The role of CT and MRI in the assessment of tibial plateau fractures according to Schatzker classification

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1 The role of CT and MRI in the assessment of tibial plateau fractures according to Schatzker classification Poster No.: P-0093 Congress: ESSR 2015 Type: Educational Poster Authors: I. Tsifountoudis, M. D. D. Sidiropoulos, I. Kalaitzoglou, E. Dionisiadis, M. P. A. Haritandi, A. S. Dimitriadis; Thessaloniki/GR Keywords: Trauma, Education, MR, CT, Bones DOI: /essr2015/P-0093 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 46

2 Learning objectives The Schatzker classification system for tibial plateau fractures is widely used by orthopedic surgeons to assess the initial injury, plan management and predict prognosis. Many investigators have found that surgical plans based on plain radiographic findings were modified after preoperative computed tomography (CT) or magnetic resonance imaging (MRI). Background The Schatzker classification divides tibial plateau fractures into six types: lateral plateau fracture without depression (type I), lateral plateau fracture with depression (type II), compression fracture of the lateral (type IIIA) or central (type IIIB) plateau, medial plateau fracture (type IV), bicondylar plateau fracture (type V), and plateau fracture with diaphyseal discontinuity (type VI) [Fig. 1]. Management of type I, II, and III fractures centers on evaluating and repairing the articular cartilage. The fracture-dislocation mechanism of type IV fractures increases the likelihood of injury to the peroneal nerve or popliteal vessels. In type V and VI fractures, the location of soft-tissue injury dictates the surgical approach and the degree of soft-tissue swelling dictates the timing of definitive surgery and the need for provisional stabilization with an external fixator. Page 2 of 46

3 Fig. 1: The Schatzker classification. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Images for this section: Page 3 of 46

4 Fig. 1: The Schatzker classification. Page 4 of 46

5 Imaging findings OR Procedure Details During a 4-year period we systematically reviewed 295 CT examinations, 330 MRI examinations and 270 arthroscopic procedures of patients with tibial plateau fractures. In many cases, CT findings mirror those of conventional radiography. However, studies of tibial plateau fractures have shown that surgical plans based on plain radiographic findings are modified in 6%-60% of cases after CT and 21% of cases after MRI. MRI is able to demonstrate most internal derangements of the knee efficiently. With arthroscopy used as the standard of reference, MRI was found to have greater than 85% accuracy in diagnosis of meniscal and ACL tears and a high negative predictive value of 92.8%. MRI is an effective diagnostic tool for ruling out internal derangement of the knee. Fracture depression and displacement are the most important factors affecting surgical management of standard tibial plateau fractures. If left untreated, depression results in joint incongruity, valgus deformity, and a sense of instability. The need for accurate assessment of fracture depression and displacement is a major reason why CT and especially 3D-CT with reconstruction images has become the current standard for preoperative evaluation of bone injury. Type I Fracture A Schatzker type I fracture is a wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement. Depression may be difficult to measure on plain radiographs, and type I fractures may look like type II fractures or vice versa (Fig. 2, 3). Type I fractures may also be very subtle at plain radiography. These fractures are caused by the lateral femoral condyle being driven into the articular surface of the tibial plateau; they represent 6% of all tibial plateau fractures and are more frequent in young patients with normal bone mineralization. In general, impaction injury to one side of the knee is associated with distraction injury to the opposite side of the knee. The mechanism of in type I fractures involves valgus force combined with axial loading on the knee and therefore may be associated with a distraction type injury to the medial collateral ligament (MCL) or ACL. The aim of treatment is to achieve a stable, aligned, mobile, and painless joint and to minimize the risk of posttraumatic osteoarthritis. Treatment options include open reduction and internal fixation with or without arthroscopy. If the meniscus is intact at arthroscopy, closed reduction with percutaneous fixation is considered. Type I fractures can be fixed with two transverse cancellous screws. Page 5 of 46

6 Fig. 2: Type I fracture in a young patient who was in a car accident. (a), (b), (c) 3D-CT images show a split fracture of the lateral tibial plateau without depression of the tibial plateau. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 6 of 46

