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CASE REPORTS

Isolated Medial Plate Fixation for a Medial Tibial Plateau FractureWith Lateral Diaphyseal Extension: An Atypical Bicondylar Tibial

Plateau FractureGinger Bryant, MD

Summary: Treatment of tibial plateau fractures that involve themedial condyle can be challenging. The surgeon must determinewhether adequate fixation can be obtained, and more importantlymaintained, from the commonly used “lateral only” plate construct.If the medial condyle is not appropriately stabilized, fracture dis-placement may occur leading to a malunion or nonunion. This casepresents a patient who sustained a medial tibial condyle fracturewith lateral diaphyseal extension, an atypical bicondylar fracturepattern, due to a fall from height. Medial condyle reduction wasobtained and the condylar fracture and the diaphyseal fractureextension were both treated with a medial locking plate only.

Key Words: bicondylar tibial plateau fracture, medial plate fix-ation, Schatzker IV, Schatzker V, Schatzker VI

INTRODUCTIONTibial plateau fractures that involve the medial condyle,

Schatzker IV, and bicondylar fractures, Schatzker V and VI, canbe challenging to treat.1

There has been an evolution of fracture fixation for bicondylartibial plateau fractures from the historic anterior incision with

bicondylar plating, possibly leading to the poor outcomes ofa “dead bone sandwich,” to the theory that the locking lateral pla-teau plate can be the “fix all” for all bicondylar fracture patterns.2 Itis now understood that bicondylar plating, using both a lateral andmedial incision, is often required for adequate fixation of certainbicondylar tibial plateau fractures when the medial condyle is frag-mented.3 Isolated medial condyle fractures are more commonlyapproached using a medial incision with medial plate fixationand anatomic fracture reduction is recommended.4 This case reportpresents an atypical bicondylar fracture pattern, a fracturewhere themajor fragment is the medial condyle, as opposed to the morecommon lateral condyle, with extension into the lateral diaphysis.

CASE PRESENTATIONA 54-year-old female presented with leg pain after a 4-foot fall

from a ladder. She had no previous injury to her extremity butcurrently complained of significant pain around her knee, denyingparesthesias. She had a known history of osteopenia, a diagnosisbased on dual-energy x-ray absorptiometry scan, but had not beentaking any medications for this diagnosis. Physical examinationdiscovered an edematous knee with a mild effusion and intact skin.Her leg compartments were soft and she had intact sensation andmotor function distal to her knee. Both posterior tibialis anddorsalis pedis arteries were palpable. Radiographs revealeda medial condyle tibial plateau fracture (Figs. 1 and 2), and com-puted tomography confirmed the displacedmedial condyle fracturewith diaphyseal extension to the lateral tibial shaft (Figs. 3–5).

SURGICAL MANAGEMENTPreoperative planning included deciding that this fracture

should be treated operatively based on the displacement of themedial condyle and the bicondylar nature of the fracture, with thegoal being anatomic reduction. It was determined that a poster-omedial surgical approach would be needed to obtain a direct

Accepted for publication November 9, 2015.

From the Division of Orthopaedic Trauma & Reconstruction, The Ortho-paedic Center, Huntsville, AL.

G. Bryant acts as a Consultant for Stryker Orthopaedics for the developmentof surgical instrumentation and implants related to the submitted work.

The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or Stryker.

Reprints: Ginger Bryant, MD, Division of Orthopaedic Trauma & Recon-struction, The Orthopaedic Center, 927 Franklin St, Huntsville, AL 35802(e-mail: bryantammons@yahoo.com).

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reduction of themedial tibial condyle and that a locking platewouldbe used because of her history of osteopenia and the bicondylarpattern of the fracture. Surgical consent was obtained and thepatient underwent open reduction internal fixation of her bicondy-lar tibial plateau fracture. A posteromedial surgical approach was

used. The pes anserine tendon insertions, which occasionally haveto be partially transected and then repaired, were mobilized. Directreduction of themedial metaphyseal fracture was obtained and thenmaintained with a “point-to-point” reduction forceps. Drillinga small hole for the points of the forceps helped the clamp remainin position on the slope of the medial tibia. The plate was slid under

FIGURE 1. Preoperative AP radiograph: medial tibial plateaufracture with rotational and angular displacement.

FIGURE 2. Preoperative lateral radiograph: fracture extensionposteriorly with displacement of the posterior tibia plateau.

FIGURE 3. Preoperative coronal computed tomography. Medialtibial metaphyseal displacement.

FIGURE 4. Preoperative coronal computed tomography. Frac-ture extension into the lateral diaphysis of the tibia demonstratinga bicondylar tibial plateau fracture.

