Tibial Plateau Fractures: A Review: P Fenton and K Porter
Tibial Plateau Fractures: A Review: P Fenton and K Porter
Tibial Plateau Fractures: A Review: P Fenton and K Porter
Review Article
Trauma
13(3) 181–187
Abstract
Tibial plateau fractures are uncommon injuries of the proximal tibia which vary in severity from minimally
displaced stable injuries to high energy complex fractures with significant articular and metaphyseal
comminution and severe associated soft tissue injuries. Following initial assessment and appropriate
investigation a number of management options are available to the treating surgeon. We discuss the
presentation, initial management and investigation as well as outlining the various treatment options
with an emphasis on operative treatment. We further discuss the common complications and outcomes
following tibial plateau fracture.
Keyword
Tibial plateau fracture
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182 Trauma 13(3)
bumper, being tackled playing football or rugby separation of the metaphysis and diaphysis
or falling from a height. Often the mechanism of of the tibia.
injury is not clear from the history. Initial assess- The AO group also use six classifications
ment in patients with a significant mechanism of for these fractures. 41-B fractures are partial
injury or multiple injuries should follow ATLS articular injuries. 41-B1 is a pure split, 41-B2
guidelines. In assessing the injured limb atten- pure depression and 41-B3 split depression.
tion must be given to the condition of the soft The 41-C injuries are complete articular injuries
tissues and relationship of any open wounds to with 41-C1 being simple articular and simple
the fractures site. The state of the muscle com- metaphyseal, 41-C2 simple articular and multi-
partments about the knee should be assessed as fragmentary metaphyseal and 41-C3 multi-
well as the presence of distal pulses and neuro- fragmentary articular.
logical status of the limb with particular respect It has been suggested that there is a high
to peroneal nerve function. interobserver variability with both the AO and
Following initial assessment the limb should Schatzker classification. Some recommend
be rested in a splint, most often an above knee describing fractures as either unicondylar or
backslab, to provide pain relief and protect the bicondylar and either pure split or depression
injured soft tissues. þ/ split (Charalambous et al., 2007).
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Fenton and Porter 183
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184 Trauma 13(3)
(intra and extra-articular) treated with the Kumar and Whittle, 2000; Chin et al., 2005;
LISS plate. Kataria et al., 2007).
When treating bicondylar fractures locking More recently external fixation has been
plates allow the fracture to be fixed from the combined with limited internal fixation to
lateral side only without the need for dual plat- improve reduction and fixation of the articular
ing. However, in their study Jiang et al. (2008) surface, a number of studies have advocated this
noted a higher incidence of malalignment fol- approach (Marsh et al., 1995; El Barbary et al.,
lowing fixation with a LISS plate compared to 2005; Katsenis et al., 2005; Catagni et al., 2007).
conventional double plating. In situations where the joint surface is
Arthroscopy has been used in conjunction severely unstable or the fracture or soft tissues
with the treatment of Schatzker types I, II and prevent optimal pin placement some authors
III fractures. It is used to assess soft tissue inju- recommend spanning the knee joint (Katsenis
ries within the knee and to ensure adequate et al., 2006; Catagni et al., 2007). In their
reduction of the joint surface. Several case study Katsenis et al. (2005) found no significant
series have reported good results with the tech- difference in outcome between fractures treated
nique (Scheerlinck et al., 1998; van Glabbeek with joint spanning or joint sparing frames.
et al., 2002). Ohdera et al. (2003) compared The Canadian orthopaedic trauma society
arthroscopically assisted surgery with conven- performed a randomised controlled trial com-
tional open surgery in finding patients in the paring open reduction and internal fixation
arthroscopy group regained knee movement with circular external fixation with or without
quicker and had improved joint reduction com- limited internal fixation. They found that the
pared with the open surgical group. outcomes between the two groups at 2 years
The role of arthroscopy is extending to were similar however the circular fixator group
include more complicated fractures, Chan et al had a shorter hospital stay, an earlier return of
reported good or excellent results in 16 of 18 function and a reduced number and severity
patients with Scatzker V or VI fractures treated of post-operative complications (Canadian
with arthroscopically assisted surgery (Chan Orthopaedic Trauma Society, 2006).
