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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Type IV (Medial) Tibial Plateau Fractures


- See:
        - Tibial Plateau Frx Menu:    Bicondylar Fractures and Type V Frx, 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 proximal tibial metaphysis deep to pes anserinus & anterior fibers 
of superficial MCL;
           - posterior butress plate is applied to the posteromedial edge of tibia;
           - be aware 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; 
    - posteromedial incision (for secondary coronal plane fracture);
           - plane between the semitendinosis and gastrocnemius
           - ref: Posterior coronal plating of bicondylar tibial plateau fractures through posteromedial and anterolateral approaches in a healthy floating supine position.


- Post Operative Care and Complications:
    - 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.

Operative strategy in postero-medial fracture-dislocation of the proximal tibia



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, July 27, 2012 10:32 am