ECR 2015 / C-1752
Tibial plateau fractures: Review of the classification systems, management, and outcome
This poster is published under an open license. Please read the disclaimer for further details.
Congress: ECR 2015
Poster No.: C-1752
Type: Educational Exhibit
Keywords: Trauma, Outcomes, Education and training, Education, Conventional radiography, CT, Musculoskeletal joint, Musculoskeletal bone
Authors: S. L. Coleman, R. Parisien, A. Guermazi, A. Murakami; Boston, MA/US
DOI:10.1594/ecr2015/C-1752

Findings and procedure details

SCHATZKER CLASSIFICATION: 6 types of tibial plateau fractures (3)

 

Fig. 2: Schatzker Classification Types I, II, and II I - Split fracture II - Split fracture with depression III - Pure depression fracture
References: Radiology, Boston Medical Center - Boston/US

  • Type I: lateral split without depression
  • Type II: split-depression lateral plateau fracture
  • Type III: pure depression lateral plateau fracture- based on the classification system this pattern can be separated into A and B, however, this is not necessarily used in the clinical setting (IIIA: compression fracture of the lateral plateau; IIIB: compression fracture of the central plateau)

 

Fig. 3: Schatzker Classification Types IV, V, and VI IV - Medial plateau fracture V - Bicondylar plateau fracture VI - Meta-diaphyseal dissociation
References: Radiology, Boston Medical Center - Boston/US

  • Type IV: medial plateau fracture
  • Type V: bicondylar plateau fracture
  • Type VI: meta-diaphyseal dissociation 

 

Type I: (Fig.9 and 10)

  • Wedge shaped pure cleavage fracture with <4mm of depression or displacement
  • Accurate assessment of depression/displacement; may need cross sectional imaging to distinguish Type I and Type II
  • 6% of all tibial plateau fractures, most frequently in young patients

  • Impaction injury to one side of the knee and distraction injury to the other side

    –May be associated with distraction injury to anterior cruciate ligament (ACL) or medial collateral ligament (MCL)

Type II: (Fig.11 and 12)

  • Combined cleavage and compression fracture of the lateral tibial plateau
  • Type I fracture with depression
  • Depression is measured between the lowest point on the intact medial plateau and the lowest depressed lateral plateau fracture fragment
  • 25% of all tibial plateau fractures
  • Injury usually occurs in bone with underlying osteopenia 
  • Valgus force on the knee; 20% with distraction injury to MCL and medial meniscus
  • Condylar widening

Type III: (Fig.13 and 14)

  • Pure compression fracture of the lateral tibial plateau with depression of the articular surface into the metaphysis
  • Axial loading
  • 36% of all tibial plateau fractures
  • Bone often has underlying osteopenia

Type IV: (Fig.15 and 16)

  • Medial tibial plateau fracture with a split or depressed component
  • Varus force with axial loading of the knee
  • Posteromedial coronal split fractures in hyperflexed knee with varus forces and axial loading
  • 10% of all tibial plateau fractures
  • Worst prognosis
  • Younger patients, high energy mechanism
  • Commonly associated with subluxation or dislocation --> increased likelihood of injury to popliteal nerve or vessel --> cross sectional imaging needed
  • Distraction to the lateral compartment-lateral collateral ligament (LCL) or posterolateral corner injury, or fracture/dislocation of fibular

Type V: (Fig.17 and 18)

  • Wedge fracture of the medial and lateral tibial plateau, often with an inverted “Y”
  • Articular depression in the lateral plateau- may be associated with intercondylar eminence
  • Maintenance of the metaphyseal-diaphyseal continuity
  • 3% of all tibial plateau fractures
  • High energy, complex mechanism
  • Associated with peripheral meniscal detachment and ACL avulsion injury
  • Condylar fractures can lead to instability by disruption of collateral ligaments and/or cruciate ligaments
  • Cross section imaging for bicondylar fractures to exclude four part fracture

Type VI: (Fig. 19 and 20)

  • Transverse subcondylar fracture with dissociation of the metaphysis from the diaphysis
  • All types of fracture patterns of the condyles can occur
  • 20% of all tibial plateau fractures
  • High energy injury
  • Complex mechanism
  • Can be associated with open fractures, soft tissue injury, and compartment syndrome 

 

AO CLASSIFICATION:(1,4)

The classification system aims to systematically classify fractures based on anatomical location and morphological characteristics of the fracture.

