Musculoskelet Surg DOI 10.1007/s12306-017-0514-8

REVIEW

A review of the management of tibial plateau fractures J. Mthethwa1   · A. Chikate1 

Received: 15 May 2017 / Accepted: 8 October 2017 © Istituto Ortopedico Rizzoli 2017

Abstract  Tibial plateau fractures form a wide spectrum of injuries presenting varying challenges to the trauma surgeon. The prognosis of this injury spectrum is largely dependent on the management of each particular configuration, and the literature is as a result littered with a number of management strategies with limited consensus. The aim of this review is to provide a concise guide to the trauma surgeon based on newer and classical peer-reviewed publications in international orthopaedic journals. A PubMed search was conducted to identify peer-reviewed publications within the last 10 years and expanded to identify classic papers pertaining to the Schatzker classification. The focus was on articles based on management techniques, controversies and recent developments. The management of specific injury patterns is based on the Schatzker classification which is a widely accepted traditional classification system. Whilst there is a general consensus on the ultimate goal of a stable anatomic reduction in this subset of fractures, there continues to be a number of controversies surrounding issues including preoperative imaging, initial assessment and definitive management of specific injury patterns, some of which do not conform to the original Schatzker classification. The majority of fractures will require operative management, and with whatever management strategy employed, the main emphasis is on respecting the soft tissue envelope. There remains a paucity of prospective randomised controlled trials comparing the different available operative techniques.

* J. Mthethwa [email protected] 1



Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK

Keywords  Tibial plateau fracture · Proximal tibia fracture · Review · Knee fracture · Trauma · Schatzker classification

Introduction The optimal treatment of tibial plateau fractures is a surgical challenge that remains largely controversial in the medical literature [1]. The tibial plateau is a major weight-bearing surface within the largest and most kinematically complex joint in the human body. Fractures occur as a result of a combination of an axial loading force and a coronal plane (varus/valgus) moment leading to articular shear and depression and mechanical axis malalignment [2]. The position of knee flexion at the time of trauma dictates the fracture configuration [3]. Whilst there is general consensus on the ultimate goals of treatment of this intra-articular subset of fractures, complication rates in the short- to long-term remain relatively high. The functional consequences of inadequate treatment of these injuries are loss of independence in affected patients and poor outcome scores. Post-operative stiffness, instability, limb malalignment and the development of post-traumatic osteoarthritis (PTOA) often necessitate the need for further surgical procedures all at added risk to the patient and at great difficulty and expense [3, 4]. An extensive zone of injury from the initial trauma and surgical exposure contributes to the early complications of wound healing and infection [5]. A plethora of factors ranging from injury characteristics, patients factors, initial and definitive management of these injuries by clinicians may play a role either alone or in combination in the prognosis of this injury spectrum. Central to a good outcome is the surgeon’s understanding of local anatomy, fracture pattern and biomechanics of fracture fixation [6]. Common to many injuries lacking a

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clear consensus on management, the medical literature is littered with a myriad on techniques and algorithms to address this difficult subset of fractures. The aim of this literature review is to provide guide on the orthopaedic management of this injury spectrum based on current evidence.

Demographics of tibial plateau fractures Tibial plateau fractures are serious but rare injury spectrum accounting for approximately 1.2% of all fractures [7]. There is a wide demographic spread from younger, fitter males involved in high-energy trauma up to frail elderly females with underlying osteoporosis where they may represent up to 8% of all fractures [8]. The highest frequency in both sexes is, however, reported to be between the ages of 40–60 years [9]. The majority (55–70%) involve the lateral tibial plateau in isolation with half the remainder (10–25%) involving the medial plateau in isolation and the rest bicondylar (~ 15%). When the injury mechanism involves a higher energy as often the case in the younger patient involved in a motor vehicle collision, fall from significant height or extreme sport, patients may present with significant local osseous, soft tissue and neurovascular injury as well as associated spinal and visceral injuries [10]. In as many as 90%, some degree of injury to the soft tissue envelope exists with approximately 1–3% presenting as open fractures [11]. The older patient presents a different type of beast with a lower energy albeit complex fracture pattern on a background of diminished bone stock but lesser insult to the soft tissue envelope.

