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Tibial plateau fractures

Description

Tibial Plateau fractures involve the proximal articular surface of the tibia.  These fractures can vary from mild displacement to severe comminution and are commonly associated with soft tissue injuries.  Patients age, bone quality and mechanism of injury are a few important variables that play a role in the severity of the injury.

Structure and function

The Tibial Plateau is the proximal articular surface of the tibia.  It is composed of the medial and lateral condyles, as well as, the intercondylar eminence.  The medial condyle is the larger and stronger of the two tibial condyles.  The medial meniscus rests on top of the medial tibial condyle and acts to decrease contact and friction between the medial condyles of the femur and tibia.  The lateral condyle is smaller, extends higher, and is more commonly fractured.  Similar to the medial meniscus, the lateral meniscus serves as a buffer between the lateral femoral and tibial condyles.  The intercondylar eminence is found between the medial and lateral tibial condyles.  It functions as the tibial attachment site of the cruciate ligaments.

Important neuro-vascular structures in this region include the popliteal artery, tibial nerve and common fibular nerve.  The popliteal artery is an extension of the superficial femoral artery which begins once the artery passes the adductor hiatus.  It descends posterior to the distal femur.  Once in the knee joint, the it runs in a slightly posterior-lateral position and can be found behind the posterior horn of the lateral meniscus.  It gives off genicular branches which serve as the primary blood supply of the knee joint. The popliteal artery terminates as it bifurcates into the anterior tibial artery and the tibial-peroneal trunk at the distal border of the popliteus muscle.  The sciatic nerve branches into the tibial and peroneal nerves at the upper portion of the popliteal space.  The tibial artery continues to descend posteriorly through the popliteal space and into the posterior compartment of the leg.  The peroneal nerve descends obliquely along the lateral popliteal fossa, coming in close proximity to the lateral tibial plateau, then winds around the fibular neck before dividing into its superficial and deep branches.

(Will include the below pictures)

http://en.wikipedia.org/wiki/File:Knee_diagram.svg

http://en.wikipedia.org/wiki/File:Gray832.png

http://en.wikipedia.org/wiki/File:Gray257.png

http://upload.wikimedia.org/wikipedia/commons/6/60/Gray551.png

Epidemiology

Tibial plateau fractures make up approximately 1% of all fractures in the general population and about 8% of fractures in the elderly.  Anywhere from 55-70% of tibial plateau fractures are isolated lateral plateau fractures, 10-25% involve only the medial plateau, and 10-30% are bicondylar fractures.  Approximately 90% of all tibial plateau fractures have some sort of soft tissue injury and 1-3% are open fractures.

Clinical presentation

The severity and extent of Tibial plateau injuries is dependent on a variety of factors including: the patients age, bone quality, as well as, the direction and magnitude of the traumatic force in comparison to the positioning of the patients legs at the time of impact. 

Tibial Plateau fractures occurring in young, healthy individuals is usually associated with high energy mechanisms such as falls from substantial height, sports related trauma, and motor vehicle collisions.  However they can also occur secondary to lower energy mechanisms such as ground level falls in those with poor bone quality.  High energy injury mechanisms will commonly have associated soft tissue injuries such as open fractures, ligament tears, meniscus tears, peroneal nerve injury and popliteal artery damage.  

These patients may present with symptoms including: pain while bearing weight, limited range of motion of the knee, tenderness, swelling, gross deformity, pale or cold foot, and numbness or tingling sensation in the foot.  A thorough clinical evaluation of these patients should include a trauma evaluation ensuring a secure airway and ventilation, as well as, assessing hemodynamic stability.  The patient should be inspected for limb deformity, additional fractures, open lacerations and other possible soft tissue injuries.  A complete neuro-vascular examination of the affected extremity should be performed and the development compartment syndrome must be ruled out and monitored.  The possibility of ligament injury should also be assessed.  

Red flags

Knee Dislocation:

Tibial plateau fractures have been associated with knee dislocations, especially when they occur secondary to high energy mechanisms of injury.  It is believed that these dislocations may spontaneously reduce, so even when gross signs of dislocation may be absent, a thorough vascular evaluation for possible popliteal artery injury should be performed.  This includes: palpating for pulses distal to the site of injury, assessing both the color and temperature of the extremity distally and obtaining ankle-brachial indices.  If the ABI is < 0.9 additional vascular studies are indicated.

Compartment syndrome:

Given the abundance of musculature and low fascial compliance of the lower leg, compartment syndrome can develop secondary to tibial plateau fractures.  As the pressure builds in a compartment, neurovascular structures can be compromised and muscle death can start to develop in as little as 6-8 hours.  Key signs and symptoms of compartment syndrome include pain out of proportion to injury, pain worsened with flexion or extension of the ankle or toes, tense compartments, pallor and paresthesias.  In patients with tibial plateau fractures, compartment syndrome must be ruled out.  Compartment pressure monitoring and frequent neurovascular checks are indicated in these patients.  If the suspicion of compartment syndrome is high emergent fasciotomy may need to be performed.

Open Fracture:

The possibility of an open fracture must always be excluded as it with change the treatment and management of the injury.

