AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

The tibial plateau is one of the most critical load-bearing areas in the human body; fractures of the plateau affect knee alignment, stability, and motion. Early detection and appropriate treatment of these fractures are critical in minimizing patient disability and reducing the risk of documented complications, particularly posttraumatic arthritis.

History of the Procedure

Sir Astley Cooper first described fractures of the proximal tibia in 1825. Anger treated most minimally displaced fractures with early knee traction mobilization.¹

Rausmusen introduced open reduction and internal fixation of tibial condylar fractures, and Sarmiento popularized functional cast bracing of most tibial condylar fractures.^{2, 3}

Frequency

More than 50% of patients who sustain a tibial plateau fracture are aged 50 years or older. The increased frequency of tibial plateau fractures in older females is due to the increased prevalence of osteoporosis in these individuals. Tibial plateau fractures in younger patients are commonly the result of high[energy injuries.

Etiology

The most common mechanism resulting in a tibial plateau fracture is a valgus force with axial loading. Of these injuries, 80% are motor vehicle–related injuries and the remainder are sports-related injuries. A bumper- or fender-related injury from a vehicle-pedestrian collision constitutes more than 25% of tibial plateau fractures. Trauma can be direct or related to a fall from a height, an industrial accident, or a sports injury.

Tibial plateau fractures may either low energy or high energy. Low-energy fractures occur in osteoporotic bone and typically are depressed fractures. High-energy fractures occur in low-energy patients often as a result of motor vehicle–related trauma, and the most common pattern of fracture in this group is a splitting fracture.

Pathophysiology

Classification:

There have been many classifications of tibial plateau fractures. In 1900, Muller proposed a classification system for tibial plateau fractures that categorized fractures based on the amount of articular involvement. Hohl and Luck proposed a classification of plateau fractures that included nondisplaced, local-depression, split-depression, and splitting fractures.⁴ Hohl later expanded the classification to include comminuted fractures.⁵ In 1981, Moore proposed a classification system for fracture-dislocation of the tibial condyle that took into consideration soft-tissue injury.⁶ 

Schatzker et al proposed a classification system of condyle fractures based on the fracture pattern and fragment anatomy, which he grouped into 6 types. This classification system, as follows, is widely accepted and used⁷:

• Type I is a wedge or split fracture of the lateral aspect of the plateau, usually as a result of valgus and axial forces. With this pattern, the wedge fragment is not compressed (depressed) because the underlying cancellous bone is strong. This pattern is usually seen in younger patients.
• Type II is a lateral wedge or split fracture associated with compression. The mechanism of injury is similar to that of a type I fracture, but the underlying bone may be osteoporotic and unable to resist depression, or the force may have been greater.
• Type III is a pure compression fracture of the lateral plateau. As a result of an axial force, the depression is usually located laterally or centrally, but it may involve any portion of the articular surface.
• Type IV is a fracture that involves the medial plateau. As a result of either varus or axial compression forces, the pattern may be either split alone or split with compression. Because this fracture involves the larger and stronger medial plateau, the forces causing this type are generally greater than those associated with types I, II, or III.
• Type V fractures include split elements of both the medial and the lateral condyles and may include medial or lateral articular compression, usually as a result of a pure axial force occurring while the knee is in extension.
• Type VI is a complex, bicondylar fracture in which the condylar components separate from the diaphysis. Depression and impaction of fracture fragments is the rule. This pattern results from high-energy trauma and diverse combinations of forces.

Clinical

Full clinical assessment is required, including evaluation of the soft tissues to determine whether a compartment syndrome is present and whether the patient has sustained a neurovascular injury. Gentle stress testing can be performed with the leg in extension in order to evaluate the stability of the ligaments and to assess any sign of fracture displacement. Approximately 50% of the knees with closed tibial plateau fractures have injuries of the menisci and cruciate ligaments that usually require surgical repair. Because of the valgus stress at the moment of impact, the medial collateral ligament is at greater risk than the lateral collateral ligament; however, disruption of the lateral collateral ligament is of grave concern because of possible injuries to the peroneal nerve and the popliteal vessels. Dislocation-relocation injuries are more common with medial plateau injuries and carry an increased risk of peroneal nerve damage.

