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Actualizado: 22/08/2022

Fracturas de la meseta tibial


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 4.4 de 154 Calificaciones

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48 Comentarios de expertos

 Podcast del tema

Daniel Tara… Mark Kar…


      
145 / 145 69 / 69 200 / 200 10 / 10 46 / 46 2

 TEMA Modo De Tarjeta Flash 

Ajustes 

Imágenes 

Resumen 


Las fracturas de la meseta tibial son lesiones
periarticulares de la tibia proximal
frecuentemente asociadas con lesiones de
tejidos blandos.


El diagnóstico se realiza con radiografías de
rodilla, pero con frecuencia requiere una
tomografía computarizada para la
planificación quirúrgica.


El tratamiento suele ser ORIF en el contexto
agudo versus fijación tardía después de que
desaparece la inflamación de los tejidos
blandos.

Epidemiología 


Incidencia
1-2% de todas las fracturas


10,3 por cada 100.000 habitantes al año




Demografía
edad media 52


distribución bimodal


hombres de 40 años (trauma de alta



energía)
mujeres en 70 (caídas de baja


energía)


Ubicación
meseta lateral 70-80%


bicondilar 10-30%


meseta medial 10-20%



Etiología 


Mecanismo
El vector de carga aplicada, la cantidad


de energía y la calidad del hueso

determinan el tipo de fractura
carga en valgo


meseta lateral


carga en varo


meseta medial


carga axial


bicondilar


combinación


dislocación de fractura


energia alta


generalmente fracturas de meseta



del lado medial

frecuentemente asociado con


lesiones de tejidos blandos

energía baja


generalmente fracturas de meseta



lateral


Condiciones asociadas
lágrimas de menisco


rotura de menisco lateral



más común que medial



asociado con el patrón de fractura



Schatzker II     
asociado con > 10 mm de


depresión articular  
asociado con ensanchamiento


condilar >6 mm
rotura de menisco medial


más comúnmente asociado con



fracturas de Schatzker IV 
 
 lesiones del LCA
más común en fracturas tipo IV y VI


(25%)  
 síndrome compartimental
 las lesiones de tejidos blandos asociadas
tienen poca influencia en los resultados
finales  
 lesión neurovascular
comúnmente asociado con fracturas-


