The Tibial Plateau Fracture

06/09/2012 The Tibial Plateau Fracture Mechanism of Injury Walter Mak, MD Department of Medical Imaging St. Michael’s Hospital University of Toront...
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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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