Rockwood & Green’s Fractures in Adults
6th Edition

Chapter 50
Fractures of the Proximal Tibia
Kenneth A. Egol
Kenneth J. Koval
The knee joint is one of three major weight-bearing joints in the lower extremity. Fractures that involve the proximal tibia affect knee function and stability. These fractures can either be intra-articular (tibial plateau) or extra-articular (proximal fourth). Generally, these injuries fall into two broad categories: low-energy and high-energy fractures. The spectrum of associated injuries, potential complications and outcomes varies with fracture pattern. There are many classification schemes to describe these injuries, with no clear consensus on indications for surgical treatment of certain fracture patterns.
Recently, more attention has been paid to the condition of the soft tissue envelope before surgical intervention. Soft tissue-friendly approaches, delayed internal fixation and minimally invasive techniques have all recently improved outcomes following these injuries. The aim of surgical treatment of proximal tibia and fibula fractures is to restore and preserve normal knee function. These goals are accomplished by anatomically restoring the articular surfaces of the tibial condyles, maintaining the mechanical axis, restoring ligamentous stability, and preserving a functional, pain-free range-of-motion in the knee.
This chapter focuses on fractures of the tibial plateau with an emphasis on surgical treatment. Principles of management will be discussed with regard to evaluation, classification, treatment of specific injuries, postoperative care, and complications. Extra-articular fractures of the proximal tibia have certain characteristics to make their treatment different and they will be discussed with fractures of the tibial shaft.
PRINCIPLES OF MANAGEMENT
Mechanism of Injury
Seventy-five years ago, fractures of the proximal tibial were described as “bumper fractures” (1) because they resulted from
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low-energy pedestrian accidents versus car fender accidents. Presently, the majority of tibial plateau fractures are secondary to high-speed motor vehicle accidents and falls from heights (2,3,4,5,6,7). Tibial plateau fracture results from direct axial compression, usually with a valgus (more common) or varus (less common) moment, and indirect shear forces (6,8). The anterior aspect of the femoral condyles is wedge-shaped; with the knee in full extension, the force generated by the injury drives the condyle into the tibial plateau (9). The direction, magnitude and location of the force, as well as the position of the knee at impact, determine the fracture pattern, location, and degree of displacement (8). Extra-articular fractures of the proximal tibia are usually secondary to direct bending forces applied to the metadiaphyseal region of the upper leg.
When a single compartment is involved in fractures of the tibial plateau, it is usually the lateral plateau (4,9,10,11,12,13,14,15). This involvement is due to the anatomic axis at the knee joint, normally 7 degrees of valgus, as well as to the predominance of injuries causing a lateral- to medial-directed force (8). Patient factors such as age and bone quality also influence the fracture pattern. Older patients with osteopenic bone are more likely to sustain depression-type fractures (16,17,18) because their subchondral bone is less likely to resist axially directed loads. In contrast, younger patients with denser subchondral bone are more likely to sustain split-type fractures and have an associated ligamentous disruption (10,19,20).
Signs and Symptoms
Fractures near the proximal tibia should be considered in the differential diagnosis any time a patient complains of knee pain and swelling after major or minor trauma. Knowledge of the mechanism of injury, clinical stability, radiographic findings, and associated injuries is essential in decision making regarding the treatment of knee fractures. Initial evaluation of the knee after trauma includes palpation to elicit tenderness over a site of potential fracture or ligamentous disruption. Generally, a hemarthrosis is present; however, capsular disruption may lead to extravasation into the surrounding soft tissue envelope.
Careful neurovascular examination of the extremity should follow documentation of the skin condition and presence of swelling. Compartment syndrome may develop following a high-energy mechanism and must be ruled out. If pulses are not palpable, Doppler studies should be performed. If the clinical signs of an impending compartment syndrome (pain out of proportion, or pain on passive stretch of the toes) are present, compartment monitoring pressures should be measured. Compartment pressures should also be measured in the unconscious patient with a tense, swollen leg. If concerns regarding the vascular integrity of the limb remain, an ankle-brachial index should be performed. If following a gentle manipulative reduction, the ankle-brachial index remains below 0.9, a vascular consultation should be obtained.
