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Techniques in Knee Surgery 6(1):17–28, 2007
Ó 2007 Lippincott Williams & Wilkins, Philadelphia
S P E C I A L F O C U S
j
j
Diagnosis and Surgical Treatment of Schatzker
Type IV Variant Biplanar Medial Tibial
Plateau Fractures in Alpine Skiers
Mark L. Purnell, MD, Andrew I. Larson, BSME, Kent A. Schnetzler, MD, MS,
N. Lindsay Harris, MD, and Tomas Pevny, MD
Aspen Foundation for Sports Medicine, Education and Research
Orthopaedic Associates of Aspen & Glenwood
Aspen, Colorado, U.S.A.
| ABSTRACT
Fractures of the tibial plateau frequently are associated
with significant intraarticular injuries that generally
require surgical treatment. The commonly used
Schatzker classification of tibial plateau fractures first
described in 1979 includes 6 types of fractures, I to VI. In
the original description of this system, Type IV fractures
involved the medial tibial plateau and were described as
either (1) split-wedge types or (2) depressed and
comminuted, and the prognosis for these fractures was
reported to be poor. Frequently attributed to a highenergy injury, these fractures are commonly felt to be
caused by a varus force. In our experience, some Type IV
fractures found in injured alpine skiers neither fit this
pattern of injury, are not adequately described by this
system, nor is the surgical treatment well defined. These
fractures can pose surgical treatment difficulties, especially if the complex, biplanar, or rotational nature of this
variant is not recognized and adequately reduced and
stabilized. This Schatzker Type IV variant found in
alpine skiers is described with emphasis on recognition,
diagnosis, and optimal surgical treatment of this serious
complex intraarticular fracture.
Keywords: Schatzker Type IV, bicondylar, posterior
approach to the knee, medial tibial plateau fracture,
skiing
F
ractures of the tibial plateau or tibial condyles can
represent serious intraarticular injuries and constitute approximately 1% of all fractures.1 The spectrum of
injury extends from less severe fractures of an isolated
plateau that may be treated nonsurgically with excellent
results to devastating involvement of the entire plateau
(and often the proximal tibial shaft) requiring extensive
Address correspondence and reprint requests to Mark L. Purnell, MD,
Orthopaedic Associates of Aspen & Glenwood, 100 E. Main St,
Aspen, CO 81611. E-mail: [email protected].
surgery. These severe injuries may result in premature
arthritis, ligamentous injury, and lifelong pain and
disability.2,3 In 1979, Schatzker et al4 described 6 tibial
plateau fracture types. These types of tibial plateau
fractures have markedly different incidences, although
reported data are lacking. Hohl1 noted that about 55% to
70% of tibial plateau fractures involve the lateral
plateau, about 10% to 23% involved the medial plateau,
and about 10% to 30% involved both tibial condyles
(bicondylar). Other authors have reported higher percentages for lateral fractures with medial and tibial
bicondylar fractures having correspondingly lower
percentages. This low frequency of occurrence can lead
to inexperience in recognizing and treating patterns such
as the Type IV medial plateau fractures.
Type IV fractures are uncommon and are typically
classified as high-energy fractures involving the medial
tibial plateau.5 Classically described and usually illustrated as a split fracture of the medial plateau in the
sagittal plane, the fracture has sometimes been called
the medial counterpart to the Schatzker Type II fracture,
especially as the partial plateau fracture form. Berkson
and Virkus6 however noted that medial plateau fractures
were not the analogues of lateral fractures. Total plateau
varieties are also described.
Certain variations of plateau fractures may present
especially difficult surgical treatment options. Unrecognized variations of previously described patterns that do
not fit into commonly used classification systems may
lead to suboptimal surgical treatment. We describe a
variant of a medial tibial plateau fracture (Schatzker
Type IV) found in skiers and discuss the optimal surgical
treatment.
| ANATOMY
The tibial plateau represents the entire proximal end of
the tibia and is composed of medial and lateral weightbearing articular surfaces. The 2 articular surfaces are
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Purnell et al
asymmetric both in size and concavity (as well as
relative density and strength). The medial plateau is
larger and stronger than the lateral plateau and is
concave in both planes. The medial plateau carries
about 60% of the knee’s load and consequently has
increased subchondral bone and a stronger, denser
plateau when compared with the lateral.6 The smaller
and weaker lateral plateau is convex in the coronal and
sagittal planes. As a result of this relative weakness
combined with the natural valgus carry-angle of the
lower extremity (the leg is often protected from varus
forces by the contralateral leg), fractures of the lateral
plateau are more common.