INDICATIONS

Section 3 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

Fracture displacement ranging from 4-10 mm can be treated nonoperatively; however, a depressed fragment greater than 5 mm should be elevated and grafted.

The following are absolute indications for surgery:

• Open plateau fractures
• Fractures with an associated compartment syndrome
• Fractures associated with a vascular injury

The following are relative indications for surgery:

• Most displaced bicondylar fractures
• Displaced medial condylar fractures
• Lateral plateau fractures that result in joint instability

RELEVANT ANATOMY

Section 4 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

The knee is a complex joint, exposed to forces in excess of 5 times the weight of the body. The joint has enhanced mobility at the cost of stability. The proximal tibia expands from the diaphysis through a metaphyseal flare. Contact is made with the head of the fibula in the posterolateral quadrant. The surface of the tibial plateau has a medial and a lateral weight-bearing portion and an intercondylar eminence, which is both nonarticular and non–weight-bearing. The medial plateau is generally larger than the lateral plateau.

The intercondylar eminence provides attachment to the medial and lateral menisci and the anterior and posterior cruciate ligaments.

The normal knee is in physiologic valgus alignment. Most of the load transmitted across the knee is medial to the eminence, and therefore, the knee has stronger cancellous bone. 

Because the medial condyle is rounded as compared with the lateral condyle, some of the anterior articular surface of the lateral plateau is exposed, especially during extension. This causes the lateral plateau to be more susceptible to bone injury and is the reason why fractures of the lateral plateau are more common than those of the medial plateau.

CONTRAINDICATIONS

Section 5 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

Contraindications to surgical treatment include (1) the presence of a compromised soft-tissue envelope (for immediate open reduction) and (2) fractures that do not result in joint instability or deformity and can therefore be treated with nonoperative modalities.

WORKUP

Section 6 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

Lab Studies

Imaging Studies

• Anteroposterior (AP), lateral, and oblique radiographs
• • Most tibial plateau fractures are easy to identify on standard AP and lateral projections of the knee. Lateral views should not be considered adequate if a rotational component obscures the visualization of the femoral condyles as one unit. Rotational malalignment can lead to missed zones of injury and an inaccurate estimation of the degree of articular depression.
  • With minimally displaced vertical split fractures, the fracture line often lies in an oblique plane and is therefore not visible on an AP or lateral radiograph. Oblique projections should be added if a nondisplaced tibial plateau fracture is suspected but not seen on the standard projections.
  • The following subtle radiologic signs may indicate the presence of an underlying plateau fracture:
    • Lipohemarthrosis: The presence of a fat/fluid level in the suprapatellar recess on the horizontal-beam lateral projection of the knee indicates that a fracture has occurred and has allowed fatty marrow to enter the joint.
    • Increased trabecular density beneath the lateral plateau on an AP film: The medial tibial condyle normally has greater trabecular density because it bears more body weight.
    • Nonalignment of the femoral condyles and tibia on the AP view.
• Tibial plateau radiograph: An AP projection of the knee, angled 15° caudally (tibial plateau view), can provide a more accurate assessment of the depth of plateau surface depression.
• Traction radiographs: These images provide a clearer image of the fracture configuration after anatomic alignment is restored. Areas of bone loss resulting from comminution can be mapped, and the appropriate size and length of the necessary implants can be ascertained.
• Contralateral knee/extremity radiographs: Corresponding views of the uninjured leg are necessary for each patient to receive accurate restoration of length and alignment of the leg.
• CT scan: By acquiring thin axial slices through the knee and reconstructing the image data in the sagittal and coronal planes, more detailed information is provided. The information obtained from a CT scan can help determine the best surgical approach based on the fracture planes seen on the computer images. Three-dimensional spiral CT reconstructions yield a better and more accurate demonstration of the tibial plateau fracture. They present the anatomy in the view the surgeon will see when surgery is performed.
• Magnetic resonance images
• • MRI is acknowledged as a reliable and accurate tool to assess meniscal, collateral, and cruciate ligamentous injury. Also, occult fractures of the tibial plateau can be identified by MRI. A bone bruise is indicated by epiphyseal and metaphyseal changes in T1- and T2-weighted images. The signals indicate normal articular and cortical bone changes and reflect changes in bone marrow. They are thought to represent edema, hyperemia, hemorrhage, and microfracture. Plateau fractures may be visualized on MRIs, even when plain film radiographs are normal.
  • A major advantage of MRI over CT scanning is that MRI does not use ionizing radiation. Disadvantages include the higher cost and greater time needed to complete the study (25 min for MRI vs 20 sec for a CT scan), which means that motion artifact can be a problem.

