Schatzker And Hohl-Moore Classification Of Tibial Plateau Fractures

Tibial plateau fractures are the result of strong valgus stress combined with axial loading. Literature statistics show that 55% to 70% of tibial plateau fractures are tibial lateral condyle fractures. At this point, the femoral condyle exerts shear and compressive stress on the underlying tibial plateau, which can lead to split fractures, collapse fractures, or both. There are different opinions in the literature about whether varus stress causes medial tibial condyle fractures. One opinion is that the lateral femoral condyle generates shear stress on the medial tibial condyle during valgus stress, causing medial tibial condyle fracture. It is believed that there is a fracture of the medial tibial condyle caused by varus stress.

Currently, with the increasing use of MRI examinations, it has been found that patients with tibial plateau fractures have a higher incidence of ligament injuries than previously thought, and are often combined with meniscal and soft tissue injuries. Combined meniscus injury accounts for approximately 67% of tibial plateau fractures. The most common causes of injuries are traffic accidents, car collisions, falls from heights, or sports injuries. Elderly people have osteoporosis, and tibial plateau fractures can occur even with minor external forces.

The Schatzker classification system is used to classify fracture types:

Type I:


Simple split fracture (Fig. 1A): a typical wedge-shaped non-comminuted fracture fragment splitting and displacing laterally and downwardly. This type of fracture is common in young patients without osteoporosis. If there is displacement, 2 transverse cancellous screws can be used to fix it.

Type II:


Split and compression fracture (Figure 1B): The lateral wedge-shaped bone fragment splits and separates, and the joint surface is compressed downward and sinks into the metaphysis. This type of fracture is common in elderly patients. If the compression exceeds 5~8mm or the knee joint is unstable, open reduction should be performed. A “whole” bone graft should be placed on the metaphysis to raise the compressed platform, and cancellous screws and lateral cortex should be used. Support steel plate fixed.

Type III:

Simple central compression fracture (Figure 1C): Simple articular surface compression sinks into the platform, and the lateral cortex is intact. It is more likely to occur in patients with osteoporosis. If the compression is severe or joint instability is confirmed, bone grafting should be used to cushion the compressed articular surface and support plates should be used to fix the lateral cortical bone.

Type IV:

Medial condyle fracture (Figure 1D): This type of fracture can be a simple wedge-shaped split, comminution or compression fracture of the medial condyle, often involving the tibial spine. This kind of fracture tends to varus into an angle, so open reduction should be performed, and subchondral bone raft fixation should be used to reduce the damage to the articular surface, with or without steel plate fixation.


Type V:


Bicondylar fracture (Figure 1E): splitting of the tibial plateau on both sides. It is characterized by the fact that the metaphysis and diaphysis still maintain their continuity. Both condyles can be fixed with supporting plates and cancellous screws to avoid fixation with larger built-in objects. Moore, Patzakis, and Harvey conducted a retrospective study of 988 patients with tibial plateau fractures, and 296 had bicondylar fractures. Among them, 95 cases underwent open reduction and internal fixation, and only 11 cases underwent both medial and lateral plate fixation. Wound dehiscence or infection occurred in 9 of 11 cases (82%). In addition, it was found that 23% of V-shaped bicondylar fractures were infected. Use a small anti-slip steel plate to fix it at the tip of the fracture with less soft tissue dissection.

Type VI:

Platform fractures with separation of the metaphysis and diaphysis (Fig. 1F): In addition to unicondylar or bicondylar and articular surface fractures, there are also transverse or oblique fractures of the proximal tibia. Due to the separation of the diaphysis and metaphysis, this type of fracture is not suitable for traction treatment. Most of the fractures are fixed with support plates and cancellous screws. If both condyles are fractured, bilateral fixation is required. Recently, some scholars have advocated the use of steel pins and wires to fix these complex fractures.


Figure 1 Fracture classification A. Type I, simple split fracture; B. Type II, split combined with collapse fracture, bone grafting at the metaphyseal void to elevate the bone fragment to achieve reduction, and supporting steel plate to fix the lateral wedge-shaped bone fragment: C. III Type, a simple central collapse fracture without an outer wedge-shaped bone fragment, and the collapse can be in front, behind, or involve the entire platform. After the bone graft collapses, it is best to add a supporting steel plate to protect it. D.N type, wedge-shaped splitting of the medial condyle, model-shaped splitting of the medial condyle (Type A, as shown in the picture) or crushing collapse (Type B, not shown in the picture) , more common in elderly patients with osteoporosis): E, V type, the tibial plateau is split on both sides. Pay attention to the continuity between the epiphysis and the diaphysis, and support steel plates must be used for bilateral fixation. F, V type, the fracture is characterized by dry The epiphysis is separated from the diaphysis, and the type of condylar fracture is uncertain. All types can occur. The proximal tibia should be fixed with bilateral support plates.

Hohl and Moore classified proximal tibial articular surface fractures with dislocation (Fig. 2). In addition to ligament damage, this type of fracture often also causes meniscus damage, and is generally irreparable. In addition, it is also accompanied by higher vascular and nerve damage, which increases from 2% in type I to 50% in type V, with an average of 15%, which is similar to the incidence of vascular and nerve damage in typical knee dislocations.


