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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 164-168

Multi-detector computed tomographic evaluation of tibial plateau fractures with review of Schatzker's classification of tibial plateau fractures


Department of Radiodiagnosis and Imaging, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Web Publication24-Sep-2018

Correspondence Address:
Mohd Ilyas
Department of Radiodiagnosis and Imaging, Government Medical College, Jammu - 180 001, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AIHB.AIHB_60_17

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  Abstract 


Objective: The main objective of the study was to assess the role of multi-detector computed tomographic (MDCT) evaluation of the tibial plateau fractures. Materials and Methods: Fifty-one patients with tibial plateau fractures were subjected to MDCT. The images were reconstructed via three-dimensional algorithms and maximum intensity projection and volume rendered technique reconstructions using syngo.via software (Siemens Healthcare, Germany). The fractures were classified according to Schatzker's Classification. Results: The most common type of tibial plateau fracture in the current study was found to be type I followed by type II and the least common being type V. Conclusion: MDCT helps in accurate classification of the tibial plateau fractures, which helps in selecting the best treatment modality for a particular class of tibial plateau fracture.

Keywords: Multi-detector computed tomography, Schatzker's classification, tibial plateau fractures


How to cite this article:
Ilyas M, Gupta A, Sharma S, Dev G. Multi-detector computed tomographic evaluation of tibial plateau fractures with review of Schatzker's classification of tibial plateau fractures. Adv Hum Biol 2018;8:164-8

How to cite this URL:
Ilyas M, Gupta A, Sharma S, Dev G. Multi-detector computed tomographic evaluation of tibial plateau fractures with review of Schatzker's classification of tibial plateau fractures. Adv Hum Biol [serial online] 2018 [cited 2020 Jul 13];8:164-8. Available from: http://www.aihbonline.com/text.asp?2018/8/3/164/241933




  Introduction Top


Fractures of the tibial plateau usually occur in association with meniscoligamentous injuries with most of them associated with particular injury patterns. Isolated fractures with disruption or displacement of articular fragments can also be there with no injury to capsular or ligamentous structures.[1]

The role of computed tomography (CT) in the accurate classification is highly appreciable due to ultra-thin high-resolution capabilities of the modern CT scanners. The Schatzker's Classification is based on the idea that 'certain pathoanatomic and aetiological factors as well as therapeutic features demand that certain injury types be grouped together'.[2]


  Materials and Methods Top


The patients with knee trauma admitted to the causality unit of our institution were evaluated over a period of 1 year from November 2015 to October 2016. Those diagnosed with the tibial plateau fractures (n = 51) were evaluated by the following protocol:

  1. Axial high-resolution knee CT images were obtained using 128 slice dual-source CT scanner (Somatom Definition Flash; Siemens Healthcare, Germany)
  2. The axial images were reconstructed using syngo.via three-dimensional algorithms with 1 mm collimation. The knee joint bones were evaluated in all the planes – axial, coronal and sagittal. The maximum intensity projection as well as volume rendered images were also obtained
  3. The tibial plateau injuries were then classified according to the Schatzker's Classification
  4. The children below 18 years of age and the pregnant females were excluded from the study.



  Results Top


Fifty-one patients were included in the final study from a cohort of patients being evaluated for knee trauma. The mean age of the patients was 33 years (18–62 years range) with 38 males and 13 female patients.

Most of the patients had Schatzker's type I fracture (n = 27) and least with type V fracture (n = 2). The number of patients with type II, type IIIa, type IIIb, type IV and type VI was 8, 5, 2, 3 and 4, respectively.

The CT images of various types of fractures are depicted from [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6].
Figure 1: (a) Coronal reformation of the tibia showing the fracture of lateral tibial plateau without any significant depression – Schatzker's Type I fracture. Also seen is the chip fracture of the lateral femoral condyle. (b) Image of the same patient as in Figure 1a showing the lateral tibial plateau fracture. (c) Coronal reformation of a different patient describing the Schatzker's type I fracture of the left lateral tibial plateau. (d) Coronal reformation of the same patient as shown in Figure 1c showing the lateral tibial plateau fracture.

