Tibial Plateau Fractures

Mechanism of injury:
Varus or valgus force combined with
axial loading as in:
1. Car striking a pedestrian (bumper
fracture).
2. FFH with varus or valgus bending.

The tibial condyle split by the opposing

femoral condyle.
FRACTURE CLASSIFICATION
(SCHATZKER)
Type I (Pure cleavage) :
A typical wedge-shaped uncomminuted fragment
is split off the lateral condyle and displaced
laterally and downward. This fracture is
common in younger patients without
osteoporotic bone.
Type II (cleavage combined with
depression) :
A lateral wedge is split off, but in addition the
articular surface is depressed down into the
metaphysis. This tends to occur in older people.
 Type III (pure central depression):
The articular surface is driven into the
plateau, the lateral cortex is intact.
These tend to occur in
osteoporotic bone.
Type IV (fractures of medial
condyle):
These may be split off as a single wedge
or may be comminuted and depressed.
The tibial spines often are involved.
 Type V (bicondylar fractures):
Both tibial plateaus are split off. The
distinguishing feature is that the metaphysis
and diaphyses retain
continuity.
Type VI (plateau fracture with
dissociation of metaphysis and
diaphyses):
A transverse or oblique fracture of the
proximal tibia is present in addition to a
fracture of one or both tibial condyles and
articular surfaces.
 Clinical Features

Swelling, deformity, extensive bruising and

doughy feeling of the joint due to
hemarthroses.

Neurovascular examination is a must

(traction N. injury) TYPE IV may cause
neuropraxia of common peroneal nerve.

Examination under anesthesia may reveal

medial or lateral collateral ligament injuries.
Plain X-ray: AP, lateral, oblique
views.

CT-scan with reconstructions:

visualize the exact comminution and
articular depression.
 Treatment
Type I:
Non displaced: aspirate the
hemarthroses then plaster
immobilization, partial wt bearing
after 3weeks, plaster removal after
4weeks, full wt bearing after 8weeks.
Displaced: can be fixed with two
transverse cancellous screws.
 Type II:
1. If the depression is less than 5mm or
if instability cannot be demonstrated
on stress, treatment is conservative.
2. If the depression is severe or if
instability can be demonstrated on
stress, the articular fragments should
be elevated and bone-grafted, and
the lateral cortex is supported with a
buttress plate.
 Type III:
The same as type II.
Type IV:

These fractures tend to angulate into

varus and should be treated by open
reduction and fixation with a medial
buttress plate and cancellous screws.
Type V:
Both condyles can be fixed with buttress
plates and cancellous screws. It is best
to avoid stabilizing condyles with large
bulky implants.
Type VI:
Should be treated with buttress plates
and cancellous screws, one on either
side if both condyles are fractured.
More recently, pin and wire fixators
also have been advocated for fixation
of these difficult fractures (illizarof).
 Complications:
Early: compartment syndrome,
neurovascular injuries, fracture
blisters.
Late: stiffness, deformity,
osteoarthrits.
 Fracture Tibia and Fibula
Subcutaneous position, commonly
fractured and commonly sustain
compound fracture.
Mechanism of injury:
1. Twisting force (spiral fracture of

both at different level), usually low

force injury and the bone may penetrate
the skin from within.
2. Angulatory direct force
(transverse or short oblique
fracture of both at the same level),
high energy lesion and crushes the
skin over the bone.
 Clinical Features
Pain, swelling, bruises, crushing the
skin, open fracture, circulatory
changes, check always for
impending compartment syndrome.

Plain X-ray: site, type, comminution,

displacement, angulations, rotation,
state of nearby joints, old or new,
pathological or not..
 Managements
Depend on certain factors:
State of the soft tissue.

Severity of bony injury( spiral or

transverse, comminuted).
Stability of the fracture( oblique,
butterfly, comminuted) are unstable.
 Conservative treatments:
For low energy fractures, minimally displaced,
gustillow type I.
Reduction if needed (MUA);

immobilization in a full POP cast from

midthigh to metatarsal necks.

If skin in doubt open a window for daily

observation.

Elevation and observation for72 hours, after 2

weeks check x-ray, then partial wt. bearing till
union(8-16weeks).
 Operative treatments:
Unstable high energy fractures, low
energy fractures cannot be hold
satisfactorily by conservative way.
1. Closed locked intramedullary
nailing: the standard method for
most fractures.
2. Plate and screw: metaphyseal
fractures (grate risk of exposure,
periosteal striping, infection..).
3. External fixation: compound
fractures, comminuted fractures,
infected fractures, non union with
bone gaps (bone transport).
 Complications
Early:
1. Vascular injury: rare, occur with
proximal fractures.
2. Compartment syndrome:
happen especially if (young patient,
severe injury, delay treatment, shock,
excessive manipulation with long
operation).
3. Infection: open fractures, after
plate and screw fixation.
4. Malunion.
5. Delay union and non union:
common( poor soft tissue,
comminuted, segmental, compound,
infected).
6. Ankle and foot stiffness.