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The Tibial Plateau Fracture

Walter Mak, MD

Department of Medical ImagingSt. Michael’s HospitalUniversity of Toronto

Mechanism of Injury

Acute knee trauma

Knee dislocation Tibial Plateau Fracture

Plain filmMRI+/- CT angiogram

Plain filmCT+/- CT angiogram

Restore ligamentous/soft tissue stability

Restore osseous stability

Where is the fracture?

Where is the fracture?

Lateral plateau fracture

Where is the fracture?

Medial plateau fracture

High energy trauma

High association with cruciate ligament and neurovascular injury

Almost always treated with open reduction and internal fixation (ORIF)

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Where is the fracture?

Medial plateau fracture,ground level fall

Varus malalignmentpoorly tolerated longterm

Usually undergo ORIF

Courtesy Dr. Ivan Diamond

Where is the fracture?

Bicondylar fracture

High energy mechanism

Almost always treated surgically

Where is the fracture?

Posterior shear fracture

Coronal fracture plane on lateral view

Direct posterior surgical approach

Bhattacharyya T. et al. J Orthop Trauma 2005, 19:305-310

Where is the fracture?

Posterior shear fracture

Coronal fracture plane on lateral view

Direct posterior surgical approach

Bhattacharyya T. et al. J Orthop Trauma 2005, 19:305-310

Is there a split and/or depressed component?

Split and/or depression?

Depression Fracture

Impaction of cancellous bone

Low energy, osteoporotic bone

During ORIF, grafting of defect may be required

Markhardt et al. Radiographics 2009; 29:585-597

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Split and/or depression?

Split Fracture

Shearing force splits plateau

Higher energy, normal bone

Usually see with depressed component

Split and/or depression?

Split fracture

No articular surface depression

ORIF without grafting

Split and/or depression?

Split-depression fracture

Very common, often clinically unstable

Split and/or depression?

Depression fracture lateral plateau

No split component

Pure depression fractures of lateral plateau often clinically stable

Is there articular incongruity?

Articular incongruity?

Articular surface depression

Measured using opposite plateau or remaining intact surface

Measure to point of maximal depression

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Condylar widening

Condylar widening

Overhang of tibial plateau in relation to femoral condyles

Sum of overhang medially and laterally if appropriate

Articular Surface Incongruity

How much is ‘too much’?No uniform consensus

Articular surface depression: >4mm at SMHCondylar widening: >4mm at SMH

Depression/widening ≥2 mm should be reported

Is there metadiaphyseal dissociation?

Metadiaphyseal Dissociation

High-energy mechanism, significant soft tissue and neurovascular injury

Tibial articular surface completely dissociated from diaphysis

Comminution of one or both tibial plateaus and articular surface

Metadiaphyseal dissociation?

Always undergo ORIF

Formal ORIF while soft tissue injuries addressed

Temporary external fixation, delayed ORIF

What other fractures are present?

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Associated fractures?

Tibial tuberosity avulsion

May result in extension lag if not fixed

Associated fractures?

Intercondylar eminence fracture, cruciate ligament avulsion

Fixed at time of ORIF if amenable to screw/suture fixation

Addressed in delayed fashion if comminuted and residual instability

Associated fractures?

Fibular head fracture –posterolateral corner injury

Timing of ORIF and/or ligament reconstruction varies

Value of CT

Value of CT: Fracture characterization

Medial plateau fracture?

CT reveals split componentthrough lateral plateau

Bicondylar fracture; surgical approach altered

Value of CT: Fracture characterization

Medial plateau fracture?

CT reveals split componentthrough lateral plateau

Bicondylar fracture; surgical approach altered

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Value of CT: Assessing articular incongruity

Depression may be underestimated on plain film

6 mm depression confirmed on CT

Value of CT: Associated Fractures

Medial plateau fracture

Intercondylar eminence fracture?

Confirmed on CT

Value of CT: Associated Fractures

Medial plateau fracture

Intercondylar eminence fracture?

Confirmed on CT

Value of CT: Fragment characterization

Coronal fracture plane; separate posteromedial fragment

Common pattern in bicondylar fractures

Requires posteromedial plate; may preclude lateral-only fixation

J Orthop Trauma 2008;22:176-182

Value of CT: Fragment characterization

Bicondylar fracture

Posteromedial fragment

Secured with posteromedial plate

Value of CT: Fragment characterization

Bicondylar fracture

Posteromedial fragment

Secured with posteromedial plate

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Value of CT: Fragment characterization

Bicondylar fracture

Posteromedial fragment

Secured with posteromedial plate

Value of CT: Fragment characterization

Comminuted, split lateral plateau

CT reveals bicondylar fracture

Gross comminution of medial plateau, not amenable to fixation

Value of CT: Fragment characterization

Comminuted, split lateral plateau

CT reveals bicondylar fracture

Gross comminution of medial plateau, not amenable to fixation

Summary: Questions toAnswer

1. Where is the fracture? Lateral, medial, bicondylar, posterior

2. Is there a split and/or depressed component?

3. Is there articular incongruity? Articular surface depression, condylar widening

4. Is there metadiaphyseal dissociation?5. What other fractures are present? Tibial

tuberosity, intercondylar eminence, fibular head

Summary: Indications forOperative Fixation

Bicondylar fractures

Medial plateau fractures

Lateral plateau fractures:•>10° varus/valgus instability•>4mm articular surface depression•>4mm condylar widening

Open fractures

Compartment syndrome/arterial injury

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Barei, D.P., et al., Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma, 2008. 22(3): p. 176-82.

Doornberg, J.N., et al., Two-dimensional and three-dimensional computed tomography for the classification and characterisation of tibial plateau fractures. Injury, 2011. 42(12): p. 1416-25.

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Bhattacharyya, T., et al., The posterior shearing tibial plateau fracture: treatment and results via a posterior approach. J Orthop Trauma, 2005. 19(5): p. 305-10.

Stevens, D.G., et al., The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma, 2001. 15(5): p. 312-20.

Markhardt, B.K., J.M. Gross, and J.U. Monu, Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics, 2009. 29(2): p. 585-97.

Martin, J., et al., Radiographic fracture assessments: which ones can we reliably make? J Orthop Trauma, 2000. 14(6): p. 379-85.

Musahl, V., et al., New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau. J Bone Joint Surg Br, 2009. 91(4): p. 426-33.

Tscherne, H. and P. Lobenhoffer, Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res, 1993(292): p. 87-100.

Dirschl, D.R. and P.A. Dawson, Injury Severity Assessment in Tibial Plateau Fractures. Clin Orthop Relat Res, 2004(423): p. 85-92.