Other Tests

Diagnostic Procedures

TREATMENT

Section 7 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

Immediate management

All high-energy fractures need to be immediately checked for soft-tissue integrity and impending compartment syndrome. The overall management can be one of the following.

• Antiedema measures: Joint aspiration, rest, immobilization, compression, elevation, and other antiedema measures are advocated in patients with high-energy fractures surrounded by evidence of compromised soft tissues (eg, skin blisters, edema). Limbs with features suggestive of compartment syndrome should not be treated with antiedema measures.
• Traction: Traction can be used as a temporary or definitive management modality. Calcaneal traction can be continued during the traction mobilization treatment of selected plateau fractures without gross articular incongruity. Traction is contraindicated in patients undergoing vascular repairs.
• Debridement of open injuries: Open fractures need to be addressed based on the universal guidelines. Patients optimally undergo surgical debridement of open traumatic wounds within 8 hours of injury. Aggressive debridement of open fracture wounds is performed, including removal of contaminating debris and any devitalized fascia, muscle, and bone.
• Fasciotomy for impending compartment syndrome: This requires emergency treatment because a delay in treatment is directly correlated with further damage. If signs of compartment syndrome are present, 4 compartment fasciotomies are performed.
• Spanning external fixator: Closed fractures undergo external fixator placement based on patient stability and operating room availability, unless the patient has signs of compartmental syndrome. Patients undergoing debridement for open fractures and fasciotomy for compartment syndrome can be treated with a temporary external fixator until the soft-tissue condition improves.

Definitive management

Treatment of these fractures is governed by the vascularity (local tissue and distal), the condition of soft tissues, and the presence or absence of compartment syndrome. Not all fractures of the tibial plateau require surgery. The first challenge in the management of upper tibial fractures is to decide between nonoperative and surgical treatment.

Medical therapy

Nonoperative treatment

In the past, long leg cast and traction mobilization were used for some fractures; however, the Sarmiento program of functional cast bracing is now preferred.

• Indications
  • Nondisplaced stable split fractures
  • Minimally displaced or depressed fractures
  • Submeniscal rim fractures
  • Fractures in elderly, low-demand, or osteoporotic patients
• Advantages
  • Simple technique
  • No surgical trauma or risk for sepsis
  • Shorter hospital stay
  • Early joint mobilization (only if functional cast brace is used) and delayed weightbearing
• Disadvantages
  • Risk of displacement and need for surgery (follow-up with imaging studies every 2 wk for 6 wk; activity restriction for 4-6 mo)
  • Prolonged immobilization and related complications: If traction is used, good motion is obtained at the cost of a lengthy hospital stay and the risk of pin-tract infection. Related complications of recumbency can include pulmonary embolism or phlebitis.
  • Joint stiffness (if immobilization >2-3 wk)
  • Instability and posttraumatic arthritis in the long term

Surgical therapy

Open or arthroscopic-assisted techniques are considered for fractures with displacement, depression of the condylar surfaces, or both. Open surgical therapy can be immediate or staged.

Operative treatment

• Internal fixation (can be an immediate or a staged procedure)
  • Biologic fixation - screw fixation, minimally invasive plate osteosynthesis, least invasive stabilization system
  • Arthroscopic-assisted fixation
  • Conventional double plating
• External fixation
  • Ilizarov fixator
  • Hybrid fixator
• Combination devices

Surgical principles

The ultimate goals of tibial plateau fracture treatment are to reestablish joint stability, alignment, and articular congruity while preserving full range of motion. In such a case, painless knee function may be achieved and posttraumatic arthritis may be prevented.