Associated Injuries
Injury to the collateral ligaments has been reported to occur in 7% to 43% of tibial plateau fractures (3,4,8,10,21,22,23,24,25,26,27,28,29), and rupture of the anterior cruciate has been reported in up to 23% of high-energy injuries (23,30). Meniscal injuries have been reported in up to 50% of tibial plateau fractures; in split-type fractures, the meniscus may be incarcerated within the fracture site (2,6,13,28,29,31,32). Ligamentous injuries may be difficult to diagnose on initial examination during the acute phase. Varus and valgus stress testing of the knee in near-full extension can be performed under fluoroscopy with sedation in the emergency department or under general anesthesia in the operating room (33). Any widening of the femoral-tibial articulation greater than 10° upon stress examination indicates ligamentous insufficiency. Split fractures of the lateral plateau have a relatively high incidence of associated ligamentous injury because the dense cancellous bone associated with split fractures does not compress. Energy is therefore not dissipated and the force is imparted to the medial collateral ligament.
Rationale
Open fractures about the knee are a cause for concern; therefore, any open wound should be evaluated for the possibility of an open joint injury (23,34). If the examining physician is unsure as to whether an open wound communicates with the joint, a large fluid bolus (at least 50 ml of sterile normal saline) should be injected into the knee away from the wound. If fluid extravasation is noted, the diagnosis is confirmed (8). The knee should be placed through a gentle range of motion, as the position of the knee at the time of injury may lead the capsule to seal in a one-way valve while in extension. One should be aware, however, that a negative injection test does not exclude the possibility of an open joint injury. If a high degree of suspicion for the presence of an open joint remains after saline injection, the wound should be explored in the operating room.
Diagnosis
Radiographic evaluation includes the standard knee trauma series of an anterior-posterior, lateral, and both oblique views (Fig. 50-1) (35,36,37,38). Because of the 10 to 15 degrees posterior slope of the tibia’s articular surface, these views may not be accurate in determining articular depression (38,39). Therefore, a 10 to 15 degrees caudally tilted plateau view should be used to assess articular step-off (33,39,40). A physician-assisted traction view is often helpful in higher-energy fractures with severe impaction and metadiaphyseal fragmentation. The ligamentotaxis afforded by gentle in-line traction often reduces the split components and can give the treating physician added information about the fracture pattern prior to computed tomography (CT) scan or temporizing fixation. In addition to providing an assessment of the fracture patterns, radiographs often provide evidence
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of associated ligamentous injury. Avulsion of the fibular head and the Segond sign (lateral capsular avulsion) are signs of associated ligamentous injury (22,33,41), whereas the Pellegrini-Stieda lesion (calcification along the insertion of the medial collateral ligament) is seen late and represents injury to the medial collateral ligament.
FIGURE 50-1 Standard radiographic trauma series. Internal oblique view (A), a lateral view (B), an anterior-posterior (C), and an external rotation oblique (D) reveal a minimally displaced split fracture of the lateral plateau.
CT has replaced plain tomography for evaluating knee fractures. CT scanning with sagittal reconstruction has increased the diagnostic accuracy in tibial plateau fractures and is indicated in cases of articular depression (Fig. 50-2) (42,43,44,45,46,47,48). CT scans have been shown to increase the interobserver and intraobserver agreement on classification in tibial plateau fractures (47). Furthermore, these studies are excellent adjuncts in the preoperative planning of lag screw placement when percutaneous fixation
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is considered. The axial images are often the most useful for determining the fracture configuration and planning of lag screw placement as well as surgical incision placement.
FIGURE 50-2 A,B. Sagittal (A) and coronal (B) CT reconstructions of the patient in Figure 50-1 reveal articular impaction and help to further define all fracture fragments.
Magnetic resonance imaging (MRI) has recently been suggested as a method for evaluating proximal tibia fractures as an alternative to CT scan or arthroscopy (Fig. 50-3) (25,26,49,50,51,52,53,54,55,56). This modality evaluates both the osseous as well as the soft tissue components of the injury in a noninvasive manner. Many studies have been able to demonstrate the advantages of this imaging modality; however, MRI may be cost prohibitive for use in standard situations. Although many surgeons champion its use as the most significant imaging modality in these injuries, there is currently no clear consensus for the use of MRI in tibial plateau fractures.
FIGURE 50-3 Radiograph (A) with accompanying MRI (B) following tibial plateau fracture. One can see the incarcerated meniscus within the fracture site as well as the injury to the anterior cruciate ligament.
FIGURE 50-4 Hohl classification.
FIGURE 50-5 Moore classification.
