06/09/2012
The Tibial Plateau Fracture
Mechanism of Injury
Walter Mak, MD Department of Medical Imaging St. Michael’s Hospital University of Toronto
Acute knee trauma
Knee dislocation
Plain film MRI +/- CT angiogram
Restore ligamentous/ soft tissue stability
Where is the fracture?
Tibial Plateau Fracture
Where is the fracture?
Plain film CT +/- CT angiogram
Restore osseous stability
Where is the fracture? Medial plateau fracture High energy trauma
Lateral plateau fracture
High association with cruciate ligament and neurovascular injury Almost always treated with open reduction and internal fixation (ORIF)
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Where is the fracture?
Where is the fracture?
Medial plateau fracture, ground level fall
Bicondylar fracture High energy mechanism
Varus malalignment poorly tolerated longterm Almost always treated surgically Usually undergo ORIF
Courtesy Dr. Ivan Diamond
Where is the fracture?
Where is the fracture?
Posterior shear fracture
Posterior shear fracture Bhattacharyya T. et al. J Orthop Trauma 2005, 19:305-310
Bhattacharyya T. et al. J Orthop Trauma 2005, 19:305-310
Coronal fracture plane on lateral view
Coronal fracture plane on lateral view
Direct posterior surgical approach
Direct posterior surgical approach
Split and/or depression? Depression Fracture
Is there a split and/or depressed component?
Impaction of cancellous bone Low energy, osteoporotic bone During ORIF, grafting of defect may be required
Markhardt et al. Radiographics 2009; 29:585-597
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Split and/or depression?
Split and/or depression?
Split Fracture Split fracture Shearing force splits plateau Higher energy, normal bone Usually see with depressed component
No articular surface depression
ORIF without grafting
Split and/or depression?
Split and/or depression?
Split-depression fracture
Depression fracture lateral plateau
Very common, often clinically unstable
No split component Pure depression fractures of lateral plateau often clinically stable
Articular incongruity? Articular surface depression
Is there articular incongruity?
Measured using opposite plateau or remaining intact surface Measure to point of maximal depression
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Condylar widening Condylar widening
Articular Surface Incongruity
Overhang of tibial plateau in relation to femoral condyles
How much is ‘too much’? No uniform consensus
Sum of overhang medially and laterally if appropriate
Articular surface depression: >4mm at SMH Condylar widening: >4mm at SMH Depression/widening ≥2 mm should be reported
Metadiaphyseal Dissociation
Is there metadiaphyseal dissociation?
High-energy mechanism, significant soft tissue and neurovascular injury Tibial articular surface completely dissociated from diaphysis Comminution of one or both tibial plateaus and articular surface
Metadiaphyseal dissociation? Always undergo ORIF Formal ORIF while soft tissue injuries addressed
What other fractures are present?
Temporary external fixation, delayed ORIF
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Associated fractures?
Associated fractures?
Tibial tuberosity avulsion
Intercondylar eminence fracture, cruciate ligament avulsion
May result in extension lag if not fixed
Fixed at time of ORIF if amenable to screw/suture fixation Addressed in delayed fashion if comminuted and residual instability
Associated fractures? Fibular head fracture – posterolateral corner injury
Value of CT
Timing of ORIF and/or ligament reconstruction varies
Value of CT: Fracture characterization
Value of CT: Fracture characterization
Medial plateau fracture?
Medial plateau fracture?
CT reveals split component through lateral plateau
CT reveals split component through lateral plateau
Bicondylar fracture; surgical approach altered
Bicondylar fracture; surgical approach altered
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Value of CT: Assessing articular incongruity
Value of CT: Associated Fractures Medial plateau fracture
Depression may be underestimated on plain film Intercondylar eminence fracture? 6 mm depression confirmed on CT
Confirmed on CT
Value of CT: Associated Fractures
Value of CT: Fragment characterization
Medial plateau fracture J Orthop Trauma 2008;22:176-182
Intercondylar eminence fracture?
Coronal fracture plane; separate posteromedial fragment
Confirmed on CT
Common pattern in bicondylar fractures Requires posteromedial plate; may preclude lateral-only fixation
Value of CT: Fragment characterization
Value of CT: Fragment characterization
Bicondylar fracture
Bicondylar fracture
Posteromedial fragment
Posteromedial fragment
Secured with posteromedial plate
Secured with posteromedial plate
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Value of CT: Fragment characterization
Value of CT: Fragment characterization
Bicondylar fracture
Comminuted, split lateral plateau
Posteromedial fragment Secured with posteromedial plate
Value of CT: Fragment characterization Comminuted, split lateral plateau
CT reveals bicondylar fracture Gross comminution of medial plateau, not amenable to fixation
Summary: Questions to Answer 1. Where is the fracture? Lateral, medial, bicondylar, posterior
CT reveals bicondylar fracture Gross comminution of medial plateau, not amenable to fixation
2. Is there a split and/or depressed component? 3. Is there articular incongruity? Articular surface depression, condylar widening
4. Is there metadiaphyseal dissociation? 5. What other fractures are present? Tibial tuberosity, intercondylar eminence, fibular head
Summary: Indications for Operative Fixation Bicondylar fractures Medial plateau fractures
References Schatzker, J., R. McBroom, and D. Bruce, The tibial plateau fracture. The Toronto experience 1968--1975. Clin Orthop Relat Res, 1979(138): p. 94-104. Browner B.D., Jupiter J.B., Levine A.M., Trafton P.G., eds: Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 4. Philadelphia, Saunders/Elsevier, 2009. Barei, D.P., et al., Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma, 2008. 22(3): p. 176-82. Doornberg, J.N., et al., Two-dimensional and three-dimensional computed tomography for the classification and characterisation of tibial plateau fractures. Injury, 2011. 42(12): p. 1416-25. Waddell, J.P., D.W. Johnston, and A. Neidre, Fractures of the tibial plateau: a review of ninety-five patients and comparison of treatment methods. J Trauma, 1981. 21(5): p. 376-81. Honkonen, S.E., Indications for surgical treatment of tibial condyle fractures. Clin Orthop Relat Res, 1994(302): p. 199-205.
Lateral plateau fractures:
•>10° varus/valgus instability •>4mm articular surface depression •>4mm condylar widening
Open fractures
Rasmussen, P.S., Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am, 1973. 55(7): p. 1331-50. Mills, W.J. and S.E. Nork, Open reduction and internal fixation of high-energy tibial plateau fractures. Orthop Clin North Am, 2002. 33(1): p. 17798, ix. Bhattacharyya, T., et al., The posterior shearing tibial plateau fracture: treatment and results via a posterior approach. J Orthop Trauma, 2005. 19(5): p. 305-10. Stevens, D.G., et al., The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma, 2001. 15(5): p. 312-20. Markhardt, B.K., J.M. Gross, and J.U. Monu, Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics, 2009. 29(2): p. 585-97. Martin, J., et al., Radiographic fracture assessments: which ones can we reliably make? J Orthop Trauma, 2000. 14(6): p. 379-85. Musahl, V., et al., New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau. J Bone Joint Surg Br, 2009. 91(4): p. 426-33.
Compartment syndrome/arterial injury
Tscherne, H. and P. Lobenhoffer, Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res, 1993(292): p. 87-100. Dirschl, D.R. and P.A. Dawson, Injury Severity Assessment in Tibial Plateau Fractures. Clin Orthop Relat Res, 2004(423): p. 85-92.
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