Two additional dense bony prominences serve as
attachment sites for tendonous structures and are located
in close proximity of the tibial plateau: (1) the tibial
tubercle located anteriorly and serving as the attachment
of the patella tendon and (2) Gerdy tubercle located
laterally and serving as the attachment of the iliotibial
band. These structures usually remain intact in most
fractures of the tibial plateau. On the medial side, the
semimembranosis attaches to a ridge at the posteromedial corner of the medial plateau just below the joint
line. The pes anserinus attaches more anteriorly and
distally, closer to the level of the tibial tubercle. These
tendons should be identified and protected when
approaching the tibial plateau from the medial side.
There are no ligamentous attachments to the lateral
tibial plateau, whereas the medial plateau has a broad
area of insertion for both the deep and superficial
medial collateral ligament posing difficulties for plate
placement on the proximal medial tibia. The posterior
aspect of the tibial plateau serves as the insertion site for
both the posterior cruciate ligament and the posterior
oblique ligament.
The entire plateau is set back from the longitudinal
axis of the tibial shaft, leaving the posterior aspect of
both the medial and lateral plateau cantilevered behind
the posterior tibial cortex. When placing a posterior
plate, this setback must be accommodated by appropriate contouring.
The shape of the proximal tibia just distal to the
tibial plateau is triangular, affecting the placement and
type of any fixation device that might be used for
stabilization. The orientation of the posterior and lateral
walls is in their described direction, providing broad
surfaces for plates and screws in the posterior to anterior
and the lateral to medial directions. The medial wall,
however, is at a more oblique angle and is oriented
posteriorly as well as medially. Any plate placed on the
broad medial surface of the proximal tibia will therefore
be oriented in a posterior as well as a medial direction.
This leaves only the narrow junction of this triangle as
the most medial surface and only a small surface area
18
for direct medial plate placement for support in the
medial to lateral direction.
| MECHANISM OF INJURY
Historically, motor vehicle or motorcycle crashes,
pedestrian versus motor vehicle collisions, and falls
have been the most common causes of tibial plateau
fractures. Originally termed a Bcar bumper^ fracture,
where the knee was struck from the lateral side by an
automobile bumper, injuries of the lateral tibial plateau
result from the natural valgus carry-angle of the lower
extremity combined with a force directed.
With varus and compressive injuring forces applied
to the knee, medial tibial plateau fractures may be
produced. Such injuries are less common, partly because
of the valgus carry-angle of the leg, greater strength of
the medial plateau, and some protection afforded by the
contralateral leg. However, such medial injuries tend to
require more energy to produce and, as a result, are
more likely to have associated severe soft tissue
injuries, including injury to the cruciate ligaments,
peroneal nerve, popliteal vessels, and the lateral collateral ligament.6,7 Posteromedial instability can cause the
femoral condyle to dislocate posteromedially when the
knee is flexed and the injury has been called a fracture
dislocation.8
| CLASSIFICATION SYSTEMS
Two common systems for classification of tibial plateau
fractures, the Schatzker and the Arbeitsgemeinschaft fu¨r
Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF), are used to describe plateau
fractures, with the Schatzker system probably the most
accepted and widely used in the clinical setting.4,9
Neither system, however, explicitly describes the variant fracture pattern we describe, although the AO/ASIF
system would likely include it in one of its subdivisions
(41-B). Other older classification systems include the
Hohl and Luck, the Moore, and a later combination of
the Hohl and Moore system. These systems are
infrequently used today. Other systems have been
proposed, some quite elaborate and inclusive, but are
not commonly used in clinical practice.
The Schatzker classification (Fig. 1) of tibial plateau
fractures combines features of the previous systems and
divides injuries into 6 types:
1. Type I or split fractures of the lateral plateau
2. Type II or split depression fractures of the lateral
plateau
3. Type III or central depression fractures of the lateral
plateau
4. Type IV or medial plateau fractures
5. Type V or bicondylar plateau fractures
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FIGURE 1. Original Schatzker Classification System. Reprinted with permission from Schatzker J, McBroom R, Bruce D.