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Classification
There are numerous classification systems that have been proposed to describe tibial plateau fractures (9,10,39,57,58,59,60). The majority of these systems are very similar, and each one recognizes wedge, compression, and bicondylar types. The Hohl classification was the first widely accepted description of tibial plateau fractures (58) classifying these fractures into displaced and undisplaced types. Under the displaced category, he recognized local compression, split compression, total condyle depression, and comminuted fractures (Fig. 50-4).
Moore expanded upon Hohl’s concepts, taking into account higher-energy injuries and resultant knee instability (59). His classification of fracture-subluxation of the knee is divided into five types. Type I is a split fracture of the medial tibial plateau in the coronal plane; Type II is an entire condyle fracture in which the fracture line begins in the opposite compartment and extends across the tibial eminence; Type III is a rim avulsion fracture (these fractures are associated with a high rate of associated neurovascular injury); Type IV is another type of rim fracture, a rim compression injury that is usually associated with some type of contralateral ligamentous injury; and Type V is a four-part fracture in which the tibial eminence is separated from the tibial condyles and the tibial shaft (Fig. 50-5) (59).
Schatzker’s classification of tibial plateau fractures is currently the most widely used and was the first to make the distinction between medial and lateral plateau fractures (Fig. 50-6) (10,61). Type I (split fracture) is a pure cleavage fracture of the lateral tibial plateau that results in a wedge-shaped fracture fragment. Type II (split-depression) is a cleavage fracture of the lateral tibial plateau in which the remaining articular surface is depressed into the metaphysis. Type III is a pure central depression
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fracture of the lateral tibial with an intact osseous rim. Type IV involves the medial tibial plateau and is divided into two subtypes: Type A, which is a split fracture and Type B, a depression fracture. Either type may be combined with a tibial spine fracture. Type V is a bicondylar fracture in which the fracture line often forms an inverted “Y”; the metaphysis and diaphysis remain intact. Type VI is a tibial plateau fracture in which there is dissociation between the metaphysis and the diaphysis; these fractures may have varying degrees of comminution of one or both tibial condyles and the articular surface (10,61). Honkonen and Jarvinen have recently modified Schatzker’s classification to take residual limb alignment into account. They divide Type VI fractures into two types; those that are medially and laterally tilted to take into account functional results in treated fractures with residual angulation (2).
FIGURE 50-6 A–F. Schatzker classification.
In the Orthopaedic Trauma Association (OTA) classification, which is based on the Association for the Study of Internal Fixation (AO/ASIF) classification, the proximal tibia is denoted as segment 43 and is divided into three main categories. Type A fractures are extra-articular. Type B fractures are partial articular and are subdivided into three main categories: B1 are pure splits, B2 are pure depression, and B3 are split-depression. Type C fractures are complete articular fractures and are also subdivided into three subtypes: Type 1 is articular and metaphyseal simple, Type 2 is articular simple and metaphyseal multifragmentary, and Type 3 is articular multifragmentary (Fig. 50-7) (60).
FIGURE 50-7 AO/TA classification.
SURGICAL AND APPLIED ANATOMY
Of the two leg bones, the tibia bears the majority of the body’s weight, while the fibula serves as a site for muscular attachment. The fibular head is the insertion point for the fibular collateral ligament as well as the biceps femoris tendon. The medial tibial plateau is the larger of the two, is concave, and is covered with hyaline cartilage. The lateral plateau is smaller, convex, and is also covered in hyaline cartilage. These anatomic conditions are useful to recognize in cases when fixation is being placed percutaneously to avoid iatrogenic joint penetration. One can differentiate the lateral from the medial tibial plateau on the lateral radiographic image. A fibrocartilaginous meniscus covers both plateaus. The coronary ligaments serve to attach the menisci to the plateaus and the intermeniscal ligament serves to connect the menisci anteriorly. Oftentimes, this ligament is incised and elevated to afford direct visualization of the articular surfaces. The tibial spines are between the plateaus. The medial and lateral tibial spines serve as attachment points for the anterior and posterior cruciate ligaments as well as the menisci.
The tibia is a triangular-shaped bone in cross section in its diaphysis. Proximally, the tibial tubercle is found anterolaterally about 3 cm below the articular surface. This site serves as a point of attachment for the patellar tendon. Directly posterior to the patellar tendon is a richly vascularized fat pad. Further lateral on the proximal tibia is Gerdy’s tubercle where the iliotibial band inserts. Continuing to move laterally, the proximal tibia and fibula form an articulation covered in hyaline cartilage. The medial (tibial) collateral ligament inserts into the medial proximal tibia and along with the lateral (fibular) collateral ligaments are instrumental in preventing varus and valgus instability, while the intra-articular anterior and posterior cruciate ligaments afford anterior-posterior stability.
