Posterolateral Fractures of the Tibial Plateau Revisited: A Simplified Treatment Algorithm

Abstract

High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980–May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by Schatzker and Kfuri, we suggest a simplified treatment algorithm highlighting the two concepts (buttressing and containment) used for plating the PL tibial plateau fragments. Based on the available current evidence, we propose an algorithm for these two morphological types of PL tibial plateau fracture. Shear-type fractures need buttressing (the “rule of thumb”), whereas noncontained peripheral rim-type fractures need peripheral repair and containment. Contained pure depression fractures are not frequent and need percutaneous-assisted elevation and subchondral rafting, either controlled by fluoroscopy or arthroscopically. It is believed that such an approach would simplify their assessment and preoperative planning and would assist the clinicians to appreciate and manage more consistently these complex injuries.

The Study of Biomechanics and Clinical Anatomy on a Novel Plate Designed for Posterolateral Tibial Plateau Fractures via Anterolateral Approach

“…The treatment of PTPFs has been one of current hotspots ( Sun et al, 2018 ). Currently, there is no consensus about the optimal internal fixation selection for PTPFs treatment due to the complicated structures of the posterolateral corner of the knee including the fibular head, the fibular collateral ligament, the popliteus tendon, and the peroneal nerve, which impedes the exposure and fixation of the fracture fragments ( Heidari et al, 2013 ; Giordano et al, 2020 ; Song et al, 2020 ). The PTPFs treatment was proposed by some experts to use a posterior buttress plate via various posterolateral approaches to expose the fracture fragment directly.…”

“…As an intra-articular fracture, tibial plateau fracture requires anatomical reduction and rigid internal fixation. However, the operative treatment of PTPF is complex because of the special anatomical structures of the PL corner of the knee joint, including the fibular head, the fibular collateral ligament, the popliteus tendon, and the peroneal nerve, which impedes the exposure and fixation of the fracture fragments ( Heidari et al, 2013 ; Giordano et al, 2020 ; Song et al, 2020 ). Currently, there is no uniform standard for selecting optimal internal fixation to treat PTPFs.…”

A posterolateral sheared fracture of the tibial plateau: a case presentation

“…However, the tibial eminence was not involved in our case, indicating that the fragment was thinner and the fixation was more challenging. Giordano et al [ 8 ] described these posterolateral corner sheared fractures of the tibial plateau as “apple-bite” fractures, which were rare and infrequently mentioned in previously published reports. Also, these fractures were typically associated with ACL rupture, lateral meniscus injury, and MCL tears, due to rotational trauma when the knee was in a slight valgus position and flexed [ 8 – 10 ].…”

“…Giordano et al [ 8 ] described these posterolateral corner sheared fractures of the tibial plateau as “apple-bite” fractures, which were rare and infrequently mentioned in previously published reports. Also, these fractures were typically associated with ACL rupture, lateral meniscus injury, and MCL tears, due to rotational trauma when the knee was in a slight valgus position and flexed [ 8 – 10 ]. In some cases with possible ACL rupture, it is challenging to diagnose posterolateral corner rim fractures with radiographs due to the superimposition of the larger medial condyle [ 11 ].…”

“…In some cases with possible ACL rupture, it is challenging to diagnose posterolateral corner rim fractures with radiographs due to the superimposition of the larger medial condyle [ 11 ]. Thus, a CT scan and an MR imaging evaluation were highly recommended to achieve a comprehensive evaluation [ 8 ].…”