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High-Energy Tibial Plateau Fractures Abstract The severity of a tibial plateau fracture and the complexity of its treatment depend on the energy imparted to the limb. Low-energy injuries typically cause unilateral depression-type fractures, whereas high-energy injuries can lead to comminuted fractures with significant osseous, soft-tissue, and neurovascular injury. Evaluation includes appropriate radiographs and careful clinical assessment of the soft-tissue envelope. Treatment is directed at safeguarding tissue vascularity and emphasizes restoration of joint congruity and the mechanical axis of the limb. Temporary joint- spanning external fixation facilitates soft-tissue recovery, whereas minimally invasive techniques and anatomically contoured plates can limit damage to the soft tissues and provide stable fixation. Alternatively, the use of limited internal fixation and definitive external fixation can minimize soft-tissue disruption, avoid complications, and allow fracture union. Complications, including infection, loss of fixation, and malalignment, are best avoided by following these biologically respectful treatment principles. T he character of a tibial plateau fracture depends on the inter- play between the anatomy of the tib- ia, the direction of force, and the en- ergy applied to the limb. As the energy to the limb increases, the complexity of treatment escalates, and the prognosis becomes poorer. 1 High-energy fractures have in- creased comminution and distinct fracture patterns compared with their low-energy fracture counter- parts. High-energy fractures also are frequently associated with signifi- cant soft-tissue injury that demands special consideration and that may affect treatment options. As understanding of the implica- tions of these soft-tissue injuries has improved, and as design of internal fixation devices has advanced, there has been a dramatic change in the treatment principles of high-energy tibial plateau fractures. Anatomic reconstruction of the proximal tibia with rigid fixation is rarely the goal. Instead, indirect reduction tech- niques and other soft tissue–preser- vation methods safeguard vasculari- ty and emphasize restoring both joint congruity and the mechanical axis of the limb. Advances in frac- ture implants, such as the develop- ment of locking plates, allow more stable fixation to be obtained with less surgical dissection. In some cas- es, this method of fixation allows stabilization of bicondylar fractures with a unilateral approach. Addi- tionally, as experience with limited internal fixation and thin-wire exter- nal fixation has increased, results Eric M. Berkson, MD Walter W. Virkus, MD Dr. Berkson is Resident, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL. Dr. Virkus is Assistant Professor, Department of Orthopedic Surgery, Rush University Medical Center, and Senior Attending Surgeon, Cook County Hospital, Chicago. Neither Dr. Berkson nor the department with which he is affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article. Dr. Virkus or the department with which he is affiliated has stock or stock options held in Stryker Corporation. Dr. Virkus or the department with which he is affiliated serves as a consultant to or is an employee of Stryker Corporation. Reprint requests: Dr. Virkus, Rush University Medical Center, 1725 W Harrison Street, Suite 440, Chicago, IL 60612. J Am Acad Orthop Surg 2006;14: 20-31 Copyright 2006 by the American Academy of Orthopaedic Surgeons. 20 Journal of the American Academy of Orthopaedic Surgeons with external fixation have also im- proved. Pathoanatomy Tibial plateau fractures are fractures of the articular portion of the proxi- mal tibia. The lateral plateau is high- er than the medial plateau, forming an angle of 3° of varus with respect to the tibial shaft. The lateral pla- teau is smaller and convex, whereas the medial plateau is larger and con- cave. These characteristics lead to an eccentric load distribution in which the medial plateau bears ap- proximately 60% of the knee’s load. 2 This asymmetric weight bear- ing results in increased medial sub- chondral bone formation and a stronger, denser medial plateau. The relative strength of the medi- al plateau, the valgus anatomic axis of the lower extremity, and the sus- ceptibility of the leg to a medially di- rected force all lead to a prevalence of lateral-side injuries in low-energy fractures. The age of the patient and the resultant strength and quality of bone play an important role. Split or wedge fractures occur in younger pa- tients with stiffer bone, whereas de- pression fractures occur in older bone, which is less able to withstand compression. High-energy proximal tibia inju- ries result in increased comminu- tion and less predictable fracture patterns. These fractures often are associated with medial plateau in- volvement. Isolated medial plateau injuries are not simply analogues of the lateral plateau fractures but typ- ify the higher level of damage associ- ated with more severe mechanisms of injury. Such injuries typically in- volve both lateral collateral and an- terior cruciate ligament injuries and can result in a fracture dislocation of the knee, in which some or all of the medial plateau is fractured and the rest of the plateau is dislocated from the femur. These fractures are more likely to have associated injuries of the popliteal artery and peroneal nerve. 