Neurovascular structures are at risk with proximal tibia fractures. The common peroneal nerve courses around the neck of the fibula distal to the proximal tibia-fibula joint before it divides into its superficial and deep branches. It is at risk with severe displacement following high-energy fractures of the proximal tibia. The trifurcation of the popliteal artery into the anterior tibial, posterior tibial, and peroneal arteries occurs posteromedially in the proximal tibia. Vascular injuries to these structures are common following knee dislocation, but can occur in high-energy fractures of the proximal tibia as well. If clinical examination indicates diminished distal pulses, further workup with ankle-brachial indices, Dopplers or an angiogram is warranted, and should be the impetus for vascular consultation. Furthermore, knee flexion during surgery will move these vascular structures farther from the posterior aspect of the plateau.
The anterior compartment musculature attaches to the proximal lateral tibia and must be carefully elevated when performing a lateral approach to the proximal tibia. The proximal medial tibial surface is devoid of muscle coverage, but serves as an attachment point for the pes tendons. This thin, soft tissue envelope about the proximal medial tibia places it at risk for secondary surgical insult following a higher-energy fracture pattern.
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CURRENT TREATMENT OPTIONS
Non- or minimally displaced fractures can be treated with nonoperative means (4,14,62,63,64). The indications for nonoperative versus operative treatment of displaced tibial plateau fractures vary widely in the literature, however. Numerous surgeons have reported excellent results with nonoperative treatment of displaced tibial plateau fractures (6,57,62,63,65,66,67), whereas others advocate anatomic articular surface restoration (4,10,61,68). The range of articular depression that can be accepted has varied from less than 2 mm to 1 cm (10,15,33,58,61,62,63). More importantly, the need for surgery on tibial plateau fractures should be based on instability greater than 10° of the nearly extended knee compared with the contralateral side (14,15). Split fractures are more likely to be unstable than pure depression fractures in which the rim is intact. As mentioned earlier, open fractures, fractures associated with vascular injury or compartment syndrome require urgent surgical intervention.
FIGURE 50-8 A–C. Follow-up films of patient shown in Figure 50-1. Following successful closed treatment with a hinged brace and protected weight bearing, the patient returned to full activities, including marshal arts.
Nonoperative Management
Nondisplaced and stable fractures are best treated nonoperatively. Protected weight bearing and early range-of-knee motion in a hinged fracture brace are the authors’ preferred treatment
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methods (Fig. 50-8). Failure to maintain reduction in the brace with range-of-motion exercises is an indication to treat the fracture operatively. Isometric quadricep exercises and progressive passive, active-assisted, and active range-of-knee motion exercises are initiated. Partial weight bearing (30 to 50 lbs) for 8 to 12 weeks is allowed with progression to full weight bearing as tolerated thereafter.
Substantial quadriceps atrophy and restricted range-of-knee motion are likely after use of a long leg cast secondary to knee joint immobilization (33,62). The use of a long leg cast should be reserved for an unreliable patient who cannot be trusted to partial weight bear; in this instance, the cast should be applied with the knee flexed to 45 degrees. Apley described the use of skeletal traction to provide alignment of displaced tibial plateau fractures that allowed for knee joint range of motion (57). This technique involves the use of a Steinmann pin inserted in the tibial shaft below the fracture and associated skeletal traction. Patients are restricted to bed rest for 6 weeks, but are allowed active range-of-motion exercises for the knee. The major limitations of this form of treatment include inadequate reduction of the articular surface and ineffective limb alignment control (33). Furthermore, the extended period of hospitalization and recumbency are not cost-effective in today’s health care environment. Historically, cast bracing has provided reasonable functional results (5,14,63,69).
Operative Treatment
Preoperative Planning
Preoperative planning is essential for any complex injury; it forces the surgeon to understand the “personality” of the fracture and mentally prepare an operative strategy. This concept applies to any attempted treatment of a complex periarticular fracture. The surgeon should understand the exact nature of the fracture before attempting any type of intervention. Radiographs of the contralateral extremity may benefit by serving as templates. Traction radiographs often allow better visualization of individual fracture fragments. All aspects of fracture reduction and fixation should be planned to avoid technical pitfalls (Fig. 50-9). Ensure that all needed equipment is available, such as a tourniquet, a femoral distractor, osteotomes, bone tamps, suture anchors, bone graft substitutes, small and/or large fragment standard or periarticular plates and screws or external fixation devices of choice.
