Tibial plateau fractures: Review of the classification
systems, management, and outcome
Poster No.:
C-1752
Congress:
ECR 2015
Type:
Educational Exhibit
Authors:
S. L. Coleman, R. Parisien, A. Guermazi, A. Murakami; Boston,
MA/US
Keywords:
Trauma, Outcomes, Education and training, Education,
Conventional radiography, CT, Musculoskeletal joint,
Musculoskeletal bone
DOI:
10.1594/ecr2015/C-1752
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Page 1 of 48
Learning objectives
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Classify fracture patterns of tibial plateau using Schatzker and AO
classification systems
Identify the indications for cross sectional imaging
Recognize the different indications for surgical intervention and be familiar
with surgical hardware
Become familiar with the long term outcome of the different fracture patterns
and surgical techniques
Background
Background:
The earliest attempt at tibial plateau fracture classification was based on the observation
of common themes and three fracture types were described: split of a condyle,
subchondral depression, and comminuted bicondylar involvement. (1,2)
Schatzker et al. presented their classification system in 1979, which was created based
on findings from AP radiographs. The Schatzker group created 6 groups of tibial plateau
fractures based on fracture pattern, which helped to direct operative versus non-operative
treatment. (2)
The AO system is part of a larger system of classification of bone fractures throughout
the body, meant to categorize the fracture by localization and severity and to predict
treatment and prognosis.
Radiograph Views for Evaluation of Tibial Plateau Fracture:
AP
Lateral
Two 45 degrees internal oblique views
10-15 degree caudally tilted AP view
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Fig. 1: AP, Lateral, Caudal AP, and Internal Oblique views
References: Radiology, Boston Medical Center - Boston/US
What to look for on radiograph views:
Fracture patterns
Depression
Condylar widening
Injuries to suggest ligamentous injury (i.e. Segond fracture, Pellegrini-Stieda lesion, and
fibular head avulsion)
Images for this section:
Page 3 of 48
Fig. 1: AP, Lateral, Caudal AP, and Internal Oblique views
Page 4 of 48
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
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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)
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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
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Type IV: medial plateau fracture
Type V: bicondylar plateau fracture
Type VI: meta-diaphyseal dissociation
Type I: (Fig.9 and 10)
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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)
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Type II: (Fig.11 and 12)
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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)
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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)
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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)
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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
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Cross section imaging for bicondylar fractures to exclude four part fracture
Type VI: (Fig. 19 and 20)
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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.
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Fig. 4: AO Classification Types A1, A2, and A3
References: Radiology, Boston Medical Center - Boston/US
Type A: Extra articular fractures
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A1: Avulsion
A2: Metaphyseal simple
A3: Metaphyseal multifragmentary
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Fig. 5: AO Classification Type B1 with subgroups
References: Radiology, Boston Medical Center - Boston/US
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Fig. 6: AO Classification Type B2 with subgroups
References: Radiology, Boston Medical Center - Boston/US
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Fig. 7: AO Classification Type B3 with subgroups
References: Radiology, Boston Medical Center - Boston/US
Type B: Partial articular fracture (Fig. 21)
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B1: Pure split
B2: Pure depression
B3: Split-depression
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Fig. 8: AO Classification Type C1, C2, and C3
References: Radiology, Boston Medical Center - Boston/US
Type C: Complete articular fracture (Fig. 22)
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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?
Page 13 of 48
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
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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:
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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)
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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.
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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.
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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)
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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)
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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:
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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)
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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):
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restoration of the articular surface
axis
meniscal integrity
stability
Range of acceptance for articular depression varies from 2mm to 1cm
Page 16 of 48
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
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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
Page 18 of 48
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 submetaphyseal cortical window
-Athroscopic reduction of type III is possible although not standard practice
Page 19 of 48
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)
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-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.
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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:
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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:
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Joint instability
articular surface incongruity
Page 22 of 48
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axial deformity
PROGNOSIS:
Outcome depends on knee stability, joint congruity, meniscal integrity and correct axis.
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Favorable outcomes have been reported for surgically treated low-energy
tibial plateau fractures (12)
Adequate surgical techniques for Split (Type-I) and Split-Depression (TypeII) 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)
Images for this section:
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Fig. 9: Schatzker Type I Fracture: Vertically oriented intra articular fracture through the
lateral tibial plateau with less than 4 mm of depression of the lateral tibial plateau.