3,4 Involvement of the tibial spines can be found in high-energy frac- tures, with associated functional dis- ruption of the anterior or posterior cruciate ligament. As the energy of the fracture increases, bicondylar tibial plateau fracture or complete dissociation of the proximal tibial metaphysis from the tibial shaft fre- quently occurs. Although multiple systems have been developed to classify proximal tibial fractures, two predominate. The AO/ASIF classification, 5 subse- quently adopted by the Orthopaedic Trauma Association, distinguishes between nonarticular (or extra- articular), partial articular, and com- plete articular fractures, then subdi- vides these classifications based on the amount of comminution. Even though interobserver reliability may be greater within this scheme, 6 clini- cians in North America favor the simpler Schatzker classification. 7,8 In general, Schatzker types I through III are low-energy injuries, whereas types IV through VI involve increas- ingly higher energy injuries (Figure 1). Clinical Evaluation High-energy tibial plateau fractures are associated with an increased likelihood of severe soft-tissue and neurovascular injury. Physical ex- amination begins with the soft- tissue envelope. The presence of significant swelling, abrasions, con- tusions, or blisters should be noted. The anteromedial surface of the proximal tibia is subcutaneous and susceptible to open injury. A careful inspection for open wounds may ex- clude the presence of an open frac- ture, whereas effusion of the knee of- ten can be recognized. When the knee capsule has been torn, howev- er, the hemarthrosis will leak into the surrounding tissue. The neurovascular status of the extremity must be carefully evaluat- ed. Stretch injuries of the peroneal nerve are more likely with medial plateau and high-energy fractures. 7 In cases of obvious leg ischemia, an- giography may be helpful in localiz- ing the injured area, but it should not delay vascular exploration and subsequent revascularization. The incidence of compartment syn- drome is high in tibial plateau frac- tures. 9 In the presence of tense ante- rior and lateral tibial compartments, combined with pain with passive stretch of involved muscles or unre- lenting pain, compartment pressures should be measured and fascioto- mies performed when necessary. Schatzker type V and VI fractures are more likely to have this potential complication. 10 Examination of leg compartments should be repeated at regular intervals because compart- ment syndrome may occur 24 hours or more after injury. 11 Radiography Plain radiographs centered on the knee provide initial information about the fracture. The anteroposte- rior view should be angled 10° in a craniocaudal direction to approxi- mate the posterior slope of the pla- teau. In this way, fracture lines ex- tending into the joint can be evaluated, and the tibial spines can be inspected. The lateral view dem- onstrates the medial plateau, which is concave and larger and lower than the lateral plateau. This view should be scrutinized for coronal plane split fractures, which are commonly found within the medial plateau and are difficult to visualize on the an- teroposterior projection alone. Ob- lique views frequently provide addi- tional information about the fracture pattern. As the energy involved in the fracture and the resultant comminu- tion increases, other imaging modal- ities are required to supplement plain radiographs. Stress views rare- ly add to treatment decisions. How- ever, traction views can permit liga- Eric M. Berkson, MD, and Walter W. Virkus, MD Volume 14, Number 1, January 2006 21 Figure 1 Tibial plateau classifications. A, The AO/ASIF classification divides fractures into nonarticular (A), partial articular (B), and complete articular (C), and subdivides fractures based on amount of comminution. Group A incorporates ligamentous avulsion fractures. Arrow (B2) indicates the force resulting in a depression fracture. B, The Schatzker classification. Types I through III typically are low-energy fractures. Types IV through VI are high-energy fractures. (Panel A adapted with permission from Watson JT, Wiss D: Fractures of the proximal tibia and fibula, in Bucholz R, Heckman J [eds]: Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp 1808. Panel B adapted with permission from Koval K, Helfet D: Tibial plateau fractures. J Am Acad Orthop Surg 1995;3:86-94.) High-Energy Tibial Plateau Fractures 22 Journal of the American Academy of Orthopaedic Surgeons mentotaxis to assist in a partial fracture reduction, preventing over- lap of fragments and elucidating the fracture pattern. Thin-cut computed tomography (CT) scans with sagittal and coronal reconstructions provide additional information about the three- dimensional fracture pattern. Three- dimensional reconstruction may yield further information. Chan et al 12 demonstrated that taking CT scans in addition to plain radio- graphs affected fracture classifica- tion, and thus the surgical plan, in >25% of cases. The degree of articu- lar depression often is underappreci- ated on plain radiographs. 