The basic goals and principles for treating tibial plateau fractures follow those of other articular fractures. First, reconstruction of the articular surface is undertaken, followed by re-establishment of tibial alignment. Adequate buttressing of elevated articular segments with bone graft or bone graft substitute should be used. Fracture fixation can involve either the use of plates and screws, screws alone, or external fixation. The choice of implant is related to the fracture patterns, degree of displacement, and familiarity of the surgeon. Finally, adequate soft tissue reconstruction including preservation and/or repair of the meniscus as well as intra- and extra-articular ligamentous structures must be addressed (68).
FIGURE 50-9 Example of a preoperative plan for repair of a tibial plateau fracture.
Surgical Exposure
Exposure of the tibial plateau can be gained through a variety of approaches (27,31,61,68,70,71,72). The surgical approach should provide adequate articular visualization, combined with preservation of all vital structures and minimal soft tissue and osseous devitalization (61,68). Skin incisions for tibial plateau fractures should be longitudinal and as close to the midline as possible. Variations of the skin incision include a lazy “S” or an “L” shape centered over the proximal lateral tibia (Fig. 50-10). Because the majority of plateau fractures involve the lateral compartment, a lateral parapatellar incision and arthrotomy is often used. Medial fractures use either a medial parapatellar approach or a posteromedial approach (71,72). In either case, the incisions should be planned so that implants do not lie directly below the skin incision. In addition, raised flaps should be full thickness down to the crural fascia and retinaculum and should include the subcutaneous fat. Midline skin incisions are previously favored in bicondylar fractures to allow access to both knee compartments and facilitate any future reconstructive procedures replaced by dual-incision approaches that are more tissue friendly. Once the level of the capsule has been reached, an arthrotomy is made. The arthrotomy can be submeniscal (Fig. 50-10) (61) or vertical with division of the anterior horn of the lateral meniscus (27,31,33,73); division of the meniscus
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has been shown to heal reliably at second-look arthroscopy (27,31,73). With either approach, the split fracture component can be displaced open, and depressed fracture fragments can be elevated. All efforts should be made to preserve and repair the meniscus. Posteromedial fractures of the plateau can be approached through a separate incision, between the medial gastrocnemius and semimembranosus and then between the medial collateral ligament and the posterior oblique ligament (Fig. 50-11) (71,72,74). Note that this approach does not provide a direct view of the articular surface.
FIGURE 50-10 A–F. Lateral approach to the proximal lateral tibia using a small “L”-shaped incision. Incision of the coronary ligaments allows for submeniscal exposure of the articular surface. This is repaired with sutures through the plate or suture anchors outside the fixation.
Occasionally, it is necessary to obtain better exposure of severely comminuted bicondylar fractures. If the tibial tubercle is a separate fragment, it can be reflected along with the patellar tendon to afford excellent exposure of both compartments. If it is not a separate fragment, the patellar tendon can be incised in a Z-plasty fashion with the same resultant exposure (33,61,75). After completion of surgery and repair of the extensor mechanism, the patellar tendon may be protected with a tension band technique.
Patient Positioning
For most cases that involve an anterior approach, the patient should be positioned supine with a bolster under the knee or on a table that has the ability to flex its “foot.” In some cases, the patient may be placed prone if a posterolateral approach is chosen. The use of a radiolucent table is preferred to facilitate intraoperative fluoroscopy. The ipsilateral iliac crest should be prepped and draped if a need for autogenous bone graft is contemplated. Furthermore, the patient’s position should take into account the need for intraoperative image intensification, with the ability to obtain anteroposterior (AP), lateral, plateau, and oblique views. The image intensifier is brought in from the opposite side. Positioning of the contralateral leg should allow for movement of the image in and out of the field during the procedure. If arthroscopy is to be used, either a well-padded leg holder or post should be available.
FIGURE 50-11 Deep (A) and superficial (B) exposure of the posteromedial approach to the proximal tibia.