The tibial plateau fracture. The Toronto experience 1968Y1975. Clin Orthop Relat Res. 1979;138:94Y104.
6. Type VI or any plateau fracture in association with a
proximal tibial shaft fracture (metaphyseal-diaphyseal
separation)
Implicit in the Schatzker system is an ever-increasing amount of energy involved to produce the injury
corresponding to the higher types. Types I, II, and III
are considered lower-energy, whereas Types IV, V, and
VI are higher-energy fracture patterns, with correspondingly increasing incidence of injury to neurovascular
and ligamentous structures about the knee. It is
important to remember that all types may be associated
with compartment syndrome.
The AO/ASIF system, later adopted by the Orthopaedic Trauma Association, is part of a unified
approach to classify fractures. Within the AO/ASIF
system, Type IV fractures correspond to B1.2, B1.3,
B2.3, B3.2, and B3.3 subgroups.10 Most useful in
research situations where the fracture can be very
specifically described, classified, and catalogued, its
use in the clinical setting is less practical.
Khan et al11 proposed a new comprehensive classification scheme that included posterior and anterior
coronal split fractures, recognizing the significance of
these atypical injury patterns not fully accounted for in
the Schatzker system (Fig. 2). Posteromedial coronal
split fractures were attributed to a combination of varus
force and axial load on a hyperflexed knee.
| HISTORICAL REVIEW
Few articles concern internal fixation of Type IV
fractures, perhaps because of their rarity. Schatzker’s
original article illustrated fixation with a medial plate.
Yang et al12 used plain radiographs and computerized
tomography (CT) to categorize Type IV fractures in 51
patients into 3 types: (1) split, (2) total condylar, and
(3) depression. In both depression and total condylar
injuries, buttress plate fixation was placed medially. In
the split injury, the plate was placed posteromedial.
De Boeck and Opdecam13 reported on posteromedial
tibial plateau fractures and recommended a posterior
approach with partial division of the medial gastrocnemius tendon to obtain exposure. Several articles have
described approaches to the posteromedial tibial plateau,
usually for surgical treatment of Schatzker V bicondylar
fractures.14Y16 Some studies have noted that the division
of the tendon of the medial gastrocnemius is not required
for exposure.15Y17
Bhattacharyya et al18 reported on an uncommon
posterior shearing tibial plateau fracture treated through
FIGURE 2. Posterior shearing tibial plateau fracture similar
to skier Type IV variant reported by Bhattacharyya et al.18
Reprinted with permission from Bhattacharyya T, McCarty
LP 3rd, Harris MB, et al. The posterior shearing tibial
plateau fracture: treatment and results via a posterior
approach. J Orthop Trauma. 2005;19:305Y310.
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19
Purnell et al
FIGURE 3. Partial description of a classification system by Khan et al.11 Reprinted with permission from Khan RM, Khan
SH, Ahmad AJ, et al. Tibial plateau fractures. A new classification scheme. Clin Orthop Relat Res. 2000;375:231Y242.
a posterior approach in 13 patients, similar to the skier
Type IV variant (Fig. 3). Such fractures defied classification as Schatzker Type IV, V, or VI fractures and
did not fit fully into the system of Khan et al.11 The
authors noted the importance of coronal plane fractures
visible only on lateral radiographs or CT. Such fracture
planes, if not properly addressed and stabilized, may
lead to inadequate reduction and the use of inappropriate or inadequate stabilization techniques. The article
illustrated the need to recognize and address coronal
plane fractures that coexist with more typical sagittal
plane fractures in the variant Type IV fracture we
describe.