13 When severe comminution is present, CT scans taken after application of a spanning fixator can provide a clear- er picture of the fracture fragments. The suitability of magnetic reso- nance imaging (MRI) for soft-tissue imaging and the large incidence of ligamentous and meniscal injuries in high-energy tibial plateau frac- tures have led many to advocate the routine use of MRI in evaluating these fractures. 14-16 Improved out- comes, however, have not been shown to be directly attributable to the use of MRI. This fact, combined with the incompatibility of MRI with most external fixation devices, makes its role in the evaluation of tibial plateau fractures largely unde- termined. Treatment Goals Historically, AO/ASIF techniques called for an anatomic reconstruc- tion of the proximal tibia with direct reduction and rigid internal fixation. Soft-tissue and osseous vascularity were sometimes sacrificed, however, because emphasis was placed on an anatomic reconstruction and abso- lute stability. With these techniques, soft-tissue complications commonly reached rates of 50%. 8,17 As rates of complications and nonunions increased, new biologi- cally favorable methods of fracture treatment were developed. Tempo- rary external fixation, techniques us- ing indirect fracture reduction, and methods that obviate the need for di- rect exposure of the fracture site avoided some of the complications associated with open reduction and internal fixation (ORIF). These new techniques use plates or external fix- ation to span metaphyseal and dia- physeal fractures and to obtain rela- tively good fracture stability. Reduction is focused on restoring overall length and alignment rather than reducing individual fracture lines. Long-term studies of tibial pla- teau fractures have recognized that knee car tilage can tolerate mild to moderate residual articular displace- ment with a low rate of severe arthrosis. 18-21 In a long-term analysis of 260 tibial condyle fractures, Lan- singer et al 18 found outcomes related better to knee stability than to the quality of articular reduction. De- spite an average of >3 mm of residu- al tibial joint line displacement, Weigel and Marsh 19 demonstrated a low rate of posttraumatic arthrosis at long-term follow-up (mean, 98 months). Some degree of joint de- pression can be tolerated, but joint deformity or a lack of congruity that leads to joint instability may pro- duce suboptimal results. 4,18,22 Thus, in high-energy fractures in which se- vere comminution may prevent an anatomic joint line reconstruction, emphasis should be placed on opti- mizing the overall joint congruity and restoring the sagittal and coro- nal plane alignment. Timing of Surgery Whereas open fractures, acute compartment syndromes, and arteri- al occlusions necessitate immediate surgical intervention, most tibial plateau fractures require a careful evaluation and, often, delayed defin- itive fracture fixation. High-energy tibial plateau fractures frequently have massive swelling and soft- tissue injury, especially in the pretibial soft tissues. In these cases, a knee-spanning external fixator can be used as temporary fixation to bring the tibia out to approximate length, to obtain provisional reduc- tion via ligamentotaxis, and to maintain proper alignment in the coronal and sagittal planes 23 (Figure 2). The stability provided by this fix- ator restores the proximal tibia clos- er to its normal anatomy and allows faster resolution of soft-tissue swell- ing than do splints or other forms of temporary immobilization. Knee- Figure 2 Temporary bridging external fixation. A knee-spanning or bridging external fixator is used for short-term maintenance of alignment and length before open reduction and internal fixation. Eric M. Berkson, MD, and Walter W. Virkus, MD Volume 14, Number 1, January 2006 23 spanning external fixators also pro- vide access for wound care and com- partment monitoring and offer sufficient stability for early patient mobilization. Traction radiographs and CT scans may be obtained, which offer improved planning for the definitive surgery. In addition, the provisional reduction can great- ly simplify definitive surgery, which can be difficult 2 or 3 weeks after in- jury, when the fracture has not been held out to appropriate length. When it is unlikely that the soft tissue will present a favorable envi- ronment within 2 or 3 weeks, then percutaneous fixation techniques to provide an early anatomic reduction should be considered, in combina- tion with an external fixator. Preoperative Planning Preoperative planning is critical in treating severe tibial plateau frac- tures. Planning begins at the initial evaluation with determination of the need for temporary bridging fix- ation. When ORIF is chosen as the definitive treatment, the preopera- tive plan should consider the follow- ing: (1) whether reduction will be open or closed, (2) which indirect reduction methods will be used, (3) which incision will be used, (4) whether a separate incision will be needed for reduction or fixation of the medial condyle, (5) which type of plate will be used, and (6) whether bone graft will be necessary. When external fixation is chosen as defin- itive management, the preoperative plan should include the need for lim- ited open or percutaneous reduction, identifying where incisions will be made, determining which internal fixation will be utilized, and decid- ing which type of frame will be used. Nonsurgical Treatment Although some minimally or non- displaced fractures have been shown to do well with nonsurgical treat- ment, high-energy injuries typically have poor outcomes without surgi- cal intervention. 7,24-26 Currently, nonsurgical treatment for high- energy tibial plateau fractures is rare and reserved for patients whose medical comorbidities prevent inter- vention. In these situations, skeletal traction with range-of-motion exer- cises to prevent stiffness can be used. This is followed by delayed casting or cast bracing. Primary cast- ing of these fractures is rarely, if ever, indicated, other than in certain minimally displaced patterns in pa- tients with risks for surgery. Surgical Treatment External Fixation External fixation plays an impor- tant role in the management of tib- ial plateau fractures. The type of ex- ternal fixation depends on the fracture type and goals of soft-tissue and fracture management. Knee- spanning frames are applied shortly after the injury and typically are in- tended to be in place for a maximum of 2 to 3 weeks, until ORIF can be performed 27 (Figure 2). A standard frame for this purpose consists of two 5-mm half-pins in the distal fe- mur and two in the distal tibia, con- nected with two bars. The pins in the femur are placed anterior or an- terolateral and should avoid the cap- sular reflection of the knee joint. The distal tibial pins should be placed distal to any anticipated ORIF incisions to minimize contamina- tion. Axial traction is applied, and the fixator is locked with the knee in slight flexion, using fluoroscopic as- sistance to assess alignment and length. Fixators used to neutralize the metaphyseal component of tibial plateau fractures typically do not bridge the knee so that knee motion can take place. These fixators are used in place of plates as definitive treatment. Thin-wire ring fixators, such as hybrid Ilizarov fixators, are useful for this application, but monolateral and half-pin fixators also may be used. 19 Excellent results have been noted with hybrid exter- nal fixation, whose mechanical con- struct is similar in strength to that of dual plating. 28 Typically, these fix- ators are placed in association with limited internal fixation in the form of lag screws, Kirschner wires, or small plates (Figure 3). The technique for limited inter- nal fixation by using external fixa- tion begins with the reduction and fixation of the articular surface. This is performed percutaneously or through small incisions, with fluoro- scopic or direct visual evaluation of the reduction. Once obtained, the re- duction is rigidly stabilized, prefera- bly with lag screws. Half-pins or, more commonly, tensioned wires can then be placed into the epi- physeal segment, with care taken to avoid passing through the patellar or hamstring tendons. Olive wires (wires with an oval nut attached) are used to increase the stability of the epiphyseal segment. Wires or pins should be placed at least 14 mm be- low the articular surface to avoid penetration of the joint capsule and thereby minimize the incidence of septic arthritis. 29 An appropriately sized ring is then affixed to the construct and the wires tensioned. An additional half- pin can be placed anterior to posteri- or and fixed to the ring for added sta- bility. Fixation distally in the tibia is usually in the form of two or three 5-mm half-pins attached with a pin clamp (hybrid) or multiple half-pins or wires attached to additional rings (Ilizarov). The shaft and articular segments are then reduced, and the appropriate bars are attached. Fluo- roscopic imaging confirms the cor- rect coronal and sagittal plane align- ment, and clinical inspection is used to verify the proper rotation. Management of an external fix- ator requires diligence from both pa- tient and surgeon in regard to pin or wire site problems, such as drainage. External fixation permits range of motion of the knee and ankle and High-Energy Tibial Plateau Fractures 24 Journal of the American Academy of Orthopaedic Surgeons prevents stiffness. Increased pin or wire site inflammation, however, can be seen with excessive motion. Daily pin care is critical, but pins or wires still may occasionally drain, particularly the proximal posterior wires. External fixators typically re- main in place for 2 to 4 months, de- pending on the rate of fracture heal- ing, which is judged on radiographs, by the ability to bear weight, and oc- casionally by stress fluoroscopic ex- aminations. Weight bearing begins once callus is visible on radiographs. Dynamization of the frame assists in maturing callus. Open Reduction and Internal Fixation Incisions Before extensive