research lesion morphology and clinical outcomes type v and vi schatzker closed tibial plateau fractures fixed by plate

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INTRODUCTION
1 / Reason for this topics
Fractured tibia plateau is kind of lesion encountered proportion of 5 to 8%
of leg fractures. Traffic accidents, labor accidents, sports accidents, accidents
activities can cause fracture tibial plateau. This type of fracture invasive joints,
anatomical lesions often complex, directly affect the function of the knee. In
addition to bone damage, broken tibial plateau can incorporate many other
lesions of the knee joint, such as ligaments, bursae, meniscus, blood vessels and
nerves
Some classifications are widely available, such as the classification of Hohl
(1967), the Shatzker (1979), the AO-ASIF (1991) Many worldwide
orthopedic and domestic surgeons use the Schatzker classification. We can be
seen, these classification systems are based on images of bone lesions on
conventional x-ray. In fact, the fracture tibial plateau is not only a fragments of
fracture tibial plateau and extent of displaced fragments but also it is often
accompanied by depression fracture fragments or more fracture complex lines,
lesion images on conventional X-ray film in a number of cases not made clear
and complete, the surgeon still have difficulty in choosing the method of bone.
In recent years, with the support of the technical advances in the diagnosis,
such as computerized tomography combined 3D renderings (3D) magnetic
resonance imaging, C-arm the assessment and identification exact image
damage bones, joints, ligaments, meniscus, blood vessels, nerves as well as
support treatment interventions and reduction and fixed displaced fragments
exactly under control by C-arm using L-shaped locking plate, helps to treat
fractured tibial plateau achieved much progress to recover the maximum
functional limb.
Worldwide, the assessment and determine the significance of computerized
tomography compared with conventional X-ray in the diagnosis and treatment of
fractured tibial plateau have been done by many surgeons and published
internationally.

In Vietnam, although there have been studies on the treatment of fractured
tibial plateau with the plate and screws, locking plate mechanism, external
fixator have been published many surgeons in the country [16], [20], [18] .
However, the comparison and evaluation of the lesions images of tibial plateau
based on conventional X-ray or computerized tomography in a systematic
manner with the number of big enough patients that is still problem many
surgeons concerned.
There are many surgical methods that are applied, such as by open
reduction internal fixation with plate and screws, closed or minimum open
reduction of fractures and fracture fixation by external fixator frame or fixed
screws under the support of the C-arm …In general, each method has
advantages and disadvantages. However, according to some surgeons there is
more than 10% of fracture tibial plateau patients with surgical treatment has not
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achieved the recovery anatomical morphology and of course, as well as the
rehabilitation function of joints failed.
From this fact, we have done a thesis with entitled " Research lesion
morphology and clinical outcomes type V and VI Schatzker closed tibial
plateau fractures fixed by plate "
2 / The objective of the thesis
- Survey morphology, degree lesions of fracture tibial plateau on
computerized tomography and assessment of accuracy conventional X-ray
compared with computerized tomography scans according to the Schatzker
classification of fracture tibial plateau. - Evaluation of clinical outcomes type V
and VI Schatzker closed tibial plateau fractures fixed by plate when combined
with imaginal roles computerized tomography before surgery.
3 / The significance of the thesis
- Contains scientific and practical for both paraclinical research and clinical
practice. Applications in paraclinical studies for the treatment of type complex
fracture tibial plateau.

- The thesis has significant news because so far, worldwidely, the treatment
of fracture tibial plateau is still a big challenge for the medicinal profession. In
Vietnam, this thesis contributes to improving the understanding of
morphological lesions and experienced fracture tibial plateau treatment.
4 / Structure of the thesis
The thesis consists of 128 pages, including sections: Introduction (2 pages);
Overview (33 pages); Subjects and research methods (21 pages); Research
results (33 pages); Discuss (37 pages); Conclusion (2 pages) and the appendix.
In the thesis has 34 tables, 49 pictures and three medical reports illustrations.
References documentary: 121, including 21 Vietnamese and 100 documents in
English.
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Chapter 1:OVERVIEW
1.1. ANATOMICAL CHARACTERISTIC OF BONY TIBIAL PLATEAU AND KNEE
JOINT
1.1.1. Anatomy and bone structure tibial plateau
Angle of medial tibial plateau about 87 ± 2 - 5 °, tilt angle of about 9 ± 5 °
1.1.2. Outline of the anatomy in the knee region
Joint area include: medial femur condyle and medial tibial plateau; lateral
femur condyle and lateral tibial plateau; joint area between the posterior patella
and femur condyle.
Ligaments, synovial bursae system:
Ligaments: Ligament system of front, posterior, colateral ligaments and
cruciate ligaments systems.
1.1.3. Popliteal region: includes triangle thigh and tibia
Filling ingredients in the popliteal: arteries, veins and nerves
1.1.4. Motion function of knee
Range of motion of the knee: flexion: 135 - 140º, extension: 0º.
1.2 Cause, mechanism, and morphology of fracture tibial plateau
The leading cause of fractured tibial plateau which is concerned by many

surgeons is traffic accident, followed by accidents at work, sport accidents, etc.
1.2.2. Mechanism fractured tibial plateau
- Power down from femoral condyle to tibial plateau.
- Tibial plateau impact on hard objects directly.
1.2.3. Morphological of fractured tibial plateau
Classification of morphological fracture of Hohl (1967) include: 6 types.
Morphological fracture of Schatzker classification (1979), including 6 type:
Type I: fracture lateral tibial plateau wedge-shape.
Type II: fracture lateral tibial plateau combined with subsided tibial plateau
Type III: fractured subsided tibia in the middle of lateral tibial plateau
Type IV: fracture medial tibial plateau
Type V: fractured both tibial plateau with continuity of tibial plateau and the
diaphysis.
Type VI: fractured both tibial plateau combined with incontinuity of tibial
plateau and the diaphysis.
AO-ASIF classification (1991) 3 types: type A, B, C
Classification of Honkonen S. E (1992) divided into 7 categories
1.3. Roles computerized tomography and magnetic resonance imagine
1.3.1. Role of computerized tomography
In 1987, Dias JJ has studied 16 cases of fracture tibial plateau with 3 type
of imagines: X-ray, tomography X-ray in two dimensions and computerized
tomography. He discovered some fracture bony walls on computerized
tomography but undetectable on conventional X-ray.
In 2000, acorrding to Wicky S et al, fracture is appreciated correctly on
diagnosis based on conventional X-ray films were 18/42 patients (43%).
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In 2001, Hackl W et al suggest that up to 40% change classification type
bacause conventional X-ray no detectable fracture line.
2002, Yacoubian SV 52 comparative diagnostic between conventional X-
ray and computerized tomography see that the change in diagnosis was 6%.

