The Tibial Plateau Fractures: Diagnosis and Treatment

Fracture of the tibial plateau is seen frequently in orthopedic trauma units and pose major threats to the structure and function of the knee joint. Tibial plateau fractures are complex injuries to treat due to their articular involvement and associated disruption of ligamentous structures in the knee. For many years several discussion has been done about the best treatment of tibial plateau fractures . A lot of orthopeadic surgeons and researchers have analyzed functional and radiologic results for nonoperative and surgical, treatments [1, 2]. Nevertheless the surgical treatment is mandatory in the tibial platueau fracture associated with an acute compartment syndrome or an acute vascular lesion and in open tibial plateau fracture.

The tibial plateau fractures classification is very important for the clinical prognosis and to plan time and needs for surgery; however, the features of this type of lesion are various, and many classification systems were developed to describe variables that contribute to lesion pattern. It is also important the evaluation of soft tissues that are often involved (compartimental syndrome, exposition), associated knee injuries (meniscal or ligamentous), and general health condition in poly-traumatized patients. The AO/OTA fracture classification system is used by The Orthopaedic Trauma Association as for other fractures. Many surgeons prefer the classification described by Schatzker et al. because it is simpler and more familiar. Despite that there is limited inter and intraobserver reliability for Schatzker and AO classifications; future classification systems or revisions of the previous ones will have to consider axial imaging to describe in a better way the fracture patterns.

Tibial plateau fractures are common injuries and the most difficult of the intra-articular fractures to manage. These fractures are usually related to high energy trauma or osteoporosis in older adults. The fractures normally occur in the 1% in older adults whereas in the elderly at 8%. In case of improper restoration of the plateau surface and the axis of the leg, these fractures could lead to development of premature osteoarthritis, injury in ligaments, as well lifelong pain and disability. The imaging is of paramount importance for assessment of the initial injury, planning management, prediction of prognosis and in the follow-up. Traditionally, the radiological examination was performed with x-rays. Presently, the computer tomography, affiliated with magnetic resonance imaging indicate more accurately the categories of fractures thus facilitating a better surgical plan.

A force over tibial plateau with axial loading and valgus or varus vector can be responsible of tibial plateau fracture. The principles of management include joint congruity, joint stability, and axial alignment and the “personality” of the fracture. It is crucial to recognize, assess and monitor soft tissue swelling. In the present era, the indications for conservative management in form of traction or cast bracing are very few. Anatomical reduction is best achieved with operative modalities, either with closed or open techniques. However, non-operative modalities do hold their importance in certain situations like incomplete or undisplaced fractures, stable injuries, those with osteoporosis, and in patients who are not fit for surgery due to their medical comorbidities. Secondary articular cartilage injuries can be managed depending upon lesion size and activity demands, with simultaneous correction of malalignment and ligament instability wherever needed.

Arthroscopic-assisted fluoroscopic treatment of tibial plateau fractures has gained popularity in the last decade and is now indicated as one of the treatments of choice in Schatzker types 1, 2 and 3 fractures; it ensures optimal reduction and a stable fixation with plate or cannulated screws may be performed after reduction. In selected type 4 fractures arthroscopy may allow an evaluation of articular fracture reduction, thereby obviating the need for extensive arthrotomy. This chapter aims to review the technical points that are useful to the successful video-assisted management of tibial plateau fractures.

The target of tibial plateau fracture management is to obtain an anatomical reduction and an early knee mobilization. Balloon tibioplasty is a new minimally invasive technique adapted for reduction of depressed tibial plateau fracture and it represents a surgical method to restore the cartilage surface. The advantages of balloon tibioplasty are: minimally invasive technique and creation of symmetric space inside the proximal tibia bone that reduces stresses on the fracture. The bone gap above the tibia plateau is filled with ceramic bone cement through a small cortex bone window. It is a technique that requires a correct learning curve, but it may be a useful tool that makes the reduction of selected depressed tibial plateau fractures easier.

