ORIGINAL ARTICLE
Operatively Treated Meniscal Tears Associated With Tibial Plateau Fractures: A Report on 661 Patients Daniel Stahl, MD,* Rafael Serrano-Riera, MD,† Kristopher Collin, MD,‡ Rebecca Griffing, BS,† Bradley Defenbaugh, MD,† and H. Claude Sagi, MD†‡
Objective: To describe the incidence and common patterns of
Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
lateral meniscal tears detected intraoperatively and surgically treated based on tibial plateau fracture patterns.
(J Orthop Trauma 2015;29:322–324)
Design: Retrospective analysis of a prospective database. Setting: Level One Regional Trauma Center. Methods: All tibial plateau fractures in skeletally mature patients treated operatively between 2002 and 2011 were included. All operative notes and radiographs were reviewed to determine type of tibial plateau fracture, mechanism of injury, intraoperative detection of a lateral meniscal tear, and operative repair/partial resection of the meniscus itself. Patients were excluded if there was no mention of a submeniscal arthrotomy, if fracture stabilization was performed percutaneously, or if the fracture was an isolated medial condyle fracture. Statistical analysis was performed using x2 analysis and Fisher exact test to determine the overall incidence of lateral meniscal tears and any correlation between meniscal tear and fracture pattern. Results: A total of 602 patients were included in the final analysis. Lateral meniscal tears requiring operative repair were detected intraoperatively in 179 patients (30%). This could be broken down into 12% for pure lateral split fractures, 45% for split depression fractures (P , 0.001), 18% for pure depression fractures, 22% for bicondylar fractures, and 26% for intraarticular plus shaft fractures. Lateral meniscal tears associated with a split depression fracture pattern were most commonly peripheral rim tears (83%). For all other fracture patterns, the type of meniscal injury was evenly distributed between peripheral and radial tear. Young males demonstrated a statistically higher rate of lateral meniscal tears (33%). Conclusions: In our series, the incidence of a lateral meniscal tear detected intraoperatively requiring repair was 30%. These tears occurred more frequently in young males, with peripheral rim tears most commonly associated with split depression fractures. Based on our data, we believe that preoperative imaging for meniscal injury overstates the true incidence of meniscal tears requiring operative intervention. Key Word: meniscal tear, tibia, tibial plateau, fracture, trauma Accepted for publication January 12, 2015. From the *Scott and White Hospital, Temple, TX; †Florida Orthopaedic Institute, Tampa, FL; and ‡University of South Florida, Tampa, FL. The authors report no conflict of interest. Reprints: H. Claude Sagi, MD, FACS, Florida Orthopaedic Institute, Orthopaedic Trauma Service, 5 Tampa General Circle, Suite 710, Tampa, FL 33611 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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INTRODUCTION Tibial plateau fractures are associated with a number of nonosseous injuries such as meniscal and ligamentous tears in addition to cartilaginous damage.1 Recognition and treatment of these associated injuries at the time of surgical fixation can have a significant and positive impact on the overall outcome.2 Although anatomic reconstruction of the articular surface is critical, meniscal integrity has been shown to affect the long-term outcome and the development of posttraumatic arthritis.3 Current literature using preoperative magnetic resonance imaging (MRI) reports the incidence of meniscal tear associated with tibial plateau fractures to be in the range of 40%–90%.4–8 The purpose of this study was to determine the true incidence of lateral meniscal tears detected intraoperatively that actually required operative repair and to determine the types of lateral meniscal tears associated with various fracture patterns.
METHODS All tibial plateau fractures in skeletally mature patients treated operatively between 2002 and 2011 were included. Patient identifiers were obtained from a prospectively collected database that recorded injury pattern, fracture pattern, and all surgical procedures performed. All operations were performed by fellowship trained orthopaedic trauma surgeons at a single institution. All operative notes, initial history and physicals, and radiographs were retrospectively reviewed to determine demographic data of the patients, the pattern of tibial plateau fracture (OTA9 classification system), mechanism of injury, intraoperative detection, and pattern of the meniscal tear (peripheral rim tears or radial tears). Patients were excluded if a submeniscal arthrotomy was not performed, if fracture stabilization was performed percutaneously, or if the fracture was an isolated medial condylar fracture (Schatzker Type IV—not classified by OTA/AO).