Hybrid fixation, with small-wire fixation, for complex
tibial plateau fractures offer satisfactory fixation stability,
but all studies show pin tract complications.19Y21 More
recently, Egol et al22 and Stannard et al23 reported on the
benefits of a locked lateral plate (less invasive stabilization system, Synthes USA, Paoli, Pa) for the management
of unstable complex tibial plateau fractures (Orthopaedic
Trauma Association class 41C, Schatzker Type IV, V,
and VI). They both reported excellent stabilization of
medial fragments with this technique with low complication rates.
| INDICATIONS AND PREOPERATIVE
PLANNING
In an excellent review article, BArticular Fractures: Does
an Anatomic Reduction Really Change the Result?^
Marsh et al24 examined the factors that affect long-term
outcome of periarticular fractures, including tibial plateau
fractures. Age of the patient, extent of articular cartilage
injury, step off of the articular surface, meniscal
pathology and menisectomy, malalignment, and instability all play a role in long-term functional results. Of these
factors, only the latter are affected by the decision-
20
making process of the orthopedic surgeon. The degree of
acceptable articular step off remains unresolved. Brown
et al25 using pressure-sensitive film in a human tibial
plateau model demonstrated a 75% increase in local peak
pressures with a 3-mm step off. Clinical follow-up
studies, however, have shown little differences in
outcome until step off exceeds 10 mm.26Y28 Instability
and malalignment on the other hand play an especially
important role in long-term outcome with any residual
varus being very poorly tolerated.2,3,27,29 Because Type
IV fractures by definition involve the medial tibial
plateau and any displacement or instability will lead to
a varus deformity, most of these fractures will require
reduction and stable fixation.
Soft tissue injury also plays a significant role in
preoperative evaluation. Abdel-Hamid et al30 used
arthroscopy to evaluate soft tissue injuries in tibial
plateau fracturesVfrequency of soft tissue injury was
71% (70/98 fractures). Although no association was
noted between fracture type and presence of meniscal,
cruciate ligament, collateral ligament, or neurovascular
injury, significantly higher rates for anterior cruciate
ligament injury were noted for Schatzker Type IV and
VI injuries. Gardner et al31 used magnetic resonance
imaging (MRI) to evaluate soft tissue injury in 103
patients. The overall incidence of injury to soft tissue
was higher than previously reported, and only 1 patient
had no soft tissue injury. Stevens et al32 noted peroneal
nerve palsies and avulsions, multiligamentous injuries,
and popliteal artery contusion in 8 Type IV fractures.
Clearly, strict attention to neurovascular status and
careful assessment of soft tissue injury are required,
and because compartment syndromes can be associated
with all Schatzker types, the tibial compartments should
be carefully evaluated and monitored throughout the
patient’s hospitalization.
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Special Focus: Type IV-Variant Tibial Plateau Fractures in Skiers
Plain radiographs in the anteroposterior (AP) and
lateral views are routine but often are inadequate to
understand the extent of displacement and nature of
these fractures.18,33 Radiographs of the normal side are
often helpful for preoperative planning and are very
useful as a template for intraoperative comparison (ie,
the cover of a puzzle box).
Computerized tomography or MRI is also highly
recommended. In a study comparing the AO/ASIF to
Schatzker system, Walton et al34 found that the addition
of CT to plain radiography increased both intraobserver
and interobserver agreement of treatment plan.35 Magnetic resonance imaging also increased the interobserver
agreement on fracture classification and operative
management of tibial plateau fractures.36 Plain radiographs of the injured knee form the basis for evaluation,
with MRI providing valuable information about soft
tissue injury and axial CT scanning (with reconstructions) clearly demonstrating multiplanar fracture lines
not apparent on plain radiographs. Computerized tomography or MRI should be routine, particularly for
those fractures that are poorly seen on plain films and
those fractures that are infrequently seen by the
orthopedic surgeon. We prefer MRI because of its
ability to evaluate soft tissue and subchondral injury as
well as the fracture pattern.
| SKIER TYPE IV PATTERN
After obtaining institutional approval, we retrospectively performed a chart review of all tibia and tibial plateau
fractures seen by an orthopedist that occurred from
FIGURE 4. Patient 1. Fracture initiation on the posterolateral articular surface of the proximal tibia.
FIGURE 5. Patient 1. Comminution and inferior displacement on the posterolateral tibial plateau.
skiing injuries at our institution (a level III hospital
treating injuries from 4 major Colorado ski mountains)
from November 2002 to April 2006. Overall, 641
patients sustained a tibia fracture (excluding the distal
tibial pilon or plafond), 190 sustained a tibial plateau
fracture, and 18 patients were classified with a
Schatzker Type IV injury. Of those with Type IV
fractures, 14 were the skier Type IV or biplanar variant
fracture currently discussed. Eight of these were men
(average age 43 T 9 years), and 6 were women (average
age 43 T 15 years). Ten patients had an intact medial
tibial plateau fragment, and 4 had an additional split of
the medial plateau in the horizontal plane.
