Continuing Education Activity

Tibial plateau fractures account for 1 percent of all fractures and are typically sustained with high-energy mechanisms. Tibial plateau fractures may be associated with injury to nearby structures including vasculature, nerves, ligaments, menisci, and adjacent compartments. While minimal tibial plateau fractures with no associated injuries can be safely managed non-operatively, typically this injury requires orthopedic consultation and operative management. This activity reviews the evaluation and management of patients with tibial plateau fractures and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

Objectives:

• Identify the etiology of tibial plateau fractures.
• Describe the typical radiographic findings of tibial plateau fractures.
• List the treatment and management options available for tibial plateau fractures.
• Employ interprofessional team strategies for improving care coordination and communication to advance the management of tibial plateau fractures and improve patient outcomes.

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Introduction

Tibial plateau fractures account for 1% of all fractures and are typically sustained with high-energy mechanisms.[1] Tibial plateau fractures may be associated with injury to nearby structures, including vasculature, nerves, ligaments, menisci, and adjacent compartments. While minimal tibial plateau fractures with no associated injuries can be safely managed nonoperatively, typically this injury requires orthopedic consultation and operative management.

Etiology

The main mechanism of injury is a varus or valgus load, along with or without an axial load. Tibial plateau fractures may be lateral, medial, or bicondylar. Injuries to the lateral part of the tibial plateau are most common and can be a consequence of a direct blow to the lateral aspect of the knee. Injuries to the medial plateau require more force and are sustained from high-energy mechanisms, including axial load from falling from a height and landing on the feet, motor vehicle collisions, and other sources of direct trauma. With high-energy mechanisms such as these, bicondylar fractures are more common than isolated medial plateau fractures. Tibial plateau fractures resulting from low-energy mechanisms are more common in the elderly and other populations with osteoporosis.

Epidemiology

Tibial plateau fractures comprise 1% of all fractures. The incidence of tibial plateau fractures is 10.3 per 100,000 people annually.[2] The mean age of patients incurring tibial plateau fractures is 52.6 years.[2] The distribution of tibial plateau fractures is bimodal, with men under the age of 50 more likely to sustain this injury via high-energy mechanisms and frequently associated with soft tissue injuries. Whilst women over the age of 70 are more likely to have tibial plateau insufficiency fractures secondary to falls.[2] Overall, men more commonly sustain tibial plateau fractures than women.

Pathophysiology

The tibia is the weight-bearing bone of the leg, located medially to the fibula. The proximal part of the bone comprises the distal part of the knee joint. The tibial plateau has 2 articular surfaces, the medial and lateral tibial condyles, also called the medial and lateral plateaus. The medial tibial condyle bears 60% of the knee’s weight and is a thicker structure. It is concave in shape and located slightly more distally compared to the lateral tibial condyle. The lateral tibial condyle is convex in shape, thinner, weaker, and more proximal than the medial tibial condyle. The intercondylar eminence is a bony structure between the 2 condyles that serves as an attachment point for the anterior cruciate ligament. Deep fascia separates the lower leg into 4 compartments containing muscles and neurovascular structures. The anterior, lateral, superficial, and deep posterior compartments border the tibia and are at risk for compartment syndrome with tibial fractures. The ligaments and menisci of the knee joint are also at risk for injury in association with tibial plateau fractures. Lateral meniscal tears are more common in association with Schatzker type II fractures and where there is more than 10 mm of articular surface depression, while medial meniscus tears are most common in Schatzker type IV plateau fractures. Anterior cruciate ligament injuries have been reported in a quarter of Shatzaker type IV and VI fracture patterns. Vascular injuries are commonly seen in Schatzker type IV fracture-dislocations.[3][4] Vascular injury is also a complication of proximal tibial fractures and Schatzker type IV tibial plateau fractures. The popliteal artery runs posterior to the knee and branches into the anterior and posterior tibial arteries. The 3-column theory of tibial plateau fractures states that a 0-column fracture is a purely articular fracture. Whilst one-column fractures are isolated articular depressions with a fracture in the column, 2-column fractures are either anteromedial with posteromedial fractures or anterolateral with separate posterolateral depression fractures.