Description of Surgical Procedure Patients were placed in the supine position on the operative table. Gravity exsanguination and a tourniquet were used to help with visualization of the articular surface and J Orthop Trauma Volume 29, Number 7, July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 7, July 2015
blood loss. Surgical exposure used an anterolateral curvilinear approach supplemented with a posteromedial approach as needed. A submeniscal arthrotomy was performed in all cases by releasing the meniscotibial ligament and capsule from its insertion on the lateral tibial rim and elevating it with a suture in the capsule (Fig. 1). In cases where the lateral capsule was torn off the lateral proximal tibia, the meniscus was found and tagged with a suture and then inspected for tears. The meniscus was inspected under direct visualization from the anterior horn to the posterior horn. To help with restoration of the mechanical axis and visualization of the articular surface and meniscus, a distractor was applied to the lateral femur and tibia, spanning the knee joint. After repair or partial resection of the meniscus, the articular surface was reconstructed, metaphyseal voids were filled, and the bone fixation was applied. The meniscotibial ligament was then repaired back to the proximal lateral tibial rim or to the plate. Bucket-handle and peripheral longitudinal tears were repaired, whereas radial tears with flaps were resected back to normal meniscus. Statistical analysis was performed using x2 test analysis and Fisher exact test to determine the overall incidence of lateral meniscal injury, the most common pattern of lateral meniscal tear, and the correlation of lateral meniscal tear with the pattern of tibial plateau fracture. Approval was obtained form the local Institutional Review board before data collection and analysis.
RESULTS After all inclusion and exclusion criteria were met, a total of 602 fractures comprised the study group. There were 390 male patients and 212 female patients with an average age of 45 years (range, 15–95 years). A total of 179 patients had meniscal tears requiring operative repair (29.7%). The incidence of operatively treated lateral meniscal tears was 12% for pure lateral split fractures, 45% for split depression fractures (P , 0.001), 18% for pure depression fractures,
Operatively Treated Meniscal Tears
22% for bicondylar fractures, and 26% for intraarticular plus shaft fractures (Tables 1 and 2). Statistical analysis revealed that a lateral split depression fracture (OTA 41-B3) had a significantly higher incidence of meniscal tears compared with all other patterns (P , 0.001). Operative notes were further analyzed to determine the type of lateral meniscal tear found during the surgery. For lateral split depression fractures, 83% were peripheral rim tears, with only 12% diagnosed as radial tears. For all other fracture patterns, the type of meniscal tear was evenly distributed between peripheral rim and radial tears. The average age of patients with a meniscal tear was 44 years (range, 15–86 years) compared with 47 years (range, 14–95) for those without a meniscal tear; this difference was found to be statistically significant (P = 0.019). The incidence of meniscal tear was 33% for males (127 tears in 390 patients) versus 25% for females (52 tears in 212 patients). This difference was also statistically significant (P = 0.05).
DISCUSSION The reported incidence of meniscal injury associated with a tibial plateau fracture based on preoperative imaging with MRI ranges from 49% to 91%.4–8 Abdel-Hamid et al6 reported on 98 patients with closed tibial plateau fractures treated arthroscopically with a meniscal tear in 57% (56 patients). Meniscal tears were also the most common soft tissue injury associated with a tibial plateau fracture in their series, but they were unable to demonstrate a difference in incidence based on fracture pattern. Stannard et al8 retrospectively reviewed 103 patients with high-energy tibial plateau fractures receiving a preoperative MRI as part of their management protocol. They found a 49% incidence of meniscal tears evenly distributed between medial and lateral tears as well as between OTA type 41B and 41C fracture patterns. Gardner et al,10 found that lateral split depression tibial plateau fractures with greater than 6 mm of joint depression and 5 mm of condylar widening on preoperative radiographs correlated with an injury to the lateral meniscus in 83% of the fractures based on preoperative MRI examinations. Ringus et al11 reported an 8-fold increase in the risk of lateral meniscus tear in patients when a preoperative computed tomography demonstrated joint depression $10 mm. Their series was comprised 85 lateral split depression fractures; 33% required surgical intervention for the meniscal tear. Additionally, they found that age ,48 increased the likelihood of a meniscal tear.