Assessment of tibial plateau fractures The initial assessment of tibial plateau fractures is often carried out in the emergency room. Mechanism of injury is of paramount importance as a large proportion of patients present following high-energy trauma with the associated injury spectrum largely dependent on the mechanism of injury. Patients falling from a height onto their lower limbs have potentially threatening pelvic or spinal injuries that may take precedence. Patients involved in motor vehicle collisions often have associated head, thoracic, abdominal, spinal injuries as well as a number of skeletal injuries [10]. In general, the principles of the Advanced Trauma Life Support (ATLS) protocol should be promptly implemented, and whilst orthopaedic priorities may exist (open fractures, vascular injury), these should never impede the addressing of higher priority life-threatening injuries. The orthopaedic evaluation of the local injury includes circumferential assessment of the soft tissue envelope, a detailed neurovascular assessment, and the evaluation for compartment syndrome [10]. Careful

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and thorough assessment of injury severity, with particular attention paid to identifying high-energy injuries, is critical to achieving optimal outcomes and avoiding complications [12]. According to a study by Stark and Tornetta in 2009, the incidence of compartment syndrome is as high as 18% in Schatzker VI injuries and 53% in medial plateau fracture dislocations [13]. The presence of an isolated medial plateau fracture should raise the possibility of knee dislocation–relocation with concomitant injury to neurovascular structures behind the knee [14]. It is therefore very important for these patients to have assessment of pedal pulses with documentation of the ABPI and a low threshold for vascular imaging. The peroneal nerve is the most commonly injured nerve with a 1% incidence and more common with varus medial plateau fractures with posterolateral corner injuries and popliteal artery injury.

Imaging Plain X‑ray Plain radiography remains the initial investigation of choice for suspected osseous injury. The standard views are orthogonal AP and lateral views which have 79% sensitivity for predominantly lateral plateau fractures. Adding oblique plain X-rays increases sensitivity to approximately 85% [15]. The caudal tilt plateau view helps to determine the degree of articular step off. The presence of a lipohaemarthrosis as viewed on the lateral radiograph may be the only finding in subtle fractures on initial evaluation and in cases of suspected high-energy injury may warrant further crosssectional imaging (Fig. 1). Medial tibial plateau fractures are most common in younger patients presenting with higherenergy trauma and often obvious on plain imaging [3].

Fig. 1  Lipohaemarthrosis: Arrow showing interface between radiolucent fat (above) and radioopaque blood (below) in a patient with an isolated medial tibial plateau fracture (apparent on plain X-ray)

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Fractures of the lateral tibial plateau, however, tend to be more common in elderly patients with low-energy trauma and are often radiographically occult [3]. Whilst AP radiographs, which form the basis of the Schatzker classification, identify most tibial plateau fractures, some fracture configurations may only be identified on lateral radiographs. Still, some fracture configurations including the so-called anterior tibial condyle fracture are often missed on orthogonal AP and lateral knee plain X-rays due to an overlap between the fracture and the normal bone [16]. We suggest that crosssectional imaging by way of CT scan should be carried out whenever there is a high index of suspicion in the presence of a lipohaemarthrosis to ensure injuries are not missed and facilitate the correct management of these.

prevalence of meniscal tears and ligamentous injuries with fractures of the lateral tibial plateau. Arthroscopic studies found soft tissue injuries in 56–71% of patients with lateral tibial plateau fractures, whilst an MRI study found associated soft tissue injuries to be as high as 90–97% [11, 22]. Our view is that cross-sectional imaging is helpful in the overall pre-operative planning and identification of associated injuries, and whilst decisions should be individualised, we would recommend its use in all high-energy injuries and a low threshold to obtain in low-energy injury if deemed likely to affect the management plan.