luxaciones de Schatzker IV   

 nervio peroneo común es la lesión
nerviosa más común

Anatomía 


Osteología
meseta tibial lateral 


de forma convexa


proximal a la meseta medial  



hueso menos denso



meseta tibial medial 



de forma cóncava


distal a la meseta tibial lateral



alineación de la tibia proximal 



pendiente tibial posterior



6-10 grados


pendiente en varo


3 grados en relación con el eje



mecánico de la tibia


ligamentos 
LCA


se inserta anteriormente entre las



espinas tibiales
restricción primaria contra la traslación


tibial anterior
estabilizador secundario de rotación


tibial
PCL


se inserta en el surco tibial posterior



debajo de la superficie articular

restricción primaria a la traslación


tibial posterior
MCL


dos componentes


LCM superficial


Inserción ancha en la tibia



proximal profunda al pie

anserinus.
estabilizador primario del


estrés en valgo
MCL profundo


se une al menisco medial



estabilizador secundario al


estrés en valgo
LCL


se inserta en la cara anterolateral de



la cabeza del peroné

restricción primaria a la tensión en


varo a 30 grados


Menisco
menisco lateral


cubre una porción más grande de la



superficie articular
más móvil


más fácil de evaluar la superficie



articular lateralmente a través de

la artrotomía submeniscal debido
a la movilidad del menisco
menisco medial


menos móvil debido a los ligamentos



coronarios


Músculos 
4 compartimentos en la parte inferior de


la pierna
compartimento anterior


compartimento lateral


posteriores superficiales


parte posterior profunda




tendones
tendón rotuliano


se inserta anteriormente en el


tubérculo tibial
banda iliotibial


se inserta en la cara anterolateral de



la tibia proximal en el tubérculo de

Gerdy
tendones isquiotibiales


inserto de pes anserine en la cara



anteromedial de la tibia proximal


Estructuras neurovasculares
La arteria poplítea discurre justo por


detrás de la cápsula de la rodilla y se

bifurca.
arteria tibial anterior


arteria tibial posterior



nervio tibial


discurre posteriormente junto con la



arteria poplítea
sensorial: cara plantar del pie


motor: inerva los compartimentos



posteriores que controlan la flexión

plantar del tobillo y la inversión del
pie
nervio peroneo común


curso alrededor del cuello del peroné



dos ramas


nervio peroneo superficial



sensorial: dorso del pie



(excepto primer espacio web

dorsal)
motor: inerva el compartimento


lateral que controla la eversión

del tobillo
nervio peroneo profundo


sensorial: primer espacio web



dorsal del pie

motor: inerva el compartimento


anterior que controla la

dorsiflexión del tobillo


Biomecánica
cóndilo tibial medial


soporta el 60% de la carga a través de



la rodilla
cóndilo tibial lateral


soporta el 40% de la carga a través de



la rodilla


Cinemática
flexión-extensión 0-140 grados


ROM funcional para caminar 0-70



grados
retroceso femoral posterior


mecanismo de tornillo


la meseta tibial medial es cóncava



creando un punto de pivote

la meseta lateral es convexa, lo


que permite el retroceso del fémur

durante la flexión
efecto neto


influye en la cantidad de flexión



terminal de la rodilla
la tibia rota externamente con la


extensión de la rodilla

Clasificación 


Clasificación de Schatzker

Clasificación de Schatzker


Tipo i Fractura paciente joven 
dividida con hueso
lateral subcondral
fuerte

Tipo II Fractura más común 
 lateral Split-
 deprimida

Tipo III Fractura por poco común, 
depresión ancianos
pura lateral osteoporóticos

Tipo IV Fractura de dislocación fx 
  meseta asociada
 medial alta tasa de
NV y lesiones
  de ligamentos


Tipo V Fractura tibial spines 
bicondílea remain
continuous
with shaft

Type Metaphyseal- significant soft- 
VI diaphyseal tissue injury
disassociation


Hohl and Moore Classification
Useful for


true fracture-dislocations


fracture patterns that do not fit into the



Schatzker classification (10% of all

tibial plateau fractures)
fractures associated with knee


instability

Hohl and Moore Classification of proximal tibia

fracture-dislocations

 
Type I Coronal split fracture 

Type II Entire condylar fracture 

Type III Rim avulsion fracture of  
lateral plateau
Type IV Rim compression fracture 
Type V Four-part fracture 


