TRAUMA

Review Article
Trauma
13(3) 181–187

Tibial plateau fractures: A review ! The Author(s) 2011

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DOI: 10.1177/1460408610396422
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P Fenton1 and K Porter2

Abstract
Tibial plateau fractures are uncommon injuries of the proximal tibia which vary in severity from minimally
displaced stable injuries to high energy complex fractures with significant articular and metaphyseal
comminution and severe associated soft tissue injuries. Following initial assessment and appropriate
investigation a number of management options are available to the treating surgeon. We discuss the
presentation, initial management and investigation as well as outlining the various treatment options
with an emphasis on operative treatment. We further discuss the common complications and outcomes
following tibial plateau fracture.

Keyword
Tibial plateau fracture

Introduction alone were put across the knee bicondylar frac-

The tibial plateau consists of a pair of concave
condylar articular surfaces, which allow articu-
lation with the menisci and femoral condyles.
On the medial side the surface is oval in shape
while on the lateral side the surface is more cir-
cular. Between the condyles is the elevated inter-
condylar eminence.
Fractures of the tibial plateau are reported as
accounting for 1% of all fractures and up to 8%
of fractures in the elderly (Hohl, 1991). Most
injuries affect the lateral plateau with isolated
medial plateau injuries accounting for 10–23%
of fractures and bicondylar fractures accounting
for 10–30% (Hohl, 1991).
Tibial plateau fractures are produced by a
combination of axial loading together with
either a varus or valgus force. In their cadaveric
study Kennedy and Bailey found that applying
valgus and compressive forces across the knee
produced recognisable patterns of tibial plateau
fractures. When significant compressive forces
tures were produced (Kennedy and Bailey,
1968). They postulated that lateral plateau frac-
tures were produced when the medial collateral
ligament was intact although with the advent of
MRI scanning it has become apparent that soft
tissue injuries are often associated with plateau
fractures (Bennett and Browner, 1994).
Initial management
Patients may present with a history of a valgus
strain to the knee such as being struck by a car
1
Walsall Manor Hospital, 87 Russell Bank Road, West
Midlands, UK.
2
Department of Clinical Traumatology, Selly Oak Hospital,
Raddlebarn Road, Birmingham, UK.
Corresponding author:
Paul Fenton, Walsall Manor Hospital, 87 Russell Bank Road,
West Midlands, UK
Email: fenton1977@hotmail.com