TABLE 1. Incidence of Meniscal Tear Based on Schatzker Fracture Classification
FIGURE 1. Intraoperative demonstration of a submeniscal arthrotomy with a torn lateral meniscus. Editor’s note: A color image accompanies the online version of this article. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Schatzker Classification
I
II
III
IV
V
VI
Total number of fractures No tear in meniscus Torn meniscus Total (%)
41 36 5 12
203 112 91 45*
12 10 2 17
46 39 7 15
90 68 22 24
259 182 77 30
*P , 0.001.
www.jorthotrauma.com |
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 7, July 2015
Stahl et al
TABLE 2. Incidence of Meniscal Tear Based on OTA Fracture Classification OTA Classification
Type 41B
Type 41C
197 105 35*
250 99 28*
No tear Tear Total (%) *P , 0.01.
tibial plateau fractures, with the highest incidence seen in young males with a lateral split depression fracture pattern. The incidence of meniscal injury is sufficiently high that we recommend direct visual inspection of the meniscus intraoperatively in these cases. REFERENCES
We found that lateral split depression tibial plateau fractures were most commonly associated with a meniscal tear, occurring in 45% of our series. Most of those tears were peripheral rim avulsions, which should offer a better outcome once repaired than intrasubstance radial tears. Our results also demonstrate that meniscal tears were more likely to be seen in younger, male, patients. This report serves as an assessment of the intraoperative detection of meniscal tears in operative tibial plateau fractures and was not designed to report on the clinical outcomes of these patients. Our data demonstrated a much lower incidence of meniscal tears requiring surgical intervention than previously reported based preoperative imaging with MRI. Those studies we believe are flawed because they fail to predict which plateau fractures will have meniscal tears requiring repair. In summary, we believe that our data are an accurate representation of the incidence of lateral meniscal pathology associated with tibial plateau fractures detected intraoperatively requiring repair. A meniscal tear that requires surgical treatment can be expected in approximately one-third of all
1. Bennet WF, Browner B. Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma. 1994;8:183–188. 2. Tscherne H, Lobenhoffer P. Tibial plateau fractures: management and expected results. Clin Orthop Relat Res. 1993;293:87–100. 3. Hunter DJ, Zhang YQ, Niu JB, et al. The association of meniscal pathologic changes with cartilage loss in symptomatic knee osteoarthritis. Arthritis Rheum. 2006;54:795–801. 4. Gardner MJ, Yacoubian S, Geller D, 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;19:79–84. 5. Colletti P, Greenberg H, Terk MR. MR findings in patients with acute tibial plateau fractures. Comp Med Imaging Graph. 1996;20:389–394. 6. Abdel-Hamid MZ, Chang CH, Chan YS, et al. Arthroscopic evaluation of soft tissue injuries in tibial plateau fractures: retrospective analysis of 98 cases. Arthroscopy. 2006;22:669–675. 7. Shepherd L, Abdollahi K, Lee J, et al. The prevalence of soft tissue injuries in nonoperative tibial plateau fractures as determined by magnetic resonance imaging. J Orthop Trauma. 2002;16:628–631. 8. Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee after tibial plateau fractures. J Knee Surg. 2010;23:187–192. 9. Marsh JL, Slongo TF, Agel J, et al. Fracture and Dislocation Classification Compendium—2007: Orthopaedic Trauma Association Classification, Database and Outcomes Committee. J Orthop Trauma. 2007;21 (suppl 10):S1–S163. 10. 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;60:319–323; discussion 324. 11. Ringus VM, Lemley FR, Hubbard DF, et al. Lateral tibial plateau fracture depression as a predictor of lateral meniscus pathology. Orthopedics. 2010;33:80–84.