Cross‑sectional imaging

A good injury classification system should act as guide to treatment, describe prognosis, categorise clinical research, facilitate clinical communication and be simple and reliable with good inter-rater agreement [14, 23]. The earliest attempts at classifying tibial plateau fractures were published in 1951 by Palmer and followed by Hohl in 1967 [17, 18]. Central to these classifications was an appreciation of the typical components within the injury spectrum: condylar split, subchondral depression and comminuted bicondylar involvement [23]. It was not until 1979 that Schatzker, observing the very same injury characteristics, published a simplistic classification based on the AP radiographs of 94 patients that to date remains the most widely adopted in the literature (Fig. 3) [19]. With six increasing numeric fracture categories I to VI, the Schatzker classification attempts to map increasing fracture severity with the worsening overall prognosis [14]. Modifications of the Schatzker classification including the study by Chen et al. [4] have since followed taking into consideration the orientation of fracture lines based on CT images to better guide the placement of fixation. In its simple form, the Schatzker classification has shown moderate to good inter-rater reliability with kappa coefficients for inter-observer reliability being up to 0.68 and intra-observer reliability up to 0.91 [24, 25]. The addition of 2D and 3D CT reconstructions further improves inter-observer reliability to up to 0.75 and 0.85, respectively [24–26]. One study has, however, argued that in terms of Schatzker classification, CT adds no benefit to conventional radiography [27]. MRI, though not routinely used, has also been shown to improve both intra-observer and inter-observer reliability [28]. A major limitation of the Schatzker classification is that it only addresses fracture lines in the sagittal plane [16]. A recent CT study looking at 127 tibial plateau fractures noted a subset of Schatzker IV, V and VI fractures which do not fit the original classification. The same authors also noted that there were 4 recurrent major fragments: lateral split fragment (75%), posteromedial fragment (43%), the tibial tubercle fragment (16%) and

Initial work and the most commonly used classifications to date were based on standard plain radiographs [17–19]. However, nowadays, computed tomography (CT) scanning plays a fundamental role in identifying covert fractures and in understanding fracture configuration whilst aiding operative planning by accurately describing fracture line orientation as well as quantifying the magnitude of articular depression (Fig. 2) [4]. It is advantageous in limiting the amount of tissue dissection within the zone of injury by acting as a guide for optimal wound placement for minimally invasive surgery and percutaneous techniques. It also aids in identifying associated injuries and coupled with angiography and may help identify vascular injuries [14, 20]. In the study by Atesok in 2007, the use on intra-operative CT helped improve reductions in 11% of standard C-arm fluoroscopically guided reductions and also precluded the use of preand post-operative CT scanning [21]. The use of MRI has also been described and is excellent at identifying ligamentous, chondral (including meniscal) as well as neurovascular injuries which have a bearing on the overall prognosis of the injury in selected high-energy cases [14]. There is a high

Fig. 2  Coronal CT image showing a displaced bicondylar tibial plateau fracture with significant condylar widening and articular gap

Classification

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Fig. 3  Schatzker et al. published their classification system in 1979, deriving it from the AP radiographs of a series of 94 patients, most of whose tibial plateau fractures were treated non-operatively

a zone of comminution that included the tibial spine and extending to the lateral condyle in 28% [20]. Lately, Luo proposed, based on computed tomography (CT) evaluation, the concept of three columns in the treatment of tibial condyle fractures, where three columns (anatomic pillars) are medial, lateral and posterior (Fig. 4) [29]. This classification is important as it covers the treatment aspects of other types of fracture configurations that may not conform to the traditional Schatzker classification, especially those involving the posterior pillar. Further modifications to this have also been proposed to cater for further variations [30]. Another useful classification although not as widely used is the AO/ OTA classification [31–33].