Figure 2 Proximal tibial fracture-dislocation Hohl and Moore classification type I-coronal split fracture:

Accounts for 37% of tibial plateau fractures and dislocations. This type of fracture involves the medial surface of the tibial plateau, which is obvious on the lateral view. On the oblique coronal transverse section, a fracture line can be seen diagonally at 45° to the medial plateau. The fracture can extend to the outside, causing avulsion fractures of the fibular styloid process, cruciate ligament attachment point, and Gerdy’s tubercle. Half of this type of fractures are stable when viewed on stress Waiting for non-surgical treatment to be effective, we often use closed reduction and percutaneous screw fixation, which can improve reduction and allow early movement of the affected limb under the protection of a cast brace, and provide protective weight-bearing exercises for 8 to 10 weeks. If open reduction is required, the fracture fragments can be reduced in extension and fixed with interfragment screws. For patients with ligament injuries, repair can be performed along the joint capsule tear.

Type II – total condylar fracture:

This type of fracture-dislocation can involve the medial or lateral tibial plateau, and the fracture line extends below the intercondylar spine to the contralateral joint compartment, which is different from type IV fractures (Figure 3). Among them, 50% of fractures involve damage to the contralateral collateral ligament, resulting in fracture or dislocation of the proximal fibula. This type accounts for 25% of all fractures and dislocations, 12% of which are accompanied by blood vessel and nerve damage. To determine whether there is potential ligament damage, stress testing is necessary. Stable fractures can be treated with cast braces, followed closely, and delayed weight-bearing. For unstable or poorly reduced fractures, interfragment screw fixation, damaged ligament repair, tubular brace fixation and delayed weight-bearing can be performed after closed or open reduction.

Type III-marginal avulsion fracture:

This type of injury accounts for 16% of all fracture-dislocation injuries, almost all of which occur on the lateral plateau, manifesting as avulsion fractures of the joint capsule attachment point, Gerdy’s tubercle or tibial plateau, often accompanied by cruciate ligament rupture. Meniscal injuries are rare, but 30% are accompanied by vascular and nerve damage, and almost all type III fractures are unstable fractures. Lateral access screws are needed to fix the articular lip and repair the avulsed iliotibial band and collateral ligament. At the same time, type IV cruciate ligament-edge compression fractures need to be repaired: this type of injury accounts for 12% of all fracture-dislocation injuries, almost All are unstable. This injury results in avulsion or tearing of the contralateral collateral ligament complex and most (approximately 75%) cruciate ligaments, subluxation of the tibia, and compression of the anterior, posterior, or “mid” articular labrum by the femoral condyle. Stable injuries may be immobilized with a cast until the ligament heals. If surgery is needed, a parapatellar approach is taken, small bone fragments are cleaned, larger bone fragments are elevated and fixed, and the cruciate ligament and the opposite collateral ligament are repaired. The characteristics of ligament injuries and their repair conditions determine the mobility of the joints after surgery.

Type V – four-part fracture:

Accounting for 10% of all fracture-dislocation injuries, almost all are unstable. 50% of them are accompanied by damage to blood vessels and nerves, and more than 1/3 are combined with damage to the popliteal artery and peroneal nerve. The collateral ligament complex is torn bilaterally by a bicondylar fracture, and the stability provided by the cruciate ligaments is lost because the intercondylar eminence has become a separate piece of bone. Although a bicondylar approach has been suggested, some scholars recommend plate fixation of the more severely comminuted side and lag screw fixation of the relatively intact side. Since bicondylar plate fixation requires extensive exposure and often causes infection and wound dehiscence, Mast introduced a method of lateral steel plate fixation and medial temporary external fixator fixation. We used limited open reduction, percutaneous needle triangular external fixator or 1lizarov external fixator to fix the knee joint in the neutral position. When dealing with Schatzker V-type bicondylar fractures, special attention should be paid to the soft tissues. Movements cannot be performed until the skin heals. The weight-bearing time is determined according to the fixation method. Patients fixed with Ilizarov external fixator can bear weight as early as they can tolerate it.


Figure 3 Tibial plateau fracture and dislocation A. Type II tibial plateau fracture and dislocation fixed with steel plate and screws, B. Internal fixation with supporting plate and screws Schatzker classification is one of the most widely used classification methods in clinical work. Research by Rao Haijun et al. found that postoperative complications in patients with tibial plateau fractures of different Schatzker classifications are mostly related to insufficient assessment of the degree of comminution, location, and direction of the fracture, leading to improper surgical approach and actual selection, which increases fracture reduction and infection. , skin necrosis and other complications, there is no obvious relationship with Schatzker classification, which is consistent with the results of this study. Tibial plateau fractures are generally caused by high-energy injuries. Patients often suffer from tissue damage. The area around the knee joint is an area with weak blood supply and soft tissue coverage. Only subcutaneous tissue and skin cover the joints and tendons. Improper timing of surgery may cause Patients experience severe swelling, which may lead to ligament and tendon necrosis, skin infection and necrosis.


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Post time: Mar-08-2024