324
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
| www.jorthotrauma.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Operatively Treated Meniscal Tears Associated With Tibial Plateau Fractures: A Report on 661 Patients Daniel Stahl, MD,* Rafael Serrano-Riera, MD,† Kristopher Collin, MD,‡ Rebecca Griffing, BS,† Bradley Defenbaugh, MD,† and H. Claude Sagi, MD†‡
Objective: To describe the incidence and common patterns of
Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
lateral meniscal tears detected intraoperatively and surgically treated based on tibial plateau fracture patterns.
(J Orthop Trauma 2015;29:322–324)
Design: Retrospective analysis of a prospective database. Setting: Level One Regional Trauma Center. Methods: All tibial plateau fractures in skeletally mature patients treated operatively between 2002 and 2011 were included. All operative notes and radiographs were reviewed to determine type of tibial plateau fracture, mechanism of injury, intraoperative detection of a lateral meniscal tear, and operative repair/partial resection of the meniscus itself. Patients were excluded if there was no mention of a submeniscal arthrotomy, if fracture stabilization was performed percutaneously, or if the fracture was an isolated medial condyle fracture. Statistical analysis was performed using x2 analysis and Fisher exact test to determine the overall incidence of lateral meniscal tears and any correlation between meniscal tear and fracture pattern. Results: A total of 602 patients were included in the final analysis. Lateral meniscal tears requiring operative repair were detected intraoperatively in 179 patients (30%). This could be broken down into 12% for pure lateral split fractures, 45% for split depression fractures (P , 0.001), 18% for pure depression fractures, 22% for bicondylar fractures, and 26% for intraarticular plus shaft fractures. Lateral meniscal tears associated with a split depression fracture pattern were most commonly peripheral rim tears (83%). For all other fracture patterns, the type of meniscal injury was evenly distributed between peripheral and radial tear. Young males demonstrated a statistically higher rate of lateral meniscal tears (33%). Conclusions: In our series, the incidence of a lateral meniscal tear detected intraoperatively requiring repair was 30%. These tears occurred more frequently in young males, with peripheral rim tears most commonly associated with split depression fractures. Based on our data, we believe that preoperative imaging for meniscal injury overstates the true incidence of meniscal tears requiring operative intervention. Key Word: meniscal tear, tibia, tibial plateau, fracture, trauma Accepted for publication January 12, 2015. From the *Scott and White Hospital, Temple, TX; †Florida Orthopaedic Institute, Tampa, FL; and ‡University of South Florida, Tampa, FL. The authors report no conflict of interest. Reprints: H. Claude Sagi, MD, FACS, Florida Orthopaedic Institute, Orthopaedic Trauma Service, 5 Tampa General Circle, Suite 710, Tampa, FL 33611 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
322
| www.jorthotrauma.com
INTRODUCTION Tibial plateau fractures are associated with a number of nonosseous injuries such as meniscal and ligamentous tears in addition to cartilaginous damage.1 Recognition and treatment of these associated injuries at the time of surgical fixation can have a significant and positive impact on the overall outcome.2 Although anatomic reconstruction of the articular surface is critical, meniscal integrity has been shown to affect the long-term outcome and the development of posttraumatic arthritis.3 Current literature using preoperative magnetic resonance imaging (MRI) reports the incidence of meniscal tear associated with tibial plateau fractures to be in the range of 40%–90%.4–8 The purpose of this study was to determine the true incidence of lateral meniscal tears detected intraoperatively that actually required operative repair and to determine the types of lateral meniscal tears associated with various fracture patterns.
METHODS All tibial plateau fractures in skeletally mature patients treated operatively between 2002 and 2011 were included. Patient identifiers were obtained from a prospectively collected database that recorded injury pattern, fracture pattern, and all surgical procedures performed. All operations were performed by fellowship trained orthopaedic trauma surgeons at a single institution. All operative notes, initial history and physicals, and radiographs were retrospectively reviewed to determine demographic data of the patients, the pattern of tibial plateau fracture (OTA9 classification system), mechanism of injury, intraoperative detection, and pattern of the meniscal tear (peripheral rim tears or radial tears). Patients were excluded if a submeniscal arthrotomy was not performed, if fracture stabilization was performed percutaneously, or if the fracture was an isolated medial condylar fracture (Schatzker Type IV—not classified by OTA/AO).