In 2004, Macarini L has concluded 3D re-create morphology was very
useful in sorting fracture tibial plateau and preoperative evaluation.
In 2009, Higgins T .F et al studied the morphology of posterior fragments
in medial tibial plateau on computerized tomography: appearance ratio of
fragments is 59%, the average height is 4.2mm, fragment and fracture surface
area of the medial tibial plateau 25% respectively.
1.4. Treatment of fracture tibial plateau
1.4.1. Cast treatment
Böhler L, representative for the classic groups, often treat fractures tibial
plateau by cast.
1.4.2. Surgical treatment
Methods of open reduction internal fixation
In 1939, Landelius used fixed wires to fix in surgical tibial plateau firstly.
1973, Rasmussen has treated 204 cases fractured tibial plateau. The result:
very good: 60%; good: 27%; pretty: 8%; bad 5%.
In 1979, Schatzker assessed 10 cases tibial fracture type V, VI by surgery.
Acceptable results were: 8 cases, not acceptable: 2 cases.
In 1983, Blokker C. P analysis of results of surgical treatment open
reduction fixation under AO principles of fracture 14 cases of tibial plateau
fracture. The authors found that preoperative subsided articular surface < 5mm
had the better results with cases that subsided before surgery > 5 mm.
In 1992, Benirschke S. K retrospective study of 14 patients with fractured
tibial plateau Schatzker types V, VI and open fracture type II and III according
to the Gustilo grading were treated surgical fixation. Results infection rate is
1%, 10 patients had excellent results, 2 patients with gratifying results, 2
patients had poor results.
In 1994, Georgiadis GM treated for a 4 patients with fracture tibial plateau
contained two fragments in the posterior wall. As a result, the bones healed in
place correctly, all patients have range of motion: Extension/Flexion: 0° - 5° /
0/120° - 145°.

In 2004, Barei D. P reported using two incision. Results showed deep
infection 8.4%, 3.6% septic arthritis, 1 patient did not heal of bone.
In 2006, Barei DP treated bony fixation with two plate and two incision of
51 cases of fracture tibial plateau. Results: 90% to be satisfied with the angle of
medial tibial plateau is 87± 5 °. 68% achieved angle of tilt posterior is 9 ± 5 °.
In 1999, Pham Thanh Xuan [21] evaluated the results of surgical treatment
of plate and screws for 41 cases fractured tibial plateau from type I to type VI
according to the Schatzker classification. Results: 85.5% excellent and good,
bad and average of 14.5%. Schatzker types V, VI cases had average and bad
results.
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In 2010, Thai Tuan evaluate treatment outcomes of 25 patients with closed
fractures tibial plateau Schatzker type V, VI fixed by plate and screws:
excellent and good results was 84%, 16% average and bad.
In 2011, Vu Nhat Dinh assess treatment outcomes for 32 patients with
fractured tibial plateau type V, VI according to Schatzker classification, were
treated with the plate and screws. Results: 3 patients infected surface, varus or
valgus: 6 patients. Range of motion of the knee: > 125 ° (22 patients), from 100
-124° (3 patients), and from 90 - 99° (1 patient).
In 2012, Nguyen Van Luong reported the initially results of 16 patients,
who were closed fractured tibia plateau from type 1 to type 6, were fixation by
locking-plate. Results: 15 patients with excellent and good, average 0 patient
and bad 1 patient.
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Chapter 2: SUBJECTS AND METHODS
2.1. RESEARCH SUBJECTS
126 cases of trauma to the knee with fractured tibial plateau
2.1.1. Criteria for patient selection
Patient selection criteria for one researched target
- There are enough conventional X-rays imagine and CT-Scanner for every

tibial plateau.
Patient selection criteria for two researched target
- Closed fractured tibia plateau types V, VI Schatzker with age >= 16 are fixed
with plate and screw.
- There are enough conventional X-rays imagines pre and post-operation.
- There are enough CT-Scanners pre-operation.
- No injury skin around the knee.
- If the patients have combined diseases, were examined and concluded to allow
operation.
- There are no contraindications for anaesthesia
2.1.2. Exclusion criteria from the study group
- The absence of a conventional Xrays imagine or CT-Scanners.
- The pathological fractured tibial plateau.
- There are a available deformities at the fractured tibia limb, injury sequelae
affecting function of the limb.
- Patients with systemic disease is contraindicated with operation.
- The case of the combined with tored ACL and PCL no reconstruction with
fixed tibial plateau at the same time.
2.2. METHODOLOGY OF RESEARCH:
Retrospective and prospective research, cross-sectional descriptive uncontrolled.
2.2.1. Selection of sample size:
Accoding to calculate, to complete the one and two researched target required
sample size included 119 patients with fractured tibial plateau.
2.2.2. General Information
- Personal characteristics of the research subjects
- Distribution of age, gender, cause.
- Take conventional X-rays by digital machine, take CT-Scanner the distal
femur and tibial plateau.
2.2.3. Research morphological lesions on conventional Xrays and CT-
Scanner:

* Research morphological lesions tibial plateau include: fractured lateral
tibial plaeau(Schatzker I, II, III), fractured medial tibial plaeau (Schatzker IV)
and fractured both of tibial plaeau (Schatzker V, VI) with the characteristic
lesions as following: fractured morphology, degree of subsidence, subsidence
areas, number of fractured fragments and assessing the accuracy of conventional
Xrays versus CT-Scanner according to the Schatzker classification.
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2.2.4. Results of treatment
2.2.5. Some of techniques and evaluation criteria
2.2.5.1. Process of taken CT-Scanner the knee
2.2.5.2. Measure degree of subsidence on conventional Xrays imagine
- Method of Lansinger O, Dias J. J Method
2.2.5.3. Method of measurement angle of tibial plateau
2.2.5.4. Assess lesions of soft tissue
- According Tscherne H, there are 4 degrees
2.2.5.5. Evaluation of knee degeneration
- By the standards of Tscherne H
2.2.6. Surgical Procedures
Prepare patients.
Spinal anesthesia.
2.2.7. Assessment results
2.2.7.1. Evaluation results of morphological research
- Fractured location, fractured lines, degree of subsidence (millimetre),
subsidence areas (anterior, center, posterior) and the relationship between the ,
degree of subsidence and subsidence areas by Kappa coefficient.
- Evaluate the accuracy of conventional Xrays versus CT-Scanner about
degree of subsidence, number of fractured fragments, subsidence areas, diagnose
using Kappa coefficient.
2.2.7.2. Evaluation of results
Close results: according to the standard of Larson-Bostman include:

- Very good: no displaced fractures, straight axis, healing incision immediately.
- Good: Angle of the fractures toward lateral or anterior <5°, toward posterior
or medial <10°, short limb < 10mm. Healing incision immediately.
- Average: Angle of the fractures toward lateral or anterior >5°, toward posterior
or medial >10°, short limb > 10mm. Surface infections at the incision.
- Less: Angle of the fractures like average standard but there is displaced
rotation. Deep infected incision, bone infections, fistula of pus.
The results far: ≥ 12 months postoperatively.
By the function standards of Rasmussen: Very Good: 27 - 30 points; Good:
20 - 26 points; Average: 10 - 19 points; Poor: <10 points.
By the Xrays standards of Rasmussen: Very good: 18 points; Good: 12 - 16
points; Average: 6 - 12 points; Poor < 6 points.
2.2.8. Analysis and data processing:
Data entry and obtained by the Excel software, analysis data by software R
(R Core Team 2013).
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Chapter 3: STUDY RESULTS
3.1. INJURY MORPHOLOGY
3.1.1. Study group characteristics:
Study results: 41 patients with lateral tibial plateau fractures (mean age: 36.7 ±
12.4 yo). 10 patients with medial tibial plateau fractures (mean age: 34.5 ± 15.5)
, 75 patients with bicondylar tibial plateau fractures (mean age: 39.7 ± 13.1 ).
Right knee: 54 cases, Left knee: 72 cases. Type Schatzker V, VI have highest
mean age. There is no difference of age between groups p = 0.035.
- Main causes of injuries are Moto vehicle accidents 89.7 %.
3.1.1. Lateral tibial plateau fracture characteristics:(type Schatzker 1, 2, 3)
Split fractures: 37 cases. Pure depression fractures: 4 cases.
Table 3.3: Comparison of fragment amounts between XRAY CT scan
Fragment amounts XRAY (n = 41) CT scan (n = 41)
1 fragment 34 (82.9%) 22 (53.65%)

2 fragments 7 (17.1%) 14 (34.15%)
≥ 3 fragments 0 (0%) 5 (12.2%)
Cases 41 (100%) 41 (100%)
The study reported poor match of fragment amounts between XRAY and CT
scan, K = 0.072.
Table 3.4. comparison of depression level between XRAY and CT scan
Depression (mm) XRAY CT scan
No depression 16 8
1 - 4 mm 10 7
5 - 9 mm 8 14
10 - 19 mm 6 11
20 mm 1 1
cases 41 41
- On CT SCAN, LTP depression are 33 cases, depression level ≥ 5mm are 26
cases (63.4%).
Table 3.5: Correlation between LTP fracture depression levels and sites on
CT scan (n = 33)
Depression
level (mm)
Depression sites Cases (n)
anterior central Posterior
1 - 4 mm 3 3 1 7
5 - 9 mm 4 4 6 14
10 - 19 mm 3 3 5 11
20 mm 0 1 0 1
cases (n) 10 11 12 33
- The more tibial depression level increase, The more central and posterior
areas affected 11/33 cases.
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3.1.3. Medial tibial plateau fracture characteristics (Schatzker 4)

Split fractures: 10 cases.
Table 3.6: Comparison of fragment amounts between XRAY CT scan
(n = 10)
Fragment amounts XRAY CT SCAN
1 fragment 10 5
2 fragments 0 5
cases 10 10
- Medial tibial plateau fracutes are most likely not comminuted. And most of
them are big fragments.
Table 3.7: Medial tibial plateau depression level
Depression level (mm) Xray CT scan
No depression 9 4
1- 4 mm 1 3
5 - 9 mm 0 2
10 - 19 mm 0 1
Cases 10 10
- Difficult to identify fracture depression on XRAY.
Table 3.8: Correlation between fracture depression levels and sites on CT
scan
Depression
levels
Depression sites cases
(n = 6)
anterior central posterior
1 – 4 mm 2 0 2 4
5 – 9 mm 0 1 0 1
15mm 1 0 0 1
Sum 3 1 2 6
- Depression occurs to every sites. Depression areas are large, and mainly down-
displaced fragments

