Trauma Society of India is a pioneering initiative to promote knowledge in the fields of orthopedics and traumatology. The society has taken a giant leap in its endeavors by launching the first ever standard guidelines for orthopedic clinicians. These guidelines would go a long way in establishing treatment protocols and providing a roadmap to clinicians that guides them in the assessment, decision-making and management of complex fracture situations. The guidelines will be published in a series of books titled Guidelines in Fracture Management, compiled by eminent Indian and international clinicians. They illustrate all possible treatment options and latest management techniques that can be used, with special emphasis on the health scenario in the Asia-Pacific region. Guidelines in Fracture Management--Proximal Tibia discusses the classification, assessment of personality, and planning and treatment protocols for the much-debated proximal tibia fractures.

1. Chapter 8
Early Complications following
Proximal Tibia Fractures
● Disturbed healing of soft-tissue envelope 00
● Postoperative hematoma 00
● Compartment syndrome 00
● Wound infection 00
● DVT/TE 00
● Postoperative damage of peroneal nerve 00
● Postoperatively recognized deficits of
osteosynthesis 00
Chapter 1
Introduction, Classification, Assessment,
Planning of Proximal Tibia Fractures
Sushrut Babhulkar
● Introduction 3
● Forces and Mechanism of Injury 6
● Classification 7
● AO Classification 10
● Evaluation 10
● Indications for Surgical Treatment 14
Thiem
e
M
edicaland
Scientific
Publishers

2. 3
Introduction, Classification, Assessment, Planning of Proximal Tibia Fractures
3
and Lobenhoffer emphasized the importance of distinguish-
ing between the “pure” plateau-fracture pattern and the
fracture-dislocation pattern. In their review of 190 proximal
tibial articular fractures, 67% of meniscal injuries occurred in
plateau-fracture patterns, whereas 96% of cruciate injuries and
85% of medial collateral ligament (MCL) injuries occurred in
fracture-dislocation patterns. Peroneal nerve injury was twice
as common in fracture-dislocation patterns. These authors also
introduced the term complex knee trauma to describe inju-
ries associated with significant damage to two or more of the
following compartments: the soft-tissue envelope of the knee,
the ligamentous stabilizers, and the bony structures of the
distal femur and proximal tibia. Complex fractures involving
the femoral and tibial articular surfaces had a 25% incidence of
vascular injury and 25% incidence of compartment syndrome.
In 19 complex fractures with severe soft-tissue injury, vascu-
lar injury occurred in 31%, compartment syndrome in 31%, and
peroneal nerve injury in 23% of fractures. Accurate determina-
tion of fracture pattern and soft-tissue injury is necessary when
developing a treatment plan. Schulak and Gunn related the fre-
quency of the type of fracture produced and the frequency of
collateral ligament injury to the type and mechanism of forces
applied to the knee. Considering the “pure” fracture patterns,
ligamentous injuries occur more frequently in minimally dis-
placed, local compression, and split compression fractures and it
is wise to obtain stress radiographs of the knee to evaluate these
structures.
1 Introduction, Classification, Assessment, Planning of
Proximal Tibia Fractures
Introduction
Proximal tibia fractures contribute to and are counted among
the major skeletal injuries. Highest incidence occurs between
the third and fifth decades in young, active individuals. If treated
inadequately, they cause long-term disability and pain. These
fractures occur as a result of high-velocity trauma, and increas-
ing severity of impact is directly proportional to the degree of
resultant comminution. This type of fracture is frequently asso-
ciated with concomitant injuries, including overlying skin injury,
ligamentous injuries, and meniscal injuries, adding to the mor-
bidity of the resultant outcome. The aim of surgical treatment of
proximal tibia and fibula fractures is to restore and preserve nor-
mal knee functions. These goals are accomplished by anatomi-
cally restoring the articular surfaces of the tibial condyles, main-
taining the mechanical axis, restoring ligamentous stability, and
preserving a functional, pain-free range of motion in the knee.
Proximal tibial articular fractures caused by high-energy
mechanisms may be associated with neurological and
vascular injury, compartment syndrome, deep vein throm-
bosis, contusion or crush injury to the soft tissues, or open
wounds. The condition of surrounding soft tissue is the most
important parameter which provides an appropriate time win-
dow to commence surgery. Compartment syndrome adversely
affects the functional results of this injury. High-energy inju-
ries with soft-tissue involvement treated by extensile surgical
approaches have yielded poor long-term outcomes. Tscherne
Introduction, Classification, Assessment, Planning of Proximal Tibia Fractures
Thiem
e
M
edicaland
Scientific
Publishers