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182
bumper, being tackled playing football or rugby
or falling from a height. Often the mechanism of
injury is not clear from the history. Initial assess-
ment in patients with a significant mechanism of
injury or multiple injuries should follow ATLS
guidelines. In assessing the injured limb atten-
tion must be given to the condition of the soft
tissues and relationship of any open wounds to
the fractures site. The state of the muscle com-
partments about the knee should be assessed as
well as the presence of distal pulses and neuro-
logical status of the limb with particular respect
to peroneal nerve function.
Following initial assessment the limb should
be rested in a splint, most often an above knee
backslab, to provide pain relief and protect the
injured soft tissues.
Investigations
Imaging begins with AP and lateral views of the
knee joint, supplementation with oblique views
of the knee may aid diagnosis where clinical sus-
picion is high. CT with axial, sagittal and coro-
nal reconstructions can provide information
regarding the degree of comminution and artic-
ular involvement and thus aid surgical planning.
MRI has come to play an increasing role in the
assessment of the soft tissue injuries associated
with these fractures. In their study comparing
the assessment of soft tissue injuries with CT
or MRI, Miu et al. (2007) found that although
CT was useful in the diagnosis of bony ligament
avulsions MRI was required to detect ligament
and meniscal injuries.
Classification
The most commonly used system to classify
tibial plateau fractures is that of Schatzker.
He divided fractures into six groups. A type I
fracture is a split of the lateral plateau; type II
involves a split and depression of the lateral
plateau; type III is a pure depression of the
lateral plateau; type IV fractures involve
only the medial plateau; type V are bicondylar
fractures; and type VI are bicondylar with
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Trauma 13(3)
separation of the metaphysis and diaphysis
of the tibia.
The AO group also use six classifications
for these fractures. 41-B fractures are partial
articular injuries. 41-B1 is a pure split, 41-B2
pure depression and 41-B3 split depression.
The 41-C injuries are complete articular injuries
with 41-C1 being simple articular and simple
metaphyseal, 41-C2 simple articular and multi-
fragmentary metaphyseal and 41-C3 multi-
fragmentary articular.
It has been suggested that there is a high
interobserver variability with both the AO and
Schatzker classification. Some recommend
describing fractures as either unicondylar or
bicondylar and either pure split or depression
þ/ split (Charalambous et al., 2007).
Conservative treatment
The management of a tibial plateau fracture will
depend on many factors including the fracture
pattern, joint displacement or depression, extent
of soft tissue injury, the comorbidities and func-
tional demands of the patient as well as the skills
of the surgeon.
The indications for operative treatment of
tibial plateau fractures are not absolutely
defined. Koval suggested that minimally dis-
placed, stable fractures could be treated conser-
vatively (Koval and Helfet, 1995). In his paper,
Honkonen advised that lateral fractures with an
articular step of 3 mm or over, valgus tilt of over
5 or condylar widening over 5 mm should be
treated operatively. Medial condyle fractures
with any displacement and all bicondylar frac-
tures should be treated operatively (Honkonen,
1994). Low energy fractures of the lateral condyle
with minimal joint displacement and a stable
knee are most amenable to conservative treat-
ment. This involves treatment in a cast brace
for 8–12 weeks with the brace initially locked in
extension and then adjusted to allow a progres-
sive range of motion up to 90 by 4 weeks.
Regular radiographs are required to ensure the
fracture position is maintained. Weight bearing is
generally commenced at between 4 and 6 weeks.
Fenton and Porter
Operative treatment
The options in operative management of plateau
fractures includes internal fixation with percuta-
neous techniques, conventional or locking
plates, external fixation with or without limited
internal fixation and staged management with
external fixation followed by internal fixation.
The choice of treatment will depend upon both
the personality of the fracture and the expertise
of the operating surgeon.
In low energy injuries surgery can usually be
performed once adequate imaging has been
performed and the patient’s condition
allows. In high energy injuries associated vis-
ceral injuries may require attention before the
limb can be definitively treated. These injuries
often have a significant soft tissue component
and limb swelling may prohibit early internal
fixation. In these situations a temporary span-
ning external fixator provides fracture stabil-
ity and allows the soft tissues to recover.
Egol et al. treated 49 high energy fractures
according to their protocol with spanning
external fixation on day one followed by
conversion to internal fixation or circular fixa-
tor when the soft tissues allowed. They
reported a low complication rate although
they acknowledged that significant knee stiff-