If fracture displacement is great enough to produce joint instability, operative management should be selected. Current internal fixation techniques include ligamentotaxis, percutaneous fixation, and antiglide techniques. When extensive comminution and damaged soft tissues prohibit the use of internal fixation, circular external fixators are an excellent fallback option for management.

Unicondylar and bicondylar plateau fractures in young patients with good bone stock and only a few well-defined articular fragments do well with modern reduction and internal fixation techniques. For osteopenic elderly persons with a bicondylar plateau fracture or for patients who are unable to cope with adequate pin care, a functional brace, possibly followed by a total knee arthroplasty, may be preferable.

Regardless of whether internal or external fixation techniques are used, appropriate management of soft tissues is an important factor in the successful management of severe injuries of the proximal tibia.

Fixation of tibial plateau fractures must be rigid, and fracture stability should be maintained. If fixation implants are obviously loose or provide inadequate fixation, they should be removed. Intra-articular sepsis combined with fixation instability results in rapid chondrolysis and destruction of the joint.

Treatment of different types of tibial plateau fractures

• Type I: Preoperative MRI or arthroscopy is necessary to visualize the lateral meniscus and the fracture. When the fracture is displaced, the lateral meniscus is commonly detached peripherally and, not infrequently, trapped within the fracture site. If a peripheral tear is present, with or without incarceration of the meniscus in the fracture site, open reduction and internal fixation is recommended with meniscal repair. If the meniscus is intact, closed reduction and percutaneous cannulated cancellous screw fixation is preferred. The quality of the reduction is assessed arthroscopically or with an image intensifier. If satisfactory reduction is not possible by closed means, open reduction is used.
• Type II: With joint instability, surgery should be used to address the impacted articular fragments. In these fractures, the depressed fragment must be elevated and supplemented with a bone graft. This can be performed either intra-articularly, elevating the anterior horn of the lateral meniscus, or by making a window in the lateral condyle and elevating the fragment with support from graft material and fixation with a buttress plate. If depression is anterior or central, a straight lateral parapatellar skin incision with transverse submeniscal joint exposure is better. Preservation and repair of the lateral meniscus is the goal. With the use of an impactor from below, the fracture fragments are disimpacted, elevated, and supported with a bone graft. In the case of minimal comminution of the lateral condyle, cancellous screws with washers suffice, while a buttress plate is advocated for a comminuted fracture in soft osteoporotic bone.
• Type III: If the depression is small and the joint remains stable, nonoperative treatment is preferred in elderly persons. However, if the joint is unstable in a physiologically younger patient, surgery is usually indicated. The depressed fracture can be visualized with arthroscopy or under a C-arm. A window is made in the metaphyseal region, the depressed articular surface is elevated, and the subarticular portion is supported with a graft and then supported with 1-2 cannulated screws or with a plate.

  (Formal open reduction and plate fixation for Schatzker type I-III fractures is an alternative to arthroscopically assisted reduction and fixation. Direct visualization of the reduction of the joint surface can be obtained via a submeniscal arthrotomy or by detaching the anterior horn of the lateral meniscus using a lateral approach. In cases with wide displacement, associated fibular head fracture, and osteoporotic bone, buttressing with a plate provides better fixation than screws alone and may decrease the risk of collapse of the elevated fragments. If in doubt, buttressing should be used.)

• Type IV: Because these are high-energy injuries, they may be associated with soft-tissue injuries and sometimes neurovascular injuries and knee dislocation, thereby adding to the knee instability. Nonoperative treatment is indicated only for nondisplaced fractures. Patients with good bone stock who have sustained low-energy trauma are better treated by closed reduction and percutaneous cannulated cancellous screw fixation. In those with high-energy fractures with tearing of the lateral collateral ligament or fracture of the fibular head, a midline or medial parapatellar approach and extraperiosteal approach is preferred.