3. 4
Chapter 1
An appropriate classification following an effective investi-
gation and then a good planning can usually render an excellent
outcome. Thus, articular fractures and their pattern assessment
are of paramount importance in a good result.
Various treatment modalities have been under considera-
tion for these fractures, starting from nonoperative option to
arthroscopic-assisted reduction of articular fragments. Recent
advances for treating such injuries have included newer
approaches, understanding the importance of posteromedial
fragment, use of raft screws and injectable bone grafting mate-
all the possible treatment options you may want to consider
to offer your patient the best possible result from this difficult
injury.
Conservative, nonoperative treatments using traction and
cast bracing have yielded satisfactory outcomes, as reported by
some investigators. Currently, with the advent of understanding
about the articular fracture patterns and their responses to the
nonoperative management, this type of treatment has become
limited to those fractures where there is articular disturbance
and comminution. A precise restoration of anatomy will look at
a better functional outcome and lessen deformity and secondary
arthritic pain. Although tibial articular surface is tolerant to a
great extent to the deforming forces, it is important to achieve
preciseanatomicalrestorationtogainbetterfunctionaloutcome
employing newer techniques, newer implants, and better
understanding of injury pattern and its behavior. The surgical
treatment with good articular reconstruction and stable
fixation offers precise limb alignment, articular restoration,
and thus a more predictable pattern of healing allowing early
weight bearing.
Some of the newer things that have happened concerning
proximal tibia fractures include soft tissue-friendly approaches,
delayed internal fixation, and minimally invasive techniques,
which have all recently improved outcomes following these
injuries (Fig. 1.1A, B).
Thiem
e
M
edicaland
Scientific
Publishers

4. 5
Introduction, Classification, Assessment, Planning of Proximal Tibia Fractures
Fig. 1.1 (A, B) 41-C3.1 fracture in a 44-year-old female after a skiing accident. In bicondylar fractures, the medial plateau is usually sheared
off “en bloc” without major damage to the articular surface.
A
B
Thiem
e
M
edicaland
Scientific
Publishers

5. 6
Chapter 1
Forces and Mechanism of Injury
Why do we need to know the force vector resulting into the
injury we are dealing with? Is it because that is the way we
are going to “undo” the pattern while reconstructing the
fracture and putting our implant on? The magnitude, type, and
directions of forces that injure the knee dictate the fracture
pattern. The greater the energy absorbed by the proximal
tibia, the more severe is the fracture and more displaced and
comminuted are the fragments. Generally, axial-loading
forces are more rapid and release greater energy than angular
forces. In cadavers, it is possible to produce typical split frac-
tures with pure valgus forces, local compression fractures with
axial forces, and split depression fractures with combination
of both forces. The MCL acts like a hinge for the lateral femo-
ral condyle, and in this cadaver study it should be present for
the lateral plateau to fracture which means that clinically the
MCL should not be torn in these lateral patterns. The proxi-
mal tibia is most likely to be subject to a valgus force because
of the normal 5 to 7 degrees of valgus alignment of the knee
besides the propensity to be struck from the lateral side.
A valgus force loads the lateral tibial plateau to failure from
direct impact with the lateral femoral condyle. A combination
of valgus and axial compressions produces lateral side depres-
sion, split depression, or less commonly, lateral split or total
lateral condyle fractures. Younger patients with good bone tend
to have split fractures with less depression while elderly patients
with osteopenic bone have a greater component of compres-
sion with a less prominent split fragment. Most commonly in
lateral fracture patterns, there is at least a small component of
both a split fracture and depression at the peripheral margin of
the fracture, less commonly than in lateral side fractures, varus
injuries lead to failure of the medial plateau. A posteromedial
fracture of the medial plateau is a common medial pattern and
can occur as an isolated split fracture or in as many as one-third
of bicondylar fractures and it is a part of the bicondylar fracture
pattern. The mechanism has been described as knee flexion
varus and internal rotation of the medial femoral condyle. This
fragment has gained a lot of importance as improper fixation
of this fragment leads to early failure. Tibial plateau fractures
most often occur with leg in a weight-bearing position, hence
load is typically some component of the injuring force. Gener-
ally, greater the axial load component, the more severe is the
fracture pattern. Bicondylar fracture patterns result when axial
load predominates with the severity varying based on the mag-
nitude of the axial forces.
Thiem
e
M
edicaland
Scientific
Publishers