All Type IV skier fractures occurred from relatively
lower-energy noncontact trauma with the patient usually
reporting a twisting-type fall while skiing. Three of 14
had a tear of the lateral meniscus; there were no other
soft tissue or ligamentous injuries. No Type IV fracture
patients had an associated neurovascular injury nor did
any of the patients develop a compartment syndrome.
All fractures were evaluated either by MRI or CT in
addition to plain radiographs. Magnetic resonance
imaging allowed evaluation of subchondral bony contusion on both the femur and tibia, and for some, CT
allowed reconstructed, 3-dimensional evaluations of
these complex fractures. All fractures demonstrated a
very similar biplanar pattern: the fracture initiates
proximally on the posterior articular surface of the
lateral tibial plateau just lateral to the tibial eminences
(Fig. 4). On MRI or CT imaging, the articular surface of
the posterolateral tibial plateau typically shows comminution and varying degrees of inferior displacement
(Fig. 5). Most of the articular damage is therefore on the
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Purnell et al
lateral and not the medial tibial plateau. Propagating
from the posterior aspect of the lateral tibial plateau, the
fracture line extents anteriorly in the sagittal plane.
From here, the fracture line extends inferiorly and
medially in the sagittal plane through the tibial
eminence (often with comminution involving the anterior cruciate ligament tibial insertion; Fig. 6). The
fracture then rotates 90 degrees as it extends distally to
exit posteriorly and medially in the coronal plane
(Fig. 7) on the tibial shaft.
With the pull of the semimembranosis and the
posterior capsule still intact, displacement of the medial
plateau is usually posterior and medial. The distal tibia
shaft fragment, deprived of medial support, usually
settles into a varus position. These displacements can be
very subtle and poorly seen on plain AP radiographs
(Fig. 8). Thus, MRI or CT is essential to understand the
Bpersonality^ of these fractures and to determine
fracture pattern and degree of displacement.
The main medial tibial plateau fragment demonstrated 1 of 2 patterns. In most of the cases, 10 of 14
patients, the medial plateau fragment was 1 piece
(Fig. 9). In 4 patients, the medial plateau fragment had
another fracture in the coronal plane, splitting the
medial plateau (Fig. 10). Whether the medial plateau
was 1 fragment or split in 2 in the coronal plane, the
pattern of articular injury of the posterolateral plateau
and the changing plane from sagittal and lateral to
coronal and posteromedial were always present.
Magnetic resonance imaging also allowed for
evaluation of femoral bony contusions which were
noted anteriorly and laterally on the lateral femoral
condyle in 10 of 14 cases. Assuming these contusions
represent the area of maximal and initial stress on the
femoral condyle and occurred by contact with the
corresponding area of comminution on the posterolateral tibial plateau, then these injuries likely occurred
with the knee in more extension than flexion. The initial
articular injury laterally may also indicate that valgus
may be a more likely force than varus. The pattern of
changing fracture planes as the fracture propagates
distally implies a rotational component of stress in
addition to axial load.
We had 3 nondisplaced fractures with the
previous findings (Fig. 11). Notable in these fractures
was the presence of nondisplaced tibial spine avulsion
fracture. This pattern of femoral and tibial contusions
and the comminution of the tibial spine demonstrate a
very similar MRI pattern to what is seen in both tibial
spine avulsions and anterior cruciate ligament (ACL)
FIGURE 6. Patient 1. Fracture line extends inferiorly and
medially through the tibial eminence.
FIGURE 8. (A) Patient 1, (B) Patient 2. The personality of
the fracture can be hardly seen on plain AP radiographs.
22
FIGURE 7. Patient 1. Rotation of the fracture 90 degrees
as it exits posteromedial in the coronal plane.
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Special Focus: Type IV-Variant Tibial Plateau Fractures in Skiers
4. reduction of any articular injury at the posterior
articular surface of the lateral tibial plateau, if
necessary; and
5. internal fixation of the fracture in first in the coronal
plane, followed by fixation in the sagittal plane.