Reduction Techniques
Reduction of tibial plateau fractures can be attained either by direct or indirect means. Direct reduction of the articular surface and tibial metaphysis can be performed either open (4,7,10) or by semiopen means (12,76,77). More recently, indirect reduction techniques have been utilized (11,64,66,70,78,79,80). These methods take advantage of ligamentous and capsular attachments to the fracture fragments to indirectly reduce the joint surface and align the tibial shaft (80). Indirect reduction techniques have the advantage of minimal soft tissue stripping and fragment devitalization (80). Ligamentotaxis will not work on centrally depressed articular fragments, however. For badly comminuted fractures, use of a femoral distractor with threaded pins placed into the femoral condyles and the tibial shaft can aid in fracture reduction (61,78,80). For unicondylar fractures, one places the femoral distractor on the side of the fracture. For bicondylar fractures, two femoral distractors or one distractor and an external fixator can be used. It is important to keep the threaded pins parallel to the joint surface. An alternative method for severe bicondylar fractures is to place the pins anteriorly, superior to the patella on the femoral side and distal to the fracture in the tibia (Fig. 50-12). With this technique, however, the knee cannot be flexed (80). Spanning external
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fixators can be used in much the same way as the femoral distractor (81). The key is to allow pin placement far enough away from the fracture site so as not to compromise future reconstructive options (80).
FIGURE 50-12 The use of an intraoperative femoral distractor aids in the exposure and reduction of fracture fragments via ligamentotaxis. One should be careful to take into account radiographic imaging when placing the distractor so that the images are not obscured.
If segments of articular surface remain depressed following attempted indirect reduction or in a pure depression fracture, a cortical window can be made in the metaphysis, the site of which depends on the depression’s location. The entire osteochondral segment should be elevated en masse using bone tamps and punches (Fig. 50-13) (10,61,66,78). Following articular surface elevation, the void left by impacted cancellous bone should be filled with either autogenous bone graft, allograft, or bone graft substitute (10,11,61,70,78,79,82,83,84,85,86,87,88,89).
FIGURE 50-13 Elevation of impacted osteochondral fracture fragments is achieved with bone tamps or elevators and provisionally stabilized with Kirschner wires until definitive fixation and grafting is completed.
Arthroscopy
The use of arthroscopy has increased steadily over the past 2 decades (12,13,76,77,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109). Arthroscopic management of tibial plateau fractures is generally accepted for Schatzker Type I, II, and III fractures (12,13). The role of arthroscopy in these fractures is twofold: it is used as a diagnostic tool to accurately assess the articular surface, menisci, and the cruciate ligaments, and it is also used as an adjunct to treatment in assessing fracture reduction (Fig. 50-14). The higher-energy fractures (Schatzker IV–VI) are associated with more soft tissue injury, capsular disruption, and metaphyseal fracture extension, and thus are at risk for fluid extravasation and compartment syndrome (110). For Type I fractures, pure splits may be treated with closed reduction and percutaneous screw placement; arthroscopy permits debridement of loose joint fragments and repair of meniscal damage in addition to direct assessment of the articular reduction. For Type II and III fractures, depressed segments can be elevated through a cortical window under image intensification and confirmed visually with the arthroscope.
Implant Options
Plates and Screws
Plates have two functions when used for the treatment of tibial plateau fractures. They can act as a buttress against shear forces or function in a capacity to neutralize rotational forces. Due to the tenuous soft tissue envelope around the proximal tibia, use of thinner plates has been advocated. Recently, percutaneous plating, which is a more biologic approach, has been described. In this technique, the plate is slid subcutaneously without soft tissue stripping. Some surgeons have advocated against double plating the tibial plateau due to an increase in soft tissue complications (111). These complications are more likely to be a result of the higher-energy injury resulting in greater soft tissue injury than from double plating (112). One may need to use double plates for a bicondylar fracture if the far cortex has an unstable fracture pattern; the use of low-profile plates with minimal soft tissue devitalization through a separate incision is recommended (30). Newer implant designs have introduced the concept of anatomically precontoured plates that are low profile and designed to fit the proximal tibia and reduce the late complication of prominent hardware. Furthermore, the trend has been to move toward smaller-diameter, fully threaded 3.5 mm lag screws placed in a “raft” configuration (Fig. 50-15), which allows the screws to be placed closed to the subchondral bone (113). This arrangement accomplishes two functions: the first is to support the elevated osteochondral segment and the second is to lag the split component together (114).
Screws can be used alone in certain situations. In the cases of simple split fractures that are anatomically reduced by closed means or in the cases of depression fractures that are elevated percutaneously, large or small fragment screws can be used to stabilize the fractures. Furthermore, in certain cases when joint fragments are avulsed by soft tissue attachments, lag screw fixation alone may be used (Fig. 50-16).
