This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.
Tibial plateau fractures are complex injuries produced by high- or low-energy trauma. They principally affect young adults or the ‘third age’ population.
These fractures usually have associated soft-tissue lesions that will affect their treatment. Sequential (staged) treatment (external fixation followed by definitive osteosynthesis) is recommended in more complex fracture patterns. But one should remember that any type of tibial plateau fracture can present with soft-tissue complications.
Typically the Schatzker or AO/OTA classification is used, but the concept of the proximal tibia as a three-column structure and the detailed study of the posteromedial and posterolateral fragment morphology has changed its treatment strategy.
Limb alignment and articular surface restoration, allowing early knee motion, are the main goals of surgical treatment. Partially articular factures can be treated by minimally-invasive methods and arthroscopy is useful to assist and control the fracture reduction and to treat intra-articular soft-tissue injuries.
Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Complex articular fractures can be treated by ring external fixators and minimally-invasive osteosynthesis (EFMO) or by ORIF. EFMO can be related to suboptimal articular reduction; however, outcome analysis shows results that are equal to, or even superior to, ORIF. The ORIF strategy should also include the optimal reduction of the articular surface.
Anterolateral and anteromedial surgical approaches do not permit adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement.
Some authors have also suggested that primary total knee arthroplasty could be an option in specific patients and with specific fracture patterns.
Cite this article: Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev 2016;1:225-232. DOI: 10.1302/2058-5241.1.000031.
Keywords: tibial plateau fractures, three-column concept, posteromedial knee approach, posterolateral knee approach, staged sequential surgical treatment
Tibial plateau fractures (TPFs) are common and difficult-to-manage injuries that can be due to high- or low-energy trauma and can affect young adults or third-age patients. When faced with one of these injuries there are some questions to be answered. They are discussed in detail below.
Both high- and low-energy trauma can cause TPFs. Usually complex knee fractures are seen in pedestrians struck by vehicles and also in work-related accidents. 1 In general, one should expect a more complex fracture pattern in higher-energy trauma. But the quality of the osteoporotic bone, particularly in third-age people, can lead to complex fracture patterns with low-energy injuries. In the same way, surrounding soft-tissue involvement is to be expected even in low-energy fractures ( Fig. 1 ). This suggests that every single fracture has to be carefully evaluated in order to identify the exact pattern, the shape, size and location of the different fragments, and must be carefully managed to prevent or anticipate soft-tissue complications.
Substantial soft tissue injuries with a broken bone inside. Extensive haemorrhagic and serous blisters 36 hours after injury in an obese female patient who suffered a low-energy trauma and sustained a partial articular fracture (Schatzker 3/ AO OTA 41B2).
The age of the patient and his/her previous functional status can be critical in deciding the type of treatment to be applied. The main objectives when treating articular fractures of the knee are the restoration of articular congruity and stability, the axial and rotational alignment of the limb, and stability and early motion of the joint. All three are critical, especially in the young patient, but there is some evidence that limb alignment and knee stability are most crucial, whereas non-anatomical reduction is less important regarding functional results. 2 Actually, it is not difficult to find patients with sub-optimal lateral plateau articular surface reductions and acceptable functional results in the clinical setting.
Soft-tissue damage in fractures around the knee is of critical importance. One should think that the fracture will not change but soft tissue will, and therefore, especially in high-energy injuries, fractures should be considered as ‘substantial soft-tissue injuries with a broken bone inside’ ( Fig. 1 ). 3 The oedema and inflammation associated with the trauma can easily lead to local venous compromise, dermal hypoxia, and additional soft-tissue injury. 4 This commonly leads to blistering of the skin and in some cases dermal and even muscle necrosis. 5 Blood-filled blisters should be expected to be associated with a worse outcome than clear fluid-filled ones. Management in the early stages of treatment should focus on preventing further soft-tissue injury while waiting to repair the fracture. Immobilisation of the knee and cryotherapy are the most commonly-used methods to diminish the inflammatory response. 1 Knee immobilisation can be achieved by splinting or by external fixation. The use of a staged approach using external fixation is recommended in complex patterns and high-energy trauma, especially in cases of axial instability. Knee-spanning external fixators can be used to approximate the fracture fragments by the process of ligamentotaxis. 1,6 A common frame consists of two 4.5 to 5.0 mm pins placed anteriorly in the middle third femoral shaft and another two in the middle or distal third of the tibial shaft. Bars should be configured in two planes, in order to control varus-valgus and flexion-extension forces, and tightened in slight traction to reduce the fracture fragments.