3.1.4. Bicondylar tibial plateau fracture characteristics: (Schatzker V, VI)
3.1.4.1. fracture types:
- Fractures type 1: 50.6%. Match ratios between XRAY vs CT SCAN:
36/38 cases (90,1%).
- Fractures type 2: 28% Match ratios between XRAY vs CT SCAN:
19/21 cases (90%).
- Fractures type 3: 8%, Match ratios between XRAY vs CT SCAN 4/6 :
(66%).
- Fractures type 4: 9,4%, Match ratios between XRAY vs CT SCAN 5/7:
(71,4%).
- Fractures type 5: 4%, Match ratios between XRAY vs CT SCAN:
100%.
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3.1.4.2. Lateral tibial plateau fractures type Schatzker V, VI
Table 3.9: Lateral tibial plateau fracture fragments on CT SCAN
Type fractures
Fragment amounts
Type V
(n = 47)
Type VI
(n = 28)
combined
(n = 75)
1 fragment 25 (53.2%) 4 (14.3%) 29 (38.7%)
2 fragments 16 (34.0%) 10 (35.7%) 26 (34.7%)
3 fragments 6 (12.8%) 14 (50.0%) 20 (26.4%)
analysis Chi-square = 16.01. d.f. = 2 P < 0.001
There is significant difference between fragments of 2 types, p < 0.001.
Table 3.10: Fracture fragment detection at the posterior wall of LTP
Fragment

amounts
Xray CT scan
Type V
(n = 47)
Type VI
(n = 28)
Combined
( n = 75)
Type V
( n = 47)
Type VI
( n = 28)
combined
( n = 75)
0
fragment
44
(93%)
28
(100%)
72
(96%)
30
(63.8%)
8
(28.6%)
38
(50.7%)
1
fragment

3
(6.4%)
0
0.0%
3
(4.0%)
16
(34%)
20
(71.4%)
36
(48.0%)
2
fragments
1
(2.1%)
0
(0.0%)
1
(1.3%)
analysis Fisher = 1, d.f. = 1, p = 0.289 Fisher = 1, d.f. = 1, p = 0.01
Fractures at the posterior wall of LTP of both type V and VI are 49.3%.
Table 3.11: LTP depression level comparison on Xray and CT scan.
Depression
level (mm)
X ray CT scan
Loại V Loại VI Kết hợp Loại V Loại VI Kết hợp
mean 1.8 ± 3.4
(mm)
3.1 ± 3.3

(mm)
2.3 ± 3.4
(mm)
3.7 ± 3.9
(mm)
5.6 ± 3.3
(mm)
4.4 ± 3.8
(mm)
analysis F = 5.72, d.f = 1.73, P = 0.019 F = 7, d.f = 1.73, p = 0.01
Mean depression level between type V and VI are different, p = 0.01.
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Table 3.12: depression sites of latera tibial plateau
Depression
site
Xray CT scan
Type V
(n = 47)
Type VI
(n = 28)
combined
(n = 75)
Type V
(n = 47)
Type VI
(n = 28)
Combine
(n = 75)
anterior 3
(6.4%)

1
(3.6%)
4
(5.3%)
7
(14.9%)
2
(7.1%)
9
(12.0%)
posterior 1
(2.1%)
0
(0.%)
1
(1.3%)
13
(27.7%)
8
(28.6%)
21
(28.0%)
central 0
(0.%)
1
(3.6%)
1
(1.3%)
8
(17.0%)

11
(39.3%)
19
(25.3%)
Whole plateau 1
(2.1%)
8
(28.6%)
9
(12%)
2
(4.3%)
5
(17.9%)
7
(9.3%)
no depression 42
(89.4%)
18
(64.2%)
60
(80%)
17
(36.2%)
2
(7.1%)
19
(25.4%)
analysis Fisher = 1, d.f. = 1, p < 0.001 Fisher = 1, d.f. = 1, p = 0.002
depression sites of LTP: central and posterior are 53.3%

3.1.4.3. MTP injuries type V and VI
Table 3.13: fragment amounts on CT scan (n = 75)
Type
fragment amounts
Type V Type VI Combined
n = 47 n = 28 n = 75
1 fragments 27 (57.4%) 9 (32.1%) 36 (48.0%)
2 fragments 16 (34.0%) 16 (57.1%) 32 (42.7%)
3 fragments 4 (8.5%) 3 (10.7%) 7 (9.3%)
cases 47 28 75
analysis Fisher = 1, d.f. = 1, p = 0.082
MTP fractures have less fragments.
Table 3.14: Fragments in posterior wall fractures of MTP
Fragment
amounts
Xray CT scan
Type V
(n = 47)
Type V I
(n = 28)
Combined
( n = 75)
Type V
( n = 47)
TypeVI
( n = 28)
Combined
( n = 75)
0
fragment

41
(87.2%)
27
(96.4%)
68
(90.7%)
23
(48.9%)
18
(64.3%)
41
(54.7%)
1
fragments
6
(12.8%)
1
(3.6%)
7
(9.3%)
24
(51.1%)
10
(35.7%)
34
(45.3%)
Annalysis
Fisher = 1, d.f = 1, p = 0.246 Chi-squar =1.67, d.f=1, p=0.197
Fragments in posterior wall fractures of MTP type V, VI are 45.3%.
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Table 3.15: Depression level of MTP
Depression
level(mm)
Xray CT scan
Type
V
Type VI Combine
d
Type V Type VI Combine
d
Mean 1.0 ±
2.7
(mm)
0.9 ± 2.2
(mm)
0.9 ± 2.5
(mm)
1.9 ±
3.8
(mm)
2.0 ± 3.2
(mm)
2.0 ± 3.6
(mm)
- MTP depression level comparison on Xray and CT scan. With K = 0,54
Table 3.16: MTP depression site comparison
Depression
sites
Xray CT scan
Type V

(n = 47)
Type VI
(n = 28)
Combined
(n = 75)
Type V
(n = 47)
Type VI
(n = 28)
Combined
(n=75)
Anterior 1
(2.1%)
1
(3.6%)
2
(2.7%)
2
(4.3%)
0
(0.0%)
2
(2.7%)
Posterior 3
(6.4%)
1
(3.6%)
4
(5.3%)
6

