DOI: 10.1097/BOT.0b013e31820b82c6
,
Issn Print: 0890-5339
Publication Date: 2011/03/01
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Excerpt
The proximal tibial head consists of a large concave medial and small convex lateral plateau. It can be further classified anatomically into four parts, or quadrants: anterolateral, anteromedial, posterolateral, and posteromedial. Most tibial plateau fractures involve the anterolateral (Schatzker Type I-III) and posteromedial (Schatzker Type IV) quadrants. Discussions of posterolateral tibial plateau fractures in the literature have recently become more common, yet the number of papers investigating this particular fracture pattern remain limited.1-4
In the August 2010 issue of J Orthop Trauma, two interesting articles described different techniques for direct exposure, reduction under visualization, and buttress plate fixation of posterolateral tibial plateau fractures. One, by Solomon et al,5 uses a lateral skin incision to perform a transfibular neck osteotomy and proximal fibular head reflection with the patient lying in the supine position. The other, by Frosch et al,6 uses a posterolateral skin incision to perform a lateral arthrotomy for visualizing the joint surface and a posterolateral approach for fracture manipulation and plate fixation while the patient is in a lateral position.
Posterolateral tibial plateau fractures can occur in isolation (only one quadrant) or in combination (more than two quadrants). To our knowledge, there are several operative approaches that can directly expose the posterolateral tibial plateau. For an isolated posterolateral tibial plateau fracture, it can be easily exposed through a posterolateral skin incision, lateral border dissection, and medial retraction of the gastrocnemius and soleus muscles with the patient in a prone position. In our experience, only limited exposure and a small buttress plate were needed for isolated posterolateral tibial fractures.4,6 For complete lateral tibial plateau fractures involving both the posterolateral and anterolateral quadrants, exposure can be obtained through a lateral skin incision and transfibular neck osteotomy approach with the patient lying in lateral position as described by Lobenhoffer et al2 and Solomon et al.5 For combined posterolateral-posteromedial fractures (ie, posterior two quadrants) or fractures additionally complicated by anteromedial fractures (three quadrants), a large posteromedial reverse L-shaped skin incision with the patient lying in a prone position can expose all three quadrants. Dividing the medial border of the gastrocnemius and soleus muscles and then retracting laterally provides an easy approach to the entire posterior plateau. For four-plateau quadrant fractures, the large posteromedial reverse L-shaped incision can be combined with an anterolateral skin incision to expose the medial and lateral plateau.
Future investigation and clinical experience will likely provide an optimal approach for posterolateral tibial plateau exposure with both isolated and combined fracture patterns.