Differential diagnosis

Soft tissue injuries occur in up to 90% of all tibial plateau fractures.  The most common associated soft tissue injuries include meniscus and ligament tears.  Meniscus tears occur in up to 50% of cases and ligament tears are found in up to 30% of cases.  Other less common soft tissue injuries associated with tibial plateau fractures include: open fractures, knee dislocations, as well as, popliteal artery and peroneal nerve injuries.



Objective evidence

Radiographs:  Standard AP and lateral views of the knee should always be obtained.  Supplemental internal and external rotation oblique films allow for a better view of the lateral and medial plateaus respectively.  A caudal tilt plateau view helps to determine the degree of articular step off.  

CT Scan:  Useful in identifying fracture configuration  and pre-operative planning.

MRI:  Useful in evaluating for associated soft tissue injuries.

ABI/Arteriography:  Should be considered if vascular damage is suspected.

Classifications

Schatzker Classification: 

Type I:  Pure split fracture of the lateral plateau

Type II:  Split and depressed fracture of the lateral plateau

Type III:  Pure depressed fracture of the lateral plateau

Type IV:  Medial plateau fracture

Type V:  Bicondylar plateau fracture

Type VI:  Plateau fracture with metaphyseal dissociation

Image like this

(It would also be nice if we could get some radiographs or CT images)

Fracture types 1-3 are usually associated with low energy mechanisms of injury. Type 2 fractures are the most common constituting up to ¾ of all tibial plateau fractures.  Type 1 fractures most commonly occur in young adults.  MCL tears are a common finding with this fracture type.  Type 3 fractures are rare and occur in individuals with poor bone quality (elderly or severely osteoporotic patients).  Types 4-6 are associated with high energy mechanisms of injury. 

OTA Classification:

See this link

Risk factors and prevention

Tibial plateau fractures commonly occur during unpredictable events such as falls from substantial height, sports related injuries, and motor vehicle accidents.  Not much can be done to prevent these events from occurring.  However, major injuries can be avoided by complying with safety precautions, wearing protective equipment, using proper technique while playing sports and using seat belts.

Treatment options

Treatment modalities for tibial plateau fractures include surgical and non-surgical interventions.  Regardless of the treatment modality chosen, initial management should include making the patient non-weight bearing and immobilization of the affected extremity.  

Non-surgical intervention is indicated in non-displaced or minimally displaced fractures, fractures stable to varus and valgus stress, patients with advanced osteoporosis, medically unstable patients and non-ambulatory patients.

Surgical intervention is indicated in fractures with significant articular depression, >10 degree instability of the knee joint, open fractures, and fractures with associated compartment syndrome or vascular injury.  The ultimate goal of surgical intervention is to reestablish joint stability, alignment, and articular congruity while preserving as much range of motion as possible.  This is achieved through open reduction and internal fixation of the fracture.  

In cases where the fracture results in significant soft tissue swelling surgical intervention should be delayed unless signs and symptoms of compartment syndrome are present.  Since it may take 1-2 weeks for the swelling to subside enough to ensure closure of the wound, external fixation may be indicated to get partial reduction of the fracture and maintain limb length.

Regardless of the treatment modality used, all patients should be non-weight bearing of the affected extremity for 8-12 weeks.  Early range of motion should be encouraged as it has been shown to improve functional outcomes.  

Type II - Image like this  

Type III -  Image like this

Type IV - image like this

Type VI -  Image like this

Type VI Ex Fix - Image like this

Outcomes

Barei et al.[ ] concluded that patient age and polytrauma are the most important parameters for lower functional outcomes in those with bicondylar tibial plateau fractures.  Additionally, Barei et al. [ ] concluded that the quality of articular reduction has an impact on functional outcomes.  A study by Bhattacharyya et al. [  ] also came to a similar conclusion.  

Early range of motion exercise in patients with tibial plateau fractures is believed to minimize joint stiffness in the future.  Meniscal preservation is also now believed to be critical for long-term joint maintenance.

Complications include

Post-traumatic osteoarthritis

Infection

Malunion or non-union

Hardware failure

Compartement Syndrome

Arthrofibrosis

Neurovascular injury

Holistic medicine

Adequate vitamin D and calcium supplementation is very important in maintaining good bone quality especially in post menopausal women.

Miscellany

In 2006 Joe Paterno, Head Coach of the Penn State University football team suffered a tibial plateau fracture with associated tears of his PCL and MCL.  The injury occurred after the helmet of a Wisconsin player struck Paterno’s knee while trying to make a tackle on the sideline. 

Question:  A 29 year old female with no previous past medical history presents with a Schatzker type III fracture after a ground level fall.  What medical condition is commonly associated with a Schatzker type III fracture?

Answer:  Osteopenia.  

Actress, Gwyneth Paltrow, was discovered to be osteopenic after she suffered a tibial plateau fracture.

Key terms

Knee dislocation

Popliteal artery injury

Peroneal nerve injury

Compartment syndrome

Meniscus tear

Cruciate and collateral ligament tears

Open Fractures

Skills

Performing a thorough neurovascular examination

Examination of the structural integrity of the knee (ie rule out ligament and meniscus tears)

Interpetation of radiographs and CT scans

Aspiration of knee joint

Compartment pressure monitoring



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Related Content

Resources for Tibial plateau fractures and related topics on OrthopaedicsOne.

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