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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]

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

Risk Factors

  • Needs to be updated

Differential Diagnosis

Differential Diagnosis Knee Pain

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

  • XR of a medial tibial plateau fracture

  • XR of a medial tibial plateau fracture

  • CT of a medial tibial plateau fracture

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
  • 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

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:
22 March 2023 14:58:29
Categories:
Knee | Trauma | Fractures | Acute

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