History and Physical

Tibial plateau fractures should be suspected in patients presenting with knee pain, possible deformity, edema, and a suspected mechanism of injury or risk factors that predispose to this type of fracture. Patients with very high-energy mechanisms of injury may present to the trauma bay and undergo complete ATLS evaluation, and prioritization should always be given to evaluating ABCs and stabilizing the patient. A pulseless distal extremity is an orthopedic emergency. Complete physical exam of a potential tibial fracture should include an examination of the entire knee, comparison to the contralateral (presumably uninjured) knee, with special attention to the following:

• Skin: The skin should be examined circumferentially to evaluate for an open fracture, lacerations, or puncture wounds.
• Knee effusion: If there is a significant effusion, the knee may be aspirated to evaluate for hemarthrosis and for the presence of lipids or bone marrow elements, suggesting intraarticular fracture.
• Neurovascular exam: Sensation, motor function, and distal pulses should be assessed. There should be a low threshold for measuring the ankle-brachial index if there is a difference in pulses between the extremities.
• Compartments: All compartments should be palpated; a firm, tense compartment suggests compartment syndrome, which can be further evaluated by measuring intracompartmental pressure.
• Laxity tests: More than 10° of laxity at the joint line with varus/valgus stress testing suggests a tear of the collateral ligaments. Laxity below the joint line is indicative of a displaced fracture.
• Range of motion and strength may be very difficult to assess secondary to pain.

Evaluation

All imaging modalities should be analyzed for the specific pattern, shape, size, and location of the different fragments. Plain radiographs should include anterior-posterior, lateral, and intercondylar notch views. The anteroposterior views may show sclerotic bands suggestive of compression, joint malalignment, or depression of the articular surface. Lateral views can be useful for spotting posteromedial fracture lines. Other additional views include oblique and tibial plateau views (10° caudal tilt), which can be helpful in determining the extent of articular surface depression. However, these views are becoming less important in the presence of computed tomography scans. Also, tibial plateau fractures can be difficult to see on plain films, with a sensitivity of 85%.[1] These injuries are associated with significant morbidity and frequently require operative management. If there is a high degree of suspicion for tibial plateau fractures and negative plain radiographs, a computed tomography scan is indicated. Some radiographic signs have been reported to be associated with injuries to the lateral meniscus, lateral collateral ligament injuries, or posterior cruciate ligament injuries. That includes articular surface depression of more than 6mm and/ or articular widening of more than 5 mm. When depression and widening are more than 8 mm, the medial meniscal injury is frequently reported.[5][6] 

Computed tomography scan assesses articular surface depression and comminution. Also, it delineates fracture pattern, size of fracture fragment, shape, and location for surgical planning. A lipohemarthrosis is an indication of an occult fracture. A computed tomography scan can alter fracture classification, and a treatment plan can be formulated based on the initial radiographs.[7] 

Magnetic resonance imaging is indicated for the assessment of suspected meniscal and ligamentous injuries. The knee joint should be evaluated for fracture lines, displacement, depression of the tibial plateau, and associated ligamentous or meniscal injury. 

None of the tibial plateau fracture classification systems is ideal.[8][9] Tibial plateau fractures can be classified based on the Schatzker Classification system, summarized below:

• Schatzker I: Lateral plateau split fracture
• Schatzker II: Lateral plateau split-depressed fracture
• Schatzker III: Lateral plateau pure depression fracture
• Schatzker IV: Medial plateau fracture
• Schatzker V: Bicondylar plateau fracture
• Schatzker VI: Metaphyseal-diaphyseal dissociation

10% of all tibial plateau fractures cannot be classified using the Schatzker classification. Especially fractures associated with dislocations or knee instability. Hohl and Moore suggested an alternative classification of tibial plateau fractures as follows:

• Type I: Coronal split fracture
• Type II: Entire condylar fracture
• Type III: Rim avulsion fracture of the lateral tibial plateau
• Type IV: Rim compression fracture
• Type V: Four-part fracture

Either computed tomography or magnetic resonance imaging can better demonstrate the extent of plateau depression and comminution than plain radiographs, and may be helpful in surgical planning should this management be indicated. Computed tomography scans are typically faster and easier to obtain in an acute setting. However, magnetic resonance imaging can identify meniscal and ligamentous injuries. 