  The fracture must be elevated, reduced, and supported by a buttress plate, and the soft tissues should be repaired. If the intercondylar eminence with the cruciate is avulsed, it should be reduced and fixed with a lag screw or loop of wire. In patients with a predominant posterior fragment, an additional posteromedial incision may be necessary. The poor prognosis associated with these fractures is due to related neurovascular injury, soft-tissue instability, increased demands placed on the articular surface of the medial plateau with weight bearing, and the high-energy forces involved in producing these fractures.

• Types V and VI: These complex plateau fractures are usually due to high-energy forces and are often associated with compromise of the surrounding soft tissues. In these cases, extensible exposure of the upper tibia with subperiosteal placement of large implants should be avoided. This approach has been associated with an increased risk of wound dehiscence and infection. Fractures involving both condyles routinely require repair. The plateau with the most severely involved articular surface should be plated first. The less involved side should be treated with minimal, biologic fixation using percutaneous implants, limited posteromedial incisions, or a small external fixator to minimize exposure and bone stripping. They are frequently comminuted, and the shaft may be dissociated with the metaphysis. Many of these fractures are better treated with external fixation.

Summary of indications, advantages, and disadvantages of various treatment modalities used for tibial plateau fractures

• Percutaneous screw fixation
  • Indications - Nondisplaced type I fractures
  • Advantages - Simple technique with minimal soft-tissue injury
  • Disadvantages - Not applicable for other patterns of fracture
• Percutaneous elevation and screw fixation
  • Indications - Type II and III fractures; bone grafting if severe depression (>10 mm) in osteoporotic bone
  • Advantages - Simple technique with minimal soft-tissue injury
  • Disadvantages - Not useful for high-energy fractures with ligamentous and meniscal injuries
• Arthroscopic-assisted elevation and screw fixation
  • Indications - Types I, II, III, and IV fractures with ligamentous and meniscal injuries
  • Advantages - Minimal soft-tissue injury; helps to diagnose and treat intra-articular injuries; aids in reduction of depressed articular fractures; allows for joint lavage
  • Disadvantages - Not useful in high-energy fractures
• Open reduction and internal fixation with or without bone grafting
  • Indications - Types III, IV, V, and VI fractures without soft-tissue injury
  • Advantages - Allows anatomic reduction with rigid internal fixation and bone grafting; facilitates joint exploration and treatment of intra-articular injuries
  • Disadvantages - Should not be performed in the acute setting in the presence of soft-tissue injury; unnecessary for type I fractures
• Biologic internal fixation
  • Indications - Types IV, V, and VI fractures with minimal displacement and comminution; polytrauma patients
  • Advantages - Simple technique with minimal soft-tissue injury; retention of fracture hematoma
  • Disadvantages - Not useful in severely comminuted and depressed fractures
• External fixators - Half-pin fixator, ring fixator, hybrid fixator
  • Indications - Open injuries and high-energy (types IV, V, and VI) fractures with soft-tissue injury; fractures with vascular injury with or without compartment syndrome; polytrauma patients
  • Advantages - Minimal soft-tissue injury
  • Disadvantages - Nonrigid fixation; difficult to achieve anatomic fracture reduction; joint stiffness; pin-tract infections; septic arthritis

Postoperative details

Recovering range of motion is a challenge for patients who (1) cannot actively participate in rehabilitation, (2) may have soft-tissue injuries that preclude immediate range of motion, and (3) have had external-fixation pins inserted near their quadriceps. Because of the potential disability associated with chronic flexion contracture, after surgery, these patients should be placed in a hinged knee brace that is locked in extension. A padded bump under the heel is used both in the hospital bed and at home after discharge to maximize knee extension. Motion is restricted until surgical and traumatic wounds are dry. Continuous passive motion begins when wounds are dry; the goal is full extension and 90° of flexion within 5-7 days. If other injuries allow, the patient is mobilized with a hinged brace locked in extension for 6 weeks.

Follow-up

Non–weight-bearing precautions generally continue for 12 weeks. Active flexion and passive extension are encouraged for 6 weeks, after which active knee extension is started. Active knee extension is delayed if open reduction and internal fixation of a tibial tubercle avulsion was required.

COMPLICATIONS

Section 8 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

Complications can be divided into early (eg, loss of reduction, deep vein thrombosis, infection) or late (eg, nonunion, implant breakage, posttraumatic arthritis). Most early complications can be viewed as biologic failures, while late complications are often associated with mechanical problems.