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Figure 2: Schatzker's Type II fracture – lateral tibial condylar fracture with more than 4 mm depression.

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Figure 3: (a) Schatzker's type IIIa fracture – true depression (lateral depression in lateral tibial plateau fracture). (b) Schatzker's type IIIb fracture – lateral tibial plateau fracture with the central depression. (c) Coronal reformation of the same patient as in 3b showing the Schatzker's type IIIb fracture.

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Figure 4: (a) Multi-detector computed tomography image displaying the Schatzker's type IV fracture – medial plateau fracture. (b) Volume rendering image of the Schatzker's type IV fracture seen in Figure 4a.

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Figure 5: (a) Schatzker's type V fracture including both tibial plateaus. (b) More posterior coronal image of the same patient as in Figure 5a showing biplateaular fracture – Schatzker's type V fracture. (c) Volume rendered technique image showing the Schatzker's type V tibial plateau fracture.

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Figure 6: (a) Type VI Schatzker's fracture involving the meta-diaphysis of the tibia. (b) Type VI Schatzker's fracture of another patient. (c) Type VI fracture of the same patient as that in Figure 6b showing bicondylar fracture with metaphyseal fracture evident by discontinuous cortex laterally.

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  Discussion Top


The tibial plateau fractures are classified based on the Schatzker's Classification. The various types range from type I to type VI.

Type I fracture

Wedge-shaped cleavage fracture with <4 mm depression or displacement involving the lateral tibial plateau corresponds to Schatzker's type I fracture. CT is highly sensitive in the measurement of the depression of a fragment which is not that easy on plain radiographs, and thus CT helps in reducing the error of classifying a type I fracture into type II or vice versa.[3] [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d demonstrates the images of type I fracture encountered in the present study.

Type II fracture

The lateral tibial plateau fracture with depression >4 mm or combined cleavage/compression fracture of lateral tibial plateau fracture belongs to Schatzker's type II fracture. CT helps in accurate differentiation of the type I fracture from the type II fracture, which is not possible on plain radiographs. The depression refers to the vertical distance between the lowest point on the intact medial plateau and the lowest depressed lateral plateau fracture fragment. [Figure 2] demonstrates the image of type II fracture seen in the present study.

Type III fracture

The lateral tibial plateau compression fracture in which articular surface is depressed and driven into lateral metaphysis by transverse forces belongs to type III type Schatzker's fracture. This type is further divided into type IIIa and type IIIb based on the lateral and central depression, respectively. The axial instability is more common in these types of fractures rather than joint instability. Joint instability if present is more common in IIIb type of fractures.[4] [Figure 3]a, [Figure 3]b, [Figure 3]c demonstrates the various images of type III fractures encountered in the present study.

Type IV fracture

The isolated medial plateau fracture with a depressed component belongs to Schatzker's type IV fracture. These kinds of fractures are more commonly associated with peroneal nerve or popliteal vessel injuries. [Figure 4]a and [Figure 4]b demonstrates the type IV fractures encountered in the present study.

Type V fracture

The wedge fracture involving both medial and lateral tibial plateaus with inverted 'Y' appearance belongs to the category of type V Schatzker's fracture. It is often associated with articular depression on the lateral side with occasional involvement of inter-condylar eminence. Multi-detector CT with high-resolution reformations helps correctly distinguishing the type V fracture from type VI by clear demonstration of the maintained meta-diaphyseal continuity. [Figure 5]a, [Figure 5]b, [Figure 5]c demonstrates various images of type V fracture encountered in our study.

Type VI fracture

The transverse sub-condylar fracture with separation of the metaphysis from the diaphysis belongs to the Schatzker's type VI fracture. [Figure 6]a, [Figure 6]b, [Figure 6]c demonstrates various type VI fracture images encountered in the current study.

