I. Tibial Plateau Fractures
1. As with most fracture patterns, the epidemiology of tibial plateau fractures is changing. In the past, tibial plateau fractures were more common in young patients following high-energy trauma, whereas now a larger percentage are a result of a low-energy fall in older patients with osteoporotic bone.
2. Tibial plateau fractures account for approximately 2% of all fractures, with bimodal incidence in both men and women and mean patient age of 48 years.
B. Anatomy (
1. Tibial plateau
a. The medial tibial plateau, the larger of the two plateau bones, is concave and covered with hyaline cartilage.
b. Both plateaus are covered by a fibrocartilaginous meniscus. The coronary ligaments attach the menisci to the plateaus, and the intermensical ligament connect the menisci anteriorly.
2. Tibial spines serve as attachment points for the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), and the menisci.
3. Tibial shaft
a. The tibial shaft is triangular in cross section.
b. Proximally, the tibial tubercle is located antero-laterally about 3 cm and is the point of attachment for the patellar tendon.
c. Laterally on the proximal tibia is the Gerdy tubercle, which is the point of insertion for the iliotibial band.
*Kenneth Egol, MD, or the department with which he is affiliated has received research or institutional support from Biomet, Smith & Nephew, Stryker, and Synthes and holds stock or stock options in Johnson & Johnson.
4. Soft-tissue structures
a. The medial (tibial) collateral ligament inserts into the medial proximal tibia.
b. The ACL and PCL provide anterior-posterior stability.
5. Neurovascular structures
a. The common peroneal nerve courses around the neck of the fibula distal to the proximal tibia-fibula joint before it divides into its superficial and deep branches.
b. The trifurcation of the popliteal artery into the anterior tibial, posterior tibial, and peroneal arteries occurs posteromedially in the proximal tibia.
c. Vascular injuries to these structures are common following knee dislocation but also can occur in high-energy fractures of the proximal tibia.
a. The anterior compartment musculature attaches to the proximal lateral tibia.
b. The proximal medial tibial surface is devoid of muscle coverage but serves as an attachment point for the pes tendons.
C. Mechanisms of injury
1. Tibial plateau fractures result from direct axial compression—usually with a valgus (more common) or varus (less common) moment—and indirect shear forces. Examples:
a. High-speed motor vehicle accidents
b. Falls from a height
c. Collisions between the bumper of a car and a pedestrian (hence the term bumper injury)
2. The direction, magnitude, and location of the force, as well as the position of the knee at impact, determines the fracture pattern, location, and degree of displacement.
[Figure 1. Anatomy of the tibia and fibula. Shaded areas indicate origins and insertions of the indicated muscles. A, Anterior view. B, Posterior view.]
3. Associated injuries
a. Meniscal tears are associated with up to 50% of tibial plateau fractures.
b. Associated injury to the cruciate or collateral ligaments occurs in up to 30% of patients.
c. Skin compromise may be present in high-energy fracture patterns.
D. Clinical evaluation
1. Physical examination
a. One should palpate over the site of potential fracture or ligamentous disruption to elicit tenderness.
b. Hemarthrosis typically is present; however, capsular disruption may lead to extravasation into the surrounding soft-tissue envelope.
c. Any widening of the femoral-tibial articulation of more than 10° on stress examination compared with the other leg indicates instability.
2. Neurovascular examination
a. If pulses are not palpable, Doppler studies should be performed.
b. One should assess for signs and symptoms of an impending compartment syndrome (pain out of proportion to the injury, pallor, pulselessness, pain on passive stretch of the toes, or impaired neurologic status).
c. Compartment pressures also should be measured if the patient is unconscious and has a tense, swollen leg.
d. Ankle-brachial index (ABI) <0.9 requires consultation with a vascular surgeon.
3. Radiographic evaluation
a. Plain radiographs—Should include a trauma series (AP, lateral, and oblique views) and a plateau view (10° caudal tilt).
b. CT—Allows for improved assessment of fracture pattern, aids in surgical planning, and improves
Figure 2. Schatzker classification of tibial plateau fractures. Type I: lateral plateau split; type II: lateral split-depression; type III: lateral depression; type IV: medial plateau fracture; type V: bicondylar injury; type VI: tibial plateau fracture with metaphyseal-diaphyseal dissociation.]
Figure 3. The Moore classification of tibial plateau fractures. A, Split fracture of the medial plateau in the coronal plane. B, An entire condyle fracture. C, Rim avulsion fracture. D, Pure compression fracture. E, Four-part fracture.]
ability to classify fractures. CT should be ordered when better visualization of the bone fragments is required.
c. MRI—Evaluates both bony and soft-tissue components of the injury in a noninvasive manner. Indications for ordering MRI for these injuries have not been well established.