6. 7
Introduction, Classification, Assessment, Planning of Proximal Tibia Fractures
Classification
Classification of the fractures is a must that leads us to plan
an effective way of executing a perfect articular and frac-
ture reconstruction.8
It should be a protocol to classify each
fracture using a plain X-ray and wherever needed, accompa-
nied by three-dimensional computed tomography (3D CT)
reconstruction. Magnetic resonance imaging (MRI) is used in
suspected soft-tissue trauma and ligamentous injuries.
Schatzker classification continues to be the mainstay for
these fractures facilitating in planning the surgery and place-
ment of implants. Currently, AO classification is the worldwide
standard in documenting fractures and exchanging thoughts.
We have discussed various classifications in this chapter to help
you apply these in your clinical practice (Table 1.1).
Honkonen and Jarvinen have recently modified Schatzker
classification to take residual limb alignment into account.
They have divided Type VI fractures into two types: those that
are medially and laterally tilted to take into account functional
results in treated fractures with residual angulation (Fig. 1.2).
In the Orthopaedic Trauma Association (OTA) classification,
which is based on the Association for the Study of Internal
Fixation (AO/ASIF) classification, proximal tibia is denoted as
segment 43 and is divided into three main categories:
Type A Fractures are extra-articular.
Type B Fractures are partially articular and are subdivided into three main categories: B1 are pure splits, B2 are pure
depression, and B3 are split depression.
Type C Fractures are complete articular fractures and are also subdivided into three subtypes: Type 1 is articular and
metaphyseal simple, Type 2 is articular simple and metaphyseal multifragmentary, and Type 3 is articular multi-
fragmentary.
Type AA
Type B
Type C
Thiem
e
M
edicaland
Scientific
Publishers

7. 8
Chapter 1
Table 1.1 Schatzker classification of tibial plateau fractures
Type Name Features
Schatzker I Lateral split A pure cleavage fracture of the lateral tibial
plateau that results in a wedge-shaped frac-
ture segment.
Schatzker II Split with depression A cleavage fracture of the lateral tibial
plateau in which the remaining articular
surface is depressed into the metaphysis.
Schatzker III Pure lateral depression A pure central depression fracture of the lat-
eral tibial with an intact osseous rim.
Schatzker IV Pure medial depression This is a medial tibial plateau fracture
with a split or depressed component. It is
usually the result of a high-energy injury
and involves a varus force with axial loading
at the knee. There is high risk of damage to
the popliteal artery and peroneal nerve and
therefore carry a worse prognosis.
Schatzker V Bicondylar A bicondylar fracture in which the fracture
line often forms an inverted the metaphysis
and diaphysis remain intact.
Schatzker VI Split extends to metadiaphysis A tibial plateau fracture in which there is
dissociation between the metaphysis and
the diaphysis; these fractures may have
varying degrees of comminution of one
or both tibial condyles and the articular
surface.
Thiem
e
M
edicaland
Scientific
Publishers

8. 9
Introduction, Classification, Assessment, Planning of Proximal Tibia Fractures
Fig. 1.2 Schatzker classification.
Type I
Type IV
Type II
Type V
Type III
Type VI
Thiem
e
M
edicaland
Scientific
Publishers