(12.8%)
6
(21.4%)
12
(16.0%)
Central 0
(0.0%)
0
(0.0%)
0
(0.0%)
4
(8.5%)
3
(10.7%)
7
(9.3%)
Whole 1
(2.1%)
3
(10.7%)
4
(5.3%)
3
(6.4%)
1
(3.6%)
4
(5.3%)
No

depression
42
(89.4%)
23
(82.1%)
65
(86.6%)
32
(68.1%)
18
(64.2%)
50
(66.7%)
cases 47 28 75 47 28 75
Annalysis Fisher = 1, d.f = 1, p <=0.001 Fisher = 1, d.f = 1, p = 0.001
- In comparrison with CT SCAN, XRAY cannot detect depression less than
20%.
3.1.4.4. Tibial spine injuries
- ACL avulsion is 6.66% (5/75 cases), PCL is 1.33 % (1/75 cases).
3.1. 5. Reliability of Schatzker classification
Table 3.17: Schatzker classification of tibial plateau fractures.
Type Xray CT scan
Type 1 16 8
Type 2 21 29
Type 3 4 4
Type 4 18 10
Type 5 40 47
Type 6 27 28
cases 126 126
Diagnosis match between Xray and CT scan is 86.61%, K = 0.83

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3.2. Surgical treatment
3.2.1. Age, gender distribution
62 fracture cases type Schatzker V, VI were surgically treated with
plating techniques include: type Schatzker V: 35 cases, type Schatzker VI: 27
cases. Males are 37 (59.7%) and females are 25 (40.3%). Mean ages: 40.11 ±
13.45 y.o.
- Injury causes: Motor vehicle accidents type V, VI. Most are motorbike
accidents.
3.2.2. Combined injuries
- Soft tissue injuries degree 0 are 55 cases, of 88.7%.
- There is no significant difference of soft tissue injuries between 2 types,
p = 0,64.
- ACL avulsion injuries are found in 5/62 cases. (8.0%).
- Fibular head fractures are found in 23 cases. (33.6%).
- There is significant difference of combined injury degree between type
Schatzker V and VI, p = 0.002.
3.2.3. The time from tibial plateau fractures to surgical treatment
- The time from tibial plateau fractures to surgical treatment are 4 to 9
days. There is no significant difference of waiting time for surgery between 2
groups, p = 0.111.
3.2.4. Surgical approach, fracture fixation plates, plating sites, surgical time
and post-op drainage
- Surgical approach: lateral: 9 cases, medial: 31 cases, combined both:
22 cases.
- Plates used: 1 plate: 43 cases (69.4%). 2 plates: 19 cases (30.6%).
- Mean surgical time of study group are 79.4 ± 23.2 minutes.
- Mean drainage fluid volume are 120.4 ± 107.3 ml.
3.2.5. Post-op accidents and complications
- There is only 1 case with incision superficial infection.

3.2.6. Results
3.2.6.1. results after 3 months post-op:
62 cases are followed up in the first 3 months with following results:
- Primary incision healing: 100%. Post-op suture removal from 12 to 14
days.
Mean range of knee flexion at 3 month post-op are 117.3° ± 16.4°.
- Time for post-op knee motion exercises are 6.3 ± 6.2 days. Time for post
– op weight bearing on surgical legs are 5.2 ± 0.9 weeks. There is significant
difference of post-op weight bearing time between type Schatzker V and VI, p <
0.001.
- Time for bone healing grade III are 15.1 ± 1.6 weeks.
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Time 3.23: Results of tibial plateau fracture reduction after 3 months post-
op
Angle (degrees ) Type V
(n=35)
Type VI
(n=27)
Combined
(n=62)
Result
analysis
Pre-op tibial
plateau angulation
85.6º ± 6.0º 88.3º ± 7.0º 86.8º ± 6.6º P = 0.077
Post-op op tibial
plateau angulation
88.6º ± 3.7º 89.1º ± 3.0º 88.8º ± 3.4º P = 0.8
Pre-op declination 13.1º ± 6.3º 12.5º ± 6.3º 12.9º ± 6.3º P = 0.289
Post-op declination 9.8º ± 4.8º 11.3º ± 4.9º 10.5º ± 4.8º P = 0.289

- Satisfied reduction for MTP angulation are 82.1%, declination are 81.4%.
Primary results: based on Larson - Bostman standards:
Excellent: 32.2%, good: 1.6%
3.2.6.2. Long term results ≥ 12 months
Only 53 cases were evaluated in long term.
Long term results:
Table 3.24: Post-op follow-up time
Follow-up years Cases (n = 53)
1 year 6 (1.28)
2 year 24 (45.34%)
3 year 17 (32.1%)
4 1year 5 (9.4%)
6 year 1 (1.88%)
Mean follow-up time are 26.3 months.
Table 3.25: Pain scores
No pain 16 (55.2%) 6 (25.0%) 22 (41.5%)
Occasional pain 11 (37.9%) 16 (66.7%) 27 (50.9%)
Local pain 0 (0.0%) 2 (8.3%) 2 (3.8%)
Pain while waliking. 1 (3.4%) 0 (0.0%) 1 (1.9%)
Pain at night rest 1 (3.4%) 0 (0.0%) 1 (1.9%)
Mean scores 5.6 ± 0.6 5.2 ± 0.6 5.4 ± 0.6
Analysis Fisher = 4.89, d.f = 1.51, p = 0.32
- only 2 cases with severe pain.
15
Table 3.26: walking ability
Walking ability Type V
(n = 29)
Type VI
(n = 24)
Combined