incisions are made, the soft-tissue envelope must have recovered. The skin should be soft, blisters should be epithelial- ized, and skin wrinkles should be present. The surgical approach is a primary concern that has implica- tions on the mode of fixation and the care of the soft tissues. A midline an- terior approach uses the same inci- sion as a traditional total knee ar- throplasty, facilitating later salvage arthroplasty. It permits simulta- neous exposure to both plateaus but involves extensive soft-tissue dissec- tion, which can result in consider- Figure 3 Hybrid external fixation. Anteroposterior (A) and lateral (B) radiographs, and a coronal CT scan (C), of a 22-year-old man who presented with a high-energy proximal tibia fracture and an ipsilateral tibia shaft fracture associated with a compartment syndrome. Postoperative anteroposterior (D) and lateral (E) radiographs. After fasciotomy and temporary external fixation, a hybrid-type fixator was applied. A single lag screw was used in combination with thin olive wires proximally to provide joint-line stabilization and to minimize further soft-tissue damage. F, Anteroposterior radiograph 6 months postoperatively demonstrating good tibial alignment despite imperfect lateral joint-line reduction. Eric M. Berkson, MD, and Walter W. Virkus, MD Volume 14, Number 1, January 2006 25 able devascularization of fracture fragments, thus delaying fracture healing and increasing the potential for infection and nonunion. When a midline incision is chosen, it is im- perative that only one side of the proximal tibia be exposed. This can be accomplished with a lateral or medial anterior parapatellar ap- proach, depending on the condyle in- volved. Concern for the vascularity of the proximal tibia has led to a trend to- ward more direct surgical approach- es. Lateral or anterolateral incisions, with separate limited medial or pos- teromedial incisions, as necessary, provide excellent exposure for the reduction and fixation of most com- plex tibial plateau fractures. Because the lateral surface of the tibia has better soft tissue for coverage, the lateral approach often is preferable. A laterally based approach is espe- cially useful in the application of “minimally invasive” plates that can be applied submuscularly through this incision, with screws placed percutaneously into the tibi- al shaft. In the lateral approach, a straight or hockey stick incision is made an- terolaterally from just proximal to the joint line to just lateral to the tibial tubercle. The incision is ex- tended down through the iliotibial band proximally and the fascia of the anterior compartment distally. The tibialis anterior muscle is elevated supraperiosteally off the proximal tibia to the level of the capsule. The coronary ligament is incised, allow- ing proximal retraction of the later- al meniscus with a holding suture when direct joint visualization is necessary. Flexing the knee and ex- erting a gentle varus stress to the leg opens the lateral compartment of the knee, allowing visualization of the plateau. Plating Options Whereas conventional plating techniques called for both medial and lateral plates through a midline incision, dual plating through two separate incisions allows protection of soft tissues and minimizes devas- cularization of the fracture frag- ments and, as a result, decreases in- fection rates. 9,30 In this method, a laterally based plate is inserted via a lateral incision. An anatomically contoured 4.5-mm plate is recom- mended. A second medial incision is placed approximately 1 cm from the posterior border of the tibia. A plate is applied through an interval creat- ed between the medial head of the gastrocnemius and the pes anserinus tendons. This plate is applied as a buttress or antiglide plate and is most effectively positioned at the lower portion of the condyle, where typically a spike keys into the me- taphysis (Figure 4). Advances in implant design have important implications in obtaining stable fixation and limiting the soft- tissue disruption of the proximal tib- ia. Locking screw-plate implants are anatomically contoured plates with screws that lock into the plate at a fixed angle. 31 These plates have nu- merous advantages. Because their stability does not depend on friction generated between the plate and the bone, they cause less compression of the periosteum and soft tissue. Addi- tionally, by functioning as modular fixed-angle devices, they provide sta- bility to the plateau adjacent to the plate as well as to the plateau oppo- site the plate. The fixed-angle con- struct allows the medial condyle to be buttressed from the lateral side and may provide enough stability to forego a separate medial plate in bi- condylar fractures (Figure 5). In fact, no statistically significant difference was found between the biomechan- ical stiffness of a single laterally based fixed-angle plate and a dual plate in a bicondylar fracture mod- el. 32,33 However, when locking screws are used, there is no freedom to place the screws in the optimal location based on fracture pattern; the screw direction is determined by the direc- tion of the threads in the