure 8 An illustration of a posteromedial shear fracture shown on AP and lateral radiographs (a and b). The CT scans give more information
regarding the posteromedial fragment and some joint comminution of the medial aspect of the lateral tibial plateau (cef). The fracture and sub-
luxation of the knee was reduced with a spanning external fixator (g). The decision was made to treat this fracture pattern with a posterior approach
in order to buttress the posterior shear fracture and also address the medial aspect of the lateral tibial plateau articular depression. A posterior
buttress plate (under contoured 3.5 mm small fragment plate LC-DCP) was applied initially after restoration of the joint depression via the fracture
site (h). The fixation was also augmented by a direct medial 3.5 mm small fragment LC-DCP. Fixation in the proximal medial fragment via the
posterior plate was added (locking screws) and the proximal medial screw aimed to attempt to provide subchondral support below the elevated
medial depressed articular fragment of the lateral tibial plateau (i). He was lost to follow-up after his 6-week check radiographs were performed
(j and k).

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 MAJOR TRAUMA

completely restore the joint line. However, it has been shown statistically significant difference in the incidence of re-operation,
that articular congruity does not necessarily correlate to func- deep infection or deep vein thrombosis. Another systematic re-
tional outcome. Similarly, radiological appearances post- view concluded that currently there is insufficient evidence to
operatively do not correlate with functional outcomes. The determine whether circular frame external fixation, in the treat-
seven studies included in this systematic review did not report a ment of bicondylar tibial plateau fractures, provides better

Figure 9 An illustration of a Schatzker VI tibial plateau fracture in a middle aged lady who fell from a ladder (AP and lateral radiographs), (a and b)
and CT scans which illustrates tibial tuberosity involvement of the fracture (c and d). Her soft tissue injury was significant (e) and within 10 days had
begun to settle (f) and the decision to perform internal fixation with an anterolateral and posteromedial approach. This patient refused to consider
external fixation. The medial column was addressed initially and a long buttress plate applied (g). The lateral tibial plateau was comminuted and
anatomic reduction not achievable and stabilized with a long anterolateral locking plate (h). Both medial and lateral plates were positioned using
minimally invasive techniques and open incisions made distally. The tibial tuberosity was fixed with a 2.4 mm plate to be as low profile as possible
(i). A distal 2.4 mm plate was used as there was a small anterior spike of bone that was tenting the skin which would have caused skin necrosis and
not controlled by the direct medial and lateral plates (j). The follow-up radiographs (AP and lateral) are acceptable but there is some valgus
deformity clinically and she was not keen on restoration of alignment with an osteotomy (j and k). The clinical photographs illustrate that she
has healed without infection and has a functional range of motion of the knee, though the medial plate is prominent but does not want further
surgery (l).

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 MAJOR TRAUMA

Figure 9 (continued)

outcome and fewer complications when compared to open fracture site. On review of current available evidence this tech-
reduction and internal fixation.23 nique carries little additional risk and has shown to produce
good outcomes but does not offer any additional benefit to pa-
Role of arthroscopic assisted surgical fixation tients compared to more conventional techniques. There are few
comparative studies available for this technique and conven-
Arthroscopic assisted fixation of tibial plateau fractures is not a
tional open reduction and internal fixation.24
new technique. It has been used to aid fracture reduction and to
minimize soft tissue dissection. It also allows the treating sur-
Complications
geon to potentially treat intra-articular pathology. A concern
with this technique was that irrigation fluid used could increase Infection
the risk of compartment syndrome due to extravasation via the Despite the use of a staged management protocol the deep
infection rate for higher energy tibial plateau fractures has been
reported to be as high as 5e8.4%, even when treated by expe-
rienced trauma surgeons.3,14 When comparing conventional
plating, locked implants and external fixation, no single tech-
nique is superior with regards to the incidence of deep infection.
Surgical time has been shown to be a risk factor for infection but
often is related to the fracture severity, complexity of the surgical
intervention required and therefore cannot be manipulated.
Weaker evidence exists that the use of negative pressure wound
therapy for high risk wounds decreases infection rates. Further
research is required in order to determine whether this is bene-
ficial in high energy tibial plateau fractures.