Analysis of the infection risk of the fracture fixation site after pin site-plate overlap shows controversial results. Even though one recent paper concludes that, with an infection rate of 7.6%, this ‘common fear does not appear to be clinically grounded’, 7 an even more recent paper analysing proximal and distal tibial fractures 8 supports the view that, with an infection rate of 12% in proximal tibia fractures, the risk of infection when there is overlapping is clearly higher. According to these reports we should place the external fixator pins in the optimal situation to control the fracture 7 and in a position that does not interfere with the definitive osteosynthesis plan. 8
Compartment syndrome can be a devastating complication affecting proximal tibia fractures. Its incidence can rise to 17% of closed and 18.7% of open complex pattern proximal tibia fractures. 6 One should be aware of the four ‘p’ rule (pain, pallor, paresthaesia and pain with passive stretch) in the initial phase of treatment to identify this condition and treat it as soon as possible.
Traditionally, initial radiograph diagnosis should include anteroposterior (AP), lateral and oblique views. But single radiographs do not allow an exact fragment identification and the initial fracture classification can change in 5% to 24% (mean 12%) of cases and treatment can change in up to 26% of cases after CT scan imaging. 9 These findings and the wider availability of CT scanning have made the oblique views less important in the diagnosis. Intra- and peri-articular soft-tissue structures can be affected even in less complex fracture patterns and some X-ray or CT scan data can also suggest the existence of a lateral or medial meniscal tear. Articular depression > 6 mm and/or articular widening > 5 mm are associated with the existence of lateral meniscus, lateral collateral ligament (LCL) or posterior cruciate ligament injuries. 10,11 The identification of soft-tissue injuries with MRI can change the surgical treatment and/or rehabilitation plan. In a study of 103 patients with various Schatzker type fractures, a total of 99% presented associated soft-tissue injuries and 77% a complete anterior cruciate ligament (ACL) or LCL injury, whereas 81% presented with a significant lateral meniscal tear and 44% a medial meniscus tear. 12 MRI can adequately identify soft-tissue injuries, but its cost and lack of availability make its systematic use problematic.
Tibial plateau fractures are usually classified with the six-type Schatzker fracture classification. 13 The AO/OTA 14 proximal tibia fracture classification (segment 41) is partially based on it, and includes extra-articular (a), partial articular (b) and complete articular (c) fractures. Schatzker Type I-II-III-IV should correspond to 41B fractures and Type V-VI to 41C fractures. Both 41B and C have different sub-types according to fragment morphology and comminution. But biplanar analysis of these fractures has been demonstrated to be insufficient to identify the fracture pattern and to guide treatment strategy. The idea of the proximal tibia as a three-column structure 15 opens the door to a new fracture understanding.
Pure articular depression (Schatzker Type III) should be a ‘zero-column fracture’. Most of the simple lateral split and split depression fractures (Schatzker Types I and II) should be a ‘one-column (lateral column) fracture’. The posterior shearing fracture, 16 an articular depression in the posterior column with a break of the posterior wall, is a ‘one-column (posterior column) fracture’ (not included in Schatzker classification). There are two common types of two-column fractures. An anterolateral fracture and a separate posterior–lateral articular depression with a break of the posterior wall is a ‘two-column (lateral and posterior column) fracture’. The other typical ‘two-column fracture’ is the anteromedial fracture with a separate posteromedial fragment (medial and posterior column fracture), which traditionally belongs to Schatzker Type IV (medial condylar fracture). The ’three-column fracture’ is defined as at least one independent articular fragment in each column. The most common three-column fracture is a traditional ‘bicondylar fracture’ (Schatzker Type V or Type VI) combined with a separate posterolateral articular fragment. Bicondylar fracture (A0-OTA C type) analysis shows the existence of a posteromedial fragment in 30% 17 to nearly 65% 18 of fractures, affecting 23% of the medial plateau articular surface as a mean. 17 The existence of a posterolateral fragment in AO-OTA type B and C fractures has been detected in about 44% of cases and affects nearly one-third of the lateral tibial plateau surface. 19 The three-column concept and knowledge about these posteromedial and posterolateral fragments have changed the understanding of fractures and strategies for treatment.
In general, tibial plateau fractures are to be operated on, but the decision whether to operate or not on a specific fracture should be based on the fracture morphology, the soft tissues and the patient’s general condition, and the expected limb axis and articular surface restoration. Usual indications for surgical treatment are: 20