CT images may be same as that of conventional radiography in many cases, but the exact differentiation of the various subtypes of the fracture is accurate on CT, particularly in differentiating type I and type II and type V and type VI fractures. The surgical plans are devised as per the particular type of the tibial plateau fracture encountered, that is why the assessment of fracture depression and displacement has become the current standard of pre-operative evaluation of bone injury. Magnetic resonance imaging (MRI) can be performed in the cases where there is suspicion of the involvement of the joint capsule or menisci or knee joint ligaments. It is seen that treatment plans modify in 6%–60% cases after CT and 21% cases after MRI.[5],[6],[7],[8] With the advent of dual-energy and multi-energy CT scanners, the need of MRI will be seen decreasing as the multi-energy CT scanners have the capability of demonstrating the ligamentous injuries and bone marrow oedema as well.

The sensitivity and specificity of computed tomography in depicting the osseous avulsions are very high as compared to MRI. Furthermore, CT has high negative predictive value for excluding ligament injury. MRI remains necessary for the pre-operative evaluation of meniscal injuries.[9]

Many authors have evaluated the CT to assess the soft-tissue injury associated with tibial plateau trauma as CT is readily available. Some believe that the depression or displacement of fracture fragment at plain radiography or CT may be predictive of soft-tissue injury.[10]

In many cases of tibial trauma, there may be associated vascular injury which can be identified clinically by absent or feeble distal arterial pulses. In addition to the exact and accurate delineation of the type of fracture, CT angiography can be performed simultaneously at the same time to evaluate the vessel which is not possible with plain radiography.[11] Computed tomography helps in getting a more accurate and comprehensive pre-operative plan for the management of tibial fractures. In addition, if there is associated abdominal trauma or trauma to head, the same can be evaluated by CT in the single setting in minimum time.

CT helps in assessing the tibial plateau fractures in such a way that an orthopaedician is able to decide whether or not to perform a surgery.

Usual indications for surgical treatment are as follows:[12]

  • Intra-articular displacement of ≥2 mm
  • Metaphyseal–diaphyseal translation of >1 cm
  • Angular deformity of >10° in the coronal (varus–valgus) or sagittal plane
  • Open fracture
  • Associated compartment syndrome
  • Associated ligament injury requiring repair
  • Associated fractures of the ipsilateral tibia or fibula.


The main contra-indications to surgery are an unfit patient or a patient unable to follow the rehabilitation protocol and soft-tissue complications. Surgical treatment is best considered for partial and complete articular fractures. These indications are best evaluated by CT than radiography or MRI.

Compartment syndrome can be a devastating complication affecting proximal tibia fractures. Its incidence can rise to 17% of closed and 18.7% of open complex pattern of proximal tibia fractures. One should be aware of the four 'p' rule (pain, pallor, paraesthesia and pain with passive stretch) in the initial phase of treatment to identify this condition and treat it as soon as possible. The cross-sectional imaging gives better idea of the development of compartment syndrome than plain radiography.[13]

Plain radiographs should include anterior-posterior, lateral and inter-condylar notch views. However, tibial plateau fractures can be difficult to see on plain films. These injuries are associated with significant morbidity and frequently require operation management; therefore, if there is a high degree of suspicion for tibial plateau fractures and negative plain radiographs, CT or MRI should be used. The knee joint should be evaluated for fracture lines, displacement, depression of the tibial plateau and associated ligamentous or meniscal injury. Either CT or MRI can better demonstrate the extent of plateau depression and comminution than plain radiographs and may be helpful in surgical planning should this management be indicated. CT scans are typically faster and easier to obtain in an acute setting. However, MRI can identify meniscal and ligamentous injury while CT cannot.[14]