ness developed in 4% of their patients (Egol
et al., 2005).
Internal fixation remains the mainstay of
operative treatment of tibial plateau fractures.
The principles of anatomical reduction of the
joint surface should be rigorously applied.
Ebraheim et al. (2004) treated 117 fractures of
all classifications with internal fixation. They
reported good to excellent results in 94, fair in
13 and poor in 10 cases.
Some fractures, particularly Schatzker I (AO
B1) or low energy type IV fractures are amena-
ble to percutaneous lag screw fixation. This
involves indirect reduction of the fracture and
fixation with two cancellous screws across the
fracture. Several studies have reported good
results with this technique (Keogh et al., 1992;
Koval et al., 1992) although it is less suitable for
fractures with significant joint depression or
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183
comminution (Duwelius et al., 1997). In a bio-
mechanical study Parker et al noted that in
Scatzker I fractures the addition of a third
screw or an antglide plate conferred no benefit
(Parker et al., 1999).
There has been a trend toward treating pure
depression fractures (Schatzker III) with a raft
screw construct. This involves elevating the
depressed fragment and supporting it with a
raft of screws beneath the articular surface.
Patil et al. reported that using four 3.5 mm
screws gave a statistically significantly stronger
repair than using two 6.5 m screws (Patil et al.,
2006). The depressed articular fragments can be
elevated via a cortical window distal to the joint
surface, any residual defect may require grafting
(see below).
In Schatzker type I, II and IV fractures with
significant comminution or in osteoporotic bone
a buttress plate can be applied to maintain the
reduction and neutralise axial forces across the
fracture. When a depressed component is pre-
sent a raft construct can be used in conjunction
with plate fixation. In a cadaveric study
Kurankar et al. compared plateau fractures
repaired with L-buttress plate with or without
bone graft, antiglide plate with 4 subchondral
raft screws or periarticular plate with 4 subchon-
dral raft screws. They found constructs using
raft screws were more resistant to depressive
loads (Karunakar et al., 2002).
Bicondylar fractures require reconstruction
of the joint surface followed by reduction of
the metaphyseal component. Reduction can be
aided by the use of femoral distractors. The joint
surface can then be elevated and the joint stabi-
lised with cannulated screws. Fixation can
then be achieved by dual plating or with a
fixed angle plate.
Locking plates are increasingly used in the
treatment of proximal tibial fractures. Implants
such as the Less Invasive Stabilisation
System (LISS) allow a minimally invasive tech-
nique to be employed with less disruption of the
soft tissues. Boldin et al. (2006) reported good
functional outcomes and a low complication
rate in 26 patients with proximal tibia fractures
184
(intra and extra-articular) treated with the
LISS plate.
When treating bicondylar fractures locking
plates allow the fracture to be fixed from the
lateral side only without the need for dual plat-
ing. However, in their study Jiang et al. (2008)
noted a higher incidence of malalignment fol-
lowing fixation with a LISS plate compared to
conventional double plating.
Arthroscopy has been used in conjunction
with the treatment of Schatzker types I, II and
III fractures. It is used to assess soft tissue inju-
ries within the knee and to ensure adequate
reduction of the joint surface. Several case
series have reported good results with the tech-
nique (Scheerlinck et al., 1998; van Glabbeek
et al., 2002). Ohdera et al. (2003) compared
arthroscopically assisted surgery with conven-
tional open surgery in finding patients in the
arthroscopy group regained knee movement
quicker and had improved joint reduction com-
pared with the open surgical group.
The role of arthroscopy is extending to
include more complicated fractures, Chan et al
reported good or excellent results in 16 of 18
patients with Scatzker V or VI fractures treated
with arthroscopically assisted surgery (Chan
et al., 2003).
External fixation can be used as a temporary
fixation before definitive internal fixation or as a
method of definitive fixation. Fixators can be
monolateral, circular or hybrid, in some cases
span the knee joint and can be used in conjunc-
tion with limited internal fixation.
Hybrid and circular fixators can be used
for high energy, complex fractures. Their ben-
efits over internal fixation are preservation
of soft tissues and early commencement of
knee motion. This is weighed against the risk
of pin site infection and septic arthritis. Several
studies have shown good outcomes with hybrid
fixators in Schatzker V and VI fractures
(Stamer et al., 1994; Gaudinez et al.,1996; Ali
et al., 2001). A number of studies have shown
similarly encouraging outcomes in complex
fractures treated with circular fixators
(Dendrinos et al., 1996; Mikulak et al., 1998;
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Trauma 13(3)
Kumar and Whittle, 2000; Chin et al., 2005;
Kataria et al., 2007).
More recently external fixation has been
combined with limited internal fixation to
improve reduction and fixation of the articular