Treatment / Management

The main keys to successful functional outcomes in tibial plateau fractures are restoration of axial and rotational alignment of the limb and knee stability.[10] Anatomical reduction and restoration of articular congruity are critical but less important for functional results.[11] Another crucial aspect is soft tissue management. Initial management involves preventing further soft tissue injury until the fracture is stabilized. This can be achieved by knee immobilization and cryotherapy.[12]

Nonoperative Management

This would be indicated in minimally displaced fractures, whether it is a split or depression pattern. These fracture patterns typically result from low-energy mechanisms and are associated with no ligamentous injuries. Also, nonambulatory patients would be candidates for nonoperative management. Fractures appropriate for nonoperative management may be placed in a hinged knee brace, immediate passive range of motion can be initiated, and patients are advised to remain nonweight-bearing for 6-8 weeks, followed by partial weight-bearing for a further 6 weeks, then full weight-bearing as tolerated. The patient should be re-evaluated weekly with plain radiographs for 3 weeks following injury, and, assuming there is no further injury or displacement, may be transitioned to biweekly or every 3-week imaging. The patient should remain in the brace until radiographic healing is complete, which may take up to 12 weeks. Physical therapy may begin at this time, and patients may not regain full function until 16 to 20 weeks or longer. Return to activities requiring prolonged weight-bearing and stress, such as certain sports, should not occur until healing is nearly complete, with the affected extremity demonstrating more than 90% of the strength of the unaffected extremity.[1][13][14][15] 

Operative Management

Open reduction and internal fixation: This is indicated for tibial plateau fractures with significant articular step-off, condylar widening, ligamentous instability, and for Schatzer IV, V, and VI injuries.[11]

The approach is tailored based on the fracture pattern. A lateral approach with a straight or hockey-stick anterolateral incision is commonly used. Posteromedial incision utilizing the interval between the pes anserinus and the medial head of the gastrocnemius has been described for medial plateau fractures and those with posteromedial extensions. A dual surgical incision, medial and lateral, is indicated for bicondylar fractures. With posterior approaches reserved for posterior shearing fractures.

Reduction (direct or indirect): It focuses on restoring continuity and congruity of the articular surface. Any metaphyseal voids should be filled with bone grafts or cement. Bone grafts could be autogenous, allogenic, or artificial substitutes. Calcium phosphate cement has demonstrated high compressive strength when used to fill metaphyseal defects.

Internal fixation can be achieved with a variety of constructs, either screws alone or a plate (locked vs nonlocked), with the aim of achieving absolute stability to maintain the articular surface. Isolated screw fixation can be used for simple split fractures or depression fractures that have been elevated percutaneously. A nonlocked plate in a buttress mode would be ideal for simple fracture patterns in healthy bones. Whilst a fixed angle construct, such as a locked plate, would be more beneficial in comminuted fracture patterns and poor bone quality, with the advantages of less compression of periosteum and soft tissues.

Postoperatively, a hinged knee brace is applied, with early passive range of motion and nonweight-bearing for 6 weeks, followed by partial weight-bearing for a further 6 weeks, then weight-bearing as tolerated.

External fixation with limited open/percutaneous fixation of the articular segment:  This is indicated in significantly comminuted fractures or highly contaminated open fractures. The principle is to perform articular surface reduction percutaneously or with mini incisions, then stabilize the reduction with subchondral lag screws or wires. After this, an external fixator or a hybrid ring fixator is applied. It allows for a knee range of motion and reduces soft-tissue injury. Patients are allowed to weight-bear after callus formation, and the fixator remains in place for 2 to 4 months. This treatment modality has been reported to be associated with a high malunion rate.[11]

Staged or Sequential fixation: Bridging external fixation with delayed open reduction internal fixation:  may be performed as a temporizing measure when there is significant soft tissue injury, or if the patient has sustained other serious injuries that require damage control orthopedics.[15] The external fixator is applied by inserting 2 4.5 or 5 mm half pins in the middle of the distal femur and the middle of the distal tibia. Then, reduce the fracture by axial traction and lock the fixator in slight flexion. Bars should be placed in 2 planes to allow control over the varus-valgus and flexion-extension forces. External fixators permit soft-tissue resuscitation prior to definitive fixation, with the advantages of decreased infection rates and wound-healing complications. The main disadvantage of this approach is the residual knee stiffness.[16]

Arthroscopically assisted reduction and internal fixation: This can provide results as satisfactory as open reduction and internal fixation. Especially in Schatzker I-III fractures.[17][18]

Primary Total Knee Arthroplasty: This could be an option in specific patients with specific fracture patterns.

