TIBIAL PLATEAU
FRACTURES
TIBIAL
PLATEAU • Tibial plateau is the
proximal end of tibia
including
metaphyseal,
epiphyseal regions as
well as articular
surfaces.
EPIDEMIOLOGY
• Tibial plateau fractures constitute 1% of all fractures and
8% of all fractures of elderly.
• Most of these fractures are associated with :-
1. Neurological and Vascular injuries
2. Compartment syndrome
3. Contusion and Crush injuries of soft tissue
TIBIAL PLATEAU FRACTURES
Lateral Plateau Medial Plateau
(55-70%) (10-25%)
Bicondylar
(10-25%)
ANATOMY
• Tibial plateau composed of articular surfaces of medial
and lateral tibial plateaus, on which cartilagenous menisci
are present.
MEDIAL PLATEAU LATERAL PLATEAU
Larger in size Smaller
Concave Convex
Inferior 2-3 mm superior
Cartilage thickness ~ 3mm ~4mm
• Normal tibial plateau has Posterio - inferior slope ~ 10
degrees (Posterior proximal tibial angle)
Medial Meniscus
Lateral Meniscus • Semicircular
• C-shaped
• Covers 50 % of the plateau
• Attached to PCL via ligaments • Thick posteriorly, so
Humphry (anterior) promoting posterior
Wrisberg (posterior) stabilization.
• Intimately attached
No attachment to LCL
to MCL
Bony Prominence near Tibial
plateau
• ANTERIORLY-: TIBIAL TUBERCLE
Patellar tendon insertion
ANTEROLATERALLY:- GERDY’S TUBERCLE
Insertion of Iliotibial band
ANTEROMEDIALY:- PES ANSERINUS
Attachment of Medial Hamstrings
Sartorius
Gracillis
Semitendinosus
NEUROVASCULAR STRUCTURE
• Common peroneal nerve:
• The common peroneal nerve courses around the neck of the
fibula distal to the proximal tibia-fibular joint before it divides into
its superficial and deep branches
• Popliteal artery
• The trifurcation of the popliteal artery into the anterior tibial,
posterior tibial, and peroneal arteries occurs posteromedially in
the proximal tibia.
MECHANISM OF
INJURY
1.Force directed medially (valgus force) or
laterally (varus force) or both
split # +collateral
lig. tear
2. Axial compressive force
depression
#
3.Both axial force and force from the side
Schatzker
classification
Type I: Pure cleavage
oWedge shaped
uncomminuted fragment
is split off and
displaced laterally &
downward oCommon in
young patients
oLateral meniscal
pathology may
be present
Type II:cleavage combined
with depression
oSplit fracture of the lateral
tibial condyle with
associated impaction or
depression of the articular
surface
oCommonly in older
individuals(osteoporotic
bones)
• Type III:pure central depression
o Pure depression of the lateral
articular surface only.
o Common in elderly
Type IV: fractures of medial
condyle
oThese may split off as
a single wedge or may be
comminuted and depressed.
oTibial spines often
involved.
Type V:Bicondylar fractures
oBoth tibial plateau are split
off
oMetaphysis & diaphysis
retain continuity
Type VI : Plateau fracture with
dissociation of metaphysis &
diaphysis
oTransverse or oblique fracture of
proximal tibia is present, along with
fracture of single or both tibial
condyles and articular surface
ASSOCIATED INJURIES
• 90% of these fractures asssociated with soft tissue
injuries
• Meniscal tears occurs in 50% of these fractures
• Associated ligamentous injuries (cruciate or collateral)
occur in 30% of these fractures
• Others-: common Peroneal nerve
Popliteal artery injury
MANAGEMENT
• Evaluation of injury
• Treatment
Evaluation of
injury
• Clinical Evaluation:-
• Neurovascular examination to rule out any neurological or
vascular injury (peroneal nerve or popliteal artery injury)
• Assessment for any ligament injury
• Assessment for compartment syndrome
• Assessment for Haemarthrosis
RADIOGRAPHIC EVALUATION
• X ray
AP view
Lateral view
40 degree Internal rotation view (lateral plateau)
40 degree external rotation view (medial plateau)
• 10 degree caudally tilted plateau view (articular surface)
10
• CT with3D reconstruction
- Better visualisation
- Preoperative planning
MRI
- Useful for evaluating injuries of menisci, cruciate &
collateral ligaments and soft tissue envelope
Arteriography
for any vascular injury in question
TREATMEN
T
NON-OPERATIVE
•
• OPERATIVE
NON-OPERATIVE
• Indicated for non-displaced or minimally displaced fractures,
without
any ligament injury & in patients with advance osteoporosis .
• Immoblisation with cast or brace for a week followed by early range
of knee motion in a hinged knee brace along with skeletal traction
• -Isometric quadriceps exercises and progressive
passive, active-assisted, and active range-of-knee
motion exercises are indicated .
• -Toe touch with bearing for 8 to 12 weeks is allowed,
with progression to full weight bearing.
OPERATIVE TREATMENT
• INDICATIONS FOR SURGERY:-
• Acceptable articular displacement is controversial
• Some authors recommended surgery articular stepoff >
2mm
• Other articular stepoff>5mm
• Some studies reported similar clinical result for operative vs non
–
Operative for articular stepoff 8mm
• Some studies reported similar clinical result for
opertative vs non operative for articular stepoff
8mm
• Most authors agreed articular stepoff > 10 mm is
• Most of authors agreed articular stepoff > 10mm is an
absolute indication for sx
• Instability > 10 degrees of nearly extended knee compared to
the
contralateral side is an absolute indication.
• Open fractures
• Associated compartment syndrome
• Associated vascular injury
• AIMS OF SURGERY:-
• Restoration of articular congruity, joint stability and original
knee axis
• Provide fracture stability allowing
for early pain free
movement of knee & mobilization of the pt.
• Obtain full functional recovery as a long term goal.
• Avoidance of posttraumatic arthritis.
• OPERATIVE TREATMENT PRINCIPLES
• Reduction and buttressing of elevated articular
segments with bone graft or bone graft substitute.
• Soft tissue reconstruction including menisci and
ligaments
• Use of Spanning external fixator as a temporizing
measure in patients with high-energy injuries or significant
soft tissue injury.
