Lateral tibial plateau fracture
Tibial plateau fractures are complex injuries of the knee joint. The tibial plateau is one of the most critical weight-bearing areas of the body. Early detection and appropriate treatment of these fractures is critical to minimize patient disability in terms of motion stability and range of motion Reduced risk of documented complications.  
Fractures were classified according to the Schatzker classification system. It divides tibial plateau fractures into six types:
- Schatzker I: nondepressed lateral tibial plateau fracture
- Schatzker II: lateral tibial plateau fracture with depression
- Schatzker III: lateral (IIIa) or medial (IIIb) compression fracture of the tibial plateau
- Schatzker IV: medial tibial plateau fracture
- Schatzker V: bicondylar tibial plateau fracture
- Schatzker VI: tibial plateau fracture with diaphyseal discontinuity 
Type I fractures are wedge-shaped, purely split fractures of the lateral tibial plateau with less than 4 mm of displacement or depression. They are caused by the lateral femoral condyle being driven to the articular surface of the tibial plateau. 
Type II fractures are combined splitting and compression fractures of the lateral tibial plateau, and type I fractures are associated with depressed components. There is a depression greater than 4mm. 
Schatzker type III fractures are pure compression fractures of the lateral tibial plateau in which the articular surface of the tibial plateau is depressed and driven by axial force into the lateral tibial metaphysis. Type III fractures are divided into two subgroups: Fractures with lateral depression (type IIIA) and central depression (type IIIB) 
Type IV is a medial tibial plateau fracture with split or depressed components. These fractures occur as a result of varus forces combined with axial loading from excessive knee flexion. Type IV fractures have the worst prognosis. 
V-type fractures consist of wedge-shaped fractures of the medial and lateral tibial plateaus and usually have an inverted “Y”-shaped appearance. Articular depression is usually seen on the lateral plateau and may be associated with intercondylar eminence fractures. 
Type VI is a bicondylar fracture with dislocation of the metaphysis from the diaphysis. This pattern is caused by a combination of high energy trauma and various forces.  
The first three are mainly the result of low-energy injuries, and the other three are the result of high-energy injuries. The magnitude of the force determines the extent of the fracture and the degree of displacement. Tibial plateau fractures often associated with anterior cruciate ligament (MCL and/or LCL) meniscus and articular cartilage injury 
Clinically Relevant Anatomy
The proximal end of the tibia terminates in a broad, flat area called the tibial plateau. The intercondylar eminence runs along the midline of the plateau and separates the medial and lateral condyles of the tibia. The two condyles form a flat, broad surface for articulation on the medial and lateral sides Femoral condyle 
The soft tissues of the knee joint are also affected in a tibial plateau fracture, see Knee Joint for more details.
Tibial plateau fractures are usually caused by high forces exerted on the calf in a varus or valgus position, or by simultaneous vertical stress and knee flexion.
Road traffic accidents are more common in sports with faster speeds such as skiing, horse riding, and certain water sports .
Due to the nature of the injury, soft tissue injuries are likely to be ligamentous ruptures and need to be considered in management. 
- Inability to weight bear
- Reduced knee range of movement (ROM)
- History of trauma
Tibial plateau fractures are a common intraatrial injury, and CT scans are often used in preoperative planning to rule out other pathologies.  Approximately 50% of knees with closed tibial plateau fractures have meniscal and cruciate ligament injuries, usually requiring Surgical repair 
Radiological evaluation of these fractures involves four views: anterior-posterior lateral esotropia and exotropia. Computed tomography (CT) is of great value in determining the location and size of joint depression, but MRI has been shown to classify and assist in management of joint depression Broken bones are best.  
Between Schatzker I and II, there is no apparent difference visible on X-ray. 
MRI scan is mandatory when soft tissue damage is suspected 
Because the tibial plateau involves a major weight-bearing joint, the outcome after fracture healing is significantly related to the resulting alignment and joint consistency, with or without surgical intervention. If the joint is stable and well aligned and there is no loss of joint motion Good results can be expected. If the infected non-healing cartilage injury or associated soft tissue damage is not addressed, the patient’s functional outcome will be diminished.
Fractures with higher Schatzker values have been reported to produce poorer outcomes due to the extent of trauma and possible soft tissue damage. 
The measurable outcome measures that may be used are:
- Imaging – one year or more after fracture to assess degree of healing 
- Knee range of movement
- Quality of life score – eg musculoskeletal assessment 
- Level of Mobility
There is currently no gold standard for accurately predicting the presence or absence of soft tissue injury in tibial plateau fractures. However, more recent studies have used preoperative magnetic resonance imaging (MRI) or surgical arthroscopy to assess tissue extent damage. 
For tibial plateau fractures, preoperative planning is fundamental. Clinical history Trauma mechanism Age and associated comorbidities affect treatment decisions. During the physical examination, soft tissue neurovascular function and associated skin lesions should be assessed for Depending on the extent of the underlying trauma, intervention will be appropriate.
Management of these fractures includes the use of comprehensive classification systems that are easily reproducible and have valid prognostic value, making it conceptually easier to define strategies and surgical approaches. 
The main goals of orthopedic/;’management are to restore the consistency of the articular surfaces and ensure mechanical axis alignment. Any deviation from the anatomical condylar position or ligamentous instability may lead to increased likelihood of degenerative osteoarthritis and subsequent Decreased functional capacity. 
It is usually managed with open reduction and internal fixation (ORIF). 
In some more complicated cases, fractures can be treated with external fixation followed by ORIF. 
Osteoarthritis after tibial plateau fractures is common (approximately one-third of all tibial plateau fractures) because the articular surfaces are still involved despite the patient’s older age at the time of the fracture. 
Physical Therapy Management
Physical therapy may be needed after a fracture to help ensure a return to optimal function as quickly as possible. The patient’s goals and psychological state must be considered to reduce the risk of persistent pain after surgery. 
Tibial plateau fractures are notoriously difficult to manage, especially when a medial or posteromedial component is present. Treatment of tibial plateau fractures aims to achieve anatomic reduction of the articular surfaces and stable osteosynthesis for early mobilization to achieve Prevent complications such as joint stiffness and general postoperative complications such as deep vein thrombosis or pulmonary embolism. 
Physiotherapy protocols vary according to surgeon preference, and there appears to be no fixed protocol for non-weight bearing time (NWB). The following are guidelines, please consult with the operating surgeon before starting post-operative physical therapy.
Non-Weight Bearing (NWB) Stage
This stage can vary depending on how traumatic it is from 4 weeks to 8 weeks. Usually secured in cricket pad cleats or fully extended locking Genu-range style brackets.
- At this stage, static quadriceps and passive knee ROM can be initiated according to the surgeon’s guidance. A continuous passive motion machine may be used. 
- Focus on analgesia and swelling.
- ROM exercises for the remaining joints, ie the hips and ankles.
Partial Weight Bearing Stage
Depending on the level of pain, gradually increase weight bearing on the operated leg with the goal of full weight bearing within 12 weeks.
- Active knee ROM exercises
- Closed kinetic chain exercises
- Focus on weight-bearing progression with good movement patterns
- Basic strengthening program
- Hydrotherapy (as appropriate)
Full Weight Bearing Stage
- Normalising gait pattern
- Focus on functional activities, i.e. sitting to standing stairs
- Proprioception exercises
- Return to normal activities of daily living.
- Advanced proprioception exercises
- Sport based drills
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