Management Initial management Fractures presenting with vascular injury as well as fracture dislocations should be managed emergently. Compartment syndrome is an emergency which requires immediate four compartment fasciotomy regardless of the planned definitive management, and evaluation for compartment syndrome should be carried out at every stage of management. Open fractures with gross contamination also warrant emergent management and follow nationally agreed guidelines. Early vascular and orthoplastic input should be sought where indicated by the type of injury and the degree of soft tissue

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Fig. 4  Three anatomic pillars: Column classification defined as below. A column fracture is defined as an articular depression in combination with a cortical fracture of the column wall. Pure articular depression fractures with intact cortex (Schatzker III) are classified as a zero-column fracture. The column borders are demarcated by four points on an axial plane. An artificial central axis located at the midpoint between the two tibial spines. A line is the drawn in the sagittal axis to roughly the tibial tuberosity (point B to point A), and this demarks the medial and lateral columns. The lateral column then extends counterclockwise from point A as far back as the anterior border of the fibular head (point C). Behind this lies the posterior column which extends further counterclockwise (with point B as its midpoint) to point D which represents the posterior medial ridge of the tibia and the start of the medial column

compromise. Whilst low-energy injuries can be treated early with a single procedure, injuries with significant compromise to the soft tissue envelope as well as high-energy injuries in an otherwise physiologically compromised host may warrant staged damage control principles [34]. Staged management refers to the use of temporising methods of care (often spanning external fixation) in high-energy injuries, as well as delaying definitive fracture surgery until such a time as the risk of soft tissue complications is decreased or the patient’s general physiology has improved (Fig. 5) [12]. An approach commonly coined as “span, scan and plan” involves the use of a spanning external fixator, subsequent CT scanning for fracture configuration, followed by planning of definitive surgery when the soft tissue envelope has improved. This may be the most appropriate approach for most high-energy Schatzker IV to VI injuries which are likely to have severe soft tissue compromise or an associated compartment syndrome. Whilst it is generally accepted that high-energy injuries require early spanning, it is debatable as to whether this should be done on an emergent versus urgent basis [35]. The timing of definitive surgery and practice of damage control, however, is fundamental in preventing complications arising from the compromised soft tissue envelope.

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Fig. 5  High-energy Schatzker VI tibial plateau fracture with vascular compromise and compartment syndrome (left—prior to bridging external fixator, right—after application of bridging external fixator).

In this case, distal perfusion was re-established after application of the spanning external fixator

Table 1  Indications for fixation of tibial plateau fractures [6, 19]

treatment of tibial plateau fractures. The operative options range from standard plating, minimally invasive and percutaneous techniques, definitive external fixation, to primary arthroplasty in elderly patients with comminuted fractures or pre-existent arthritis with a desire for early post-operative full weight bearing. A recent systematic review concluded that there is insufficient evidence to favour one fixation method over another as well as ascertain the best method of filling metaphyseal voids. It did, however, note that the evidence supports minimally invasive approaches and the avoidance of autograft donor site complications through the use of bone substitutes [37]. The treatments of specific fracture types according to the Schatzker classification are not described.

Open fractures Compartment syndrome Vascular injury Lateral plateau fractures with  Articular step off > 3 mm  Condylar widening > 5 mm  Coronal plane instability Displaced medial plateau fractures Bicondylar fractures

Definitive management of individual fracture configurations As an intra-articular fracture of a major weight-bearing joint, the standard goals of exact reduction and rigid fixation cannot be over emphasised. The definitive treatment of tibial plateau fractures emphasises the restoration of articular congruity, the re-establishment of normal mechanical alignment of the lower limb whilst safeguarding the viability of the soft tissue envelope to promote healing and reduce the risk of developing PTOA [10]. The ultimate goal is to obtain a stable joint permitting early range of motion for cartilage nourishment and preservation [3]. The majority of fractures in the Schatzker series were treated non-operatively, and though the authors noted that these fared poorly, this remained the major practice in the 1980s [19, 36]. With the exception of undisplaced lateral plateau fractures or the presence of severe medical contraindications, the majority of displaced fractures are nowadays managed operatively. Table 1 summarises the accepted indications for operative