 

The system creates a 5-element alphanumeric code, which represents: a description of the location (bone segment), fracture type, and morphological characteristics of the fracture.

 

The long bones are divided into three segments.  The fractures of each segment are then divided into three types, with a further subdivision into three groups and their subgroups. 

 

Fig. 4: AO Classification Types A1, A2, and A3
References: Radiology, Boston Medical Center - Boston/US

 

Type A: Extra articular fractures 

  • A1: Avulsion
  • A2: Metaphyseal simple
  • A3: Metaphyseal multifragmentary

 

Fig. 5: AO Classification Type B1 with subgroups
References: Radiology, Boston Medical Center - Boston/US
Fig. 6: AO Classification Type B2 with subgroups
References: Radiology, Boston Medical Center - Boston/US
Fig. 7: AO Classification Type B3 with subgroups
References: Radiology, Boston Medical Center - Boston/US

 

Type B: Partial articular fracture  (Fig. 21)

  • B1: Pure split
  • B2: Pure depression
  • B3: Split-depression

 

Fig. 8: AO Classification Type C1, C2, and C3
References: Radiology, Boston Medical Center - Boston/US

 

Type C: Complete articular fracture (Fig. 22)

  • C1: Articular simple, metaphyseal simple
  • C2: Articular simple, metaphyseal multifragmentary
  • C3: Articular multifragmentary

 

 

Example:

What is the AO Classification of the Tibial Plateau fracture shown below?

 

Fig. 21: AO Classification: 41.C.3. Proximal tibia, articular, complex metadiaphyseal and complex articular
References: Radiology, Boston Medical Center - Boston/US

  

1. Anatomical location:

Anatomical location designated by two numbers, one for the bone and one for the segment

–Long bone = Tibia = 4

–Proximal tibia = 41

–Mid tibia = 42

–Distal tibia = 43

 

Answer= 41

 

 

2. Type of fracture:

Types of fractures are coded by three letters: A, B, C

 

Answer=C (complete articular)

 

 

3. What group within the type of fracture?

Within the fracture types there are groups: 1, 2, 3

 

Answer=3 (articular multifragmentary)

 

Full AO Classification of above fracture = 41.C.3

 

 

 

CLASSIFICATION SYSTEMS AND TREATMENT:

  • Tibial plateau fractures are often complicated to repair surgically due to the highly complex nature and intra articular involvement 
  • Adequate, reliable, and reproducible pre-operative classification of fracture patterns is essential in aiding operative treatment (5)

Comparison of systems: 

 

One study showed substantial reliability in intra-observer assessment of both the Schatzker and AO classifications. The AO system was mildly more reliable in regards to inter-observer assessment. (5)

  • As the AO classification becomes more specific (i.e group and subgroup) the reliability of classification breaks down due to the complexity of the system.  Better reliability is seen in assessing AO type of fracture pattern. (5)

CT imaging may be indicated when classification is not clear to increase accuracy of classification.

  • AO classification inter-observer reliability improved to "good" with CT imaging, compared to "moderate with radiograph assessment. 
  • Fellowship trained orthopedic surgeons and skeletal radiologists showed better intra-observer reliability overall.  With CT imaging, only skeletal radiologists showed significant improvement in reliability.
  • Observers noted extreme difficult distinguishing between certain types of AO fractures with radiographs, however, they had no difficulty classifying the same types with CT imaging. (6)
  • Schatzker classification inter-observer reliability improved to "good" with use of CT imaging, compared to "moderate" with radiograph assessment.
  • Intra-observer reliability of the Schatzker classification was “good” with radiograph assessment and did not change with use of CT imaging.
  • Certain fracture patterns were difficult to classify with radiographs (type I vs II and type V vs type VI), however, the same observers had no difficulty classifying these same fractures with CT imaging. (6)

Additional studies have supported improved classification with CT imaging over radiographs (1)

 

At our institution CT imaging is utilized for pre-operative management of split depression, bicondylar, and meta-diaphyseal fractures identified on radiographs.