plate. Be- cause of this, a lateral locking plate will not always provide adequate stabilization of bicondylar fractures. When the medial condyle is small, comminuted, or osteoporotic, or when the condyle has a coronal split, it is usually prudent to place an ad- ditional plate supporting the medial condyle. Locking plate techniques call for placement of the implant through a lateral incision. Because locked screws do not generate a lag force across articular fracture lines, percu- taneous or open techniques with screw or Kirschner wire fixation typ- ically provide supplemental fixation at the joint line. The plate provides support to the joint line and allows healing ofthe metaphysisand diaph- ysis. An option for some implants is to use nonlocking screws in the locking plate when a lag effect is de- sired. Locking plates can be inserted submuscularly through a limited in- cision with percutaneously placed locking screws to minimize soft- tissue injury. These plates function equally well when applied through a carefully planned open approach. Longer plates with fewer widely spaced screws provide mechanical advantage compared with shorter plates. Indications for locking plates are not fully developed. The cost-benefit ratio should be weighed in each case because locking plates are approxi- mately double the cost of standard plates, and locking screws are four to six times the cost of standard screws. Early results of locking plates show decreased infection rates and the successful utilization of a single plate for most bicondylar fractures. 34-36 Even so, an additional strategically placed, medially based plate may be necessary when insuf- ficient fixation of the medial frag- ments exists or in patients with poor bone quality. High-Energy Tibial Plateau Fractures 26 Journal of the American Academy of Orthopaedic Surgeons Treatment Recommendations Open Fractures Open fractures require appropri- ate antibiotics and emergent irriga- tion and débridement to minimize the chance of infection. Incisions used to extend open wounds for dé- bridement should anticipate future incisions likely to be used for defin- itive fixation. After thorough débridement, acute joint reconstruction can be performed in minimally contami- nated wounds with lag screws and Kirschner wires. In clean wounds, it may be acceptable to obtain defini- tive fixation with a buttress plate or a thin-wire or pin external fixator. More commonly—and in all cases of severely contaminated wounds—a joint-spanning external fixator can be applied with delayed reconstruc- tion after subsequent débridements. Antibiotic beads are beneficial in pa- tients with severe bone loss or as a temporizing measure before delayed closure or flap placement. Type IV Fractures Isolated medial condyle fractures can represent a fracture dislocation of the knee. Neurovascular injury must be evaluated and treated. In these cases, the medial plateau often Figure 4 Dual plating through medial and lateral incisions. Preoperative anteroposterior (A) and lateral (B) radiographs and three- dimensional CT reconstruction (C) of a bicondylar tibial plateau fracture, demonstrating the obliquity of the medial plateau, in a 26-year-old man following a motor vehicle accident. Postoperative anteroposterior (D) and oblique-lateral (E) radiographs. A fixed-angle construct was applied laterally, while the posteromedial fragment was reduced with an antiglide plate through a small posteromedial incision. The plate was contoured to the condyle and positioned over a metaphyseal spike to maintain anatomic reduction. Eric M. Berkson, MD, and Walter W. Virkus, MD Volume 14, Number 1, January 2006 27 Figure 5 Single locking plate for a bicondylar fracture. Preoperative anteroposterior (A) and lateral (B) radiographs of a 22-year-old man who presented with a bicondylar high-energy tibial plateau fracture. C, Preoperative coronal reconstruction CT scan. D, Intraoperative fluoroscopy demonstrating reduction of the articular surface and placement of a lag screw. Postoperative anteroposterior (E) and lateral (F) radiographs. A locking lateral plate has been applied to the proximal tibia, restoring the mechanical axis and articular congruity in the immediate postoperative radiographs. No additional medial plate was required because fixation into the large medial fragment was excellent. Alternatively, the plate may be placed more proximal, with one or two lag screws inserted through the plate. Anteroposterior (G) and lateral (H) radiographs taken 1 year postoperatively. The fracture is healed and the reduction maintained. High-Energy Tibial Plateau Fractures 28 Journal of the American Academy of Orthopaedic Surgeons represents the intact stable frag- ment. The entire lower leg acts as a long lever arm; any fixation placed medially is subject to higher stress- es. This can be complicated by the complete disruption of the lateral ligaments as well as anterior and posterior cruciate ligament injuries. Fixation can be achieved with a medially based plate or with applica- tion of an external fixator. Lag screws alone should not be used in cases associated with ligament inju- ry because the long lever arm of the leg