3-column concept   
tibial plateau divided into 3 columns


medal column


lateral column


posterior column


utility


includes posterior plateau fractures



that are not considered in Schatzker

classification
helps determine fixation strategy


Presentation 


History
mechanism of injury


high-energy vs low-energy


unable to bear weight after injury



baseline functional status



comorbidities



Physical exam
inspection


look circumferentially to rule-out an



open injury
assess soft-tissues for timing of


operative intervention
palpation


evaluate for compartment syndrome




 varus/valgus stress testing
any laxity >10 degrees indicates


instability
often difficult to perform or deferred in


acute setting given pain

stability assessed in full extension


 neurovascular exam
perform ankle-brachial index if any


asymmetry in pulses 
ABI <0.9 proceed with arteriogram


assess tibial and common peroneal



nerve function

Imaging 


Radiographs
recommended views


AP 

lateral


oblique


oblique is helpful to determine



amount of depression
optional views


plateau view


10 degree caudal tilt to match



posterior tibial slope

findings


on AP

depressed articular surface 



sclerotic band of bone indicating



depression
abnormal joint alignment


fracture plane involving



medial/lateral plateau
on lateral


posteromedial fracture lines must



be recognized    
abnormal tibial slope



CT scan
indication


negative radiographs with high index



of suspicion for tibial plateau fracture

preoperative planning  


obtain after ex-fix if definitive



fixation delayed if soft-tissues are

not amenable for surgery
findings


articular depression


degree of comminution


fracture plane and location



posterior coronal split fracture best



appreciated on axial and sagittal

views
lipohemarthrosis indicates an occult


fracture   


MRI
indications


not well established



identify meniscal and ligamentous



pathology 
occult fractures


DIFFERENTIAL 


Distal femur fracture 


Knee dislocation 


Patella instability 


Patella fracture 


Patella tendon rupture 


Quadriceps tendon rupture 


ACL tear 


Meniscus tear 

Treatment 


Nonoperative
closed reduction / immobilization


indications


minimally displaced split or



depressed fractures
low energy fracture stable to


varus/valgus alignment
nonambulatory patients


significant comorbidites that



preclude surgical intervention

modalities


patella-tendon-bearing (PTB) cast



knee immobilizer


hinged knee brace




Operative
ORIF (acute vs staged)    


 
 indications
 articular depression > 5-10 mm
 condylar widening > 5mm
 varus/valgus instability >10 deg
 medial plateau fractures 
 bicondylar fractures
 timing
 acute ORIF
lower-energy fractures with


mild swelling
 temporizing knee-spanning
external fixation w/ delayed ORIF
        
  
significant soft tissue


injury/swelling
polytrauma


 outcomes
 restoration of joint stability is
strongest predictor of long-term
outcomes
 postoperative infection after ORIF
associated with   
male gender


smoking


pulmonary disease


bicondylar fracture patterns



intraoperative time over 3



hours
 timing of definitive fixation (before,
during or after) relative to
fasciotomy closure does not
increase the risk of infection  

 worse results with
ligamentous instability


   
meniscectomy


alteration of limb mechanical



axis > 5 degrees    

 external fixation/Ilizarov +/- limited
open/percutaneous fixation of articular
segment
indications