Typically, the surgical approach and patient position
are dependent on both fracture location and displacement.
Minimally or mildly displaced fractures may be
approached with the patient positioned supine and with
the knee flexed over a support. Fractures with more
articular comminution of the lateral plateau, a split medial
fragment, and with significant displacement of the medial
fragment are better managed through a posterior approach,
with the patient in a prone position.13,17,18,37
Anterior Approach
FIGURE 9. Patient 2. Type IV variant with the medial
plateau in 1 piece.
ruptures. These fractures may therefore represent a
similar mechanism of injury to an ACL rupture or spine
avulsion with the addition of a higher axial load and a
rotational fracture pattern extending medially, in other
words, an ACL injury gone bad.
| SURGICAL TECHNIQUE
This consistent fracture pattern and personality facilitates a systematic approach to open reduction and
internal fixation of these Type IV variant fractures:
1. Reduction and fixation of any coronal split component of the medial tibial plateau;
2. reduction of varus displacement of distal tibia shaft
fracture fragment;
3. reduction of flexion deformity of the medial plateau;
The lower extremity is prepared and draped free and is
usually supported with a fracture triangle. Restoration of
length is first addressed by either manual traction or via
use of a femoral distracter. Fluoroscopic evaluation is
crucial at this point to assess residual flexion deformity of
the medial plateau fragment. If no residual flexion is
noted, then stabilization in the coronal plane can be
obtained by simple interfragmentary fixation between the
medial tibial shaft and the medial tibial plateau. This can
be performed from either an anterior to posterior or
posterior to anterior direction. However, if persistent
flexion is noted, then a posterior medial incision is made
to reduce and stabilize the distal spike of the medial
fragment. An incision is first made along the posteromedial aspect of the proximal tibia at the level of the
fracture. Deep dissection is performed bluntly to preserve
the neurovascular structures. The tendons of the pes
anserinus are identified and retracted proximally or
distally, depending on need for access. The medial head
of the gastrocnemius is lifted posteriorly to identify the
FIGURE 10. (A and B) Patient 3. Type IV medial split variant.
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Purnell et al
purchase, and therefore screws are usually place from
lateral to medial. If more substantial fixation, such as a
locked plate, is needed, a standard lateral approach is
made through of slightly curving or hockey stick anterolateral incision. The incision is carried deep with sharp
dissection incising the fascia and capsule between the
iliotibial band and the patellar tendon. The iliotibial band
is reflected off of the Gerdy tubercle, leaving its
connection to the tibial facial intact. The anterior
compartment musculature is dissected from the anterolateral tibia exposing the tibia for fixation. A locked plate
in this location is ideal for unstable Type IV fractures,
once reduction is obtained. Before fixation, the joint can
be entered if necessary through this incision, and
posterior comminution can be addressed through the
anterolateral bone window, reducing the fragments with
either a tamp or small elevator (Fig. 12).
Posterior Approach
FIGURE 11. Patient 3. Nondisplaced Type IV fracture.
medial fragment spike. The spike is then reduced and fixed
either with interfragmentary screws or with plate and
screw fixation. Typically, fractures that exist more
medially than posteriorly are amenable to reduction and
fixation from this approach. For those fracture that exit
more posteriorly or are significantly displaced, then a
posterior medial approach as described by De Boeck and
Opdecam13 or Burks and Schaffer37 should be used, with
the patient in the prone position. Once fracture stabilization in the distal coronal plain is obtained, comminution
posterolateally and fixation in the sagittal plane can be
addressed. Only rarely is posterolateral comminution
displaced to the degree that open reduction fixation is
required. Access to the posterior aspect of the tibial
plateau through an anterior lateral approach is quite
difficult because visualization is extremely limited.
Arthroscopy can give excellent fracture visualization at
this point, and reduction can be attempted through a bone
window created anteriorly on the lateral tibial shaft distal
to Gerdy tubercle. If significant posterolateral articular
displacement is present, then a posterolateral approach,
as advocated by Carlson,17 will be more appropriate.