FIGURE 50-14 A 42-year-old male sustained this lateral tibial plateau depression fracture. A. Initial injury radiograph. B. He underwent percutaneous elevation of the depressed fragment under fluoroscopy. C. Arthroscopy confirms articular depression. D. Successful elevation of the fragment with a bone tamp under fluoroscopy. E. Arthroscopic visualization confirms the reduction. F. Final radiograph reveals a reduced fracture stabilized with multiple 3.5-mm raft screws and calcium phosphate bone cement.
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External Fixation
External fixation can involve half-pins, thin wires, or a combination of the two (hybrid). External fixators may be placed across the fracture such that thin wires, with or without olive beads, capture fracture fragments or cross the knee joint in a bridging fashion to make use of ligamentotaxis (Fig. 50-17) (81,115,116,117,118,119,120,121,122,123,124,125). The key is to place the pin or wire 10 to 14 mm below the articular surface to avoid penetration of the synovial recess posteriorly. Pin placement in this fashion will help to minimize the development of septic arthritis from a pin tract infection (126). Anatomical studies have shown cadavers to have some communication between the tibiol-fibular joint and the knee joint. Thus, a transfibular wire could potentially seed the knee joint if a pin tract infection were to develop (126). Smooth wires should be placed parallel to the articular surface and below any percutaneously placed screws. If an Ilizarov construct is used, half pins or wires are placed into the intact tibial diaphysis below the fracture (81,115,124).
Advantages of external fixation include minimal soft tissue
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dissection and the ability to alter frame stiffness and thus control compression across comminuted fracture fragments. These frames can be dynamized during fracture healing, which may help if delayed or nonunion occurs in the metaphyseal regions. Furthermore, external fixation provides excellent stability in cases where there is severe soft tissue or bony defect. Finally, external fixation allows for correction if there is a malalignment or deformity.
FIGURE 50-15 Smaller-diameter screws are placed in parallel beneath elevated articular segments to support the joint. These screws are placed in lag fashion to compress simple condylar splits. This construct has been referred to as a “raft” and has been found to be the construct most resistant to postoperative local depression.
External fixators that span the knee joint may be either half-pin or smooth wire. These constructs can be used temporarily to allow the soft tissue envelope time to heal (127). In certain situations, however, spanning external fixators used in conjunction with limited internal fixation may be considered definitive fixation and may be left on for a longer period of time (30,127).
Postoperative Care
After surgical treatment, the knee should be protected in a hinged brace. Many surgeons have reported the benefits of early range of motion to the knee following tibial plateau fracture (9,57,62). Continuous passive motion from 0° to 30° may be started on postoperative day 1 and increased as tolerated. Physiotherapy should consist of active and active-assisted range of motion to the knee, isometric quadriceps strengthening, and protected weight bearing. Progressive weight bearing depends on fracture healing. Some surgeons allow full weight bearing in cases in which there is an isolated lateral plateau fracture and in which a well-molded cast brace is used to unload the affected compartment (63,64,67,69). For patients treated with external fixation, dynamization may be delayed 4 to 6 weeks after surgery, and the fixator is removed upon radiographic evidence of fracture healing.
FIGURE 50-16 Rim avulsion fracture (Moore Type III) with a large articular fragment involving the lateral tibial plateau. A–C. Postoperative films reveal reduction and fixation with lag screw fixation only (D–F).
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COMPLICATIONS
Complications in the treatment of tibial plateau fractures can occur whether operative or nonoperative management is chosen. Complication rates of 10% to 12% (10,64) have been reported for patients treated via nonoperative means and 1% to 54% (7,9,65,81,111) for those treated with surgery. Most complications that occur with nonoperative treatment are related to prolonged recumbency and include thromboembolic disease and pneumonia (9,64,65). In addition, peroneal nerve palsy has been reported to occur with cast-brace treatment (64). Finally, pin tract infection can occur in patients if proximal tibial pin skeletal traction is chosen.