Differential Diagnosis

Tibial plateau fractures commonly present with knee deformity and effusion. It is important to evaluate for other possible intra-articular fractures, such as the distal femur and tibial spine. The diagnosis of tibial plateau fractures is made with plain radiographs and computed tomography. Additional soft tissue injuries to the medial and lateral meniscus, ACL, and the collateral ligaments should all be considered.[19]

Prognosis

Many studies have shown that after open reduction and internal fixation of any type of tibial plateau fracture, functional outcomes are poorer. However, when evaluating for post-traumatic knee arthritis on plain radiographs, this did not correlate with functional outcome. Studies have shown that higher energy mechanisms of trauma are associated with poor outcomes.[20] The crucial factor that influences long-term outcomes is the restoration of joint stability. External fixation for significantly comminuted fractures has shown a high malunion rate, along with indications for delayed arthroplasty in elderly patients. The worst long-term outcomes were reported when there was associated ligamentous instability, meniscectomy, or an alteration in the limb mechanical axis by more than 5°.

Complications

Postoperative infections have been associated with male gender, smoking, lung diseases, bicondylar features, and increased intraoperative time. Compartment syndrome can be a devastating complication, and the treating physician should have a high level of suspicion for this complication. Long-term complications of tibial plateau fractures may affect the quality of life.[20][21][22][23] For patients whose jobs require a high degree of mobility, a tibial plateau fracture may significantly delay return to employment.[24] These include the following:

• Abnormal gait
• Post-traumatic knee osteoarthritis: This has been associated with meniscectomy, axial malalignment, septic arthritis, and ligamentous instability
• Post-traumatic ankle osteoarthritis is secondary to an abnormal gait
• Chronic pain

Deterrence and Patient Education

It is important to educate patients about tibial plateau fractures when discussing operative and nonoperative treatment regarding prognosis. Prompt outpatient orthopedic follow-up is extremely important.

Enhancing Healthcare Team Outcomes

Tibial plateau fractures are best managed by an interprofessional team that includes orthopedic nurses and therapists. An orthopedic consult is essential in all cases to determine the type of treatment. Most patients need extensive rehabilitation to regain muscle strength and function. The outcomes are generally good, but a return to sports may be delayed for months.

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References

1.

Mthethwa J, Chikate A. A review of the management of tibial plateau fractures. Musculoskelet Surg. 2018 Aug;102(2):119-127. [PubMed: 29043562]

2.

Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE. Population-Based Epidemiology of Tibial Plateau Fractures. Orthopedics. 2015 Sep;38(9):e780-6. [PubMed: 26375535]

3.

Mustonen AO, Koivikko MP, Lindahl J, Koskinen SK. MRI of acute meniscal injury associated with tibial plateau fractures: prevalence, type, and location. AJR Am J Roentgenol. 2008 Oct;191(4):1002-9. [PubMed: 18806134]

4.

Colletti P, Greenberg H, Terk MR. MR findings in patients with acute tibial plateau fractures. Comput Med Imaging Graph. 1996 Sep-Oct;20(5):389-94. [PubMed: 9007366]

5.

Gardner MJ, Yacoubian S, Geller D, Pode M, Mintz D, Helfet DL, Lorich DG. Prediction of soft-tissue injuries in Schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma. 2006 Feb;60(2):319-23; discussion 324. [PubMed: 16508489]

6.

Spiro AS, Regier M, Novo de Oliveira A, Vettorazzi E, Hoffmann M, Petersen JP, Henes FO, Demuth T, Rueger JM, Lehmann W. The degree of articular depression as a predictor of soft-tissue injuries in tibial plateau fracture. Knee Surg Sports Traumatol Arthrosc. 2013 Mar;21(3):564-70. [PubMed: 22965381]

7.

Chan PS, Klimkiewicz JJ, Luchetti WT, Esterhai JL, Kneeland JB, Dalinka MK, Heppenstall RB. Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma. 1997 Oct;11(7):484-9. [PubMed: 9334949]

8.

