- Discussion:
- consists of wedge frx of
medial &
lateral plateau;
- if articular depression is present, it is usually present on the lateral plateau;
- frx may have an inverted Y appearance, w/ the articular frx origininating in the intercondylar region;
- associated injuries:
- 50% of plateau fractures will have peripheral meniscal detachment;
- ACL avulsions may occur in about 1/3 patients;
-
compartment sydrome
-
popliteal artery injury
- referernces:
-
Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique.
- Radiographs: 
- Non Operative Treatment:
- because of soft tissue attachment to fracture fragments, traction occassionally provides an acceptable reduction & once frx has become
sticky may be managed in a cast brace;
- note, however, that loss of frx position & alignment is common when plaster cast is used after bicondylar fractures;
- PreOp Planning
- consider CT scan to clearly define fracture patterns;
- soft tissue evaluation:
- pay attention to abrasions, bruising, and hemarthrosis since these are risk factors for wound breakdown;
- w/ ORIF w/ extensive periosteal stripping may result in a 20% incidence of wound breakdown & infection (some small series report even
higher rate of infection) that often leads to poor clinical results;
-
compartment syndrome:
- insist on general anesthesia inorder to avoid dips in blood pressure (which occurs with spinal anesthesia) and inorder to allow for immediate neurovascular exams;
- Operative Technique: (see
4.5 LCP proximal tibial plate
-
indirect reduction stratedgy:
- consider using
universal femoral distractor for assistance of reduction thru ligamentotaxis;
- condylar reduction can be improved w/ percutaneously applied reduction forceps;
-
open reduction stratedgy:
- single anterior incision (which is compatible with a total knee replacement incision for the future);
-
fixation stratedgy:
- ultimate goal is to have a Synthese Lateral Locking Plate with Medial Washer to provide fixation for both plateau frx;
-
medial plateau:
- usually fixation of the medial plateau is easier than the lateral plateau;
- consider temporary fixation of the medial w/ a simple medial butress plate;
- even if there is a coronal split into the medial plateau, the butress plate will allow a near anatomic reduction which then allows fixation
of the lateral plateua using the medial joint line as a reference;
- references:
-
Frequency and Fracture Morphology of the Posteromedial Fragment in Bicondylar Tibial Plateau Fracture Patterns.
-
lateral plateau:
- lateral locking plate is applied in the usual manner;
- once the lateral plate proximal anterior and posterior locking screws are applied, the medial buttress plate is removed, allowing a
medial washer to be inserted over the central proximal screw;
-
wound closure:
- expect that anterior compartment swelling will interefere with wound closure;
- consider proximal wound closure and leaving the distal half of the wound open to prevent compartment syndrome;
- "pie crust" technique is a simple technique to facilitate delayed wound closure;
- ref:
Multiple relaxing skin incisions in orthopaedic lower extremity trauma.
-
Post Operative Care and Compications:
- varus deformity is common w/ type V frx;
External Fixation and Limited Internal Fixation for Complex Fractures of the Tibial Plateau. J.L. Marsh MD JBJS (Am). Vol. 77-A, No. 5, May 1995.
The use of an anterior incision of the meniscus for exposure of tibial plateau fractures requiring open reduction and internal fixation.
EH Karas, LS Weiner, and EC Young. J. Orthop Trauma. Vol 10, No 4, p 243-247.
Anterior Approach to the Knee with Osteotomy of the Tibial Tubercle for Bicondylar Tibial Fractures. Fernadez DL. JBJS- Am. 70: 208, 1988.
Combined Anterior and Posterior Approaches for Complex Tibial Plateau Fractures. Geordiadis GM. JBJS (Br) 76: 285, 1994.
Treatment of Complex Tibial Plateau Fractures with the Ilizarov External Fixator. R. Buckle J. Orthop. Trauma 7: 167, 1993.
Early Results of a New Technique for Treatment of High Grade Tibial Plateau Fractures. Christensen K J. Orthop. Trauma 4: 226, 1990.
Internal versus External Fixation of Bicondylar Tibial Plateau Fractures. AR Mallik, DJ Covall, and GP Whielaw. Orthop. Rev. 21: 1433, 1992.
Single lateral locked screw plating of bicondylar tibial plateau fractures.
Recovery of knee function following fracture of the tibial plateau.
Complications after tibia plateau fracture surgery.
Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.
Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.
Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique.
Posteromedial second incision to reduce and stabilize a displaced posterior fragment that can occur in Schatzker Type V bicondylar tibial plateau fractures.
Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.
Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Surgical technique.
Early wound complications after operative treatment of high energy tibial plateau fractures through two incisions.
Complications after tibia plateau fracture surgery.
Nicotine in plastic surgery : a review
-
case example:
- 40 yo female involved in MVA, sustaining bicondylar tibial plateau frx, but no other injuries;
- interesting points about this case:
1) the initial AP of the knee did not adequately show the lateral plateau frx, since the knee immobilizer had been left in place;
2) because the medial plateau was more comminuted and displaced than the lateral plateau, the surgeon decided to apply a "T" butress
plate to the medial side w/ two proximal 6.5 mm cannulated screws angled slightly posteriorly to engage the lateral plateau frx;
-
case example:
