Tibial plateau

Question 1

Schatzer Classification

Answer 1

I - lateral split
II - lateral split depression
III- lateral pure depression
IV - medial plateau
V - bicondylar
VI - metaphyseal-diaphyseal discontinuity

Question 2

what injuries are associated With tibial plateau fractures?

Answer 2

COLLATERAL LIGAMENT INJURIES
- simple split fractures - contralateral collateral
- MCL more commonly injured due to direct plateau insertion

CRUCIATE
significant AP displacement
exiting the intercondylar notch

MENISCUS
- significant depression fracture
- can be incarcerated

Question 3

Tibial plateau treatment options:

Answer 3

**INITIAL MANAGEMENT **
- ATLS, examine soft tissues, NV status - CPN and distal pulses
- splint in backslab for comfort
- CT scan - characterise fracture
- MRI - ligamentous/ meniscal injury

NON-OPERATIVE
- Hinged knee brace - to allow ROM - stiffness is a major problem

OPERATIVE
indications:
- vascular or neurological injury
* instability
* varus/ valgus >10 deg
* posterior shear fractures - high rates of flexion instability - poorly tolerated
* bicondylar fractures
* significant articular step off
* medial fractures - higher rates of long term displacement

Goals
- restore articular surface
- restore alignment of the knee
- reduce stiffness

**options: **
complex fracture needing an MDT approach by a surgeon used to dealing with tibial plateau fractures
- EX-fix then delayed ORIF - dependent on soft tissues
- ORIF +/- bone graft
- Taylor spatial frame fixation - olive tipped wires +/- perc screws
- primary arthroplasty - elderly patients > 65 with pre-existing OA - better outcomes than ORIF followed by TKR

ORIF options:
Screws
- simple split or depression fractures
- lag screws
- RAFT screws - placed in subchondral bone parallel to joint surface to support elevated articular fragments
Plate
- non-locking plate - buttressing posteromedial/ simple split fractures
- fixed angle locking plate - mitigates varus deformity - comminuted/ osteoporotic bone

Bone graft options:
to fill metaphyseal void, three options:
- autograft - rare
- allograft - cancellous chips
- bone substitute - calcium phosphate cement - high compressive strength - less subsidence than autograft - biodegradable and osteoconductive

REHABILITATION
- 6 weeks - NWB in hinged knee brace

Question 4

Dual surgical approach and fixation of tibial plateau fracture

Answer 4

• appropriately consented, marked and WHO checklisted patient
• IV abx before thigh tourniquet is inflated
• supine with a triangle - lateral X-rays
• dual approach - anterolateral and posteromedial
• if medial fragment is undisplayed, might be possible to fix from lateral side