 

In our opinion radiologists should recommend CT imaging for the following indications:

  • Unclear classification that may change management
  • Condylar widening
  • Articular incongruity
  • Depression/compression of the articular surface

 

Treatment:

Non-operative treatment is usually indicated in non-displaced or mildly depressed plateau fractures (7)

  • Partial weight bearing in a hinged brace for 8-12 weeks with regular radiographs is recommended(3, 8)

 

Goals of surgical treatment of intra-articular fractures to avoid or postpone posttraumatic arthritis(8):

  • restoration of the articular surface
  • axis
  • meniscal integrity
  • stability  

Range of acceptance for articular depression varies from 2mm to 1cm

 

Some degree of joint depression can be tolerated.

 

Despite an average of >3 mm of residual tibial joint line displacement, Weigel and Marsh demonstrated a low rate of posttraumatic arthrosis at long-term follow-up(9)

 

Treatment based on Schatzker Classification:

Type I, II, III (8)

-Lower energy injuries

-Goal is to restore: Joint congruity, length, alignment, stability

-meniscal and/or ligamentous repair

 

Type I (low energy) (3)

-Open reduction and internal fixation (ORIF) with or without arthroscopy

-Hardware: Screw osteosynthesis with lag technique; lateral locking or buttress plate

 

Fig. 24: Schatzker Type I fracture repaired with open reduction and fixation using a lateral plate and screws.
References: Radiology, Boston Medical Center - Boston/US

 

Type II (low energy) (3, 10)

-ORIF for all unstable fractures

-Articular elevation

-Meniscal repair (reduces incidence of degenerative changes)

-Bone grafting: cancellous bone chips; bioresorbable calcium phosphate cement; aoralline hydroxyapatite; autogenous iliac bone graft

-Hardware: Rafting screw to support impacted joint surface; lateral locking or buttress plate

 

Fig. 25: Schatzker Type II fracture status post open reduction and internal fixation with a lateral plate and screws.
References: Radiology, Boston Medical Center - Boston/US

 

Type III (low energy) (3)

–If extent of articular depression is small and joint is stable = non-operative

–May result in joint instability -->elevation of the depressed portion of the plateau via sub-metaphyseal cortical window

-Athroscopic reduction of type III is possible although not standard practice

 

Fig. 26: Schatzker Type III fracture status post open reduction and internal fixation with a lateral plate and screws.
References: Radiology, Boston Medical Center - Boston/US

 

Type IV (high energy) (3)

-Tend to angulate into varus position

-ORIF

-Hardware: medial buttress plate and cancellous screws

 

Soft tissue injuries dictate management in Types V and VI  (3)

-Severe soft tissue impairment may benefit from primary external fixation with secondary ORIF

 

Type V (high energy) (3, 11)

-Initial management depends on soft tissue integrity

-Temporary external fixation

-Wait for soft tissue inflammation and edema to decrease before definitive fixation

-Secondary ORIF

-Hardware: Buttress plating, locked plating, dual plating, circular fixator

 

Fig. 27: Schatzker Type V fracture pattern with internal fixation using a longer lateral plate and screws.
References: Radiology, Boston Medical Center - Boston/US

 

Type VI (3)

-No traction secondary to meta-diaphyseal dissociation

-Hardware: If extra-articular --> tibial intramedullary nail may be used.

 

Fig. 29: Schatzker Type VI fracture treated with external fixation only.
References: Radiology, Boston Medical Center - Boston/US

 

 

 

Treatment based on AO Classification: (4)

 

Non-displaced stable fractures are treated non-operatively:

  • Put in brace to prevent displacement
  • Exceptions include: fractures of the medial tibial plateau because of high risk of secondary displacement and associated complications requiring surgical treatment

Operative treatment is indicated for:

  • Joint instability
  • articular surface incongruity
  • axial deformity

 

 

PROGNOSIS: 

 

Outcome depends on knee stability, joint congruity, meniscal integrity and correct axis.

  • Favorable outcomes have been reported for surgically treated low-energy tibial plateau fractures (12)
  • Adequate surgical techniques for Split (Type-I) and Split-Depression (Type-II) fractures yield more than 90% good and excellent results (13)
  • Studies have shown that operative treatment with a fracture that disrupts the articular surface leads to good functional results 2-10 years post injury, possibly due to early mobilization (7), particularly for elderly patients
  • Maintaining meniscal and ligamentous stability is important (14)

Posttraumatic arthrosis is related to initial chondral injury or result of residual joint incongruity (14, 15)

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