Schatzker I fractures Undisplaced fractures in low-demand patients can be appropriately managed in coronal plane stabilising brace with restriction in weight bearing but permit a full range of movement. This can reduce the incidence of stiffness, shorten rehabilitation time and has a low risk of secondary displacement. These fractures in general carry the best prognosis. In patients with higher demand and generally good bone stock, percutaneous screw fixation and early range of motion can be considered. The standard would be the use of partially threaded cancellous screws though a recent biomechanical study showed that the use of a combination of part and fully threaded cancellous screws was biomechanically superior at early loading cycles [2]. Locking plate constructs do not offer any biomechanical advantage over standard low-profile buttress plating in good bone. However, locking plate constructs may permit earlier weight bearing. In either case,

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patients should not have any post-operative restriction of range of motion exercises. Schatzker II and III fractures Type II fractures are common and involve an articular step off that requires reduction in addition to a condylar split and frequently require operative treatment. Type III fractures involve an articular step off in the absence of a condylar split and are less common and often occur in the setting of underlying osteopaenia. The degree of articular step off may not always be appreciated on standard films, and CT is beneficial in quantifying the magnitude of the step off as well as aiding surgical planning. The traditional approach has been to elevate the articular surface, reduce the condylar split where present and fill the resultant metaphyseal void with bone graft (calcium phosphate cement is stronger than autograft and avoids the associated donor site complications) [37]. This is classically followed with application of a subchondral raft of screws and an antiglide plate [38]. Recently, anatomic peri-articular fixed angle locking plate constructs have gained favour over standard plates due to their superior biomechanical profile and can be used as condylar reduction aids in non-locked fashion. The traditional approach is anterolateral, with elevation of the iliotibial band and tibialis anterior in continuity off Gerdy’s tubercle and a sub-meniscal approach to the articular surface. A recent modification is the Tsherne–Johnson approach which involves an osteotomy of Gerdy’s tubercle which provides a good view of the anterolateral approach without disrupting the iliotibial band [39]. Posterolateral fractures may offer unique challenges with standard anterolateral approaches, and these can be managed very well via a posterolateral trans-fibula approach [40, 41]. An alternative modification of the anterolateral approach with the use of a rim plate has also been recently described to stabilise posterolateral fractures [42]. Because of the desire to minimise trauma to the already compromised soft tissue envelope, a number of minimally invasive techniques have been proposed. First described by Caspari in 1985, arthroscopic-assisted reduction and internal fixation (ARIF), when compared with traditional open procedures, are less invasive allow additional full evaluation of intra-articular lesions whilst ensuring exact anatomic reduction in Schatzker types I, II and III fractures [43]. A recent systematic review has also shown that patients treated with ARIF return to sport a lot sooner than those treated by standard open reduction and internal fixation [44]. A fluoroscopy-assisted percutaneous technique has also been described using a supportive raft of screws combined with an additional interference screw for support [38]. Balloonguided inflation tibioplasty is a newer technique where calcium phosphate (or PMMA)-loaded balloon is used to indirectly reduce the articular surface under fluoroscopic

