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Lateral Tibial Plateau Frx: Type I (“Minimally Displaced”)

- Discussion: Type I Fractures:
    - this is the wedge fracture of a lateral plateau;
    - it occurs mostly in young people since the dense cancellous bone of lateral plateau resists depression;
    - "Minimally Displaced Fractures" (from the Holh Classification)
           - frx shows depression or deplacement of < 4 mm;
           - note: a frx appearing to be minimally displaced may have been considerably displaced during injury which then became spontaneously reduced;

- Exam:
    - knee stability is important in choosing treatment for minimally displaced frx;
    - test in full extension and at 20 deg flexion;

- Radiographs:
    - if knee is unstable ( > 5 deg instability), stress x-rays are be made to determine whether instability is 2nd to movement at frx site or to ligament injury;
    - w/ displaced lateral type I frx, be suspicous of lateral meniscal detachment, and consider ordering MRI;

- Non Operative Management:
    - undisplaced frx:
         - if undisplaced, these frxs require early motion & protection from wt bearing, because, under stress, displacement may occur;
         - cast brace and NWB for 6 to 8 weeks;
    - stable displaced frx:
         - stability is tested 1st w/ knee extended and then flexed 15 deg
         - if such testing shows < 5 deg of instability (compared to nl knee), the knee is considered to be stable;
         - if instability is due to frx movement (as seen on x-rays), apply cast brace is to stabilize the leg;

- Indications for Surgery:
    - a displace wedge or split frx of lateral plateau, is unstable and is an indication for surgery;
    - any degree of condylar widening is an indication for surgery;
    - lateral meniscus may become trapped in the frx & will require surgical correction via open arthrotomy;

- Operative Treatment:
    - Work Up and PreOp Planning:
    - surgical approach:
          - consider using a midline incision if ligament repair or if meniscal reattachment is needed along with repair of the fracture;
          - if preoperative MRI shows that meniscus is not entraped w/ in frx site, then consider use of percutaneous reduction and screw fixation;
    - reduction:
          - if the split fragment is depressed, it needs to be brought out to length with use of a femoral distraction;
                - the distractor is placed on the same side as the fracture;
          - once the fracture fragment has been elevated w/ ligamentotaxis, then medial or lateral displacement can be corrected;
          - reduction is achieved w/ percutaneous applied reduction forceps w/ flourscopic assistance;
          - consider applying the reduction forceps eccentrically, and then torque the reduction forceps to achieve reduction;
          - adequate reduction implies less than 1-2 mm step off;
          - depressed fragments:
                - make a small window in the metaphyseal cortex and elevate the depressed fragment with a bone tamp;
    - fixation:
          - percutaneous screws:
                 - wedge of type I frx of lateral plateau can usually be fixed w/ only cancellous percutaneous lag screws and washers (plates are usually not necessary);
                 - consider 6.5 mm cancellous screws (over washers) which are placed in a triangular position; 
                 - ref: Combined Arthroscopic Treatment of Tibial Plateau and Intercondylar Eminence Avulsion Fractures
          anti-glide screw:
                 - antiglide screws are typically placed after 1-2 percutaneous lag screws are placed thru the frx fragment;
                 - antigluide screws (over washers) are placed just distal to the frx edge to prevent distal displacement;
                         - 4.5 mm cortical screws over washers are typically used;
          - butress plate:
                 - w/ good bone stock, butressing is not required, but in older pts a butress plate is required to prevent redisplacement;
                 - see: lateral plateau butress plate characteristics:
                 - typically a 6 hole plate is utilized which will allow three screws to be placed distal to the frx line;
          - consider repair collateral ligament damage after fixing fracture;
          - see: ligament damage

- Post Operative Care

- Complications of Lateral Type I Plateau Frx:
    - type I lateral plataue frx (or "minimally displaced frxs" of lateral plateau are stable (esp if fibula is intact) & require little external support during healing;
    - operatively treated frx may fail with inferior toggling of the screws, causing the frx to re-depress

Split Fractures of the Lateral Tibial Plateau: Evaluation of Three Fixation Methods

The role of arthroscopy in the management of tibial plateau fractures. 

Indirect Reduction and Percutaneous Screw Fixation of Displaced Tibial Plateau Fractures

Tibial Plateau Fractures. A review of operative treatment using AO technique.  

Closed reduction/percutaneous fixation of tibial plateau fractures: arthroscopic versus fluoroscopic control of reduction.

Compartment syndrome of the leg after arthroscopic examination of a tibial plateau fracture. Case report and review of the literature.