7 Fig. 3: Type I fracture in another young patient. (a), (b), (c), (d) Axial CT images show a split fracture of the lateral tibial plateau with mimimal depression of the tibial plateau. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Type II Fracture A Schatzker type II fracture is a combined cleavage and compression fracture of the lateral tibial plateau, a type I fracture with a depressed component (Fig. 4, 5). Depression may not be appreciated on plain radiographs, and type II fractures may look like type I fractures. Tibial plateau depression is measured as the vertical distance between the lowest point on the intact medial plateau and the lowest depressed lateral plateau fracture fragment. Schatzker et al originally defined depression as measuring greater than 4mm. These fractures represent 25% of all tibial plateau fractures and are more frequent in patient populations in the 4th decade of life or later because a degree of osteopenia is typically required for depression to occur. The mechanism of injury involves valgus force on the knee, and 20% of patients have associated distraction injuries to the MCL or medial meniscus. Formal open treatment is often performed for all unstable fractures of the tibial plateau. Page 7 of 46

8 Fig. 4: Tibial plateau fracture in a 48-year-old man. (a), (b) Coronal T1-W and respective T2-W FS image show a subtle fracture in the tibial plateau without reaching the articular surface. (c), (d) Sagittal T1-W and corresponding T2-W FS image show an associated avulsion injury of the PCL. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 8 of 46

9 Fig. 5: Type II fracture in the same patient with figure 4, who was involved in a motor vehicle accident after nine months from his previous injury. (a), (b) Coronal T1-W and respective T2-W FS image show remarkable depression of the lateral tibial plateau, a finding indicative of a type II fracture. (c), (d) The associated avulsion injury of the PCL is still present on sagittal T1-W and corresponding T2-W FS image. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Type III Fracture A Schatzker type III fracture is a pure compression fracture of the lateral tibial plateau in which the articular surface of the tibial plateau is depressed and driven into the lateral tibial metaphysis by axial forces. Occasionally, depression may not be immediately evident on plain radiographs and may be clearly demonstrated only at cross-sectional imaging. These fractures represent 36% of all tibial plateau fractures and are more frequent in the older age groups (the 4th and 5th decades of life), in whom some degree of osteopenia is more likely to occur. Type III fractures are divided into two subtypes: those with lateral depression (type IIIA) (Fig. 6, 7) and those with central depression (type IIIB) (Fig. 8, 9, 10). Joint stability is rarely affected in type III fractures, but axial instability may occasionally occur in type IIIB fractures. Treatment for type Page 9 of 46

10 IIIA fractures may be nonoperative if the extent of articular depression is small and the joint remains stable. A type IIIB fracture may result in joint instability, in which case the depressed portion of the plateau is typically elevated by means of a submetaphyseal cortical window. Arthroscopic reduction of type III fractures is also possible. Although arthroscopic assistance is frequently employed for Schatzker type I and type III fractures to assess for and occasionally reduce injury to the cartilage, it is less commonly employed for type II, IV, V, and VI fractures. Fig. 6: Type IIIA fracture in a 50-year-old woman who fell and injured her knee. (a), (b), (c), (d) 3D-CT images show the lateral tibial plateau depression. The fracture was managed nonoperatively with no weight bearing for 3 months. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 10 of 46

11 Fig. 7: Type IIIA fracture in a 53-year-old man who fell and injured his knee. (a), (b) Coronal T1-W image and corresponding T2-W FS image and (c), (d) sagittal T1-W and corresponding T2-W FS image show the lateral tibial plateau depression. The fracture was managed nonoperatively with no weight bearing for 12 weeks. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 11 of 46

12 Fig. 8: Type IIIB fracture in an 35-year-old man who fell and twisted his knee. (a), (b) Coronal T1-W and corresponding T2-W FS image and (c), (d) sagittal T1-W and respective T2-W FS image show a compression fracture of the central aspect of the lateral tibial plateau. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 12 of 46

13 Fig. 9: Type IIIB fracture in the same patient with figure 8. (e), (f) Axial T1-W and corresponding T2-W FS image show the fracture line of the central aspect of the lateral tibial plateau. (g) Sagittal T2-W FS image shows an associated ACL tear in the upper portion of the ligament and (h) coronal T2-W FS image shows an associated 2nd degree tear of the MCL. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 13 of 46

