This document provides an overview of the management of tibial plateau fractures. The goals of management are to restore joint congruity, preserve the normal mechanical axis, achieve a stable joint, and restore knee motion. Surgical treatment is indicated for fractures with articular depression over 2mm, condylar widening over 5mm, or instability. Implant options include plating, screws, external fixation, and hybrid fixation depending on the fracture pattern and soft tissue injury. Schatzker classification and AO/OTA classification are discussed to characterize the fracture personality and guide appropriate treatment.

1. MANAGEMENT OF TIBIAL
PLATEAU FRACTURE
DR.KHADIJAH NORDIN

2. Introduction
• one of the most critical loadbearing areas in
the human body.
• Goal of management:
– Restore joint congruity
– Preserved normal mechanical axis
– Stable joint
– Restore knee motion

3. • Issues
– Severe comminution
– Variable bone quality
– Overlying soft tissue injury associated injury to
• Cartilage
• Meniscus
• Stabilizing ligament
– Underlying medical condition
– Financial background

6. Low n high energy trauma
• In low energy trauma the problem is
mechanical fixation in osteoporotic bone
• In high energy trauma the problem is
biological and associated with damage to the
soft tissue

7. Clinical presentation
• History
– High energy trauma in young
– Low energy trauma in elderly
• Assessment
– Open or closed fracture
– Compartment syndrome
– Instability
– Neurovascular
– ATLS

8. Imaging
• Radiographs
– Knee AP/LAT
– Oblique ( subtle plateau depression)
– Plateau view ( 10 caudal tilt)
• Knee CT
– Articular involvement comminution
– Schatzker IV V VI
– Pre op planning
• Knee MRI
– Schatzker I II III
– Assesment meniscus n ligament
• Angiography

9. Personality of fracture
• Soft tissue damage
• Degree of dislocation
• Degree of comminution
• Degree of join involvement
• Osteoporosis
• Nerve / blood vessel injury

10. Classification
• Schatzker classification
• AO/OTA
• Three column classification

11. Schatzker classification

12. AO/OTA classification

13. The three column classification

14. • Zero column = schatzker type III
• One column = schatzker type I and II
– Articular depression in the posterior column with a
break of the posterior wall is also defined as a one-
column (posterior column) fracture (this type of
fracture is not included in any type of the Schatzker
classification)
• Two column = schatzker type IV
– the concurrence of an anterolateral fracture and a
separate posterior-lateral articular depression with a
break of the posterior wall
• Three column = schatzker type V and IV
– is defined as at least one independent articular
fragment in each column

16. Management
• Non operative
• Operative

17. Non operative
• No joint step >2mm
• No axial instability
• Severe osteoporosis
• General and local contraindication

18. • Method:
– Protected weight bearing and early knee ROM
with hinged knee brace
– Isometric quadriceps exercise and progressive
passive active assisted and active knee ROM
exercise
– PWB for 8-12 weeks with progression to full
weight bearing

19. Emergency operative treatment
• Vascular injury
• Compartment injury
• Open fracture injury
• Gross dislocation
• Floating knee
• Polytrauma

20. Indication for surgery
• Depression of the joint equal to the depth of the cartilage
– 4mm lateral plateau
– 2.5mm for medial plateau
– > articular step – off > 3mm
• Condylar widening >5mm
• valgus/ varus instability
• Medial plateau fracture
• Bicondylar fracture
• Open fracture
• Extensive soft tissue contusion/ compartment syndrome
• Vascular injury

23. Timing for surgery
• General principles:
– Understanding the configuration of the fracture
– Suitable implant and instrument
– Skilled surgical team
– Pre op plan
• Closed schatzker I – III
– Axial stable, minimal soft tissue compromise ideally timing on
day 5 -7 ( skin wrinkling)
• Closed schatzker IV – VI
– Axial unstable will shorten, soft tissue compromise, if delay in
definative op – joint spanning external fixation / traction
within 24h

24. Principle of surgical management
• Goals of treatment
• Reconstruction of articular surface
• Re-establisment of tibial alignment
• Stable construct
• Early ROM

25. • Reducing and buttressing elevated articular
segment with bone graft and implant
• Spanning external fixators as temporary
measure in patients with high energy injury,
severe soft tissue injury and polytrauma
• Arthroscopy assisted surgery
• Soft tissue reconstruction (meniscuss/
ligament)
Principle of surgical management

