Assessment
Tibial plateau fractures are articular injuries in which the soft-tissue envelope is often as important as the fracture pattern.
Assess:
- mechanism and energy
- skin, swelling, blisters and open wounds
- neurovascular status
- common fibular nerve function
- compartment syndrome
- associated ligamentous injury
Imaging
Obtain orthogonal radiographs. CT is central to modern operative planning because it defines:
- articular depression and split fragments
- posterior-column involvement
- comminution
- metaphyseal-diaphyseal relationship
MRI may identify meniscal and ligament injuries, but it is not required routinely when it will not alter acute management.
Plain radiographs define gross pattern, but CT is central for:
- depression
- split fragments
- posterior-column involvement
- surgical planning
MRI may help define meniscal or ligament injury in selected cases but is not routinely required for every fracture.
Classification
Schatzker classification remains useful for communication. A column-based CT concept is particularly helpful for identifying posterior fragments that may not be adequately treated through a standard anterolateral approach.
Treatment goals
- restore a functional articular surface
- restore coronal and sagittal alignment
- restore length and rotation
- provide sufficient stability for early knee motion
- protect soft tissues
Perfect radiographic reduction should not be pursued at the cost of a devastated soft-tissue envelope.
Staged treatment
A swollen high-energy bicondylar injury may require:
- spanning external fixation to restore length and alignment
- CT after temporary reduction
- delayed definitive fixation when the soft tissues are suitable
The CT should be obtained after temporary restoration of length and alignment so definitive fixation can be planned from the reduced fracture anatomy.
Fixation strategy
The articular component may need direct or indirect reduction with lag-screw fixation. The metaphyseal component may then be stabilised with:
- lateral locked plate
- dual plating through separate safe approaches
- circular external fixation in selected injuries
Complications
compartment syndrome
infection and wound breakdown
stiffness
malalignment
post-traumatic osteoarthritis
fixation failure
nonunion, particularly where metaphyseal biology is poor
infection
compartment syndrome
stiffness
malalignment
post-traumatic OA
fixation failure
peroneal nerve injury
Injury assessment
Tibial plateau fractures range from low-energy split injuries to high-energy bicondylar fractures with major soft-tissue damage.
Assess:
- skin swelling and blisters
- open wounds
- compartment syndrome
- neurovascular status
- ligament injury
- peroneal nerve function
The soft-tissue condition may determine timing more than the radiograph.
Goals
Treatment aims to restore:
- joint congruity where clinically important
- coronal and sagittal alignment
- condylar width
- stable fixation
- early knee motion
- soft-tissue viability
Perfect articular reduction with damaged soft tissue is not a success.
Non-operative treatment
Selected minimally displaced stable fractures may be treated with bracing and protected weight bearing, with close radiographic review.
Operative strategy
Options include:
- percutaneous elevation and screws
- lateral plate
- medial/posteromedial fixation
- dual plating
- staged external fixation
- ring fixation in selected cases
High-energy swollen knees may benefit from temporary spanning fixation until soft tissues recover.
Depression defects
Elevated subchondral fragments may require support with:
- bone graft
- bone substitute
- rafting screws
The construct should prevent secondary collapse.
Meniscus
Meniscal entrapment or tear is common and should be assessed when the joint is exposed. Meniscal preservation/repair can contribute to joint function.
FRCS synthesis
The operative plan should be based on fracture columns and soft tissue, not classification name alone.