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Tibial Plateau Fracture
From WikiSM
Contents
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]
Introduction
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]
Anatomy of the 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
- Acute Compartment Syndrome
- According to Stark et al, as high as 18% in Schatzker VI[7]
- Knee Dislocation
- Isolated medial plateau fracture should raise suspicion of spontaneously reduced knee dislocation[8]
- Associated soft tissue injuries range from 56% to as high as 97%[9]
- Neurovascular Injury
Risk Factors
- Needs to be updated
Differential Diagnosis
Differential Diagnosis Knee Pain
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
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
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
Non-Operative
- Indications
- Absolutely no displacement, depression of the tibial plateau, comminution
- No associated ligamentous or meniscal injury
- Absence of neurovascular injuries
- Immobilization
- Place in a Hinged Knee Brace
- Non-weight bearing for 6 weeks
- 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/Work
- Needs to be updated
Prognosis and Complications
Prognosis
- Functional consequences of inadequate treatment
- Loss of independence in affected patients
- Poor outcome scores
Complications
- Post-traumatic osteoarthritis (PTOA)
- Inability to regain normal gait
- Joint instability
- Postoperative stiffness
- Chronic pain
- Acute Compartment Syndrome
See Also
Internal
External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ 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
- ↑ Jacofsky DJ, Haidukerwych GJ (2006) Tibia plateau fractures. In: Scott WN (ed) Insall & Scott Surgery of the knee. Churchill Livingstone, Philadelphia, pp 1133–1146
- ↑ 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
- ↑ Roberts JR (2012) High-risk orthopedic injuries: tibial plateau fractures. Emerg Med News 34(4):14–15
- ↑ 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
- ↑ Berkson EM, Virkus WW (2006) High-energy tibial plateau fractures. J Am Acad Orthop Surg 14(1):20–31
- ↑ 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
- ↑ 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
- ↑ Mthethwa, J., and A. Chikate. "A review of the management of tibial plateau fractures." Musculoskeletal surgery 102.2 (2018): 119-127.
- ↑ 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