eMedicine Specialties > Orthopedic Surgery > Knee

Tibial Plateau Fractures

Author: S Vidyadhara, MBBS, MD, MS(Ortho), DNB(Ortho), FNB(Spine Surgery), MNAMS, Consultant, Department of Spine Surgery, Manipal Hospital, India
Coauthor(s): Sharath K Rao, MBBS, MS, D'Ortho, Professor and Head of Unit V, Department of Orthopedics, Kasturba Medical College Hospital, India; Mundkur Sudhakar Shetty, MBBS, MS, MCh, Senior Professor and Head Orthopedic Department, Yenapoya Medical College and Hospitals, Mangalore
Contributor Information and Disclosures

Updated: Mar 4, 2009

Introduction

The tibial plateau is one of the most critical load-bearing areas in the human body; fractures of the plateau affect knee alignment, stability, and motion. Early detection and appropriate treatment of these fractures are critical in minimizing patient disability and reducing the risk of documented complications, particularly posttraumatic arthritis.¹

History of the Procedure

Sir Astley Cooper first described fractures of the proximal tibia in 1825. Anger treated most minimally displaced fractures with early knee traction mobilization.²

Rausmusen introduced open reduction and internal fixation of tibial condylar fractures, and Sarmiento popularized functional cast bracing of most tibial condylar fractures.^3,4

Frequency

More than 50% of patients who sustain a tibial plateau fracture are aged 50 years or older. The increased frequency of tibial plateau fractures in older females is due to the increased prevalence of osteoporosis in these individuals. Tibial plateau fractures in younger patients are commonly the result of high-energy injuries.

Etiology

The most common mechanism resulting in a tibial plateau fracture is a valgus force with axial loading. Of these injuries, 80% are motor vehicle–related injuries and the remainder are sports-related injuries. A bumper- or fender-related injury from a vehicle-pedestrian collision constitutes more than 25% of tibial plateau fractures. Trauma can be direct or related to a fall from a height, an industrial accident, or a sports injury.

Tibial plateau fractures may be either low energy or high energy. Low-energy fractures occur in osteoporotic bone and typically are depressed fractures. High-energy fractures occur in low-energy patients often as a result of motor vehicle–related trauma, and the most common pattern of fracture in this group is a splitting fracture.

Pathophysiology

Classification:

There have been many classifications of tibial plateau fractures.⁵ In 1900, Muller proposed a classification system for tibial plateau fractures that categorized fractures based on the amount of articular involvement. Hohl and Luck proposed a classification of plateau fractures that included nondisplaced, local-depression, split-depression, and splitting fractures.⁶ Hohl later expanded the classification to include comminuted fractures.⁷ In 1981, Moore proposed a classification system for fracture-dislocation of the tibial condyle that took into consideration soft-tissue injury.⁸

Schatzker et al proposed a classification system of condyle fractures based on the fracture pattern and fragment anatomy, which he grouped into 6 types. This classification system, as follows, is widely accepted and used⁹ :

• Type I is a wedge or split fracture of the lateral aspect of the plateau, usually as a result of valgus and axial forces. With this pattern, the wedge fragment is not compressed (depressed) because the underlying cancellous bone is strong. This pattern is usually seen in younger patients.
• Type II is a lateral wedge or split fracture associated with compression. The mechanism of injury is similar to that of a type I fracture, but the underlying bone may be osteoporotic and unable to resist depression or the force may have been greater. See images below.
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    Type II tibial plateau fracture in a young active adult with good bone stock treated with percutaneous elevation and cannulated cancellous screw fixation without bone grafting.

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    Type II tibial plateau fracture in a young active adult with good bone stock treated with percutaneous elevation and cannulated cancellous screw fixation without bone grafting.

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    Type II tibial condyle fracture involving the tibial spine and more than 50% of the medial condyle fixed with biological buttress plating of the lateral plateau.

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    Type II tibial condyle fracture involving the tibial spine and more than 50% of the medial condyle fixed with biological buttress plating of the lateral plateau.

• Type III is a pure compression fracture of the lateral plateau. As a result of an axial force, the depression is usually located laterally or centrally, but it may involve any portion of the articular surface. See image below.
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    Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous elevation, bone grafting, and cancellous screw fixation.