E. Fracture classification
1. The Schatzker classification is most commonly used (Figure 2).
2. The Moore classification accounts for patterns not described in the Schatzker classification (Figure 3).
Figure 4. The OTA classification of proximal tibia/fibula fractures. Type A fractures are extra-articular, type B fractures are partial articular, and type C fractures are complete articular. A1: avulsion; A2: metaphyseal simple; A3: metaphyseal multifragmentary; B1: pure split; B2: pure depression; B3: split depression; C1: articular simple, metaphyseal simple; C2: articular simple, metaphyseal mulitfragmentary; and C3: articular multifragmentary.]
3. The OTA classification is the internationally accepted classification system (Figure 4).
F. Nonsurgical treatment
1. Indicated for nondisplaced and stable fractures.
2. Patients are placed in a hinged fracture brace, and early range-of-motion exercises are initiated.
3. Partial weight bearing (30 to 50 lb) for 8 to 12 weeks is allowed, with progression to full weight bearing as tolerated thereafter.
4. If this approach fails to maintain the reduction, surgical treatment is indicated.
G. Surgical management
a. For closed fractures, the range of articular depression considered to be acceptable varies from ≤2 mm to 1 cm. Instability >10° of the nearly extended knee compared to the contralateral side is an accepted indication for surgical treatment of closed tibial plateau fractures.
b. For open fractures, irrigation and debridement are required, with either temporary fixation or immediate open reduction and internal fixation. Regardless of approach, the knee joint should not be left open.
c. If there will be a delay in surgical intervention, consider use of temporary spanning external fixation if the limb is shortened or subluxated.
2. Reduction techniques
a. Indirect techniques have the advantage of minimal soft-tissue stripping and fragment devitalization. Ligamentotaxis, however, will not work on fractures with centrally depressed articular fragments.
b. With direct techniques, depressed articular fragments may be elevated through a cortical window.
3. Fixation techniques
a. Arthroscopy can be used as a diagnostic tool to assess intra-articular structures in patients who sustain low-energy fractures; it also can be used as an adjunct to treatment in assessing the quality of fracture reduction.
b. Most fracture patterns are treated with a lateral approach and buttress plating.
c. A posteromedial approach is used to buttress posteromedial fragments.
d. Screws alone can be used for simple split fractures that are anatomically reduced, for depression fractures that are elevated percutaneously, and for fractures with fragments that are avulsed by soft-tissue attachments.
e. Plates may be placed percutaneously for fractures that extend to the metadiaphyseal region.
4. External fixation techniques
a. A hybrid technique can be used, consisting of placement of a pin or wire 10 to 14 mm below the articular surface to avoid penetration of the synovial recess posteriorly.
b. A circular frame is an alternative to a long percutaneous plate.
5. Identify and repair all meniscal damage intraoperatively.
6. Bicondylar tibial plateau fractures
a. Bicondylar fractures require dual plate fixation or unilateral fixation with a locking plate.
b. Anterior midline incision should be avoided for bicondylar fractures because of the high rate of wound slough.
H. Postoperative management
1. Continuous passive motion from 0° to 30° may be used. It is started a few days after surgery and may be continued until the patient regains full range of knee motion.
2. Physical therapy should consist of active and active-assisted range-of-motion exercises, isometric quadriceps strengthening, and protected weight bearing.
3. Progressive weight bearing depends on the rate of fracture healing.
1. Early complications
a. Infection rates vary widely, from 1% to 38% of patients; superficial infections are more common (up to 38% of patients), whereas deep wound infections are less common (up to 9.5%). Pin tract infections are common when external fixation is used.
b. Thromboembolism is less common, with deep venous thrombosis developing in up to 10% of patients and pulmonary embolism in 1% to 2%.
2. Late complications
a. Painful hardware can occur.
b. Posttraumatic arthrosis may be related to chondral damage that occurs at the time of the injury.
c. Nonunion is rare.
d. Loss of reduction, collapse, and/or malunion can occur with failure to adequately buttress elevated fragments.
II. Tibia-Fibula Shaft Fractures
1. Most tibial shaft fractures result from low-energy mechanisms of injury and account for 4% of fractures seen in the Medicare population. When these fractures occur in younger patients, a high-energy injury such as motor vehicle accident usually is the cause.
2. Isolated fibular shaft fractures are rare and usually the result of direct blow; they also can be associated with rotational ankle injuries (Maisonneuve fractures).
