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Tibial Plateau Fracture

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Other Names

  • Proximal Tibia fracture
  • Knee Fracture
  • Tibial condylar fracture

Background

  • This page refers to proximal Tibia fractures, most commonly tibial plateau

History

Epidemiology

  • 1.2% of all fractures[1]
  • Distribution of tibial plateau fractures is bimodal[2]
    • Men under the age of 50 via high energy mechanisms
    • Women over the age of 70 secondary to falls
  • Highest frequency reported between ages 40 and 60[3]

Pathophysiology

  • Fracture location
    • Lateral tibial plateau in isolation (55-70%)
    • Medial plateau in isolation (10-25%)
    • Bicondylar (15%)
  • Up to 90% have associated soft tissue injury[4]
    • 1-3% present as open fractures

Etiology

  • Fractures typically occur occur as a result of a combination of[5]
    • Axial loading force and a coronal plane (varus/valgus) moment
    • Leading to articular shear and depression and mechanical axis malalignment
  • High-energy mechanisms
    • Associated with injury to nearby vasculature, nerves, ligaments, menisci, and adjacent compartments
    • Also more likely to be associated with extra-articular injuries such as spine, viscera[6]

Pathoanatomy

  • Tibia
    • Primary weight-bearing bone of the lower leg
    • Proximal component represents distal part of the Knee Joint
    • Two articular surfaces, the medial and lateral tibial condyles or plateaus
    • Medial tibial condyle bears 60% of the knee’s weight, thicker, concave
    • Lateral tibial condyle is convex, thinner,
    • Intercondylar eminence: bony structure between the two condyles that serves as an attachment point for the Anterior Cruciate Ligament

Associated Injuries


Risk Factors

  • Needs to be updated

Differential Diagnosis


Clinical Features

  • History
    • In high energy mechanism, important to follow principles of ATLS
    • Patient will describe acute mechanism
    • Inability to bear weight
  • Physical Exam: Physical Exam Knee
    • Tenderness along proximal tibia
    • Swelling of knee and typically hemarthrosis
    • Inability to bear weight
    • Decreased ROM
    • Attempt ligamentous exam if patient will tolerate
    • Important to perform a thorough neurovascular exam
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Knee, Standard Radiographs Tibia Fibula
    • Standard views: AP/Lateral views
    • 79% sensitive for lateral plateau fractures (need citation)
    • Adding oblique view increases sensitivity to 85%[10]
  • Helpful additional views
    • Tibial plateau view
    • Oblique view
    • Caudal Tilt plateau view: can show step off
  • Findings
    • Cortical break
    • Hemarthrosis/ effusion

CT

  • Typically indicated if tibial plateau suspected or identified on radiographs
  • Will find occult and subtle fractures
  • Help with preoperative planning
  • CT Angiograph
    • Strongly consider for any suspicion of vascular injury
    • Indicated for high-energy mechanism, Schatzker type IV, V, or VI fractures, diminished distal pulses, expanding hematoma, bruit, nerve injury

MRI

  • Useful for suspected ligamentous injuries

Classification

Schatzker Classification

  • Type I: Lateral split fracture
  • Type II: Lateral Split-depressed fracture
  • Type III: Lateral Pure depression fracture
  • Type IV: Medial plateau fracture
  • Type V: Bicondylar fracture
  • Type VI: Metaphyseal-diaphyseal disassociation

Hohl and Moore Classification

  • Type I: Coronal split fracture
  • Type II: Entire condylar fracture
  • Type III: Rim avulsion fracture of lateral plateau
  • Type IV: Rim compression fracture
  • Type V: Four-part fracture

Management

Prognosis

  • Functional consequences of inadequate treatment
    • Loss of independence in affected patients
    • Poor outcome scores

Non-Operative

  • Indications
    • Absolutely no displacement, depression of the tibial plateau, comminution
    • No associated ligamentous or meniscal injury
    • Absence of neurovascular injuries
  • Immobilization
  • Re-evaluation
    • Weekly with plain radiographs for 3 weeks following injury
    • If no further injury or displacement, transition to imaging biweekly or every three weeks
  • Partial weight bearing after bony callus forms
    • Remain in the brace until radiographic healing is complete, which may take up to 12 weeks
    • Physical therapy after healing is complete
    • May not regain full function until 16 to 20 weeks or longer

Operative

  • Indications
    • Significant articular step-off
    • Condylar widening
    • Ligamentous instability
    • Schatzer IV to VI injuries
    • Open fracture
    • Vascular Injury
    • Acute Compartment Syndrome
  • Technique
    • ORIF

Rehab and Return to Play

Rehabilitation

  • Should not occur until healing is nearly complete
  • Affected extremity should demonstrate more than 90% of the strength of the unaffected extremity

Return to Play

  • Needs to be updated

Complications

  • Post-traumatic osteoarthritis (PTOA)
  • Inability to regain normal gait
  • Joint instability
  • Postoperative stiffness
  • Chronic pain
  • Acute Compartment Syndrome

See Also


References

  1. Cole P, Levy B, Schatzker J, Watson JT (2009) Tibial plateau fractures. In: Browner B, Levine A, Jupiter J, Trafton P, Krettek C (eds) Skeletal trauma: basic science management and reconstruction. WB Saunders Co., Philadelphia, PA, pp 2201–2287
  2. Jacofsky DJ, Haidukerwych GJ (2006) Tibia plateau fractures. In: Scott WN (ed) Insall & Scott Surgery of the knee. Churchill Livingstone, Philadelphia, pp 1133–1146
  3. Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE (2015) Population based epidemiology of tibial plateau fractures. Orthopaedics 38(9):e780–e786
  4. Roberts JR (2012) High-risk orthopedic injuries: tibial plateau fractures. Emerg Med News 34(4):14–15
  5. Salduz A, Birisik F, Polat G, Bekler B, Bozdag E, Kilicoglu O (2016) The effect of screw thread length on initial stability of Schatzker type 1 tibial plateau fracture fixation: a biomechanical study. J Orthop Surg Res 11:146
  6. Berkson EM, Virkus WW (2006) High-energy tibial plateau fractures. J Am Acad Orthop Surg 14(1):20–31
  7. Stark E, Stucken C, Trainer G, Tornetta P (2009) Compartment syndrome in Schatzker type VI plateau fractures and medial condylar fracture-dislocations treated with temporary external fixation. J Orthop Trauma 23(7):502–506
  8. Markhardt BK, Gross JM, Monu JU (2009) Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics 29(2):585–597
  9. Mthethwa, J., and A. Chikate. "A review of the management of tibial plateau fractures." Musculoskeletal surgery 102.2 (2018): 119-127.
  10. Gray SD, Kaplan PA, Dussault RG, Omary RA, Campbell SE, Chrisman HB et al (1997) Acute knee trauma: how many plain film views are necessary for the initial examination? Skelet Radiol 26(5):298–302
Created by:
John Kiel on 7 July 2019 06:17:42
Last edited:
4 October 2022 15:44:34
Categories:
Knee | Trauma | Fractures | Acute