Description of Surgical Procedure Patients were placed in the supine position on the operative table. Gravity exsanguination and a tourniquet were used to help with visualization of the articular surface and J Orthop Trauma Volume 29, Number 7, July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 7, July 2015
blood loss. Surgical exposure used an anterolateral curvilinear approach supplemented with a posteromedial approach as needed. A submeniscal arthrotomy was performed in all cases by releasing the meniscotibial ligament and capsule from its insertion on the lateral tibial rim and elevating it with a suture in the capsule (Fig. 1). In cases where the lateral capsule was torn off the lateral proximal tibia, the meniscus was found and tagged with a suture and then inspected for tears. The meniscus was inspected under direct visualization from the anterior horn to the posterior horn. To help with restoration of the mechanical axis and visualization of the articular surface and meniscus, a distractor was applied to the lateral femur and tibia, spanning the knee joint. After repair or partial resection of the meniscus, the articular surface was reconstructed, metaphyseal voids were filled, and the bone fixation was applied. The meniscotibial ligament was then repaired back to the proximal lateral tibial rim or to the plate. Bucket-handle and peripheral longitudinal tears were repaired, whereas radial tears with flaps were resected back to normal meniscus. Statistical analysis was performed using x2 test analysis and Fisher exact test to determine the overall incidence of lateral meniscal injury, the most common pattern of lateral meniscal tear, and the correlation of lateral meniscal tear with the pattern of tibial plateau fracture. Approval was obtained form the local Institutional Review board before data collection and analysis.
RESULTS After all inclusion and exclusion criteria were met, a total of 602 fractures comprised the study group. There were 390 male patients and 212 female patients with an average age of 45 years (range, 15–95 years). A total of 179 patients had meniscal tears requiring operative repair (29.7%). The incidence of operatively treated lateral meniscal tears was 12% for pure lateral split fractures, 45% for split depression fractures (P , 0.001), 18% for pure depression fractures,
Operatively Treated Meniscal Tears
22% for bicondylar fractures, and 26% for intraarticular plus shaft fractures (Tables 1 and 2). Statistical analysis revealed that a lateral split depression fracture (OTA 41-B3) had a significantly higher incidence of meniscal tears compared with all other patterns (P , 0.001). Operative notes were further analyzed to determine the type of lateral meniscal tear found during the surgery. For lateral split depression fractures, 83% were peripheral rim tears, with only 12% diagnosed as radial tears. For all other fracture patterns, the type of meniscal tear was evenly distributed between peripheral rim and radial tears. The average age of patients with a meniscal tear was 44 years (range, 15–86 years) compared with 47 years (range, 14–95) for those without a meniscal tear; this difference was found to be statistically significant (P = 0.019). The incidence of meniscal tear was 33% for males (127 tears in 390 patients) versus 25% for females (52 tears in 212 patients). This difference was also statistically significant (P = 0.05).
DISCUSSION The reported incidence of meniscal injury associated with a tibial plateau fracture based on preoperative imaging with MRI ranges from 49% to 91%.4–8 Abdel-Hamid et al6 reported on 98 patients with closed tibial plateau fractures treated arthroscopically with a meniscal tear in 57% (56 patients). Meniscal tears were also the most common soft tissue injury associated with a tibial plateau fracture in their series, but they were unable to demonstrate a difference in incidence based on fracture pattern. Stannard et al8 retrospectively reviewed 103 patients with high-energy tibial plateau fractures receiving a preoperative MRI as part of their management protocol. They found a 49% incidence of meniscal tears evenly distributed between medial and lateral tears as well as between OTA type 41B and 41C fracture patterns. Gardner et al,10 found that lateral split depression tibial plateau fractures with greater than 6 mm of joint depression and 5 mm of condylar widening on preoperative radiographs correlated with an injury to the lateral meniscus in 83% of the fractures based on preoperative MRI examinations. Ringus et al11 reported an 8-fold increase in the risk of lateral meniscus tear in patients when a preoperative computed tomography demonstrated joint depression $10 mm. Their series was comprised 85 lateral split depression fractures; 33% required surgical intervention for the meniscal tear. Additionally, they found that age ,48 increased the likelihood of a meniscal tear.