Surgical fixation of tibial plateau fractures is technically challenging, carrying significant risks of complications for both patient and surgeon. A detailed understanding of the knee joint, coupled with classification of tibial plateau fractures, allows for accurate pre-operative planning and appropriate patient selection, resulting in the best possible outcome for patients. Open reduction and internal fixation of such fractures is done with the aim of restoring alignment, native articular surface of the knee, preventing early onset osteoarthritis. This chapter will explore the various surgical approaches described when approaching the tibial plateau, outlining the merits and drawbacks of each when undertaking open reduction and internal fixation of tibial plateau fractures.

The plateau tibial fracture is a challenging pathology where associated lesions can complicate by far the fracture treatment. External fixation could be a valuable option, both in the emergency stabilization and in the definitive synthesis, especially when general or local patient's conditions demand for a tissue sparing approach. This chapter is divided in two, the first part talks about the indications and the technical rules of the bridging external fixators and the clinical applications of Damage Control Orthopedics (DCO) to tibial plateau fractures. The second part is focused on those complex (because of the soft tissue envelope conditions or the fracture pattern) lesions that could take advantage of a definitive treatment based on the external fixation, more frequently circular. Technical and mechanical characteristics, indications, surgical application, pros and cons of the circular frames are described.

Tibial plateau fractures are associated with a broad spectrum of injuries. Associated soft tissue injuries in tibial plateau fractures can be divided as soft tissue envelope lesions, neurovascular injuries and intra-articular lesions. Careful preoperative soft tissue envelope management is important in avoiding additional injury. The neurovascular status of the extremity must be evaluated, although concomitant injuries of neurovascular structures are rare. Lesions of the ligaments and/or the menisci has been reported in several studies and may contribute, if not properly treated, to the substandard outcomes associated with this type of fractures. Traditionally, meniscal tears are reported in 20-50% cases of all the tibial plateau fractures, while ligaments lesions are reported in 10-30%. Even if the examination of knee stability and of the conditions of menisci and ligaments is not so easy, is recommended to perform a careful evaluation of the patient in order to determine associated ligamentous damage. The imaging studies routinely performed for tibial plateau fractures are plain anteroposterior and lateral radiographs and threedimensional CT, while MRI has not yet become a standard tool. The final outcome of surgical treatment may be influenced by associated lesions of the menisci or of the knee ligaments. There is a wide uniformity of behaviours in treating meniscal tears: central tears in white zone must be resected, while peripheral lesions in red zone and meniscocapsular disjunction must be repaired. Ligamentous injuries associated with bony avulsion should be acutely treated during fracture fixation; in the absence of bony avulsion, functional and residual laxity should be addressed at a later date.

Total Knee Arthroplasties (TKAs) in tibial plateau fractures can be performed in the acute or chronic settings. Treatment of tibial plateau fractures with Open reduction and Internal Fixation (ORIF) in elderly patients can lead to poor results because of poor bone quality, fracture complexity and higher risk of complications. For these reasons primary TKA in the acute setting can be an option in elderly patients. Most of the authors agree in confirming that this is a safe treatment with good clinical outcomes, but inferior compared to whom obtained in elective TKAs, with a higher risk of complications, similar to those reported in revision TKAs. On the other hand ORIF is the gold standard treatment in tibial plateau fractures in younger patients, but the incidence of post-traumatic arthritis is high, with the need of TKA conversion. There are few reports on literature on TKAs performed after tibial plateau fractures, but there is agreement in affirming that clinical outcomes and implant survival in those cases are lower than in TKA performed for primary arthritis. In this chapter we will analyze the indication for primary TKR in tibial plateau fractures, both in acute and chronic setting, with a literature review on the clinical outcomes.

Tibial plateau fractures are common and severe joint lesions which usually require surgical fixation. They may cause severe postoperative pain and require long hospitalization to provide effective analgesia and to start an appropriate rehabilitation. Specific programs of post-operative rehabilitation are necessary for acceptable recover. Nowadays, well established specific rehabilitation protocols do not exist and treatment is often experience-based. This chapter focuses on physical therapy and on the rehabilitation techniques after tibial plateau fractures; also, it evaluates the effectiveness of the most common techniques.