MANAGEMENT OF TIBIAL

PLATEAU FRACTURE
DR.KHADIJAH NORDIN

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

 Issues
Severe comminution
Variable bone quality
Overlying soft tissue injury associated
injury to
Cartilage
Meniscus
Stabilizing ligament

Underlying medical condition

Financial background

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

Clinical presentation
History
High energy trauma in young
Low energy trauma in elderly

Assessment
Open or closed fracture
Compartment syndrome
Instability
Neurovascular
ATLS

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

Personality of fracture

Soft tissue damage

Degree of dislocation
Degree of comminution
Degree of join involvement
Osteoporosis
Nerve / blood vessel injury

Classification
Schatzker classification
AO/OTA
Three column classification

Schatzker classification

AO/OTA classification

The three column

classification

 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

Management
Non operative
Operative

Non operative

No joint step >2mm

No axial instability
Severe osteoporosis
General and local contraindication

 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

Emergency operative
treatment

Vascular injury
Compartment injury
Open fracture injury
Gross dislocation
Floating knee
Polytrauma

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

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

Principle of surgical
management

Goals of treatment
Reconstruction of articular surface
Re-establisment of tibial alignment
Stable construct
Early ROM

Principle of surgical
management
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)

Surgical approach

Straight midline
Anterolateral
Posteromedial
Two approaches for bicondylar
fracture
MIPO

 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

 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 iliotibial tract.

 Skin incision
Identify Gerdys
tubercle. Make a
straight incision
about 5cm in
length starting
posteriorly to
Gerdys tubercle
and running distally
and anteriorly.

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

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 islocked in slight
flexion

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

Ring external fixation

Indication
Severe open
fracture with bone
loss
Fracture with loss of
soft tissue cover

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

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

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

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

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

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

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

Thank you