26. Surgical approach
• Straight midline
• Anterolateral
• Posteromedial
• Two approaches for bicondylar fracture
• MIPO

27. • lateral incision (most common)
– straight or hockey stick incision anterolaterally from just
proximal to joint line to just lateral to the tibial tubercle
• midline incision (if planning TKA in future)
– can lead to significant soft tissue stripping and should be
avoided
• posteromedial incision
– interval between semimembranosus and medial head of
gastrocnemius
• dual surgical incisions with dual plate fixation
– indications
• bicondylar tibial plateau fractures
• posterior
– can be used for posterior shearing fracture

28. • Skin incision
• With the knee in slight flexion
make a straight or slightly
curved incision running from
the medial epicondyle towards
the postero-medial edge of
the tibia. The incision can be
extended as needed both
proximally and distally as
indicated by the dashed line.
• Anterolateral approach
• Make a straight incision
lateral to the patella. Then,
open the deep fascia
anterior to the ilio-tibial
tract.

29. • Skin incision
• Identify Gerdy’s
tubercle. Make a
straight incision
about 5cm in length
starting posteriorly
to Gerdy’s tubercle
and running distally
and anteriorly.

31. Implant option
• Choice of implant if related to the fracture
pattern, degree of displacement and the
familiarity of surgeon
– Plate and screw
• Buttressing against shear forces or neutralizing rotational
forces
• Thinner plate
• MIPO
• Double plating
– Screw alone
• Simple split
• Depressed fracture elevated percutaneusly
– External fixation

32. Bridging external fixators
• Indication:
– Open fracture with severe soft
tissue injury
– Joint instability
– Polytrauma
– Severe soft tissue compromised
– Serious medical co-morbidity
• Contra indication in osteoporosis
• Advantages
– Provide temporary immobilization
of fracture
– Soft tissue friendly
– Fast procedure
– Restore n maintain length
– Restore axial alignment
– Improves position of bone
fragment by ligamentosis
• Disadvantages:
– Bridging the joint
– Risk of pin tract infection
– Risk of knee stiffness
• Technique
– two 5-mm half-pins in distal femur,
two in distal tibia
– axial traction applied to fixator
– fixator is locked in slight flexion

33. Hybrid external fixation
• Indication
– Severe open fracture
– Major joint instability
– Severe soft tissue
compromise, not
permitting definitive
internal fixation
• post-operative care
– begin weight bearing when
callus is visible on
radiographs
– usually remain in place 2-4
months
• technique
– reduce articular surface
either percutaneously or
with small incisions
– stabilize reduction with lag
screws or wires
– must keep wires >14mm
from joint
– apply external fixator or
hybrid ring fixation

34. Ring external fixation
• Indication
– Severe open fracture
with bone loss
– Fracture with loss of soft
tissue cover

35. Plate osteosynthesis
• Minimal invasive plate
osteosynthesis (MIPO)
with the aids of plate
with locking screws
• Less traumatizing to
soft tissue
• Indication
– Osteoporosis bone
– Articular, displaces,
unstable fracture
– Open fracture

36. Schatzker I
• Closed reduction then
stabilized with 6.5mm
cancellous screw lag
screw with washer to gain
compression
• Anterolateral approach
• In young patient screw
fixation is adequate
• ± antiglide screw /plate
• In elderly buttress plate is
required

37. Schatzker II
• Open reduction and elevation
of the depress fragment
• Anterolateral approach
• Bone graft is placed to support
the elevation fragment
• Temporarily held with k-wire
• Position of plate is determine
by location of the fracture
– Buttress plate
– Lag screw
• Compression of the articular
fragment and of large
metaphyseal fragment

38. Schatzker III
• Open reduction/
arthroscopic assisted
• Anterolateral
approached
• Elevation through a
metaphyseal window
• Temporary k-wire
• Bone grafted
• Subchondral plate/
screws

39. • Medial buttress plate
– Counteract the shear
forces acting on the
medial plateau
– Lag screw alone not
sufficient to stabilize the
fracture
Schatzker IV

40. • Required lateral and
medial stabilization of
fracture
• Stabilization
– Double plating
– Locking plate
– External fixators
Schatzker V

41. Double plating complete articular
fracture
• Two incision:
– Anterolateral and
posteromedial
• Indication:
– Displaced posteromedial
fragment need to be
buttressed with posterior
plate
– Medial articular
involvement
– Displacement of medial
column

45. Thank you