Maripuri SN, Rao P, Manoj-Thomas A, Mohanty K. The classification systems for tibial plateau fractures: how reliable are they? Injury. 2008 Oct;39(10):1216-21. [PubMed: 18439607]

9.

Taşkesen A, Demirkale İ, Okkaoğlu MC, Özdemir M, Bilgili MG, Altay M. Intraobserver and interobserver reliability assessment of tibial plateau fracture classification systems. Eklem Hastalik Cerrahisi. 2017 Dec;28(3):177-81. [PubMed: 29125816]

10.

Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev. 2016 May;1(5):225-232. [PMC free article: PMC5367528] [PubMed: 28461952]

11.

Hall JA, Beuerlein MJ, McKee MD., Canadian Orthopaedic Trauma Society. Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Surgical technique. J Bone Joint Surg Am. 2009 Mar 01;91 Suppl 2 Pt 1:74-88. [PubMed: 19255201]

12.

Borrelli J. Management of soft tissue injuries associated with tibial plateau fractures. J Knee Surg. 2014 Feb;27(1):5-9. [PubMed: 24357043]

13.

Schmidt AH, Finkemeier CG, Tornetta P. Treatment of closed tibial fractures. Instr Course Lect. 2003;52:607-22. [PubMed: 12690886]

14.

Ziran BH, Hooks B, Pesantez R. Complex fractures of the tibial plateau. J Knee Surg. 2007 Jan;20(1):67-77. [PubMed: 17288092]

15.

Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res. 1993 Jul;(292):87-100. [PubMed: 8519141]

16.

Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma. 2005 Aug;19(7):448-55; discussion 456. [PubMed: 16056075]

17.

Verona M, Marongiu G, Cardoni G, Piras N, Frigau L, Capone A. Arthroscopically assisted reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) for lateral tibial plateau fractures: a comparative retrospective study. J Orthop Surg Res. 2019 May 24;14(1):155. [PMC free article: PMC6534860] [PubMed: 31126304]

18.

Elabjer E, Benčić I, Ćuti T, Cerovečki T, Ćurić S, Vidović D. Tibial plateau fracture management: arthroscopically-assisted versus ORIF procedure - clinical and radiological comparison. Injury. 2017 Nov;48 Suppl 5:S61-S64. [PubMed: 29122125]

19.

Chang H, Zheng Z, Shao D, Yu Y, Hou Z, Zhang Y. Incidence and Radiological Predictors of Concomitant Meniscal and Cruciate Ligament Injuries in Operative Tibial Plateau Fractures: A Prospective Diagnostic Study. Sci Rep. 2018 Sep 06;8(1):13317. [PMC free article: PMC6127198] [PubMed: 30190502]

20.

van Dreumel RL, van Wunnik BP, Janssen L, Simons PC, Janzing HM. Mid- to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures. Injury. 2015 Aug;46(8):1608-12. [PubMed: 26071324]

21.

Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma. 2001 Jun-Jul;15(5):312-20. [PubMed: 11433134]

22.

Warschawski Y, Elbaz A, Segal G, Norman D, Haim A, Jacov E, Grundshtein A, Steinberg E. Gait characteristics and quality of life perception of patients following tibial plateau fracture. Arch Orthop Trauma Surg. 2015 Nov;135(11):1541-6. [PubMed: 26386838]

23.

Timmers TK, van der Ven DJ, de Vries LS, van Olden GD. Functional outcome after tibial plateau fracture osteosynthesis: a mean follow-up of 6 years. Knee. 2014 Dec;21(6):1210-5. [PubMed: 25311514]

24.

Elsoe R, Larsen P, Petruskevicius J, Kold S. Complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported QOL: a prospective observational study of 46 complex tibial fractures treated with a ring fixator. Strategies Trauma Limb Reconstr. 2018 Apr;13(1):25-33. [PMC free article: PMC5862708] [PubMed: 29103207]

Disclosure: Saloni Malik declares no relevant financial relationships with ineligible companies.

Disclosure: Tom Herron declares no relevant financial relationships with ineligible companies.

Disclosure: Ahmed Mabrouk declares no relevant financial relationships with ineligible companies.

Disclosure: Naomi Rosenberg declares no relevant financial relationships with ineligible companies.