TABLE 1. Incidence of Meniscal Tear Based on Schatzker Fracture Classification
FIGURE 1. Intraoperative demonstration of a submeniscal arthrotomy with a torn lateral meniscus. Editor’s note: A color image accompanies the online version of this article. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Schatzker Classification
I
II
III
IV
V
VI
Total number of fractures No tear in meniscus Torn meniscus Total (%)
41 36 5 12
203 112 91 45*
12 10 2 17
46 39 7 15
90 68 22 24
259 182 77 30
*P , 0.001.
www.jorthotrauma.com |
323
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 7, July 2015
Stahl et al
TABLE 2. Incidence of Meniscal Tear Based on OTA Fracture Classification OTA Classification
Type 41B
Type 41C
197 105 35*
250 99 28*
No tear Tear Total (%) *P , 0.01.
tibial plateau fractures, with the highest incidence seen in young males with a lateral split depression fracture pattern. The incidence of meniscal injury is sufficiently high that we recommend direct visual inspection of the meniscus intraoperatively in these cases. REFERENCES
We found that lateral split depression tibial plateau fractures were most commonly associated with a meniscal tear, occurring in 45% of our series. Most of those tears were peripheral rim avulsions, which should offer a better outcome once repaired than intrasubstance radial tears. Our results also demonstrate that meniscal tears were more likely to be seen in younger, male, patients. This report serves as an assessment of the intraoperative detection of meniscal tears in operative tibial plateau fractures and was not designed to report on the clinical outcomes of these patients. Our data demonstrated a much lower incidence of meniscal tears requiring surgical intervention than previously reported based preoperative imaging with MRI. Those studies we believe are flawed because they fail to predict which plateau fractures will have meniscal tears requiring repair. In summary, we believe that our data are an accurate representation of the incidence of lateral meniscal pathology associated with tibial plateau fractures detected intraoperatively requiring repair. A meniscal tear that requires surgical treatment can be expected in approximately one-third of all
1. Bennet WF, Browner B. Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma. 1994;8:183–188. 2. Tscherne H, Lobenhoffer P. Tibial plateau fractures: management and expected results. Clin Orthop Relat Res. 1993;293:87–100. 3. Hunter DJ, Zhang YQ, Niu JB, et al. The association of meniscal pathologic changes with cartilage loss in symptomatic knee osteoarthritis. Arthritis Rheum. 2006;54:795–801. 4. Gardner MJ, Yacoubian S, Geller D, 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;19:79–84. 5. Colletti P, Greenberg H, Terk MR. MR findings in patients with acute tibial plateau fractures. Comp Med Imaging Graph. 1996;20:389–394. 6. Abdel-Hamid MZ, Chang CH, Chan YS, et al. Arthroscopic evaluation of soft tissue injuries in tibial plateau fractures: retrospective analysis of 98 cases. Arthroscopy. 2006;22:669–675. 7. Shepherd L, Abdollahi K, Lee J, et al. The prevalence of soft tissue injuries in nonoperative tibial plateau fractures as determined by magnetic resonance imaging. J Orthop Trauma. 2002;16:628–631. 8. Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee after tibial plateau fractures. J Knee Surg. 2010;23:187–192. 9. Marsh JL, Slongo TF, Agel J, et al. Fracture and Dislocation Classification Compendium—2007: Orthopaedic Trauma Association Classification, Database and Outcomes Committee. J Orthop Trauma. 2007;21 (suppl 10):S1–S163. 10. 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;60:319–323; discussion 324. 11. Ringus VM, Lemley FR, Hubbard DF, et al. Lateral tibial plateau fracture depression as a predictor of lateral meniscus pathology. Orthopedics. 2010;33:80–84.
324
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| www.jorthotrauma.com
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