et al., 2003). In fractures with a depression of the articular
External fixation can be used as a temporary surface which has been elevated the resulting
fixation before definitive internal fixation or as a defect in the bone often requires bone grafting.
method of definitive fixation. Fixators can be This is usually achieved with autologous cancel-
monolateral, circular or hybrid, in some cases lous bone. Biomechanical and animal studies
span the knee joint and can be used in conjunc- have suggested that the use of calcium phos-
tion with limited internal fixation. phate cements may have improved ability to
Hybrid and circular fixators can be used prevent subsidence of the articular surface com-
for high energy, complex fractures. Their ben- pared to conventional bone graft (Yetkinler
efits over internal fixation are preservation et al., 2001; Welch et al., 2003; Trenholm
of soft tissues and early commencement of et al., 2005). Several clinical studies have
knee motion. This is weighed against the risk reported favourable results in treating lateral
of pin site infection and septic arthritis. Several tibial plateau fractures with the use of cal-
studies have shown good outcomes with hybrid cium phosphate cements (Lobenhoffer et al.,
fixators in Schatzker V and VI fractures 2002; Horstmann et al., 2003; Simpson and
(Stamer et al., 1994; Gaudinez et al.,1996; Ali Keating, 2004).
et al., 2001). A number of studies have shown Post-operatively the emphasis is on early pas-
similarly encouraging outcomes in complex sive range of movement exercises to regain
fractures treated with circular fixators joint motion and nourish articular cartilage.
(Dendrinos et al., 1996; Mikulak et al., 1998; Weight bearing will depend on the fracture
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Fenton and Porter 185
pattern, method of fixation and surgeon prefer- Lobenhoffer, 1993), peroneal nerve injury and
ence. It will be guided by serial radiographs. avascular necrosis of articular fragments.
In certain situations some surgeons advocate
supplementing fixation with a cast brace.
Outcomes
Long term data on outcomes after tibial plateau
Complications
fractures is limited. Rademakers et al. (2007)
Complications following tibial plateau fractures studied 109 patients with a mean of 14 years
can be secondary to the initial injury or the sub- follow up. All patients were treated operatively.
sequent treatment. Mean range of movement was 135 , secondary
Knee stiffness can be a significant problem; arthritis developed in 31% with an increased
factors that contribute to its development incidence in those with over 5 of malalignment.
include initial injury, surgery, scarring and Results were better in monocodylar compared to
immobilisation. The risk of stiffness developing bicondylar fractures.
is reduced by early fixation with attention to soft
tissue handling and early post-operative mobili-
sation of the joint.
Summary
Infection rates are reported between 2% Tibial plateau fractures though uncommon can
(Wadell et al., 1981) and 11% (Muller et al., present a significant challenge to the operating
1992). Barei et al. (2004) reported an 8.4% surgeon. Following initial management and
deep infection rate in 83 patients with high identification of associated injuries judicious
energy bicondylar fractures treated with dual use of appropriate imaging allows the extent of
incision plating. Attention to the timing of sur- the injury to be defined. Treatment will be
gery, site of incision in relation to soft tissue guided by the fracture personality, patient
injuries, meticulous soft tissue handling and comorbidities and operative experience of the
use of percutaneous techniques where appropri- surgeon. Management can vary from conserva-
ate can reduce the risk of infection. tive therapy in cast brace for minimally dis-
Secondary osteoarhritis can result from chon- placed stable fractures to complex joint
dral damage at the time of the initial injury, reconstruction utilising internal fixation, circular
residual articular discontinuity or disruption frames or both. In cases with significant joint
of the mechanical axis post-operatively. depression bone graft is often required.
Honkonen (1995) reported a rate of secondary Following surgery knee stiffness and secondary
arthritis of 44% at a mean of 7.6 years post- osteoarthritis can be significant problems. To
injury. The incidence of arthritis was increased date long-term data regarding outcomes follow-
in patients who underwent meniscectomy com- ing tibial plateau fractures is limited.
pared to those with intact or repaired meniscus.
Malunion can result from inadequate ini-
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