Post-traumatic osteoarthritis and conversion to total

knee arthroplasty (TKA)
The reported incidence of post-traumatic radiographic osteoar-
thritis of the knee following tibial plateau fractures varies from
25% to 45%. The incidence increases with the severity of frac-
ture, malalignment of greater than 5 and loss of reduction.25
Scott et al reported that patients with instability or nonunion
needed TKA earlier (14 and 13.3 months post injury) than those
with intra-articular malunion (50 months).26 In this study the
most common mode of failure was varus/valgus collapse and
this reiterates the point that the outcome in tibial plateau frac-
tures is more closely related to restoring the mechanical axis than
to accurate reduction of the joint surface. Regardless of operative
fixation, sustaining a tibial plateau fracture requiring surgery
Figure 10 An example showing a bone void filled with a calcium
increases the likelihood of TKA by 5.3 times. 8246 patients were
phosphate bone cement for a Schatzker type II fracture (AP and lateral
intra-operative radiographs). identified who sustained a tibial plateau fracture between 1996

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 MAJOR TRAUMA

Figure 11 An example of a 40 year old male who fell from a height sustaining a Schatzker VI tibial plateau fracture who was treated with external
circular frame and raft screw fixation. Pre-operative radiograph and CT images are shown (a and b). A temporary spanning external fixator was
used. Definitive treatment using 2 raft screws positioned percutaneously to reduce the articular surface and an Ilizarov frame (c). Post frame
removal radiographs (AP and lateral) illustrating a congruent articular surface and restored alignment of the lower limb (d and e).

and 2009 and cross matched to a cohort of the general popula- sporting activities. The secondary outcome measure of this study
tion.27 At ten years, 7.3% of patients underwent TKA versus showed that there was no relationship between the radiographic
1.8% in the cohort group. There was no difference between the features of osteoarthritis and mid- to long-term functional outcome.
internal and external fixation groups in conversion to TKA. In another study comparing Musculoskeletal Function Assessment
in AO/OTA C3 fractures following medial and lateral plate stabili-
Nonunion/malunion zation, residual dysfunction was common, with a mean follow-up
Nonunion and malunion can occur at the metaphyseal period of 59 months post-operatively.29 Accurate articular reduc-
ediaphyseal junction. A thorough assessment, including the use of tion (less than 2 mm residual step or gap) was possible in half of
full length standing radiographs, is required comparing the injured patients and was associated with better outcome scores. As with
and uninjured extremity. Early revision surgery needs to be many significant intra-articular orthopaedic injuries, realistic ex-
balanced against the risk of infection and is sometimes a difficult pectations should be explained to patients at an early stage in their
decision to make. If malalignment occurs and is symptomatic then treatment.
osteotomy to restore the limb axis is required.
Summary
Outcomes Tibial plateau fractures are challenging and technically demanding
Functional outcome assessment following tibial plateau fractures, fractures to treat, even by experienced trauma surgeons. The soft
with a median follow-up of 6.17 years, showed significantly higher tissue component to the injury necessitates careful timing of sur-
Knee Injury and Osteoarthritis Outcome Scores for pain, daily gical fixation in order to minimize wound complications. No
function, sports and recreation and quality of life.28 40% of patients particular surgical method of fixation (ORIF versus external fixa-
complained of metalwork prominence, about one third of patients tion) has been proven to date to be superior. Being aware of the
did not return to work and only 50% returned to their original posterior coronal shear fractures and utilizing the appropriate

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 MAJOR TRAUMA

surgical approach will allow the treating surgeon to apply biome- 12 Berber R, Lewis CP, Copas D, Forward DP, Moran CG. Postero-
chanically well positioned fixation in more complex injury patterns. medial approach for complex tibial plateau injuries with a
The surgical principles of treatment remain the same regard- postero-medial or postero-lateral shear fragment. Injury 2014;
less of the treatment modality used. These are to: 45: 757e65.
 Respect the soft tissues 13 Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee
 Restore the mechanical alignment of the lower limb (often after tibial plateau fractures. J Knee Surg 2010; 23: 187e92.
with indirect reduction and relative stability in the meta- 14 Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged
physeal region) management of high-energy proximal tibia fractures (OTA types
 Avoid instability of the knee joint 41): the results of a prospective, standardized protocol. J Orthop
 Attempt to achieve anatomic reduction of the articular Trauma 2005; 19: 448e55. discussion 56.
surface to restore articular congruity with rigid fixation and 15 Giannoudis PV, Tzioupis C, Papathanassopoulos A,
avoid subsequent collapse of the articular surface Obakponovwe O, Roberts C. Articular step-off and risk of post-
 Following surgical fixation always perform an examination traumatic osteoarthritis. Evidence today. Injury 2010; 41: 986e95.
of the knee to assess stability 16 Lansinger O, Bergman B, Korner L, Andersson GB. Tibial condylar
 Enable early movement and rehabilitation of the knee fractures. A twenty-year follow-up. J Bone Joint Surg Am 1986;
joint. 68: 13e9.
The concept of height stability of the tibial plateau in order to 17 McNamara IR, Smith TO, Shepherd KL, et al. Surgical fixation
restore stability to the knee, and avoiding malalignment of the methods for tibial plateau fractures. Cochrane Database Syst Rev
mechanical axis, are important factors in the principles of sur- 2015; Cd009679. http://dx.doi.org/10.1002/14651858.CD009679.
gical treatment. A pub2.
18 Frosch KH, Balcarek P, Walde T, Sturmer KM. A new postero-
lateral approach without fibula osteotomy for the treatment of
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