(n = 53)
Walking< 15 min. 1 (3.4%) 2 (8.3%) 3 (5.7%)
Walking < 60 min 7 (23.7%) 9 (47.5%) 16 (30.7%)
Normal walking 21 (72.9%) 12 (50.0%) 33 (63.5%)
Walking in house 0 (0.0%) 1 (4.2%) 1 (1.9%)
Wheelchair use 0 0 0
Mean scores 5.4 ± 1.1 4.7 ± 1.5 5.1 ± 1.3
Analysis Fisher = 3.25, d.f =1.51, p = 0.077
- There is no significant difference between 2 groups, p = 0,077.
Table 3.27: knee extension
Knee extension Type V
(n = 29)
Type VI
(n = 24)
Combined
(n = 53)
Knee extension limit > 10° 0 0 0
Knee extension limit < 10º
(4 points)
2 (6.9%) 2 (8.3%) 4 (7.5%)
Normal extension (6 points) 27 (93.1%) 22 (91.7%) 49 (92.5%)
-There are 4 cases with knee extension limit because there are no improvement
of tibial plateau declination compared to properation
Table 3.28: knee flexion
Knee flexion Type V
(n = 29)
Type VI
(n = 24)
Combined
(n = 53)

< 90º (2 points) 0 1 1
from - < 120° (4 points) 1 1 2
120º - < 140 °(5 points) 12 9 21
≥ 140º (6 poits) 16 13 29
Mean flexion range 133,6°
- Mean flexion range are 133.6º (min 80º, max 145º).
Table 3.29: Knee stability
Knee stability Type V
(n = 29)
Type VI
(n = 24)
Combined
(n = 53)
Stable at 20° flexion
position
28 (96.6%) 22 (91,7%) 50 (94.3%)
Unstable at < 10°
extension position
0 (0.0%) 1 (4.2%) 1 (1.9%)
Unstable at >10°
extension position
1 (3.4%) 0 (0.0%) 1 (1.9%)
Unstable at 20° flexion
position
0 (0.0%) 1 (4.2%) 1 (1.9%)
Mean points 5.9 ± 0.4 5.9 ± 0.4 5.9 ± 0.4
16
Knee instability were caused by residual tibial plateau depression and
malalignment.
Functional results following Rasmussen standards.

Excellent: 81.1%, good: 15.1%, fair: 3.8%.
Table 3.30: Xray results following Rasmussen standards
Evaluation index Type V
(n = 29)
Type VI
(n = 24)
combined
(n = 53)
Tibial plateau enlargement.
< 5mm
> 5mm
normal
0.0
3.6% (1)
96.4% (28)
4.2% (1)
0.0% (0)
95.8% (23)
1.9% (1)
1.9% (1)
96.2% (51)
Articular step-off (points)
4 points
6 points
(n = 29)
13.8% (4)
86.2% (25)
(n = 24)
20.8% (5)
79.2% (19)

(n = 53)
17.0% (9)
83% (44)
Malalignment (points)
4 points
6 points
(n = 29)
6.9% (2)
93.1% (27)
(n = 24)
12.5% (3)
87.5% (21)
(n = 53)
9.4% (5)
90.6% (48)
Xray results of 53 cases: excellent: 75.5%, good: 24.5%.
17
Chapter 4: DISCUSSION
4.1. CHARACTERISTICS RESEARCH GROUP
Average age fractured tibial plateau in the study was 38.3 ± 13.08 years
old. 89.7% fractured tibial plateau causes by traffic accidents, largely due to the
motorcycle accident.
4.2 MORPHOLOGICAL LESIONS
4.2.1. Lesion of lateral plateau (I, II, III Schatzker group)
On computerized tomography imagines, isolated fractured tibial plateau
with the morphological lesions following:
- Fragments no subsided was 19.5%, fragments together with subsidence
70.7% and pure depression fracture 3.2%. The research results showed on
computerized tomography imagines that fragments together with subsidence
accounted for most of the types of fractured tibial lateral plateau. According to

Schatzker classification, it is type II.
- Fractures of the two fragments is 46.35%. the poor suitable of some
fragments between X-rays imagines and computerized tomography with k =
0.072, so the X-ray imagines reveal not exactly fractured fragments. Because
fracture with two fragments accounted so high, so we must pay attention when
performed percutaneous screws on the surgery. Screws go between two surface
of fragments easily.
- The rate of fractured posterior wall after combining fractured tibial lateral
plateau is 18.9%.
- Subsidence of lateral tibial plateau more than 5mm is 63.4%. On
conventional X-ray imagines, the fractured tibial lateral plateau with subsided
more than ≥ 5mm will rise appearance the fragments at the posterior wall. And
the more subsided degrees increase, the more subsided area increase at the
posterior. Therefore, when we find that the sudsided fragment ≥ 5mm, the
patients should be taken computerized tomography.
4.2.2. Lesions in the medial tibial plateau (Schatzker type IV)
Fractures of the isolated medial tibial plateau accounted for 7.9% of the
type of fracture tibial plateau, with following morphological lesions:
- Fracture with fragments, fewer fragments but usually large fragments.
Percentage of fragment at posterior wall of tibial plateau 4/10 cases and
fragments usually go down.
- Subsided at the medial tibial plateau is not much, but fragments often tilt
toward medial. Therefore need to properly assess lesions. Reduction to correct
the tilt fragments is very important. According to some authors recommend
using a plate to fix fracture fragment at medial tibial plateau.
- Subsidence in the medial tibial plateau happens at front and center and
posterior surface plateau.
We found that the assessment fracture medial tibial plateau by conventional
X-ray imagines is not difficult and does not require taking computerized
tomography. However, when fracture medial tibial plateau with the fragment at