severe open fracture with marked



contamination
highly comminuted fractures where


internal fixation not possible

outcomes


higher malunion rates



 arthroplasty
indications


consider in patients >65-years-old



with osteoporotic bone

outcomes   


earlier time to weight bearing



improved outcomes for primary



TKA compared to TKA for failed

ORIF

Techniques 


Closed reduction / immobilization
technique


NWB or PWB in a hinged-knee brace



for 8-12 weeks

early passive ROM is important to


maintain motion


Knee-spanning external fixation
(temporary)
technique


place pins outside area of planned



definitive fixation
two 5-mm half-pins in femur and


two in tibia shaft

axial traction applied to fixator


indirect reduction of fracture



through ligamentotaxis
fixator is locked in slight flexion to


avoid tensioning posterior NV

structures
advantages


allows soft tissue swelling to decrease



before definitive fixation  

decreases rate of infection and wound


healing complications    
restores length and alignment which


helps to better characterize fracture on

preop CT
findings


transient increase in leg compartment



pressures during external fixator

placement  
not been shown to increase risk of


compartment syndrome


External fixation with limited internal
fixation (definitive)
technique 


reduce articular surface either



percutaneously or through small

incisions
stabilize reduction with percutaneous


lag screws or wires

must keep wires >14mm from joint


to avoid intracapsular pin

placement
pros


minimizes soft tissue insult



cons


pin site complications



arthrofibrosis


incidence as high as 15% after



temporizing external fixator  


 high malunion rates    


Open reduction internal fixation 
goals


restore alignment


coronal

sagittal


tibial slope


normal condylar width



congruent articular surface



stable knee


minimize additional soft tissue trauma



approach


anterolateral approach (most



common)
supine 

lazy S or hockey stick incision



centered over Gerdy's tubercle

elevate anterior compartment


musculature and IT band

submeniscal arthrotomy to assess


articular surface and meniscus tear

posteromedial incision


supine with leg in figure-4 or prone



interval between pes anserinus



and medial head of gastrocnemius

      
 can be extensile and access
posterolateral column
release medial head of


gastrocnemius off femur

elevate soleus and popliteus


 articular surface not routinely

visualized directly
fluoroscopically or


arthroscopically
 posterolateral approach 
 prone or lateral
 biceps and peroneal nerve
retracted lateral
 lateral gastroc and soleus
retracted medial
 fibular neck osteotomy
 posterolateral access infrequently
used due higher risk of NV
complication
 posterior
 can be used for posterior shearing
fractures   
 midline incision (if planning TKA in
future)
 can lead to significant soft tissue
stripping and should be avoided
 dual surgical incisions with dual plate
fixation       
      
indications


bicondylar tibial plateau



fractures
 reduction
assess reduction


submeniscal arthrotomy


fluoroscopically


arthroscopically


depressed fragments


open fracture split and elevate



("open the book")

create cortical window


and elevated with bone tamps

fill metaphyseal void


three main options



autograft (ICBG - rare)



allograft (cancellous chips)



bone graft substitutes



calcium phosphate cement



     
  
 high compressive
strength for filling
metaphyseal void
less subsidence


than ICBG
 osteoconductive
 biodegradable
 highly porous
 internal fixation
absolute stability constructs should be


used to maintain the joint reduction 


 screws
 can be used in isolation but often
used in conjunction with plate
fixation
isolated depression


simple split fracture



 options
raft screws


placed in subchondral bone



parallel to joint surface to

support elevated articular
fragments
lag screws


placed perpendicular to


plane of split fractures

  plate fixation
 conventional non-locking plates 

 buttress plates best indicated

for partial articular fractures
     
posteromedial fractures


simple split


peri-articular locking plates



fixed angle mitigates risk of



varus collapse
comminuted fractures


osteoporotic bone


 postoperative
hinged knee brace with early passive
ROM
gentle mechanical compression on


repaired osteoarticular segments

improves chondrocyte survival 

 NWB or PWB for 8 to 12 weeks

Complications 


Post-traumatic arthritis
incidence


25-35%


5-7% undergo TKA at 10+ years




 risk factors for arthritis 
 meniscectomy
 malalignment > 5 deg
 instability
 risk factors for future TKA
 age
 bicondylar fracture
 increasing comorbidities


Compartment syndrome 
incidence


7-20% 

risk factors 


Schatzker type IV


high-energy mechanism


associated fibula fracture



fracture length


associated plateau-shaft injury



treatment


emergent fasciotomy



Infection
incidence


2-11%


risk factors


poor surgical timing based on swelling



open fractures


longer operative time



treatment


irrigation and debridement + IV abx



removal of hardware if loose or



grossly infected
ex-fix and staged revision ORIF


retain hardware if fracture still healing



and implant still providing stability


Nonunion/malunion
incidence


2-4% 

uncommon due to rich blood



supply of cancellous bone

risk factors


Schatzker type VI (metaphyseal-



diaphyseal junction)
comminution


unstable fixation


treatment


revision osteosynthesis augmented



with bone graft


Knee stiffness
incidence


10-25%


risk factors 


increasing age


higher BMI


severity of fracture


prolonged immobilization


involvement of tibial eminence



polytrauma


treatment


arthroscopic lysis of adhesions with



MUA
indicated if unable to achieve 90


deg of flexion within 4 weeks


Loss of reduction
incidence


5-30%

risk factors


inadequate fixation


severity of fracture


osteoporosis


treatment


revision ORIF to address inadequate



fixation
i.e. posteromedial buttress plate


for coronal fracture not captured

with lateral plate only


Deep vein thromobosis
incidence


nonoperative 9%


operative 6%


Prognosis 


Mortality rate 
5% at 1 year



Return to work
70-90% at 1 year


residual dysfunction or reduced work



load is common


Mean ROM
10-145 degrees at 1 year


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 TECHNIQUE GUIDES (2) 