Page 24 of 48
Fig. 10: CT imaging of Type I fracture in Fig. 9. Coronal and sagittal CT images in bone
algorithm that more accurately demonstrates a Type I from Type II fracture, with less than
4 mm of depression of the lateral tibial plateau.
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Fig. 11: Schatzker Type II Fracture- Intra articular vertical fracture of the lateral tibial
plateau with depression and mild distraction, consistent with a Type II fracture pattern.
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Fig. 12: CT imaging of the Type II fracture in Fig. 11. Coronal and sagittal CT reformats in
bone window demonstrating a Type II fracture of the lateral tibial plateau. An intra articular
split fracture of the lateral tibial plateau with depression (>4mm) and condylar widening.
Page 27 of 48
Fig. 13: Schatzker Type III Fracture - Pure depression fracture of the lateral tibial plateau
without displacement (split) of the fracture fragment.
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Fig. 14: CT imaging of Type III fracture in Fig. 13 - Coronal and sagittal images in bone
algorhitm better demonstrating the depression of the articular surface of the lateral tibial
plateau into the metaphysis.
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Fig. 19: Schatzker Type VI Fracture - Shows a transverse fracture of the tibial diaphysis
with a depressed split fracture of the lateral tibial plateau and a split fracture of the medial
tibial plateau.
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Fig. 20: CT Imaging of Type VI fracture in Fig. 19 - Transverse tibial diaphyseal fracture
causing metaphyseal-diaphyseal dissociation. There is a displaced split fracture of the
lateral tibial plateau with depression of the articular surface and a minimally distracted
longitudinal fracture of the medial plateau with less < 4mm of articular depression.
Page 31 of 48
Fig. 22: AO Type B3 fracture - split depression fracture of the lateral tibial plateau
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Fig. 23: AO Classification Type C3 fracture - Comminuted, multifragmentary, intra
articular fracture of the bilateral tibial plateaus with extension to the metaphysis.
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Fig. 18: CT Imaging of Type V fracture in Figure 17 demonstrating a bicondylar split
fracture with mild depression of the articular surfaces.
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Fig. 17: Schatzker Type V Fracture - Bicondylar spit fracture with mild depression of the
articular surfaces.
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Fig. 28: Surgical repair of Schatzker Type V fracture with bicondylar plates.
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Fig. 16: CT imaging of Type IV fracture in Fig.15. Coronal and sagittal images in bone
algorithm better demonstrating depression of the articular surface of the medial tibial
plateau into the metasphysis.
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Fig. 15: Schatzker Type IV Fracture - Depression fracture of the medial tibial plateau only.
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Fig. 2: Schatzker Classification Types I, II, and II I - Split fracture II - Split fracture with
depression III - Pure depression fracture
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Fig. 3: Schatzker Classification Types IV, V, and VI IV - Medial plateau fracture V Bicondylar plateau fracture VI - Meta-diaphyseal dissociation
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Fig. 4: AO Classification Types A1, A2, and A3
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Fig. 5: AO Classification Type B1 with subgroups
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Fig. 6: AO Classification Type B2 with subgroups
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Fig. 7: AO Classification Type B3 with subgroups
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Fig. 8: AO Classification Type C1, C2, and C3
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Fig. 21: AO Classification: 41.C.3. Proximal tibia, articular, complex metadiaphyseal and
complex articular
Page 46 of 48
Conclusion
CONCLUSIONS:
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Classification systems can be useful to standard fracture pattern
descriptions, but may need to be updated or revised as imaging standards
change.
Classification systems that are simple for both radiologists and orthopedic
surgeons to understand are the most useful. The more complex the system
the more inaccuracy that occurs in classifying the fracture pattern.
Radiographs, particularly with tibial plateau views, are often sufficient to
classify tibial plateau fracture patterns.
Cross sectional imaging can improve more accurate classification and
address soft tissue injuries, which may change management.
CT imaging should be recommended when radiographs show condylar
widening, articular incongruity, and depression/compression of the articular
surface.
The goal of treatment is to restore joint stability and functionality.
Stability dictates operative management in low energy fracture patterns.
Additional soft tissue injuries can influence surgical approach in high energy
fracture patterns.
Long-term prognosis is dependent on how well joint stability is preserved
with treatment.
Personal information
References
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4.
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