18
the posterior wall should be taken computerized tomography to locate the exact
position to have the correct path with a fracture fragment.
4.2.3. Lesions in both of the tibial plateau (Schatzker V, VI)
4.2.3.1. Morphological fracture
In this study, fracture type V, VI 75/126 cases, accounting for the
proportion (59.5%). There were 5 morphological fracture following:
Morphological fracture type 1: fractured line comes from a lateral tibial
plateau then go down to the tibial epiphysis and split into two fractured lines, the
first lines go out the lateral and second lines toward the medial tibial plateau.
For this type of fracture, lateal tibial plateau surface has many small fragments
and often subsided. The lateral tibial plateau is separated from the tibial
diaphysis. Lateral tibial plateau surface is less likely to break and be tilt to the
medial, made subluxation knee lateraly, is the most common type of fracture.
Shown impulsing mechanisms.
Morphological fracture type 2: fractured lines derived from inter-spikes
tibial with two fracture lines going down the epiphysis and come out to both
sides medial and lateral tibial plateau. This type of fracture, both of two tibial
surfaces be less fracture and subsidence equaly. Two fragments of tibial plateau
can move posterior angle deviation. This type of fracture accounted for 28%, the
second frequency. This mechanism is fractured by the force put on both femoral
condyle to tibial plateau.
Morphological fracture type 3: fractured lines comes from two tibial
plateau go straight down the epiphysis and made fracture. For this fracture type,
both tibial surface are often fractured fragments and fractured fragments were
sinking into epiphysis. The rate of this type of fracture accounted for 8%.
Morphological fracture type 4: fractured line comes from two inter-spikes
tibial go straight down the diaphysis and make fractured of two tibial plateau at
the epiphysis or diaphysis. For this type of fracture, both of tibial are splited
widely and tend to tilt to on both sides. Tibial plateau’s surface are often less

broken bones. This type of fracture rate of 9.4% and appropriate diagnosis
between the conventional X-ray imagines and computerized tomography is
71.4%.
Morphological fracture type 5: fractured line breaks come from lateral
tibial plateau and go into the epiphysis and ends at the medial wall of the medial
tibial plateau. This is a simple fracture. Lateral tibial plateau’s surface without
3rd fractured fragment. Fragment of medial tibial plateau tends to be pulled
away from the epiphysis of the bone. This type of fracture rates in this study was
4% and the rate of appropriate diagnosis between conventional imagines and
computerized tomography is 100%.
Can outline morphological fracture both tibial plateau as follows:
19
Figure 4.1. Morphological fracture both tibial plateau
4.2.3.2. Lesions of the lateral tibial plateau (Schatzker V, VI)
The degree of lesions the tibial plateau on computerized tomography as
follows:
Types of fracture with many fragments and fragment are often small. The
rate of fracture in the posterior lateral tibial plateau is 49.3%. The average
subsidence of lateral tibial plateau: 3.7 ± 3.9 mm. Subsidence area usually at the
posterior and center. This research suggest that surgical should be reduced
fracture and subsidence fragments at the posterior wall area
4.2.3.3. Lesions of the medial tibial plateau (Schatzker V, VI)
The degree of lesions the medial tibial plateau in include:
Types of fracture with few fragments and fragment are often large The
rate of fracture in the posterior wall medial tibial plateau was 45.3%. The
average subsidence of medial tibial plateau was 2.0 ± 3.6 mm. Subsidence of
medial tibial plateau is often posterior side. Some surgeon found that fracture
medial tibial plateau with the fracture posterior fragment is kind of unstable
fracture, secondary displaced easily and should be fixed by surgery or
immobilization by cast or splint.

Through research, we found that computerized tomography has proven to
be a valuable tool in the diagnosis of fractured tibial plateau. It’s advantages
compared with conventional X- ray include: a more accurate description of the
location and number of fragments, fracture line, settlement and subsidence areas
of the tibial plateau. For this type of fracture is taken computerized tomography
both tibial plateaus is essential.
4.2.4. Evaluation of the Schatzker classification
According to Schatzker classification, comparing on diagnosis of fracture
tibial plateau between conventional X-ray imagines and computerized
tomography there are 17 cases (13.49%) were classified changes, most are from
type I to type II, followed by from type IV to type V and a case of changing
from V to VI because undetectable subsidence and fractures in conventional X-
ray imagine. These lesions are only detected when take computerized
tomography. So if not taken computerized tomography, we won’t see the whole
lesions of the tibial plateau.
Through research, we found that the classification of Schatzker fracture
tibial plateau based on conventional X-ray imagines with high accuracy. The
appropriate diagnosis between conventional X-ray imagines versus
computerized tomography reached: 86.51%.
20
4.3. RESULTS OF SURGICAL TREATMENT
Short-term results: 62 cases with 62 fractured tibial plateau were
evaluated according to the standard of Larson-Bostman: very good achieved:
59.7% (37 cases), good: 38.7% (24 cases) and average 1.6% (1 case).
Situation of incisions: healed completely, suture should be cut 12 days after
surgery for preventing from dilation or split the incision.
No cases of deep infection. Only 1 case of superficial infections. In our
opinion, the cause of infection depends on many factors, but there are two
factors that should be more concerned:
- Skin at the tibial plateau area was damaged without treatment stability but

conducted operations.
- Invasive soft tissue so much, extend operation time because reduction in
correction perfectly, create favorable conditions for wound infections easily.
- Not completely drain.
-For a good reduction results, should be measure tibial angle preoperation
and preoperative planning, good preparation equipments and tools preoperative.
Especially on reductive problems with control C-arm is very important.
For our experience, surgery should wait until the skin of the knee healed
completely. During surgery, we manipulate so gently limited action causing
damaged to the tissue of skin.
For fracture medial tibial plateau with a posterior-medial fracture fragment
should be used plate to fix. The plate acts as a base for the fracture fragments
not displaced fractures and limit of subsidence tibial plateau.
On the issue of bone graft: we are not bone graft although gaps remain, of
course, space is not large, these patients did not pressure us early compression.
We rely on the theoretical basis of calcified hematoma drives and many practical
cases porous bones in the bone plate to another baseball has created a fracture
bones in place.
The long-term results
Knee pain after surgery: despite the pain any degree also reflect function
knee is not normal. In our opinion, the cause of pain is the inflammation and
adhesive of soft tissue at surgical area, together with the stick patella and
femoral condyle that limit joint mobility. Joint’s surface was still subsidence.
We see, these elderly patients after fracture tibial plateau and operated.
Despite good functional results, the patients did not dare walk a lot because of
fear of an fall or accident again.
We also interventional advocate to elevate tibial plateau as degree of
subsidence ≥ 3mm. To limit secondary subsidence, we needs reduction, elevate
tibial plateau perfectly and fixed tibial plateau stabilizing and snugly.
Long-term follow-up for detection of knee osteoarthritis after fractured

