Study of Fracture Patterns in Tibial Plateu

 

 

Abstract               Background: Tibial plateau fractures must be properly identified before they can be treated. In the Schatzker classification, each increasing numeric fracture category indicates increasing severity and also an increasingly worse prognosis. Aim: To study the fracture patterns in tibial plateu. Material and Methods: In this prospective study 30 cases with closed tibial plateau fractures were studied for their patterns and classified according to Schatzker’s Classification. Results: majority of the fractures were found to be of Type IV (30%), followed by the Type VI (23.33%) and Type V (20%). Rest of the fracture types i.e. Type I, Type II and Type III were not that common and accounted for a total of 26.67% of all the 30 cases. Conclusion: Schatzker’s Classification is easily repeatable in clinical practice, to study the tibial plateau fracture patternsand it can be used as a further tool for surgical treatment.

Key Word: Tibial plateau fractures, Schatzker’s Classification, pattern

 

 

INTRODUCTION

Tibial plateau fractures are frequently intra-articular injuries with high potential of developing chronic pain, limited knee motion, post traumatic osteoarthritis and other related complications.¹Standard tibial plateau fractures involve cortical interruption or depression or displacement of the articular surfaces of the proximal tibia without concomitant significant injury to the capsule or ligaments of the knee.² Tibial plateau fractures must be properly identified before they can be treated. The Schatzker classification system focuses on standard tibial plateau fractures. This classification is based on the idea that certain pathoanatomic and etiological factors as well as therapeutic features demand that certain injury types be grouped together.^3,4 In the Schatzker classification, each increasing numeric fracture category indicates increasing severity, reflecting not only increased energy imparted to the bone at the time of injury but also an increasingly worse prognosis. Therefore, orthopedic surgeons find the Schatzker classification useful in assessing the initial injury, planning management, and predicting prognosis. In the present study an attempt was made to study the fracture patterns in tibialplateu.

 

MATERIAL AND METHODS

In this prospective study 30 cases with closed tibial plateau fractures admitted in Department of Orthopedics at a tertiary care hospital were studied over a period of two years. The study was approved by the local ethical committee and the patients gave their informed consent to participate.

Inclusion Criteria

• The patients with closed tibial plateau fractures.
• The patients of 18-55 yrs age group of both sexes.
• Closed and open (compound) injuries.

Exclusion Criteria

• Paediatric age group and patients with age more than 55 yrs old.
• Fractures of the shaft of the tibia below the level of tibial plateau.
• Foreign body sensitivity.

Detailed history, clinical examination and investigations were done. After anaesthetic fitness the patients were posted for surgery as early as possible. The tibial plateau fractures were divided into six types by Schatzker classification system: lateral tibial plateau fracture without depression (I), lateral tibial plateau fracture with depression (II), compression fracture of the lateral (IIIA) or central (IIIB) tibial plateau, medial tibial plateau fracture (IV), bicondylartibial plateau fracture(V), and tibial plateau fracture with diaphyseal discontinuity (VI). All operations were performed under pneumatic tourniquet. All the CC screw fixations and CREF with UMEX were done percutaneously following a closed reduction technique. For Open Reduction and Internal fixation with plating either anterolateral incision or anteromedial approach was used depending on the fracture. First, reconstruction of the articular surface was undertaken, followed by re-establishment of tibial alignment. Adequate buttressing of elevated articular segments with bone graft or bone graft substitute was used. The patients were discharged with the advice not to do heavy work and were followed up in OPD after 1week, 3 weeks, six weeks, and after that every month for at least 6 months.

RESULTS

The present study constituted 30 cases with closed tibial plateau fractures with maximum incidence in the age group of 21-30.Majority of the patients were male (60%) and the female were 40%.

 

Table 1: Age and Sex distribution

In our study we did not find any variance in the side of the limb involved as the no of cases with the involvement of the right and the left limb were equal. Majority of the patient’s mode of injury was road traffic injuries accounting for 80% of the total populations with compared to the patients with fall from height. In 7 patients associated injuries were observed. A 24 years old male patient came to casualty following a RTA had a blunt trauma to the abdomen with no signs of haemoperitonium, his fracture was managed with percutaneous CC screw fixation. Three patients came with fractures involving the lower end of radius, all the three cases had a history of RTA, out of which one case had a fracture of the lower end of radius of the opposite side, which was treated with closed reduction with 2 cross K-wires; another was having a undisplaced fracture of the lower end of radius of the ipsilateral side which was treated conservatively with a colle’s cast and third case was treated with ORIF with DCP for the fracture of the lower end of the radius with intraarticular extension of the opposite hand. A history of a RTA with head injury was observed in one case which was treated conservatively under the care of neurosurgeon. Case with ipsilateral femur shaft fracture was treated with femur interlock nailing along with the CREF of the tibial plateau fracture with UMEX. A 47 years old male with a history of fall from height from 1^st floor of a construction site with a calcaneum fracture treated conservatively.