14 Fig. 10: Type IIIB fracture in a 14-year-old adolescent who experienced trauma to his left knee during a soccer game. (a), (b), (c), (d) Coronal T1-W and corresponding T2-W FS images show a compression fracture of the intercondylar eminences and the central aspect of the lateral tibial plateau. (e), (f), (g) Sagittal T1-W, T2-W and 3DFSPGR images show an associated avulsion injury of the ACL. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Type IV Fracture A Schatzker type IV fracture is a medial tibial plateau fracture with a split or depressed component (Fig. 11). The mechanism of injury involves varus force with axial loading at the knee. Posteromedial coronal split fractures occur as a result of varus forces combined with axial loading in a hyperflexed knee. These fractures represent 10% of all tibial plateau fractures and carry the worst prognosis. Younger patients tend to have a high-energy mechanism of injury and commonly have a component of subluxation or dislocation that reduces spontaneously. Owing to the subluxation or dislocation, cross-sectional imaging may be more accurate than standard radiography for assessment of fracture extent. The fracture-dislocation mechanism of type IV fractures increases the likelihood of injury to the peroneal nerve or popliteal vessels. This fracture is also frequently associated with Page 14 of 46

15 distraction injury to the lateral compartment, resulting in lateral collateral ligament (LCL) complex or posterolateral corner injury or in fracture or dislocation of the proximal fibula (Fig. 12, 13). Older patients may sustain a type IV fracture from a low-energy force. In such cases, fracture-dislocation and associated soft-tissue injuries may not occur. In Schatzker type IV fractures, the risk of compromise to the popliteal artery and peroneal nerve is significant and should direct initial therapy. Type IV fractures tend to angulate into varus position and are typically treated by means of open reduction and internal fixation with a medial buttress plate and cancellous screws (Fig. 14, 15, 16). Fig. 11: Type IV fracture in a 48-year-old woman who had a high-speed car accident. (a), (b), (c), (d) 3D-CT images show a split fracture of the medial tibial plateau with subtle medial subluxation of the knee. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 15 of 46

16 Fig. 12: Type IV fracture in a 47-year-old man who was in a high-speed motorcycle collision. (a), (b) Coronal T1-W and corresponding T2-W FS image, (c), (d) sagital T1W and respective T2-W FS image and (e) axial STIR image show the medial tibial plateau fracture extending to the intercondylar eminences and medial subluxation. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 16 of 46

17 Fig. 13: Associated lessions in type IV fracture of the same patient with figure 12. (f) Coronal T2-W FS image shows a bucket-handle tear of the medial meniscus and edematous appearance of the posterolateral corner. (g) Coronal T2-W FS image posteriorly to (f) demonstrates PCL tear. (h), (i) Coronal T1-W and corresponding T2W FS image show a fracture at the tip of the fibula with avulsion of the LCL and the tendon of the long head of the biceps femoris muscle. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 17 of 46

18 Fig. 14: Type IV fracture in a 45-year-old man who fell off a ladder onto his knee. (a), (b) Coronal T1-W and corresponding T2-W FS image show the medial tibial plateau fracture extending to the intercondylar eminences. (c), (d) Sagittal T1-W and respective T2-W FS image show associated ACL avulsion injury. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 18 of 46

19 Fig. 15: Type IV fracture in the same patient with figure 14. (e), (f) Axial CT images show the fracture line at the medial tibial plateau extending to the intercondylar eminences. (g), (h), (i), (j), (k), (l) 3D-CT images give a detailed description of the fracture demonstrating the exact degree of medial subluxation. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 19 of 46

20 Fig. 16: Type IV fracture in the same patient with figure 15. The fracture described on (m) and (n) plain radiographs (face and profile views respectively) treated successfully by means of open reduction and internal fixation with a medial buttress plate and cancellous screws (o), (p). References: Radiology, 424 General Military Hospital - Thessaloniki/GR Type V Fracture A Schatzker type V fracture consists of a wedge fracture of the medial and lateral tibial plateau, often with an inverted "Y" appearance (Fig 17). Articular depression is typically seen in the lateral plateau, and there may be associated fracture of the intercondylar eminence. Type V fractures are distinguished from type VI fracture patterns by the maintenance of metaphyseal-diaphyseal continuity. These fractures represent only 3% of all tibial plateau fractures and are typically associated with a high-energy mechanism of injury, such as a motor vehicle collision. The mechanism of injury tends to be complex, involving a combination of varus or valgus stresses combined with axial loading. Up to one-half of patients with type V fractures have peripheral meniscal detachment, and one-third have ACL avulsion injury. Condylar fractures cause instability by disrupting the anchor of the collateral ligaments (Fig. 18). Injury to the collateral ligaments themselves Page 20 of 46