1. Bony structures
a. The anteromedial crest of the tibia is subcutaneous.
b. The proximal medullary canal is centered laterally.
c. The anterior tibial crest is made of dense cortical bone.
d. The fibular shaft is palpable proximal and distally. The fibula serves as the site of the muscular attachment for the peroneal musculature and the flexor hallucis longus, but it contributes little to load bearing (15%).
a. The anterior compartment contains the tibialis anterior, extensor digitorum longus, extensor hallucis longus, the anterior tibial artery, and the deep peroneal nerve.
b. The lateral compartment contains the peroneus longus and brevis and the superficial peroneal nerve.
c. The superficial posterior compartment contains the gastrocnemius-soleus complex, the soleus, the popliteus, and the plantaris muscles, as well as the sural nerve and saphenous vein.
d. The deep posterior compartment contains the tibialis posterior, flexor digitorum longus, flexor hallucis longus, tibial nerve, peroneal nerve, and posterior tibial nerve.
3. Vascular structures
a. The nutrient artery supplies the inner two thirds of the cortex, and the periosteal vessels supply the outer third.
b. Popliteal artery branches located in the proximal tibia are the anterior and posterior tibial arteries and the peroneal artery.
C. Mechanism of injury
1. Tibia-fibula shaft fractures result from either torsional (indirect) or bending (direct) mechanisms.
2. Indirect mechanisms result in spiral fractures.
3. Direct mechanisms result in wedge or short oblique fractures (low energy) or increased comminution (higher energy).
4. Associated injuries include open wounds, compartment syndrome, ipsilateral skeletal injury (ie, extension to the plateau or plafond), and remote skeletal injury.
D. Clinical evaluation
1. Physical examination
a. One should inspect the limb for gross deformity, angulation, and malrotation.
b. Palpation for tenderness and swelling is important as well. The fact that the anterior tibial crest is subcutaneous makes identification of the fracture site easier.
2. Neurovascular examination
a. One should assess for signs and symptoms of impending compartment syndrome (tense compartment, pain out of proportion to the injury, pallor, paresthesia, pain on passive stretch, or pulselessness).
b. Intracompartmental monitoring is critical with a high index of suspicion for compartment syndrome.
c. Compartment syndrome release is indicated if the patient has one or more of the above signs and symptoms and an absolute pressure >40 mm Hg or <30 mm Hg difference between compartmental pressure and diastolic pressure.
d. Once the diagnosis is made, all four compartments must be released.
3. Radiographic evaluation
a. Plain radiographs should include a trauma series (AP, lateral, and oblique), with dedicated ankle or plateau views if the fracture extends to the surface of the joint. The entire tibia and fibula must be visualized, from knee to ankle.
b. With any fracture manipulation, postreduction views must also be obtained.
c. CT can be used to assess fracture healing or identify nonunion, but it plays no role in acute fracture management.
E. Fracture classification
1. Fractures are usually described based on the pattern, location, and amount of comminution.
2. The OTA classification includes types 42A (simple patterns—ie, spiral, transverse, oblique), 42B (wedge), and 42C (complex, comminuted) (
3. Soft tissue classification
a. Oestern and Tscherne for closed fractures (
b. Gustilo for open fractures (
F. Nonsurgical treatment
a. Low-energy stable tibia fractures (ie, axially stable fracture patterns)
b. Virtually all isolated fibular shaft fractures
2. Long leg casting is indicated, followed by functional bracing in a patellar tendon bearing brace or cast, with weight bearing as tolerated after 2 to 3 weeks. Cast wedging may be used, if needed.
3. At follow-up, shortening after closed treatment averages 4 mm, with nonunion in 1.1% of patients and <6° angulation.
[Figure 5. OTA classification of tibia/fibula diaphyseal fractures.]
G. Surgical treatment
a. Failure to maintain acceptable reduction parameters (<50% displacement, <10° angulation, <1 cm shortening, 10° rotational malalignment)
b. Open fractures, fractures with associated compartment syndrome, inherently unstable patterns (segmental, comminuted, short), and patients with multiple injuries (eg, floating knee)
2. Intramedullary (IM) nailing
Reamed IM nailing is the treatment of choice for unstable fracture patterns because it allows
[Table 1. Oestern and Tscherne Classification of Closed-Fracture Soft-Tissue Injury]
for use of a larger diameter nail (with larger locking bolts) and results in increased periosteal perfusion. In addition, with a reamed IM nail, there is no significant concern for embolization of marrow contents.
A nonreamed IM nail is looser fitting and associated with less cortical necrosis. It is also associated with a higher rate of locking screw breakage than reamed IM nailing.
Use of blocking screws, a unicortical plate, a lateral starting point, and IM nailing in a semi-extended position may help prevent proximal fractures from extending into valgus.
