Tibial Plateau Fractures - Trauma

Overview

• Tibial Plateau fractures are periarticular injuries of the proximal tibia.
• Frequently associated with soft tissue injury.
• Diagnosis: knee radiographs, often requires CT scan for surgical planning.
• Treatment: ORIF in acute setting or delayed fixation after swelling subsides.

Epidemiology

• Incidence: 1-2% of all fractures, 10.3 per 100,000 people annually.
• Demographics: Mean age 52, bimodal distribution (males in 40s for high-energy trauma, females in 70s for low-energy falls).
• Location: Lateral plateau (70-80%), bicondylar (10-30%), medial plateau (10-20%).

Etiology

• Mechanisms: Valgus load (lateral plateau), varus load (medial plateau), axial load (bicondylar).
• High-energy: Often medial plateau, associated with soft tissue injuries.
• Low-energy: Often lateral plateau.

Associated Conditions

• Meniscal tears: Lateral more common than medial.
• ACL injuries: Common in type IV and VI fractures.
• Compartment syndrome, neurovascular injury (common with Schatzker IV fracture-dislocations).

Anatomy

• Osteology: Lateral tibial plateau (convex, less dense), medial tibial plateau (concave, more distal).
• Ligaments: ACL, PCL, MCL, LCL.
• Meniscus: Lateral (more mobile), medial (less mobile).
• Muscles: 4 compartments in the lower leg.
• Neurovascular structures: Popliteal artery, tibial nerve, common peroneal nerve.

Biomechanics

• Medial tibial condyle bears 60% of knee load, lateral tibial condyle 40%.
• Kinematics: Flexion-extension 0-140 degrees.

Classification

• Schatzker Classification:
  • Type I: Lateral split fracture.
  • Type II: Lateral split-depressed fracture.
  • Type III: Lateral pure depression fracture.
  • Type IV: Medial plateau fracture.
  • Type V: Bicondylar fracture.
  • Type VI: Metaphyseal-diaphyseal dissociation.
• Hohl and Moore Classification: For true fracture-dislocations.

Presentation

• History: Mechanism (high vs low energy), inability to bear weight.
• Physical Exam: Inspection, palpation, varus/valgus stress testing, neurovascular exam.

Imaging

• Radiographs: AP, lateral, oblique views.
• CT scan for preoperative planning.
• MRI for meniscal, ligamentous pathology.

Differential Diagnosis

• Includes distal femur fracture, knee dislocation, patella instability, ACL tear, meniscus tear.

Treatment

• Nonoperative: Minimally displaced fractures, significant comorbidities.
• Operative: ORIF for significant depression, condylar widening, or instability.
  • Timing: Acute or staged ORIF.
  • Outcomes: Joint stability is a key predictor.

Techniques

• Closed reduction & immobilization.
• Provisional external fixation.
• External Fixation with limited internal fixation.
• Open reduction internal fixation (ORIF).

Complications

• Post-traumatic arthritis.
• Compartment syndrome.
• Infection, nonunion/malunion.
• Knee stiffness, loss of reduction, deep vein thrombosis.

Prognosis

• Mortality rate: 5% at 1 year.
• Return to work: 70-90% at 1 year.
• Mean ROM: 10-145 degrees at 1 year.