21 may not be clinically significant. In bicondylar fractures, the cruciate ligaments become crucial for joint stability. Additional fracture of the intercondylar eminence is referred to as a four-part fracture and renders the knee unstable due to loss of the cruciate ligament anchor (Fig 19). Further evaluation of bicondylar fractures with cross-sectional imaging may be helpful to exclude unstable four-part fractures. Initial management involves splinting or temporary external fixation. To reduce the risk of infection, it is customary to wait for soft-tissue inflammation and edema to subside before surgical management (Fig 9). Many of these fractures are not treated with internal fixation at all because of the risks of complication. In a case review study of tibial plateau fractures, Moore et al. found that 23% of Schatzker type V fractures became infected after treatment. In their series, 82% of the fractures that required both medial and lateral plating were complicated by wound dehiscence or infection. More recent studies have found that use of two-incision techniques can reduce infection rates to around 12%. Fig. 17: Type V fracture in a 39-year-old man who fell down a flight of stairs. (a), (b), (c) Plain radiograph, coronal and axial CT images and (d), (e), (f), (g) 3D-CT images show a bicondylar split fracture. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 21 of 46

22 Fig. 18: Type V fracture in the same patient with figure 17. (h), (i) Coronal T1-W and corresponding T2-W FS image show a bicondylar split fracture and an associated 3rd degree tear of the MCL from its tibial attachement. (j), (k) Axial T1-W and respective T2-W FS image show a bicondylar split fracture. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Page 22 of 46

23 Fig. 19: Four-part fracture in a 56-year-old man who was involved in a car accident. (a), (b) Coronal T1-W and corresponding T2-W FS image and (c), (d) sagittal T1-W and respective T2-W FS image show a four-part fracture of the tibial plateau with a remarkable depression of the lateral tibial condyle. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Type VI Fracture Schatzker type VI fracture is a transverse subcondylar fracture with dissociation of the metaphysis from the diaphysis (Fig 20). The fracture pattern of the condyles is variable, and all types of fractures can occur. These fractures represent 20% of all tibial plateau fractures and are the result of high-energy injury to the knee. The mechanism of injury is complex, similar to type V fractures. One-third of type VI fractures are open, and frequently there is extensive soft-tissue injury with increased risk of compartment syndrome. The dissociation between the metaphysis and diaphysis makes this fracture unsuitable for treatment with traction. Most such fractures are treated with buttress plates and, if both condyles are fractured, cancellous screws on either side. Page 23 of 46

24 Fig. 20: Type VI fracture in a 47-year-old woman who fell down from the stairs. (a), (b), (c), (d), (e) 3D-CT images show a metaphyseal-diaphyseal fracture with apparent extension into the joint space. The lateral split fracture component of the type VI tibial plateau fracture is well demonstrated on the reformatted CT images. References: Radiology, 424 General Military Hospital - Thessaloniki/GR Images for this section: Page 24 of 46

25 Fig. 2: Type I fracture in a young patient who was in a car accident. (a), (b), (c) 3D-CT images show a split fracture of the lateral tibial plateau without depression of the tibial plateau. Page 25 of 46

26 Fig. 3: Type I fracture in another young patient. (a), (b), (c), (d) Axial CT images show a split fracture of the lateral tibial plateau with mimimal depression of the tibial plateau. Page 26 of 46

27 Fig. 4: Tibial plateau fracture in a 48-year-old man. (a), (b) Coronal T1-W and respective T2-W FS image show a subtle fracture in the tibial plateau without reaching the articular surface. (c), (d) Sagittal T1-W and corresponding T2-W FS image show an associated avulsion injury of the PCL. Page 27 of 46

28 Fig. 5: Type II fracture in the same patient with figure 4, who was involved in a motor vehicle accident after nine months from his previous injury. (a), (b) Coronal T1-W and respective T2-W FS image show remarkable depression of the lateral tibial plateau, a finding indicative of a type II fracture. (c), (d) The associated avulsion injury of the PCL is still present on sagittal T1-W and corresponding T2-W FS image. Page 28 of 46

