Tibial Plateau Fracture
Classification systems
- AO/OTA grouping for the proximal tibia
Mechanism
Axial loading combined with a varus or valgus force drives the femoral condyle into the plateau. A pedestrian struck by a vehicle bumper classically produces a lateral plateau depression; a fall from height produces bicondylar comminution. Low-energy valgus injury in osteoporotic bone gives a depressed lateral plateau with little comminution.
Age considerations
- Paediatric
- The proximal tibial physis is involved instead; be alert to the vascular relationship of the popliteal artery at this level and to the risk of growth disturbance and progressive valgus.
- Young adult
- High-energy patterns with soft tissue compromise, compartment syndrome risk and associated meniscal and cruciate injury. Staged management with a temporary spanning frame followed by definitive fixation once the soft tissues recover is standard.
- Elderly
- Depressed low-energy patterns in poor bone; restoring the joint line with subchondral support and void filling, or in selected patients accepting a degree of depression and treating symptomatically, are both defensible. Primary arthroplasty is occasionally considered in a severely arthritic knee.
Management options
Temporary knee-spanning external fixationshowhide
Indication
High-energy fractures with severe swelling, blistering or an open wound, and any fracture with metaphyseal-diaphyseal dissociation presenting acutely.
Implant design notes
Femoral and tibial pins connected by bars, spanning the knee to restore length and protect the soft tissues; pins are sited outside the eventual definitive incisions and away from the joint capsule.
Approach
Percutaneous pin insertion in the femoral shaft and the tibial diaphysis distal to the fracture.
Steps overview
- Assess and document compartments and distal neurovascular status; repeat serially
- Place femoral and tibial pins clear of the planned definitive incisions
- Restore length and coronal and sagittal alignment by traction and lock the frame
- Obtain cross-sectional imaging after the frame is applied for definitive planning
- Allow the soft tissues to settle, watching for the wrinkle sign
- Convert to definitive fixation when the envelope permits, usually within one to three weeks
Notes
The frame buys soft tissue recovery and lets you plan approaches from a reduced-length film. It does not treat the articular injury.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Open reduction and internal fixation with buttress platingshowhide
Indication
Displaced articular fractures with joint depression or widening exceeding acceptable limits, and all fractures producing knee instability.
Implant design notes
Anatomical periarticular buttress plate, often locking, applied to the involved column; raft screws placed just beneath the subchondral bone support the elevated articular surface. A bicondylar injury commonly needs a second posteromedial plate rather than a single lateral locking plate, because the medial column collapses otherwise. Voids are filled with bone graft or substitute to prevent redepression.
Approach
Approach chosen by column: anterolateral for the lateral column, posteromedial for the medial and posterior column, and a combination for bicondylar patterns with an adequate skin bridge. Avoid a single midline extensile incision.
Steps overview
- Plan approaches from cross-sectional imaging using the column concept; confirm soft tissues are ready
- Position supine with a radiolucent triangle, tourniquet available
- Through a submeniscal arthrotomy, visualise the articular surface directly
- Elevate depressed segments from below, using the intact condyle and the femur as templates
- Support the surface with subchondral raft screws and fill the metaphyseal void
- Apply the buttress plate to the involved column, then address the second column with a separate plate if needed
- Repair the meniscus and capsule, and assess ligamentous stability once fixed
- Confirm alignment and articular reduction radiographically; start early motion with delayed weight bearing
Notes
Maintain an adequate skin bridge between dual incisions. Redepression from an unfilled subchondral void is a preventable failure.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- Compartment syndrome is the emergency to mention first, particularly in the metaphyseal-diaphyseal dissociation pattern.
- Assess the soft tissue envelope before you plan any incision — staged treatment exists because of skin, not bone.
- Use the column concept from cross-sectional imaging to choose approaches; the posteromedial fragment is the one a single lateral plate cannot hold.
- Fill the metaphyseal void after elevating a depressed segment, or it will redepress.
- Restoring the mechanical axis matters as much as the articular surface for long-term outcome.
- Examine and document the peroneal nerve and popliteal vessels, and consider vascular imaging in a knee dislocation-equivalent pattern.
Sources for further reading
- Rockwood and Green's Fractures in Adults — tibial plateau
- Standard operative orthopaedics textbook — fractures of the proximal tibia
- AO principles of fracture management — articular fractures and buttress plating
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Resident-authored study summary in original wording, not reproduced from copyrighted source text.