can lead to failure. In most cases, a 4.5-mm plate is preferred. Anatom- ic reduction by closed methods can be exceedingly difficult because of the obliquity of the fracture line and the propensity of the displaced medi- al condyle to shorten and rotate in the sagittal plane. The repair of associated soft- tissue injuries is determined on an individual basis. Meniscal injuries should be repaired whenever possi- ble. Osseous avulsion of cruciate lig- aments can be directly repaired with suture or screws. Further ligament reconstructions are best delayed un- til bone healing has occurred and knee range of motion has returned. Type V and VI Fractures Schatzker type V and VI tibial pla- teau fractures often are treated sim- ilarly to type IV fractures. These fractures usually have significant soft-tissue injuries; therefore, defin- itive treatment with an external fix- ator may be appropriate. Limited ar- ticular reconstruction, followed by neutralization with an external fix- ator, can provide excellent re- sults. 19,28,37 This technique is partic- ularly useful in cases with severe soft-tissue injuries, open fractures, and long segments of comminution into the diaphysis of the tibia. Alter- natively, ORIF with dual or locking plates can be performed when soft- tissue swelling has resolved after use of a joint-spanning external fixator. Joint-line comminution, including the tibial spines, can make deter- mining the proper height of the frac- tured condyles difficult, even in type V fractures, in which a small portion of the epiphysis is still attached to the metaphysis. Articular reconstruction can be achieved by reducing the tibial condyles to the metaphysis, or by first fixing the condyles to each other and then reducing the entire articu- lar segment to the shaft. When reducing the condyles to the meta- physis individually, the less commi- nuted condyle (usually the medial) is reduced and provisionally fixed. Un- less the condyle is minimally dis- placed, this is done open using the distal spike of the medial condyle as a key to the reduction. This reduc- tion is complicated by rotation of the medial condyle, which can be diffi- cult to assess on lateral fluoroscopy. The fracture line through the medial condyle is typically not in the direct sagittal plane, making it difficult to apply a clamp to produce the proper vector to reduce this fragment. The distal portion of the lateral plateau fragment likewise can act as the key to defining lateral joint height by reducing the lateral cortex to the appropriate position on the lateral metaphysis. Anterior-to-pos- terior screws may be necessary to stabilize coronal fractures of the tib- ial plateau or to stabilize the tibial tubercle. Fixation then proceeds with dual or locking plates, as de- scribed above. Care must be taken to avoid overcompressing the condyles and narrowing the proximal tibia. Rehabilitation Early mobilization and range-of- motion exercises are key to the suc- cessful treatment of proximal tibia fractures. When the internal fixation is stable, the motion can begin as early as postoperative day one. At no time, however, is motion performed at the expense of loss of fracture re- duction. For this reason, mobiliza- tion in a hinged rehabilitation brace is often prefer red. Although efforts to reduce stiff- ness are instituted early, full weight- bearing is delayed until approxi- mately 12 weeks after surgery. Care must be taken during this time to prevent an equinus contracture of the foot. The use of passive motion machines is controversial. Results and Complications Results of high-energy tibial plateau fractures are difficult to evaluate giv- en the wide range and severity of in- jury and the advancement of man- agement techniques over the years. Recent long-term studies of high- energy fractures, however, indicate that satisfactory knee function can be obtained with severe injuries. Weigel and Marsh 19 reported on 31 fractures (30 patients) treated with a monolateral external fixator and limited internal fixation of the artic- ular surface. At a minimum 5-year follow-up, range of motion averaged 3° to 120°, the average Iowa Knee Score was 90, and only 21% of knees had evidence of grade 2 or 3 arthrit- ic changes. More recently, Stannard et al 38 reported on 39 high-energy fractures (37 patients) treated with a percutaneous locking plate and a minimally invasive approach. At early follow-up, no patient required additional surgical intervention, and only two patients demonstrated any malalignment. As mentioned, complications are more likely to result from high- energy tibial plateau fractures than from their low-energy counterparts. Soft-tissue compromise and devas- cularization from the injury itself predisposes these fractures to infec- tion. Large open surgical approaches for internal fixation add to this risk, with historic rates of infection reaching 80%. 17,39 Heightened atten- tion to the soft-tissue envelope and newer, minimally invasive tech- niques offer the possibility of mini- mizing these risks, but infection rates in high-energy fractures still Eric M. Berkson, MD, and Walter W. Virkus, MD Volume 14, Number 1, January 2006 29