Early Complications
The most severe complication that occurs with operative treatment of tibial plateau fractures is infection. Infection rates range from 3% to 38% (7,65,81,128) depending on which technique is employed. Superficial infections occur in 3% to 38% of cases (7,9,65,81)
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and deep wound infections in 2% to 9.5% of cases (7,65,81). Pin tract infections are common when external fixation is utilized for tibial plateau fractures and may be seen in up to 33% of cases (120,129,130). The concern here is the development of septic arthritis if there is communication between the pin or wire and the knee joint capsule. Skin slough is a risk factor for late infection and is of particular concern in the proximal leg secondary to poor soft tissue coverage. Factors relating to skin slough include poor surgical timing and improper soft tissue techniques with extensive osseous devitalization and the use of bicondylar implants (Fig. 50-18) (111).
FIGURE 50-17 Use of spanning external fixation across a high-energy tibial plateau fracture allows for generalized reduction of fracture fragments (A,B). Improved patient comfort, and management of any soft tissue wounds (C).
Thromboembolic complications occur following operative treatment of tibial plateau fractures (16). Deep vein thrombosis rates are reported to be 5% to 10% (7,128), and pulmonary embolus occurs in 1% to 2% of patients (7,128). Deep vein thrombosis prophylaxis includes the use of compression stockings, low-molecular-weight heparin or Coumadin; aggressive treatment of suspected pulmonary embolus is critical.
Late Complications
Late complications include painful hardware, loss of fixation, posttraumatic arthritis, and malunion. The most common late complication following operative treatment of tibial plateau fractures is “symptomatic hardware,” and the reported range is between 10% to 54% (11,31,81). Hardware may be removed 1 year after the initial treatment. Loss of fixation is a complication that can be minimized by proper preoperative planning. Improper use of implants and/or the failure to adequately utilize bone graft or bone graft substitutes to buttress the articular surface may lead to a loss of reduction (8,10). Posttraumatic arthrosis may result from the initial chondral damage or may be related to residual joint incongruity (131,132). Satisfactory functional results can be obtained in the face of poor radiographic results, however, and may be due to preservation of the meniscus and its ability to bear the load of the lateral compartment (3,11,14,69). Malunion can occur either intra-articularly because of inadequate reduction, due to loss of reduction, or with respect to the articular surface to the tibial shaft (Fig. 50-19). Results of patients with malunions and residual varus or valgus of greater than 10° have been correlated with poor long-term functional results (2,33). Rare complications include popliteal artery lacerations, osteonecrosis, and nonunion (Fig. 50-20) (33).
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CONTROVERSIES AND FUTURE DIRECTIONS
There is still controversy between those who recommend open reduction and internal fixation of complex higher-energy fracture patterns and those who recommend limited internal fixation and external fixation for these fracture patterns. The historically high rate of wound complications with open reduction internal fixation (ORIF) of high-energy fractures initially led many toward hybrid external fixation. Results with these fixation devices also yielded a unique set of complications. Currently, many surgeons recommend initial bridging external fixation to temporize the bone and soft tissue envelope until definitive surgical intervention can be undertaken.
The recent development of locking plates represents the first new technology in internal fixation in the last decade. Locked plating systems provide both angular and axial construct stability through a threaded interface between the screw heads and the plate body, which fixes the screw to the plate. With this inherent device stability, the need for compressing the plate directly to a bony surface is obviated, preserving blood supply and reducing the need for plate contouring. Furthermore, angular and axial stability of locked plates minimize the risk of primary or secondary loss of reduction. These plates have provided surgeons with the ability to address complex fracture patterns through single, minimally invasive approaches, theoretically leading to a decrease in patient morbidity.
In the past, the standard for filling bone voids following elevation and reduction of fracture fragments has been autogenous iliac crest. Currently, there are numerous options available to surgeons with regard to bone graft substitutes. Because the
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requirement in these fractures is only for osteoconduction many products are available and include hydroxyapatite, calcium sulfate, calcium phosphate, cancellous allograft, injectables, and putties.
FIGURE 50-25 A–D. Plain radiographs and a CT scan of a 30-year-old female who sustained this bicondylar (Schatzker V) tibial plateau fracture. She underwent ORIF via a dual incision and double plating. E,F. At 6 months, the patient had healed with a 130 degree arc of knee motion.
FIGURE 50-26 Anteroposterior and lateral radiographs demonstrate a Schatzker VI tibial plateau fracture (A,B) initially treated with a bridging external fixator (C), which was later converted to internal fixation with a locked plate when the soft tissue envelope allowed (D,E). The angular stability provided by the plate screw interface allowed stable fixation of the medial component of the fracture.
Future directions include the use of computer-assisted technologies and surgical navigation. Furthermore, advances in cartilage regeneration may provide strategies to deal with articular surface damage at the time of injury.
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