29 Fig. 6: Type IIIA fracture in a 50-year-old woman who fell and injured her knee. (a), (b), (c), (d) 3D-CT images show the lateral tibial plateau depression. The fracture was managed nonoperatively with no weight bearing for 3 months. Page 29 of 46

30 Fig. 7: Type IIIA fracture in a 53-year-old man who fell and injured his knee. (a), (b) Coronal T1-W image and corresponding T2-W FS image and (c), (d) sagittal T1-W and corresponding T2-W FS image show the lateral tibial plateau depression. The fracture was managed nonoperatively with no weight bearing for 12 weeks. Page 30 of 46

31 Fig. 8: Type IIIB fracture in an 35-year-old man who fell and twisted his knee. (a), (b) Coronal T1-W and corresponding T2-W FS image and (c), (d) sagittal T1-W and respective T2-W FS image show a compression fracture of the central aspect of the lateral tibial plateau. Page 31 of 46

32 Fig. 9: Type IIIB fracture in the same patient with figure 8. (e), (f) Axial T1-W and corresponding T2-W FS image show the fracture line of the central aspect of the lateral tibial plateau. (g) Sagittal T2-W FS image shows an associated ACL tear in the upper portion of the ligament and (h) coronal T2-W FS image shows an associated 2nd degree tear of the MCL. Page 32 of 46

33 Fig. 10: Type IIIB fracture in a 14-year-old adolescent who experienced trauma to his left knee during a soccer game. (a), (b), (c), (d) Coronal T1-W and corresponding T2-W FS images show a compression fracture of the intercondylar eminences and the central aspect of the lateral tibial plateau. (e), (f), (g) Sagittal T1-W, T2-W and 3D-FSPGR images show an associated avulsion injury of the ACL. Page 33 of 46

34 Fig. 11: Type IV fracture in a 48-year-old woman who had a high-speed car accident. (a), (b), (c), (d) 3D-CT images show a split fracture of the medial tibial plateau with subtle medial subluxation of the knee. Page 34 of 46

35 Fig. 12: Type IV fracture in a 47-year-old man who was in a high-speed motorcycle collision. (a), (b) Coronal T1-W and corresponding T2-W FS image, (c), (d) sagital T1-W and respective T2-W FS image and (e) axial STIR image show the medial tibial plateau fracture extending to the intercondylar eminences and medial subluxation. Page 35 of 46

36 Fig. 13: Associated lessions in type IV fracture of the same patient with figure 12. (f) Coronal T2-W FS image shows a bucket-handle tear of the medial meniscus and edematous appearance of the posterolateral corner. (g) Coronal T2-W FS image posteriorly to (f) demonstrates PCL tear. (h), (i) Coronal T1-W and corresponding T2-W FS image show a fracture at the tip of the fibula with avulsion of the LCL and the tendon of the long head of the biceps femoris muscle. Page 36 of 46

37 Fig. 14: Type IV fracture in a 45-year-old man who fell off a ladder onto his knee. (a), (b) Coronal T1-W and corresponding T2-W FS image show the medial tibial plateau fracture extending to the intercondylar eminences. (c), (d) Sagittal T1-W and respective T2-W FS image show associated ACL avulsion injury. Page 37 of 46

38 Fig. 15: Type IV fracture in the same patient with figure 14. (e), (f) Axial CT images show the fracture line at the medial tibial plateau extending to the intercondylar eminences. (g), (h), (i), (j), (k), (l) 3D-CT images give a detailed description of the fracture demonstrating the exact degree of medial subluxation. Page 38 of 46

39 Fig. 16: Type IV fracture in the same patient with figure 15. The fracture described on (m) and (n) plain radiographs (face and profile views respectively) treated successfully by means of open reduction and internal fixation with a medial buttress plate and cancellous screws (o), (p). Page 39 of 46

40 Fig. 17: Type V fracture in a 39-year-old man who fell down a flight of stairs. (a), (b), (c) Plain radiograph, coronal and axial CT images and (d), (e), (f), (g) 3D-CT images show a bicondylar split fracture. Page 40 of 46