Use of blocking screws and or fibular plating may help prevent distal fractures from going into valgus (if at the same level as a fibula fracture), or into varus (if the fibula is intact).
Open plating techniques typically have been associated with wound problems and nonunion.
Contraindications for IM nailing include a preexisting tibial shaft deformity that may preclude IM nail passage and a history of previous IM infection.
3. Plates and screws
a. Newer plate designs and minimally invasive techniques have allowed these implants to play a role in metadiaphyseal fractures or in tibial shaft fractures in which IM nailing is not possible (ie, following total knee arthroplasty, tibial plateau fixation).
b. Lateral placement may be preferred to anteromedial placement when there are soft-tissue concerns.
[Table 2. Gustilo Classification of Open Fractures]
4. External fixation
a. This has gained popularity in open tibia fractures with soft-tissue compromise because of dissatisfaction of outcomes treated by traditional techniques.
b. Advantages are that it is low risk, provides access to wounds, provides a mechanically stable construct, and allows for radiographic evaluation.
c. Several types of frame constructs are available, including half-pin monolateral frames, which are considered safe and violate tissues on one side only; thin wire circular frames that allow for fixation in metaphyseal bone; and hybrid frames.
d. Construct stiffness is increased with increased pin diameter, number of pins on either side of the fracture, rods closer to the bone, and multiple plane construct.
5. Treatment of open fractures
a. Require emergent debridement and fracture stabilization.
b. Current evidence supports immediate closure of wounds, if possible.
c. Vacuum-assisted closure versus early flap (rotational versus free)
d. First-generation cephalosporin, with or without aminoglycoside, should be given in the emergency department.
e. Tetanus immunoglobin should be given if immune status is known and up to date; toxoid should be added if status is unknown or if patient has not had immunization for more than 10 years.
1. Following nonsurgical treatment of axially stable fractures, patients should be able to bear weight as tolerated after 1 to 2 weeks.
2. Following surgical treatment, weight-bearing status depends on the fracture pattern and implant type. With axially stable fracture patterns with bony contact, weight bearing as tolerated is allowed. With comminuted fractures, partial weight bearing is allowed until radiographic signs of healing.
3. Repeat radiographs should be obtained at 6 and 12 weeks.
4. External fixators should be dynamized before removal to ensure healing and prevent repeat fracture.
5. External bone stimulation has been shown to help in fracture healing.
1. Nonunion/delayed union
a. Nonunion—A fracture that has lost its capacity to unite.
b. Delayed union—A fracture that takes longer than expected to unite.
c. Treatment can consist of dynamization, exchange nailing, or bone graft.
2. Compartment syndrome—Failure to identify impending compartment syndrome is the most serious complication after tibia-fibula shaft fractures.
3. Knee pain occurs in up to 30% of patients following tibial nailing.
4. Infection—either superficial or deep. Deep infection usually is associated with open fractures (fracture hematoma communication) and may lead to osteomyelitis.
5. Painful hardware can occur because locking bolts and plates are usually placed on the subcutaneous border of the tibia.
6. Nerve injury, usually affecting the peroneal (most common) or the saphenous nerve, may occur. Peroneal nerve injury may occur secondary to pressure from the fracture table, whereas the saphenous nerve can be injured as a result of placement of the locking bolts.
7. Malalignment often is associated with late loss of reduction (ie, cast, external fixator) in proximal and distal metaphyseal fractures.
a. Immediate postoperative malalignment is preventable with careful surgical technique and awareness of this potential complication, particularly with nailing of proximal or distal tibia fractures.
b. Methods to prevent malalignment during tibial nailing include blocking screws, provisional plating, distractions, and fibular plating.
c. A more lateral proximal entry site should be considered to avoid valgus with a proximal one-third fracture.
Top Testing Facts
1. Skin compromise may be present in high-energy fracture patterns.
2. If there will be a delay in surgical intervention after tibial plateau fracture, consider use of temporary spanning external fixation if the limb is shortened or subluxated.
3. Identify and repair all meniscal damage intraoperatively.
4. Bicondylar tibial plateau fractures require dual plate fixation or unilateral fixation with a locking plate.
5. Anterior midline incision should be avoided for bicondylar tibial plateau fractures because of the high rate of wound slough.
6. Failure to identify impending compartment syndrome is the most serious complication after tibia-fibula shaft fractures.
7. Immediate postoperative malalignment is preventable with careful surgical technique and awareness of this potential complication, particularly with nailing of proximal or distal tibia fractures.
8. Methods to prevent malalignment during tibial nailing include blocking screws, provisional plating, distractors, and fibular plating.
9. A more lateral proximal entry site should be considered to avoid valgus with a proximal one-third fracture.
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