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guidance, that is deemed to subject the subchondral bone and articular cartilage to less trauma than using a standard punch without compromising osseous viability [45]. Schatzker IV fracture It is imperative that a possibility of a knee dislocation–relocation be actively excluded before addressing medial plateau fractures. Because of the natural location of Mickulicz point on the medial plateau, 60% of the weight bearing forces are pivoted through this area, and as such, medial plateau fractures should be managed operatively as the risk of secondary displacement is high [46]. The medial condyle fracture is often posteromedial and not purely medial as noted by Moore, for which they recommended posteromedial plating [47]. In many cases, the medial collateral ligament is the only ligamentous link between the distal femur and tibia and cantilever fixation with an isolated lateral locking plate construct should be avoided. There have been reports of an isolated coronal plane fracture, involving only the posterior aspect of the medial condyle [48]. In such cases, the fractured condyle is displaced posteriorly, carrying with it the medial femoral condyle. Such fractures can be missed on AP X-ray, but can be diagnosed in lateral X-rays and CT. Coronal bicondylar tibial plateau fracture involving the posterior condyles has also been reported [48]. The relevance of recognising the coronal component of these fractures lies in the fact that the buttress plate has to be put from behind via a posteromedial approach [49]. Percutaneous and limited open techniques may be used for more simple fracture patterns particularly involving the anteromedial condyle. Schatzker V and VI These complexes often comminuted high-energy subset of fractures involve both the medial and lateral plateaus with (type VI) or without (type V) meta-diaphyseal dissociation [19]. Bicondylar fractures can also involve the tibial tubercle, which represents a disruption to the extensor mechanism and warrants operative stabilisation [50]. The generally more extensive soft tissue insult often necessitates staged management of these fractures [38]. Complication rates have been reported to be as high as 30%, and staged management reduces these to about 10% even in the best-case scenario with careful patient selection and minimal soft tissue dissection [38, 51]. Whilst controversies do exist on fixation methods of these poorer prognosis injuries, there is consensus on the operative goals: restoration of articular congruity, maintenance of joint stability, restoration of mechanical alignment with the utmost minimum trauma to the soft tissues helping in early mobilisation of knee joint. The classical approach is combined medial and lateral incisions to address articular disruption and the use of dual low-profile

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plates [52]. This approach, whilst perhaps better than midline soft tissue stripping approaches to both condyles, does involve a fair amount of soft tissue trauma as well, which might not appeal well in many cases. Recent studies have shown an argument for the use of isolated lateral column locking plate constructs with more modern designs able to support the medial plateau once reduced by limited exposure techniques. Midline incisions often chosen to cater for future need for conversion to arthroplasty should be avoided as they cause extensive soft tissue injury and de-vascularise fracture fragments increasing the overall complication risk. The use of limited internal fixation and definitive external fixation can minimise soft tissue disruption, avoid complications and allow fracture union with reduced infection rates [53]. Options include the use of temporary or definitive spanning monolateral constructs or definitive ring or hybrid fine wire fixators with limited articular exposure (Fig. 6). Complications, including infection, loss of fixation and malalignment, are best avoided by respecting these biologic treatment principles [10]. Elderly patients presenting with these complex fractures on a background of poor bone stock or pre-existent osteoarthritis are best treated with primary total knee arthroplasty enabling them to fully weight bear early and results

Fig. 6  Coronal view of high-energy tibial fracture managed with definitive fine wire ring fixator and a limited percutaneous reduction after closure of fasciotomies. A and B limited percutaneous reduction

are very promising [43, 46, 54]. More complex configurations often necessitate the need for further approaches to access the posterolateral and posteromedial tibial plateau. The options for posterolateral access have been described earlier, and an excellent approach for the posteromedial tibial plateau was described by Lobenhoffer et al. [55].

Conclusion The management of tibial fractures continues to evolve which is a reflection of the complexity of this injury spectrum, and the variable outcomes achieved following management. The basic goals of exact articular reduction and rigid fixation whilst re-establishing mechanical alignment of the lower limb and respecting the soft tissue envelope should be adhered to as a guide to optimising outcomes. Whilst the Schatzker classification is widely accepted, the management of the more complex patterns and higher-energy injuries is still open to much debate and further clinical studies are required. Even with the prospect of further studies, the individuality of each injury makes it very challenging to reach

with McDonalds dissector. C reduction in lateral condylar split with olive wires and injection of calcium phosphate cement into metaphyseal void. D final reduction with rings in place

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consensus and the paucity of higher-level randomised trials is testimony to this. Compliance with ethical standards  Conflict of interest  The authors declare that they have no conflict of interest. Human and animal participants  This article does not contain any studies with human participants or animals performed by any of the authors. Informed consent  For this type of study, formal consent is not required.

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