Bicondylar Tibial Plateau ORIF with Lateral

Locking Plate
Orthobullets Team

 Trauma - Tibial Plateau Fractures

Tibial Plateau Fracture External Fixation

Orthobullets Team

 Trauma - Tibial Plateau Fractures

 FLASHCARDS (145) 

Settings 

Tibial Plateau Fractures OBC

Epidemiology

What percent of all fracture are tibial plateau

fractures?

 Show Bullets

by Daniel Tarazona

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 EVIDENCE (200) 

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Evidence

PMID: 28630761 EFORT Open Rev. 2017…

Partial proximal tibia fractures.

Raschke MJ Kittl C Domnick C.

 Trauma - Tibial Plateau Fractures

Raschke MJ, EFORT 2017

52 views 5/1/2017

2.7
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PMID: 28461952 EFORT Open Rev. 2016…

Treatment strategy for tibial plateau fractures:

an update.
Prat-Fabregat S Camacho-Carrasco P.

 Trauma - Tibial Plateau Fractures

Prat-Fabregat S, EFORT 2016

136 views 5/1/2016

3.3
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PMID: 23200030 Injury. 2013 Feb;44(2):2…

Prolonged operative time increases infection

rate in tibial plateau fractures.
Colman M Wright A Gruen G Siska P Pape HC Tarkin I.

 Trauma - Tibial Plateau Fractures

Colman M, INJURY 2013

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84 views 2/1/2013

3.0
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 VIDEOS & PODCASTS (12) 

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All Videos (10) Podcasts (2)

Orthopaedic Summit Evolving Techniques 2020 3/25/2022

Open Tibial Plateau Fractures: When To Use A

Flap, What's The Right One To Use, How I Can
Help - Theodore Kung, MD
 Trauma - Tibial Plateau Fractures
108 views

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4/22/2021

Repair of Tibial Plateau Fracture Schatzker II -

Kenneth A. Egol, MD
 Trauma - Tibial Plateau Fractures

689 views

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4/9/2021

Anterolateral Approach to the Lateral Tibial

Plateau.
Kemal Gokkus

 Trauma - Tibial Plateau Fractures

526 views

5.0 (1)
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Trauma
 | Tibial Plateau 10/15/2019
Fractures
 Trauma - Tibial Plateau Fractures

22:55 min
  Listen Now
2570 plays

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Question
 Session Tibial 11/8/2019
Plateau Fractures & Physeal
Considerations
Orthobullets Team

 Trauma - Tibial Plateau Fractures

25:6 min
  Listen Now
216 plays

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 CASES (46) 

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Novant Health Orthopedics & Sports Medicine Institute 7/2/2022


Tibial Plateau Fracture in 36F (C102065)
Lisa Cannada

 Trauma - Tibial Plateau Fractures

10690  51  149 

 4/30/2022

Tibia Plateau Fracture in 43M (C102039)

Travis Jones

 Trauma - Tibial Plateau Fractures

203  9  2 

 17/11/2021

Tibia Plateau Fracture in 68F (C101853)

Travis Jones

 Trauma - Tibial Plateau Fractures

155  7 0

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 COMENTARIOS DE EXPERTOS ( 48 ) 

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COMENTARIO RECIENTE

anton lambers
22:04 el 10/07/22

Un buen artículo de analogía: el enfoque

posterior de la meseta comparado con el
enfoque FCR de la muñeca:

PMID: J Orthop Trauma. 2020

31821275 junio;34(6):e221-e224.

The "FCR" Approach to the Knee for

the Management of Posterior Tibial
Plateau Fractures.
Berwin JT | Donovan RL | Riddick A | Kelly MB.

Comments (47) 

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