Tibial Plateau Fracture — ABOS Oral Boards Preparation
What examiners expect and how to prepare
Clinical Scenario
A 45-year-old right-hand-dominant female attorney is brought to the emergency department after being struck by a car as a pedestrian at low speed. She reports immediate right knee pain and inability to bear weight. She has no significant past medical history and takes no medications. On exam, the right knee is swollen with a tense effusion. There is tenderness over the lateral tibial plateau. Valgus stress testing is painful and demonstrates increased laxity compared to the contralateral side. The peroneal nerve is intact — she has normal ankle dorsiflexion and eversion, and sensation is intact in the first web space. Distal pulses are symmetric.
AP, lateral, and oblique radiographs of the right knee reveal a split-depression fracture of the lateral tibial plateau with approximately 8 mm of articular depression and lateral condylar widening. A CT scan with coronal, sagittal, and axial reconstructions confirms a Schatzker II fracture with a 10 mm depressed articular fragment and an intact posteromedial column. MRI obtained demonstrates an intact ACL and PCL, a lateral meniscus tear with entrapment in the fracture, and an MCL sprain without complete disruption.
You performed open reduction and internal fixation through an anterolateral approach with submeniscal arthrotomy. The depressed articular fragment was elevated, the metaphyseal void was filled with calcium phosphate bone substitute, and the fracture was stabilized with a lateral periarticular locking plate. The entrapped lateral meniscus was reduced and repaired. Post-operatively, the patient was placed in a hinged knee brace, non-weight-bearing for 8 weeks, with immediate range of motion exercises.
What Examiners Look For
- Data gathering: Describe the complete workup — why did you get CT and MRI? What additional information did each provide beyond plain films?
- Diagnosis: Schatzker classification from imaging and how it directs treatment. Identify which column is involved using three-column theory.
- Treatment plan: What are your indications for surgery? How much articular depression is acceptable? What role does the meniscal entrapment play?
- Technical skill: Describe the elevation of the depressed fragment, void management, and why you chose a submeniscal arthrotomy over arthroscopy.
- Complications: What if she develops post-traumatic arthritis at 5 years? What are her options? How does the meniscal status affect this?
- Applied knowledge: Discuss the three-column classification concept and how it has changed fixation strategy for these fractures.
Common Pitfalls
- Not addressing the soft tissue injury — meniscal pathology and ligamentous injury must be discussed with every tibial plateau fracture.
- Forgetting to check and document the peroneal nerve — especially with lateral plateau injuries and valgus mechanism.
- Using articular depression thresholds without understanding that functional demand and compartment affected matter.
- Not discussing weight-bearing protocols and how timing affects outcomes.
- Skipping the non-operative discussion — know which Schatzker patterns can be treated in a brace.
Key Classifications
Related Scenarios
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