 

Table 2: Characteristics of the injury

As per Schatzker’s Classification, majority of the fractures were found to be of Type IV (30%), followed by the Type VI (23.33%) and Type V (20%). Rest of the fracture types i.e. Type I, Type II and Type III were not that common and accounted for a total of 26.67% of all the 30 cases.

Table 3: Incidence of Type of fracture (Schatzker’s Classification)

 

DISCUSSION

Tibial plateau fractures are complex injuries of the tibial head and joint surface. Majority of the fractures occur in the age group of 21-40 years with maximum incidence being in the productive age group of 21-30.Sament R et al⁵showed an incidence of 19-60 years with average age of 36 years and Almisferet al showed a range of 23-55 years and an average of 34 yrs.⁶ In our study, majority of our patients were male i.e. 18 out of 30 i.e. 60%. This can be attributed to our typical Indian setup where the male population largely works outdoors making them more prone to RTAs or FFHs and the female population confined to indoor household work. In our study patients showed no variance in the sex distribution pattern. Sament R et al⁵ (85.7%) and Almisferet al⁶ (78.2%) in their study showed a high preponderance of male patients for tibial plateau fractures. Lee et al⁷ (65.71%) and Raza et al⁸ (85.36%) et al in their study also showed high incidence of tibiallateau fractures in males. Tibial plateau fractures are one of the most common fractures as a result of road traffic accident, fall from height, sports injury or assault. It is found that the increased modernization, mechanization and industrial development made more automobile accidents due to increase in the number of populations and automobiles. As tibial plateau is a result of high velocity injury, in our study we recorded 80% patients with history of RTA and 20% with history of fall from height. Similarly, Sament R et al⁵ studied 89.30% patients with cause of injury to be RTA and FFH to be 10.7%.Lee et al⁷ reported an incidence of 80% due to RTA and 11.50% due to FFH and 8.50% incidence of injuries due to shot gun injuries and direct blow. The Schatzker classification system divides tibial plateau fractures into six types. The first three types (I, II, and III) are typically the result of low-energy injury.^9,10 The second three types (IV, V, and VI) are typically the result of high-energy injury. However, relatively low-energy trauma to osteoporotic bones may produce fracture patterns similar to those of high-velocity injuries.¹¹ The magnitude of the force determines both the degree of fragmentation and the degree of displacement.⁹ The frequency and type of associated soft-tissue injury and the surgical approach vary by fracture type and are discussed under each fracture type. In our study patients we found 50% patients with Type I fracture, 20% with Type II and Type IV each and 10% with Type III. Sament R et al⁵in their study showed almost equal incidence of Type II and Type V fractures i.e. 39.28% and 35.71% respectively, and 16.07% and 8.92% with Type I and Type IV respectively. Almisfer et al⁶ showed an incidence of 82.60% patients with Type I and 17.40% of Type II fractures. In conclusion, the method of typing of tibial plateau fracture by Schatzker’s Classification is easily repeatable in clinical practice, to studytibial plateau fracture patterns.It can be used as a further tool for surgical treatment.

 

REFERENCES

1. Mattiassich G, Foltin E, Scheurecker G, et al. Radiographic and clinical results after surgically treated tibial plateau fractures at three and twenty two years postsurgery. IntOrthop 2014; 38:587-94. 
2. Moore TM. Fracture-dislocation of the knee. ClinOrthopRelat Res 1981; 156:128–140.
3. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto experience, 1968–1975. ClinOrthopRelat Res 1979; 138:94–104.
4. Schatzker J. Compression in the surgical treatment of fractures of the tibia. ClinOrthopRelat Res 1974; 105:220–239.
5. Sament R, Mayanger JC, Tripathy SK, Sen RK. Closed reduction and percutaneous screw fixation for tibial plateau fractures. J Orthop Surg. 2012; 20(1):37-41.
6. Almisfer AK, Almukaimi AZ, Hussain T. Closed Reduction and Percutaneous Fixation of Non-Osteoporotic Tibial Plateau Fractures. Kuwait Medical Journal 2004; 36(1):15-18.
7. Lee JA, Papadakis SA, Moon C, Zalavras CG. Tibial plateau fractures treated with the less invasive stabilisation system. IntOrthop. 2007; 31(3):415–418.
8. Raza H, Hashmi P, Abbas K, Hafeez K. Minimally invasive plate osteosynthesis for tibial plateau fractures. J Orthopaed Surg. 2012; 20(1):42-7.
9. Watson JT, Schatzker J. Tibial plateau fractures. In: Browner BD, ed. Skeletal trauma: basic science, management, and reconstruction. 3rd ed. Philadelphia, Pa: Saunders, 2003; 2047–2130.
10. Tscherne H, Lobenhoffer P. Tibial plateau fractures: management and expected results. ClinOrthopRelat Res 1993; 292:87–100.
11. Su EP, Westrich GH, Rana AJ, Kapoor K, David HL. Operative treatment of tibial plateau fractures in patients older than 55 years. ClinOrthopRelat Res 2004; 421:240–248.