At this point, the fracture can be stabilized in the
sagittal plane. The medial plateau is reduced and secured
to the stable lateral plateau. In minimally or nondisplaced
fractures with good-quality bone, a simple percutaneous
screw fixation may be adequate. Screws may be placed
from either medial to lateral or lateral to medial,
depending on bone quality. Typically, the lateral plateau
has good lateral cortical bone for screw head or plate
fixation, but very poor subchondral bone for screw thread
purchase. The medial plateau, on the other hand, will
usually have good subchondral bone for screw thread
24
If the medial plateau is significantly displaced, if the
articular surface of the medial plateau has a split
component in the coronal plane, or if the posterior
articular surfaces are significantly displaced, a posterior
approach is more appropriate.13,17,18
The patient is placed prone on the operating table,
and bony prominences are appropriately padded. The leg
is then prepared and draped free. The knee is held in
slight flexion with a trauma bump placed under the
ankle.18 An S-shaped or L-shaped (Fig. 13) incision is
then made, centering the horizontal limb at the joint line
on the posterior aspect of the knee.13,17 The medial arm
of the incision is made just posterior to the medial edge
of the tibia. Sharp dissection is carried deep and the posterior fascia is incised, exposing the gastrocnemius. The
gastrocnemius is then elevated posteriorly and laterally,
FIGURE 12. Patient 4. Open reduction internal fixation
AP screws medially and locked plate laterally.
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FIGURE 13. Description of L-shaped incision described by Burks and Schaffer.37 Reprinted with permission from Burks
RT, Schaffer JJ. A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res.
1990;254:216Y219.
exposing the posterior tibia. The neurovascular structures
are safely protected deep to the gastrocnemius muscle,
but overzealous retraction should be avoided to prevent
traction injury to the tibial nerve. If more exposure is
needed, the medial gastrocnemius tendon can be released
near its insertion, leaving a small cuff for later repair. The
soleus and popliteus muscles are then elevated from the
medial edge of the tibia by sharp dissection, exposing the
fracture site. The joint can then be entered posteriorly
while carefully protecting the capsular and ligament
insertions. If a coronal split is present, dissection is
carried anteriorly and medially while retracting the pes
anserinus tendons and the medical ligament. A split
fragment can then be reduced using direct visualization
and fluoroscopy and fixed with interfragmentary screws.
The entire medial fragment can then be reduced to the
tibia shaft using flexion of the knee to bring the distal
tibial shaft to the medial plateau. Lateral plateau
depression can be addressed through this incision, but if
it is severe, it is probably best addressed through a
posterolateral approach, as advocated by Carlson17 and
Bhattacharyya et al.18 We currently have no experience
with this exposure. Once the medial and posterior
fragments are reduced, the medial fragment should be
fixed with a contoured buttress plate.18 This addresses
stability in the coronal plane. The proximal sagittal
plane of the fracture can now be addressed, fixing the
medial to the lateral plateau. Interfragmentary screw
fixation is usually sufficient. With a single medial
fragment, a percutaneous screw is placed from the
lateral tibial cortex into the medial tibial plateau (Fig.
14). If a split of the medial plateau is present, screw
should be placed from medial to lateral. If more secure
fixation is required, the patient must be turned to the
supine position and a locked plate placed laterally
through an anterolateral incision. Bone grafting is rarely
necessary in these fracture types but can be performed
in the usual fashion from the posterior approach.
With the fracture reduced and fixed, the wound is
closed. The soleus and popliteus are reduced, overlaying
the plate and tacked in place. The medial gastrocnemius
tendon is repaired with heavy suture. The subcutaneous tissues and skin are closed, leaving the fascia
open. All patients were given perioperative antibiotics.
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25
Purnell et al
FIGURE 14. Patient 2. Open reduction internal fixation
from the posteromedial approach. Posteromedial buttress
plate. The screws are inserted laterally to medially.
