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14 Jul 2025
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Complex Bicondylar Tibial Plateau Fracture with Extensive Soft Tissue Injury

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Clinical Details

Clinical and radiological findings:  A 44-year-old male was struck by a car traveling at approximately 20 mph, resulting in a closed injury. The patient sustained a Schatzker IV fracture, which is considered a knee dislocation equivalent. The initial assessment revealed no head, chest, or abdominal injuries, and the patient was neurovascularly intact despite an operative spine injury. Radiological imaging, including CT scans, demonstrated a multifragmentary medial joint fracture, ACL and PCL avulsions, and significant tension failure of the posterolateral corner (PLC) and lateral capsule/iliotibial band (ITB). Despite the high risk for vascular injury, peroneal nerve injury, and compartment syndrome, none were present.

Preoperative Plan

Planning remarks:  The preoperative plan involved using a medial distractor to facilitate reduction by moving the femur out of the way. The approach was to address the posteromedial fragment first, followed by elevation of the joint through a corticotomy anterior to the medial collateral ligament (MCL). An intra-osseous blade plate (shelf plate) was planned for fixation to support the elevated joint.

Surgical Discussion

Patient positioning:  Supine positioning was utilized for the procedure.

Anatomical surgical approach:  A medial approach was employed initially, working anterior to the MCL to perform a corticotomy for joint elevation. The posteromedial fragment was reduced first. Following medial fixation, attention was turned to the lateral side, where a full capsular avulsion and proximal fibula tension failure were addressed.

Operative remarks: 

The surgeon noted the necessity of a medial distractor to facilitate reduction of the femur and allow access to the posteromedial fragment. The intra-osseous blade plate was favored for its ability to elevate and support the joint in a fixed angle. On the lateral side, a full capsular avulsion and proximal fibula tension failure were repaired using four suture anchors for the capsular and ITB avulsion. The fibular head (PLC) was repaired with #5 heavy braided suture through a bone tunnel, supplemented by a static tension band plate for osseous compression. The ACL and PCL footprints were intact and not addressed surgically.

Postoperative protocol:   Postoperative rehabilitation protocol was not specified.

Follow up:   Not specified.

Orthopaedic implants used:   Intra-osseous blade plate (shelf plate), 4 suture anchors, #5 heavy braided suture, static tension band plate.

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