tibial plate is essential. The number of our patients with the mean follow-up time
was 26.3 ± 11.5 months but do not have any patient was osteoarthritis. We
thought that we had reducted subsidence by surgery and good rehabilitation as
21
instructed, combinations following treatment were somewhat limited degree of
osteoarthritis.
4.4. SOME FACTORS AFFECTING THE RESULTS OF TREATMENT
* Surgical time: There are 35/62 patients operated within 4-9 days after the
accident. Many surgeon suggest this is the most swollen time. Our experience,
treat early by continued tractor, using analgesics, reducing swollen until the soft
tissue in place to allow surgery. When skin and soft tissue at operative field is
dry, stable, not hot, elastography, we can do surgery.
* Associated lesions at knee
For vascular lesions or compression chamber: when the patients had signs
of blood vessel damage or compression chamber,we should intervene early
actively to prevent complications unfortunate happens.
For meniscal lesions: should treat at the same time with fixation fracture.
The purpose of that to ensure stability knee after surgery, facilitate rehabilitation
after surgery.
Lesions at the ligament attachment: tear of colateral ligaments tendons,
avulsion the attachment of the cruciate ligaments should treat at the same time
with fracture fixation. Cruciate ligament should leave afterwards.
* The role of incision:
Experience has shown, we used the lateral approach and a plate placed
laterally with many fracture fragments at lateral tibial plateau or much
subsidence while one or two large fragments at medial tibial plateau.
We use medial approach and a plate placed medially with many fragments
at medial tibial plateau or associated subsidence, simple one fracture fragment at
lateral plate.
During surgery can incise lateral or medial approach to reduce the opposite

fracture tibial fragment if necessary.
We use both lateral and medial approach two plates at both sides when
fracture both tibial plateaus associated subsidence of many fragments and
displacement angle.
* Role of device:
We use plate L sample for lateral tibial plateau and T sample for medial
plateau. Big fragments are fixed by 6.5 screws and small fragments by 3.5
screws
* Role of computerized tomography scan:
With type of the fracture two tibia plateaus should be taken computerized
tomography scan and three-dimensional reconstruction pre-operation to assess
the completely damage and schedule proper treatment plan.
22
CONCLUSIONS
Research morphological lesions of tibial plateau fractures on conventional
radiologic film, CT-Scanner of 126 injuried fracture tibial plateau patients and
assessment of the surgical treatment results of 62 patients with tibial type V, VI
Schatzker fractures fixed by plate in 175 Military Hospital, from 06/2006 to
05/20013, we infer some conclusions:
1 / Lesions morphology plateau tibial fractures:
We can see the difference in morphology between the groups according to
the Schatzker classification.
* For lesion in the latreral tibial plateau (Schatzker types I, II, III):
- Tibial plateau with fragments no subside with the majority in 70.7%
(29/41 cases), followed by fracture fragment no subsidence is 19.5%, subsided
fractures purely 3.2%, fracture with two fragments is 46.35%. Rate of fracture
posterior tibial wall in combination is 18.9%, and subsidence ≥ 5 mm is 63.4%.
As degree of subsidence increased, the subsidence area appears posterior
increase.
- Normally, we can be used conventional X-ray imagine vulnerability

assessment without necessarily computerized tomography. However, on the
conventional X-ray imagines, the lateral tibial plateau subsidence ≥ 5mm should
be taken computerized tomography.
* For lesions in the medial tibial plateau (Schatzker type IV):
- Fractures of the medial tibial plateau occupies 7.9% of the type of fracture
tibial plateau.
- Usually large fragments with few fragments.
- Subsided of medial tibial plateau in not much, but fragments often
inclined inside. Medial tibial plateau fracture with posterior wall fragments
should be taken CT-Scanner to locate exactly the fracture fragment to have the
correct incision to broken fragments.
* For lesions both two tibial plateau (Schatzker type V and VI)
Lesion of lateral tibial plateau is types of many fracture fragments. Average
subsided was: 3.7 ± 3.9 mm
2
. The rate in posterior wall was 45.3%. Subsidence
of medial tibial plateau often in posterior and centre of surface area.
Lesion of medial tibial plateau is type of fewer fracture fragments. Mostly
have 1-2 fragments. Fragments is typically large. The rate of fragments in
posterior wall is 45.3%. Average subsided was 2.0 ± 3.6 mm. Subsidence of
medial tibial plateau often in posterior.
Fracture both two tibial plateaus: Type 1: 50.6% ; Type 2: 28% ; Type 3:
8% ; Type 4: 9.4% ; Type 5: 4%.
The reliability ratio conventional radiologic film compared with CT-
Scanner procedures in diagnosis tibial plateau fracture: 86.51%.
23
2 / Therapeutic results
Results according to Larson - Bostman standards: Excellence 66.1%: good
32.2%, Average: 1.6%. Angle of medial tibial plateau after reduction reached:
88.8 ° ± 3.4 °, tilt posterior angle reached 10.5° ± 4.8°. Compared with the

anatomical origin of the medial tibial plateau, manipulation results achieved:
82.1%. And compared to the tibial plateau tilted angle, the manipulation results
achieved 81.4%. Healing stability bone: 100%.
Evaluation results of Rasmussen standards showed functional outcomes
recovery reached 81.1% good, 15.1% good and average is 3.8%.

LIST OF SCIENTIFIC WORKS
ANNOUNCING RESULTS OF THE DISSERTATION THEME
1. Tran Le Dong, Le Phuoc Cuong, My Duy Tien (2014)‘ Evaluation of
clinical outcomes type V and VI Schatzker closed tibial plateau fractures
fixed by plate when combined with imaginal roles computerized tomography
before surgery’. Vietnam Medicine, No 2, page 17 – 21.
2. Tran le Dong, Le Phuoc Cuong, My Duy Tien (2014) ‘ Tibial plateau
fracture - role of CT scan - compare with Xray’ . Vol 39, No 1, P 115-119