Postoperative management followed standard protocols
for intraarticular lower-extremity fractures. All patients
were started on immediate passive range-of-motion
exercises via a continuous passive motion machine and
started on a physical therapy program while hospitalized. All patients were treated with pharmaceutical and
mechanical deep venous thrombosis prophylaxis. The
fractures were protected with either nonYweight bearing
or touch down weight bearing, depending on the degree
of comminution and security of fixation until fracture
healing. Additionally, the knees were protected with
postoperative bracing, allowing full range of motion as
tolerated. There were no infections and no postoperative
complications, although because of the transient nature
of our patient population, the long-term outcome of
these patients is not known.
| DISCUSSION
Although no complications or associated soft tissue
injuries occurred in our small series, the injuries we
describe typically resulted from lower-energy ski trauma than reported for other studies of Type IV tibial
plateau fractures. Bhattacharyya et al18 reported on a
similar type of fracture (12/147 surgically treated
injuries or 8%), which they described as a posteriorshearing tibial plateau fracture. Most of those patients
represented high-velocity, high-energy trauma: 5 injuries were from motor vehicle collisions, 3 from
motorcycle collisions, and 5 from falls. One patient
presented with a compartment syndrome. They reported
only 2 complicationsV1 wound dehiscence managed
26
with local wound care and 1 flexion contracture
managed with dynamic splinting. All fractures healed,
and there were no losses of reduction or failures of
fixation. One patient underwent hardware removal for a
prominent posteromedial plate. Eight of 9 responding
patients stated that they were highly satisfied with their
resultsV1 patient was dissatisfied. The functional
outcome score and patient-related satisfaction seemed
to be related to the quality of articular reduction; the 1
dissatisfied patient had a poor anatomical reduction,
although 2 patients rated as Bhighly satisfied^ also had
poor reductions. The other highly satisfied patients had
either anatomical or near-perfect reductions.
Carlson17 also reported on a similar-sounding
fracture which he termed the posterior bicondylar tibia
plateau fracture. He reported on 8 patients with 6- to 24month follow-up: 3 injuries resulted from a motorcycle
crash or automobile collision, and the remaining 5 from
either jumps or falls from height. Seven of 8 patients
had complications or associated pathology; 1 patient
died because of a medical comorbidity. All patients
returned to near-full activities but reported aching with
prolonged standing. Range of motion averaged 2 to 120
degrees of flexion and only 3 of 5 patients returned to
their preinjury manual labor jobs.
Chang et al38 reported on a series of 107 tibial
plateau fractures to evaluate the incidence of compartment syndromes. The overall incidence of compartment
syndromes in all types was 10.3%, but the incidence in
Schatzker Type IV, V, and VI was up to 30.4%. Stevens
et al32 prospectively studied 47 patients with tibial
plateau fractures, 8 of whom had Type IV fractures. All
8 of these Type IV fractures resulted from high-energy
trauma (motor vehicle accident, fall or pedestrian), 4 of
8 had significant neurovascular injuries (peroneal nerve
and popliteal artery), and 2 had associated ligamentous
injury to the ACL, medial collateral ligament, and
lateral collateral ligament. Long-term functional analysis for all fracture patterns with the 36-item Short-Form
Health Survery and Western Ontario and McMaster
Osteoarthritis Index scores showed no significant difference between matched healthy controls or between
fracture types, unless the patient was older than 40
years. Patients older than 40 years at the time of injury
had similar Western Ontario and McMaster Osteoarthritis Index scores to matched controls only in 57% of the
patients. They concluded that open reduction and
internal fixation is a satisfactory technique for managing
tibial plateau fractures, particularly in younger patients.
| CONCLUSION
Schatzker Type IV fractures of the medial tibial plateau
are rare and potentially difficult fractures to understand
and treat. We have presented a description of a variant of
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Special Focus: Type IV-Variant Tibial Plateau Fractures in Skiers
these fractures seen in skiing injuries. These patients
usually describe a low-energy, twisting injury to the leg
and present a fracture pattern consistent with rotational
and axial stresses. These fractures initiate proximally on
the posterior articular surface of the lateral tibial plateau
and propagate anteriorly and medially in the sagittal
plane. As the fractures extend distally, they rotate to the
coronal plane and exit posteriorly on the tibial shaft. Left
unsupported, the distal tibia settles into a varus position,
and the plateau can fall into flexion. This displacement
is poorly tolerated and should be reduced and stabilized.
By understanding this pattern, the surgeon can plan
appropriate steps for reduction and fixation.
15. Bendayan J, Noblin JD, Freeland AE. Posteromedial
second incision to reduce and stabilize a displaced
posterior fragment that can occur in Schatzker type V
bicondylar tibial plateau fractures. Orthopedics. 1996;19:
903Y904.
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