Tibial Plateau Fractures - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes fractures of the tibial plateau - Schatzker classification.

Lateral tibial plateau – convex in shape and proximal to the medial plateau
Medial tibia plateau – concave in shape and distal to the lateral tibial plateau.
Screw placement from lateral to medial may have a risk of joint penetration since the medial tibial plateau is concave and distal. 50% of tibial plateau fractures are associated with soft tissue injuries such as meniscal injury (lateral meniscus tears more than the medial meniscus), medial collateral ligament injury, anterior cruciate ligament injury, and compartment syndrome. Lateral meniscal tears occur commonly with Schatzker Type II fractures (split-depressed). Medial meniscal tears occurs with Schatzker Type IV fractures (medial plateau).
Type I: pure cleavage fracture of the lateral tibial plateau. Treatment is a buttress plate – prevents collapse and shear forces.
Type II: cleavage fracture of the lateral tibial plateau with articular surface depression. Lateral meniscal tear is associated with type II fractures. Joint depression greater than 6 mm and widening of greater than 5 mm was associated with a lateral meniscal injury over 80% of the cases. Treatment is to elevate the fracture, fill the gap, plate with high compressive strength cement.
Type III: pure central depression fracture of the lateral tibial plateau with an intact osseous rim. Depression fracture that usually occurs in older populations. Treatment is to elevate the fracture, fill the gap, plate with high compressive strength cement.
Type IV: split or depression fracture of the medial tibial plateau. Possible vascular injury and medial meniscal tears are associated with Type IV fractures. The fracture produces temporary dislocation of the knee with possible popliteal artery injury. Frequent neurovascular checks, ABI and arteriography may be needed. When the fracture line extends beyond the medial eminence, it is associated with more complication such as compartment syndrome. Treatment is surgical repair (for all) A-B index for vascular complications. Vascular complications should be avoided by assessing the patient by the ankle/brachial index.
Type V: Bicondylar tibial plateau fracture with intact metaphysis and diaphysis. Treatment is surgical repair followed by internal fixation technique when the soft tissue condition permits.
Type VI; unicondylar or bicondylar tibial plateau fracture with metaphyseal-diaphyseal dissociation. Treatment is an external fixator followed by internal fixation when the soft tissue condition permits. If both sides need to be fixed, medial and lateral plate fixation should be done through two approaches.
Physical examination:
•Examine the neurovascular status of the patient
•Examine for compartment syndrome
•If varus/valgus tests demonstrate laxity of more than 10 degrees, this indicates instability and it requires surgery (this is an important point usually found on the board exam).
•Neurovascular exam
oAny differences in pulse exam between extremities should be further investigates with ankle-brachial index measurement.
Imaging
•Obtain plateau view
o10 degree caudal tilt
•Important findings
oPosteromedial fracture lines must be recognized
•CT scan is the study of choice
•MRI
oUseful to determine meniscal and ligamentous pathology
Posteromedial Fractures:
•Must be recognized
•If you see it, fix the fracture (do two separate incisions):
oLateral plate
oPosteromedial plate: fix it with a posteromedial plate placed through a separate incision between the semimembranosus and the medial head of gastrocnemius (Baker’s cyst location).
Surgery
•The aim of surgery is to restore joint stability and alignment, provide a stable fixation and achieve early return of range of motion
•Early range of motion helps maintain cartilage
•Buttress plates are used in Unicondylar fractures
•Locked plates are used more frequently in bicondylar fracture
•Superficial and deep peroneal nerve injury may occur with percutaneously placed long lateral submuscular locking plate.
•In external fixation, keep the wire of pins more than 14 mm away from the joint.
Spanning external fixation is used in:
•Ligamentous injury
•Bicondylar fractures with shortening
•Soft tissue injury
•Polytrauma
•Comminution
The outcome of surgery depends on restoring adequate stability and mechanical alignment.

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