Bryant

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and then placed just posterior to the tendon insertions. There wasa small area of posterior comminution that was left unaddressedbecause it was less than 2 mm and the reduction of the main medial

FIGURE 5. Preoperative sagittal computed tomography. Com-minution of the posterior tibial articular surface with non-contiguous posterior metaphyseal fracture displacement.

FIGURE 6. Postoperative AP radiograph reduction of the medialand lateral columns of the bicondylar tibial plateau fracture witha medial locking plate.

FIGURE 7. Postoperative lateral radiograph. The medial plate isplaced slightly posterior and the posterior screws positioned tocontrol the posteromedial fracture fragments.

FIGURE 8. Four month postoperative AP radiograph.

Atypical Bicondylar Tibial Plateau Fracture

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metaphyseal fracture fragment was anatomic. However, if the pos-terior fragment had not obtained acceptable reduction, a posteriorbuttress plate would have been used to achieve reduction in thatarea. After anatomic reduction of the medial condyle, a lockingmedial tibial plateau plate was used for fracture fixation5 (Figs. 6and 7).

OUTCOMESPostoperatively, the patient was encouraged to regain full

motion of her knee as soon as possible and was limited to toe-touch weight-bearing only for 8 weeks. At her 4 month post-operative appointment, she had range of motion from full extensionto 110 degrees, compared with 0–120 at the contralateral knee.Radiographs demonstrated a healed fracture and maintenance ofanatomic reduction (Figs. 8 and 9).

DISCUSSIONAs with most fractures, the treatment methods of tibial plateau

fractures have evolved because of advances in technology andevaluation of clinical outcomes. Schatzker I, II and III fractures,AO-OTA A and B fractures, if they meet operative indications, arecommonly treated with a lateral plate using a lateral incision.Schatzker IV fractures are typically approached using a medialincision and fixed with a medial plate. Schatzker V and VI, or AO-OTA C, fractures may sometimes be adequately treated with

a lateral plate only, however, many of these fractures require a dualincision and both a lateral and medial plate to obtain and, moreimportantly, maintain anatomic reduction.5 The size of the medialand/or posteromedial fracture fragments is often the determiningfactor if a medial plate is required. Condyle and metaphyseal com-minution are also considered when determining if bicondylar plat-ing is warranted.6,7 If the medial tibial condyle is not appropriatelystabilized, fracture displacement may occur leading to a malalign-ment of the mechanical axis of the leg or articular incongruity, thusleading to less than optimal outcomes.7 Fracture fixation must bestable enough to allow immediate motion of the knee. If range ofmotion in conjunction with fracture and joint stability cannot beachieved, fracture fixation should be revised.

CONCLUSIONSMedial tibial plateau fractures are often believed of as knee

dislocations and can have associated injuries including ligamen-tous disruption, vascular compromise, and meniscal tears. Varusdisplacement is common and comminution of the articular surfaceand metaphysis may occur. These factors, as well as any extensioninto the lateral column, thus producing a bicondylar fracture, are thecommon operative indicators for medial condylar fractures, andthus, are the reasons why most medial condyle fractures requireoperative treatment.8

REFERENCES1. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Tor-onto experience 1968-1975. Clin Orthop Relat Res. 1979;138:94–104.

2. Anglen J, Kyle R, Marsh JL, et al, eds. Locking Plates For ExtremityFractures, A Technology Overview. AAOS Now; 2009.

3. Barei DP, Nork SE, Mills WJ, et al. Functional outcomes of severebicondylar tibial plateau fractures treated with dual incisions and medialand lateral plates. J Bone Joint Surg Am. 2006;88:1713–1721.

4. Ratcliff JR, Werner FW, Green JK, et al. Medial buttress versus laterallocked plating in a cadaver medial tibial plateau fracture model. J OrthopTrauma. 2007;21:444–448.

5. Stannard J, Martin S. Tibial plateau fractures. In: Stannard J, Schmidt A,Kregor P, eds. Surgical Treatment of Orthopaedic Trauma. New York:Thieme; 2007:711–741.

6. Stannard J. Proximal tibial fractures: locked plating. In: Wiss D, ed. Mas-ters Techniques in Orthopaedic Surgery: Fractures. 2nd ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2006:439–451.

7. Cuéllar VG, Martinez D, Immerman I, et al. A biomechanical study of poster-omedial tibial plateau fracture stability: Do they all require fixation? J OrthopTrauma. 2015;325–330.

8. Watson T, Schatzker J. Tibial plateau fractures. In: Browner, Jupiter,Levine, Trafton, eds. Skeletal Trauma. 2nd ed. Philadelphia, PA: WBSaunders Co; 1998:2143–2186.

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FIGURE 9. Four month postoperative lateral radiograph.

Bryant

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