- See:
-
Bicondylar Fractures and Type V Fractures:
-
Type IV Fractures:
-
Total Depression Fracture:
- Discussion:
- frx of medial tibial plateau (see
total depression frx):
- carries
worst prognosis of all tibial plateau fractures;
- 2 subsets of injury:
-
low energy frx in elderly pt w/ osteoporotic bone;
- medial tibial plateau crumbles into irreconstructible mass of fragments;
-
high velocity injury in young patient;
- in addition to medial plateau frx, there may be an associatted:
-
intercondylar eminence frx & adjacent bone w/ attached cruciates;
- lateral ligament rupture & rupture of
peroneal nerve from traction;
- see:
ligamentous instability or even
knee dislocation;
- Radiographs:
- simple wedge frx;
- intercondylar eminence frx;
- if knee is unstable (greater > 5 deg instability), stress x-rays are made to determine whether the instability is secondary to movement at frx site
or to
ligament injury;
- when instability is due to a fracture movement, a cast brace is used to stabilize the leg;
- Indications for Treatment:
- medial condyle frxs although displaced or depressed only a few mm, need ORIF to prevent frx migrantion;
- this is esp true w/
intact fibula;
- Non Op Treatment:
- observe degree of restoration of tibial condyles w/ traction
- if reduced, then 4-6 weeks of traction w/ ROM exercises as frx pain subsides;
- traction is contra-indicated w/ > 10 deg of varus or valgus instability thru arc of motion;
- varus knee is common problem;
- these frxs may lose position gradually w/ Non Op Rx & return to the displacement that was present during the traumatic incident;
- this occurs more often w/ oblique frx that extend from region of intercondylar notch to medial or lateral tibial cortex;
- may occur more often w/
intact fibula;
-
x-ray should be obtained riodically during 1st few wks to assure that
reduction is maintained;
- Operative Treatment:
-
PreOp Planning
-
Surgical Approach: Medial Compartment:
-
percutaneous screws:
- usually fixation w/ screws in not sufficient w/ this injury;
- loss of position w/ medial plateau frx is common:
- varus malunion resulting from
loss of position of medial plateau fracture promotes early osteoarthritis;
-
butress plate:
- operative fixation requires butress plate, as do frxs of
lateral plateau;
- this also applies to assoc posterior split wedge frx of medial plateau;
- anterior butrress plate is applied to anteromedial face of the proximal tibial metaphysis deep to
pes anserinus and the anterior
fibers of the superficial
MCL;
- posterior butress plate is applied to the posteromedial edge of tibia;
- beaware of difficulty of laging the posteromedial fragment from posterior to anterior;
- in some cases, a second postero-medial incision is required;
- if the intercondylar eminence is avulsed (w/ attached ACL), it should be reanchored to the tibia w/ screw fixation;
- Post Operative Care and Compications:
- minimally displaced fractures of
lateral plateau are stable & require little external support during healing;
- medial plateau frxs, whether stable or unstable, have tendency to displace, esp w/ intact fibula;
- varus deformity gradually develops after non operative treatment;
- varus malunion from resulting from
loss of position of medial plateau frx promotes early development of traumatic arthritis;
- these frxs may lose position gradually during non op treatment & return to displacement that was present during traumatic incident;
- this is especially likely to occur in oblique frx that extend from region of intercondylar notch to medial or lateral tibial cortex;
-
radiographs should be obtained periodically during first few wks after injury to assure that reduction is being maintained;
- Complications of Medial Type I Plateau Frx:
- medial plateau frxs, however, whether stable or unstable, have tendency to displace;
- varus deformity may gradually develop after non-op treatment;
- varus malunion resulting from
loss of position of medial plateau fracture promotes early osteoarthritis;
-
loss of position w/ medial plateau frx:
- these frxs may lose position return to displacement that was initially present;
- this is esp. likely to occur in oblique frx that extend from region of intercondylar notch to medial or lateral tibial cortex;
- x-ray should be obtained periodically during 1st few wks to assure that reduction is maintained;
Posteromedial tibial plateau fractures. Operative treatment by posterior approach.
The posterior shearing tibial plateau fracture: treatment and results via a posterior approach.
Medial buttress versus lateral locked plating in a cadaver medial tibial plateau fracture model.
Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.
Medial tibial plateau fractures: a new classification system.