These injuries may be managed non-operatively only if there is absolutely no displacement, depression of the tibial plateau, comminution or associated ligamentous or meniscal injury. These typically occur with low-energy mechanisms. Fractures appropriate for non-operative management may be placed in a hinged knee brace and made non-weight bearing. Open reduction with internal fixation (ORIF) is recommended for tibial fractures with significant articular step-off, condylar widening, ligamentous instability and Schatzker's IV to VI injuries. If the injury is too comminuted for internal fixation, external fixation with limited open/percutaneous fixation of the articular segment may be performed. If there is significant soft tissue injury, or if the patient has sustained other serious injuries that require more immediate attention, ORIF may be delayed and bridging external fixation may be performed as a temporising measure.[15]


  Conclusion Top


CT imaging is more accurate than plain radiography for characterisation and classification of tibial plateau fractures, and the results of CT imaging can be important for surgical planning. Non-contrast axial CT images should be obtained of all the patients presenting in the causalities with history of significant knee trauma so that accurate classification is made and treatment plan modified accordingly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moore TM. Fracture – Dislocation of the knee. Clin Orthop Relat Res 1981;156:128-40.  Back to cited text no. 1
    
2.
Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968–1975. Clin Orthop Relat Res 1979;138:94-104.  Back to cited text no. 2
    
3.
Schatzker J. Compression in the surgical treatment of fractures of the tibia. Clin Orthop Relat Res 1974;105:220-39.  Back to cited text no. 3
    
4.
Honkonen SE, Järvinen MJ. Classification of fractures of the tibial condyles. J Bone Joint Surg Br 1992;74:840-7.  Back to cited text no. 4
    
5.
Wicky S, Blaser PF, Blanc CH, Leyvraz PF, Schnyder P, Meuli RA, et al. Comparison between standard radiography and spiral CT with 3D reconstruction in the evaluation, classification and management of tibial plateau fractures. Eur Radiol 2000;10:1227-32.  Back to cited text no. 5
    
6.
Yacoubian SV, Nevins RT, Sallis JG, Potter HG, Lorich DG. Impact of MRI on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma 2002;16:632-7.  Back to cited text no. 6
    
7.
Macarini L, Murrone M, Marini S, Calbi R, Solarino M, Moretti B, et al. Tibial plateau fractures: Evaluation with multidetector-CT. Radiol Med 2004;108:503-14.  Back to cited text no. 7
    
8.
Fathi El-Kharbouty AM. Multi-detector computed tomography assessment of tibial plateau fractures. Egypt J Radiol Nucl Med 2015;46:695-9.  Back to cited text no. 8
    
9.
Mui LW, Engelsohn E, Umans H. Comparison of CT and MRI in patients with tibial plateau fracture: Can CT findings predict ligament tear or meniscal injury? Skeletal Radiol 2007;36:145-51.  Back to cited text no. 9
    
10.
Gardner MJ, Yacoubian S, Geller D, Pode M, Mintz D, Helfet DL, et al. Prediction of soft-tissue injuries in Schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma 2006;60:319-23.  Back to cited text no. 10
    
11.
Watson JT, Schatzker J. Tibial plateau fractures. In: Browner BD, editor. Skeletal Trauma: Basic Science, Management, and Reconstruction. 3rd ed. Philadelphia, Pa: Saunders; 2003. p. 2047-130.  Back to cited text no. 11
    
12.
Hall JA, Beuerlein MJ, McKee MD, Canadian Orthopaedic Trauma Society. Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Surgical technique. J Bone Joint Surg Am 2009;91 Suppl 2 Pt 1:74-88.  Back to cited text no. 12
    
13.
Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): The results of a prospective, standardized protocol. J Orthop Trauma 2005;19:448-55.  Back to cited text no. 13
    
14.
Malik S, Rosenberg N. Fracture, Tibial Plateau. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2017. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470593/. [Last updated on 2017 Nov 21].  Back to cited text no. 14
    
15.
Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE, et al. Population-based epidemiology of tibial plateau fractures. Orthopedics 2015;38:e780-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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