9. 10
Chapter 1
AO Classification
The AO/OTA classification employs the designation of number
4 for the tibia and number 1 for the proximal portion of the
bone. Consequently, all the tibial plateau fractures have the
designation of 41. A letter is then added to classify the frac-
tures. The letter A indicates a proximal fracture that does not
enter the knee joint. A B-type fracture is a unicondylar injury
and correlates to Schatzker Type I through IV patterns. Although
many fractures in the 41B group are low-energy injuries,
medial plateau fractures are important. A 41C fracture is a
bicondylar injury and correlates to Schatzker Types V and VI
injuries. These are normally high-energy injuries. Each of the
major patterns (41A, 41B, and 41C) is further subdivided into
nine additional patterns. A major advantage of the AO/OTA
classification is precision and detail, with 27 subclassifications.
This provides a major advantage for research and clinical out-
come analysis, and allows a comparison of identical fracture
types. The classification becomes cumbersome and difficult to
use clinically if taken beyond the major patterns (Fig. 1.3).
Evaluation
A detailed history including determination of the mecha-
nism of injury and the patient’s overall medical status, age,
and functional and economic demands must be obtained. A
detailed physical examination is necessary to detect concomi-
tant ligamentous injuries, neurovascular injuries, compartment
syndrome, additional fractures, and other injuries. Compart-
mental pressures should be measured with an accurate method
if compartment syndrome is suspected. An arteriogram should
be obtained in fractures with suspected vascular injury or in
patients with fracture dislocations. Patients with obvious vas-
cular injuries should be taken promptly to the operating room
for vascular exploration and revascularization (Fig. 1.4A–D).
Anteroposterior, lateral, and oblique X-rays and CT are
necessary to evaluate these fractures. Whatever the injury,
the damage to the joint usually is more extensive than the
X-rays indicate. The bony attachments of one or both cruciate
ligaments may be avulsed and lie as free fragments in the
Thiem
e
M
edicaland
Scientific
Publishers

10. 11
Introduction, Classification, Assessment, Planning of Proximal Tibia Fractures
Fig. 1.3 Müller AO classification.
41–A1
41–B1
41–C1 41–C2 41–C3
41–B2 41–B3
41–A2 41–A3
Thiem
e
M
edicaland
Scientific
Publishers

11. 12
Chapter 1
Fig. 1.4 The rare case of an isolated fracture of the medial plateau, 41-B3.2 (or Schatzker IV) fracture, which may be associated with an injury
to the popliteal vessels.
Fig. 1.4 (A) Standard anteroposterior view. Fig. 1.4 (B) 3D reconstruction as seen from behind.
A B
Fig. 1.4 (C) Lateral view.
C
Fig. 1.4 (D) Lateral 3D reconstruction.
D
Thiem
e
M
edicaland
Scientific
Publishers

12. 13
Introduction, Classification, Assessment, Planning of Proximal Tibia Fractures
joint. Comminuted fragments of the articular surface often lie
at angles to their normal plane and may be upside down. The
meniscus often is torn at its periphery and a part or all of it
may lie between the comminuted fragments. Assessment of
the degree and the size of depressed articular fragments may
be possible only with conventional tomography or CT. 3D CT
reconstruction is very helpful in looking at displacement of
various articular fragments and their possible reconstruction.
Often the classification of the fracture made from standard
X-rays is changed to another type after CT tomograms are eval-
uated. The upper tibial articular surface is normally inclined
posteriorly 10 to 15 degrees, and an anteroposterior radiograph
with the beam angled caudally 10 to 15 degrees provides bet-
ter views of the tibial plateaus. Stress radiographs for collateral
ligament injury have been mentioned earlier. Any widening of
the femoral–tibial articulation greater than 10 degrees upon
stress examination indicates ligamentous insufficiency. Split
fractures of the lateral plateau have a relatively high incidence
of associated ligamentous injury, because the dense cancellous
bone associated with split fractures does not compress. Energy
is therefore not dissipated, and the force is imparted to the MCL.
Injury to the collateral ligaments has been reported to occur
in 7 to 43% of tibial plateau fractures, and rupture of the ante-
rior cruciate has been reported in up to 23% of high-energy
injuries. Meniscal injuries have been reported in up to 50% of
tibial plateau fractures. In split-type fractures, the meniscus
may be incarcerated within the fracture site. Colletti, Green-
berg, and Terk analyzed MRI findings in 29 tibial plateau frac-
tures and found tibial collateral injuries in 55%, lateral meniscal
tears in 45%, fibular collateral ligament injuries in 34%, anterior
cruciate ligament injuries in 41%, posterior cruciate ligament
injuries in 28%, and medial meniscal tears in 21% of fractures.
This study showed the spectrum of soft-tissue injuries associ-
ated with tibial plateau fractures; however, MRI scans are not
routinely indicated.
Thiem
e
M
edicaland
Scientific
Publishers