surface, a number of studies have advocated this
approach (Marsh et al., 1995; El Barbary et al.,
2005; Katsenis et al., 2005; Catagni et al., 2007).
In situations where the joint surface is
severely unstable or the fracture or soft tissues
prevent optimal pin placement some authors
recommend spanning the knee joint (Katsenis
et al., 2006; Catagni et al., 2007). In their
study Katsenis et al. (2005) found no significant
difference in outcome between fractures treated
with joint spanning or joint sparing frames.
The Canadian orthopaedic trauma society
performed a randomised controlled trial com-
paring open reduction and internal fixation
with circular external fixation with or without
limited internal fixation. They found that the
outcomes between the two groups at 2 years
were similar however the circular fixator group
had a shorter hospital stay, an earlier return of
function and a reduced number and severity
of post-operative complications (Canadian
Orthopaedic Trauma Society, 2006).
In fractures with a depression of the articular
surface which has been elevated the resulting
defect in the bone often requires bone grafting.
This is usually achieved with autologous cancel-
lous bone. Biomechanical and animal studies
have suggested that the use of calcium phos-
phate cements may have improved ability to
prevent subsidence of the articular surface com-
pared to conventional bone graft (Yetkinler
et al., 2001; Welch et al., 2003; Trenholm
et al., 2005). Several clinical studies have
reported favourable results in treating lateral
tibial plateau fractures with the use of cal-
cium phosphate cements (Lobenhoffer et al.,
2002; Horstmann et al., 2003; Simpson and
Keating, 2004).
Post-operatively the emphasis is on early pas-
sive range of movement exercises to regain
joint motion and nourish articular cartilage.
Weight bearing will depend on the fracture
Fenton and Porter
pattern, method of fixation and surgeon prefer-
ence. It will be guided by serial radiographs.
In certain situations some surgeons advocate
supplementing fixation with a cast brace.
Complications
Complications following tibial plateau fractures
can be secondary to the initial injury or the sub-
sequent treatment.
Knee stiffness can be a significant problem;
factors that contribute to its development
include initial injury, surgery, scarring and
immobilisation. The risk of stiffness developing
is reduced by early fixation with attention to soft
tissue handling and early post-operative mobili-
sation of the joint.
Infection rates are reported between 2%
(Wadell et al., 1981) and 11% (Muller et al.,
1992). Barei et al. (2004) reported an 8.4%
deep infection rate in 83 patients with high
energy bicondylar fractures treated with dual
incision plating. Attention to the timing of sur-
gery, site of incision in relation to soft tissue
injuries, meticulous soft tissue handling and
use of percutaneous techniques where appropri-
ate can reduce the risk of infection.
Secondary osteoarhritis can result from chon-
dral damage at the time of the initial injury,
residual articular discontinuity or disruption
of the mechanical axis post-operatively.
Honkonen (1995) reported a rate of secondary
arthritis of 44% at a mean of 7.6 years post-
injury. The incidence of arthritis was increased
in patients who underwent meniscectomy com-
pared to those with intact or repaired meniscus.
Malunion can result from inadequate ini-
tial treatment or late collapse of fractures.
Nonunion is not common but can follow
Scatzker VI fractures particularly at the
metaphyseal/diaphyseal junction. It is more
common in high energy, comminuted, inade-
quately fixed or infected fractures.
Other complication include venous thrombo-
embolism, with one study showing rates of
deep vein thrombosis of 9% in non-operated
and 6% in operated fractures (Tscherne and
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185
Lobenhoffer, 1993), peroneal nerve injury and
avascular necrosis of articular fragments.
Outcomes
Long term data on outcomes after tibial plateau
fractures is limited. Rademakers et al. (2007)
studied 109 patients with a mean of 14 years
follow up. All patients were treated operatively.
Mean range of movement was 135 , secondary
arthritis developed in 31% with an increased
incidence in those with over 5 of malalignment.
Results were better in monocodylar compared to
bicondylar fractures.
Summary
Tibial plateau fractures though uncommon can
present a significant challenge to the operating
surgeon. Following initial management and
identification of associated injuries judicious
use of appropriate imaging allows the extent of
the injury to be defined. Treatment will be
guided by the fracture personality, patient
comorbidities and operative experience of the
surgeon. Management can vary from conserva-
tive therapy in cast brace for minimally dis-
placed stable fractures to complex joint
reconstruction utilising internal fixation, circular
frames or both. In cases with significant joint
depression bone graft is often required.
Following surgery knee stiffness and secondary
osteoarthritis can be significant problems. To
date long-term data regarding outcomes follow-
ing tibial plateau fractures is limited.
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