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    Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous elevation, bone grafting, and cancellous screw fixation.

• Type IV is a fracture that involves the medial plateau. As a result of either varus or axial compression forces, the pattern may be either split alone or split with compression. Because this fracture involves the larger and stronger medial plateau, the forces causing this type are generally greater than those associated with types I, II, or III. See image below.
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    Type IV medial tibial condyle fracture treated with arthroscopy-assisted elevation and percutaneous cancellous screw fixation along with percutaneous screw fixation of the tibial spine fracture.

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    Type IV medial tibial condyle fracture treated with arthroscopy-assisted elevation and percutaneous cancellous screw fixation along with percutaneous screw fixation of the tibial spine fracture.

• Type V fractures include split elements of both the medial and the lateral condyles and may include medial or lateral articular compression, usually as a result of a pure axial force occurring while the knee is in extension.
• Type VI is a complex, bicondylar fracture in which the condylar components separate from the diaphysis. Depression and impaction of fracture fragments is the rule. This pattern results from high-energy trauma and diverse combinations of forces. See images below.
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    Type VI tibial plateau fracture undergoing biological fixation of the lateral condyle and external fixation of the medial plateau, resulting in an acceptable clinical and radiological result.

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    Type VI tibial plateau fracture undergoing biological fixation of the lateral condyle and external fixation of the medial plateau, resulting in an acceptable clinical and radiological result.

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    Type VI tibial plateau fracture with severe soft tissue injury successfully treated with Ilizarov external ring fixator.

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    Type VI tibial plateau fracture with severe soft tissue injury successfully treated with Ilizarov external ring fixator.

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    High-energy type VI tibial plateau fracture treated with bone grafting and double plating after the soft tissue condition improved.

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    High-energy type VI tibial plateau fracture treated with bone grafting and double plating after the soft tissue condition improved.

Presentation

Full clinical assessment is required, including evaluation of the soft tissues to determine whether a compartment syndrome is present and whether the patient has sustained a neurovascular injury. Gentle stress testing can be performed with the leg in extension to evaluate the stability of the ligaments and to assess any sign of fracture displacement. Approximately 50% of the knees with closed tibial plateau fractures have injuries of the menisci and cruciate ligaments that usually require surgical repair. Because of the valgus stress at the moment of impact, the medial collateral ligament is at greater risk than the lateral collateral ligament; however, disruption of the lateral collateral ligament is of grave concern because of possible injuries to the peroneal nerve and the popliteal vessels. Dislocation-relocation injuries are more common with medial plateau injuries and carry an increased risk of peroneal nerve damage.

Indications

Fracture displacement ranging from 4-10 mm can be treated nonoperatively; however, a depressed fragment greater than 5 mm should be elevated and grafted.

The following are absolute indications for surgery:

• Open plateau fractures
• Fractures with an associated compartment syndrome
• Fractures associated with a vascular injury

The following are relative indications for surgery:

• Most displaced bicondylar fractures
• Displaced medial condylar fractures
• Lateral plateau fractures that result in joint instability

Relevant Anatomy

The knee is a complex joint, exposed to forces in excess of 5 times the weight of the body. The joint has enhanced mobility at the cost of stability. The proximal tibia expands from the diaphysis through a metaphyseal flare. Contact is made with the head of the fibula in the posterolateral quadrant. The surface of the tibial plateau has a medial and a lateral weight-bearing portion and an intercondylar eminence, which is both nonarticular and non – weight-bearing. The medial plateau is generally larger than the lateral plateau.

The intercondylar eminence provides attachment to the medial and lateral menisci and the anterior and posterior cruciate ligaments.

The normal knee is in physiologic valgus alignment. Most of the load transmitted across the knee is medial to the eminence, and therefore, the knee has stronger cancellous bone. 

Because the medial condyle is rounded as compared with the lateral condyle, some of the anterior articular surface of the lateral plateau is exposed, especially during extension. This causes the lateral plateau to be more susceptible to bone injury and is the reason why fractures of the lateral plateau are more common than those of the medial plateau.

Contraindications

Contraindications to surgical treatment include (1) the presence of a compromised soft-tissue envelope (for immediate open reduction) and (2) fractures that do not result in joint instability or deformity and can therefore be treated with nonoperative modalities.

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