13. 14
Chapter 1
Indications for Surgical Treatment
Nonoperative management utilizing cast brace is appropriate
for some fractures of the tibial plateau. Indications for closed
management may include the following fractures:
1. Nondisplaced or minimally displaced (< 3 mm)
2. Stable to varus and valgus stress
3. Peripheral submeniscal fractures
4. Low-energy fractures with minimal comminution, and
5. Low demand patients with medical contraindications to
surgery.
Outcome results reported with cast bracing have been variable
and often depend on the pattern and stability of the injury. A
key to obtaining a successful outcome is to allow adequate early
motion. Both bicondylar and split depression fractures have
been noted to be associated with less favorable outcome when
treated with closed reduction and cast bracing compared with
open reduction, internal fixation (ORIF). Poor results have been
reported in 10 to 32% of fractures.
The decision to treat a tibial plateau fracture with surgery is
multifactorial, involving patients, fracture, and surgeon. Issues
to consider regarding the patient include their age, activity,
type of employment, associated injuries, and medical problems.
Important factors associated with the fracture include the pat-
tern, degree of comminution, displacement, joint impaction,
mechanism of injury or energy imparted to the tissues at the
time of injury, condition of the soft tissue around the fracture,
and stability of the knee. Factors a surgeon should consider
include the surgical team’s experience and the operating-room
environment and equipment.
The most important factor to consider prior to embarking
on surgical management of tibial plateau fractures is the condi-
tion of the local soft tissues. Severe damage to the soft-tissue
envelope is the most common contraindication to early surgical
treatment of tibial plateau fractures. It is important to grade the
soft-tissue condition and carefully consider this factor follow-
ing both open and closed fractures. Delaying definitive surgical
treatment until optimal soft-tissue conditions exist minimizes
complications.
Absolute indications for surgery include open fractures, frac-
tures associated with a compartment syndrome, and fractures
associated with a vascular injury. Relative indications for surgi-
cal stabilization include most displaced bicondylar and medial
condyle fractures, lateral plateau fractures that result in joint
instability, condylar widening that exceeds 5 mm, fracture
dislocations of the knee, and fractures in the polytraumatized
patient that will prevent early mobilization of the patient if the
knee is treated nonoperatively.
Thiem
e
M
edicaland
Scientific
Publishers

14. 15
Introduction, Classification, Assessment, Planning of Proximal Tibia Fractures
Tips and Pearls
● Tibial plateau fractures have high incidence of concomitant injuries, such as meniscus injury, cruciate
injury, and collateral ligament injury. They need identification and appropriate treatment for good
long-term outcome.
● Conservative treatment has a very limited role in articular fractures.
● With newer approaches and fixation techniques, improved outcome is achievable.
● The proximal tibia is most likely to be subject to a valgus force because of the anatomy of the knee.
A combination of valgus and increasing axial compression produces lateral side depression, split
depression, or, less commonly, lateral split or total lateral condyle fractures.
● Bicondylar patterns result when axial load is high.
● A posteromedial fracture of the medial plateau is a common medial pattern and can occur as an
isolated split fracture or in as many as one-third of bicondylar fractures. It needs identification and a
dedicated treatment.
● CT scan has a crucial role to play in identifying comminution, displacement of fragments, and
planning.
● MRI is seldom required except in situation of suspected soft-tissue injuries.
● Articular surface involving fracture should be surgically reconstructed to recreate the normal articular
anatomy and supporting diaphyseal axis.
Thiem
e
M
edicaland
Scientific
Publishers