41 Fig. 18: Type V fracture in the same patient with figure 17. (h), (i) Coronal T1-W and corresponding T2-W FS image show a bicondylar split fracture and an associated 3rd degree tear of the MCL from its tibial attachement. (j), (k) Axial T1-W and respective T2W FS image show a bicondylar split fracture. Page 41 of 46

42 Fig. 19: Four-part fracture in a 56-year-old man who was involved in a car accident. (a), (b) Coronal T1-W and corresponding T2-W FS image and (c), (d) sagittal T1-W and respective T2-W FS image show a four-part fracture of the tibial plateau with a remarkable depression of the lateral tibial condyle. Page 42 of 46

43 Fig. 20: Type VI fracture in a 47-year-old woman who fell down from the stairs. (a), (b), (c), (d), (e) 3D-CT images show a metaphyseal-diaphyseal fracture with apparent extension into the joint space. The lateral split fracture component of the type VI tibial plateau fracture is well demonstrated on the reformatted CT images. Page 43 of 46

44 Conclusion CT and especially 3D-CT images and MRI are more accurate than plain radiography for Schatzker classification of tibial plateau fractures, and use of cross-sectional imaging can improve surgical planning. References 1. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto experience, Clin Orthop Relat Res 1979; 138: Hohl M. Fractures of the proximal tibia. In: Rockwood CA, Green DP, Bucholz RW, eds. Fractures in adults. Philadelphia, Pa: Lippincott, 1991; Wicky S, Blaser PF, Blanc CH, Leyvraz PF, Schnyder P, Meuli RA. Comparison between standard radiography and spiral CT with 3D reconstruction in the evaluation, classification and management of tibial plateau fractures. Eur Radiol 2000; 10(8): Yacoubian SV, Nevins RT, Sallis JG, Potter HG, Lorich DG. Impact of MRI on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma 2002; 16(9): Macarini L, Murrone M, Marini S, Calbi R, Solarino M, Moretti B. Tibial plateau fractures: evaluation with multidetector-ct. Radiol Med 2004; 108 (5-6): Watson JT, Schatzker J. Tibial plateau fractures. In: Browner BD, ed. Skeletal trauma: basic science, management, and reconstruction. 3rd ed. Philadelphia, Pa: Saunders, 2003; Canale TS. Tibial plateau fracture. In: Canale ST, ed. Campbell's operative orthopaedics. 10th ed. Philadelphia, Pa: Mosby, 2006; Honkonen SE, Jarvinen MJ. Classification of fractures of the tibial condyles. J Bone Joint Surg Br 1992; 74(6): Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am 2006; 88(8): Page 44 of 46

45 10. Kode L, Lieberman JM, Motta AO, Wilber JH, Vasen A, Yagan R. Evaluation of tibial plateau fractures: efficacy of MR imaging compared with CT. AJR Am J Roentgenol 1994; 163(1): Gardner MJ, Geller D, Suk M, et al. The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma 2005; 19(2): Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull 2007; 84: Gardner MJ, Yacoubian S, Geller D, et al. Prediction of soft-tissue injuries in Schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma 2006; 60(2): ; discussion Mui LW, Engelsohn E, Umans H. Comparison of CT and MRI in patients with tibial plateau fracture: can CT findings predict ligament tear or meniscal injury? Skeletal Radiol 2007; 36(2): Markhardt BK, Gross JM, Monu JU.Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics 2009; 29(2): Yang G, Zhai Q, Zhu Y et al. The incidence of posterior tibial plateau fracture: an investigation of 525 fractures by using a CT-based classification system. Arch Orthop Trauma Surg 2013; 133: te Stroet MA, Holla M, Biert J, van Kampen A. The value of a CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures. Emerg Radiol 2011; 18: Zhai Q, Congfeng Luo C, Yi Zhu Y et al. Morphological characteristics of splitdepression fractures of the lateral tibial plateau (Schatzker type II): a computertomography-based study. International Orthopaedics (SICOT) 2013; 37: Gicquel T, Najihi N, T. Vendeuvre T et al. Tibial plateau fractures: Reproducibility of three classifications (Schatzker, AO, Duparc) and a revised Duparc classification. Orthopaedics & Traumatology: Surgery & Research 2013; 99: Zeltser DW, Leopold SS. Classifications in Brief. Schatzker Classification of Tibial Plateau Fractures. Clin Orthop Relat Res 2013; 471: Page 45 of 46

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