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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 treatme

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

The 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.

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.2This 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 vmedi-algus 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.9In 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-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.)

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

al12 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 cartilage can tolerate mild to moderate residual articular displace-ment with a low rate of severe arthrosis.18-21In a long-term analysis

of 260 tibial condyle fractures, Lan-singer et al18found outcomes related better to knee stability than to the quality of articular reduction De-spite an average of >3 mm of

residu-al tibiresidu-al joint line displacement, Weigel and Marsh19demonstrated 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.4,18,22Thus,

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 planes23(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

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 performed27 (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.19Excellent 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 exterinter-nal fixa-tion begins with the reducfixa-tion 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 fposteri-or 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

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

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 mcreat-edial 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.31These 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 of the metaphysis and 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.34-36Even 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

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

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

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.19,28,37This 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 rotareduc-tion 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 tibtib-ial 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 rehabilitamobiliza-tion brace

is often preferred

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 Marsh19reported 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 al38 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%.17,39Heightened 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