Early complications

• Compartment syndrome
• Vascular injuries
• Swelling and wound-healing problems
• Infections
• Deep vein thrombosis
• Nerve injuries

Late complications

• Knee stiffness
• Knee instability
• Angular deformities
• Late collapse
• Malunion
• Osteoarthrosis

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

Media file 1:  Type II tibial plateau fracture in a young active adult with good bone stock treated with percutaneous elevation and cannulated cancellous screw fixation without bone grafting.
	View Full Size Image
Media type:  X-RAY

Media file 2:  Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous elevation, bone grafting, and cancellous screw fixation.
	View Full Size Image
Media type:  X-RAY

Media file 3:  Type VI tibial plateau fracture undergoing biological fixation of the lateral condyle and external fixation of the medial plateau, resulting in an acceptable clinical and radiological result.
	View Full Size Image
Media type:  X-RAY

Media file 4:  Type II tibial condyle fracture involving the tibial spine and more than 50% of the medial condyle fixed with biological buttress plating of the lateral plateau.
	View Full Size Image
Media type:  X-RAY

Media file 5:  Type VI tibial plateau fracture with severe soft tissue injury successfully treated with Ilizarov external ring fixator.
	View Full Size Image
Media type:  X-RAY

Media file 6:  High-energy type VI tibial plateau fracture treated with bone grafting and double plating after the soft tissue condition improved.
	View Full Size Image
Media type:  X-RAY

Media file 7:  Type IV medial tibial condyle fracture treated with arthroscopy-assisted elevation and percutaneous cancellous screw fixation along with percutaneous screw fixation of the tibial spine fracture.
	View Full Size Image
Media type:  X-RAY

Media file 8:  Shown is an intra-articular fracture of the medial condyle of the tibial plateau.
	View Full Size Image
Media type:  X-RAY

Media file 9:  Shown is a Schatzker type V fracture, with a displaced and depressed medial tibial plateau.
	View Full Size Image
Media type:  X-RAY

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Multimedia
• References

1. Burrows HJ. Fractures of the lateral condyle of the tibia. J Bone Joint Surg Br. Aug 1956;38-B(3):612-3. [Medline].
2. Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am. Oct 1973;55(7):1331-50. [Medline].
3. Sarmiento A. Functional bracing of tibial and femoral shaft fractures. Clin Orthop Relat Res. Jan-Feb 1972;82:2-13. [Medline].
4. Hohl M, Luck JV. Fractures of the tibial condyle; a clinical and experimental study. J Bone Joint Surg Am. Oct 1956;38-A(5):1001-18. [Medline].
5. Hohl M. Tibial condylar fractures. J Bone Joint Surg Am. Oct 1967;49(7):1455-67. [Medline].
6. Moore TM. Fracture--dislocation of the knee. Clin Orthop Relat Res. May 1981;(156):128-40. [Medline].
7. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968--1975. Clin Orthop Relat Res. Jan-Feb 1979;(138):94-104. [Medline].
8. Agnew SG. Tibial plateau fractures. Oper Tech Orthoped. 1999;9(3):197-205.
9. Dennan S. Difficulties in the radiological diagnosis and evaluation of tibial plateau fractures. Radiography. 2004;10:151-8.
10. Lubowitz JH, Elson WS, Guttmann D. Part I: Arthroscopic management of tibial plateau fractures. Arthroscopy. Dec 2004;20(10):1063-70. [Medline].
11. Lubowitz JH, Elson WS, Guttmann D. Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures. Arthroscopy. Jan 2005;21(1):86-92. [Medline].
12. Mills WJ, Barei DP. High-energy tibial plateau fractures: Staged management. Oper Tech Orthoped. 2003;13(2):96-103.
13. Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, et al. Complications after tibia plateau fracture surgery. Injury. Jun 2006;37(6):475-84. [Medline].
14. Smith WR, Shank JR. Tibial plateau fractures: Minimally invasive fracture techniques. Oper Tech Orthoped. 2001;11(3):187-94.

Article Last Updated: Sep 24, 2007