Tibial Plateau Fractures
- Article Author:
- Saloni Malik
- Article Author:
- Tom Herron
- Article Editor:
- Naomi Rosenberg
- Updated:
- 11/1/2020 12:56:57 PM
- For CME on this topic:
- Tibial Plateau Fractures CME
- PubMed Link:
- Tibial Plateau Fractures
Introduction
Tibial plateau fractures account for 1% of all fractures and are typically sustained with high-energy mechanisms.[1] Tibial plateau fractures may be associated with injury to nearby structures including vasculature, nerves, ligaments, menisci, and adjacent compartments. While minimal tibial plateau fractures with no associated injuries can be safely managed non-operatively, typically this injury requires orthopedic consultation and operative management.
Etiology
Tibial plateau fractures may be lateral, medial, or bicondylar. Injuries to the lateral part of the tibial plateau are most common, and typically involve a blow to the lateral knee. Injuries to the medial plateau require more force and are sustained from high energy mechanisms including axial load from falling from a height and landing on the feet, motor vehicle collisions, and other sources of direct trauma. With high-energy mechanisms such as these, bicondylar fractures are more common than isolated medial plateau fractures. Tibial plateau fractures as a result of low energy mechanisms are more likely to occur in the elderly, or other populations with osteoporotic disease.
Epidemiology
Tibial plateau fractures comprise 1% of all fractures. The incidence of tibial plateau fractures is 10.3 per 100,000 people annually[2]. The mean age of patients incurring tibial plateau fractures is 52.6 years.[2] The distribution of tibial plateau fractures is bimodal, with men under the age of 50 more likely to sustain this injury via high energy mechanisms, and women over the age of 70 more likely to have tibial plateau fractures secondary to falls.[2] Overall, men more commonly sustain tibial plateau fractures than women.
Pathophysiology
The tibia is the weight-bearing bone of the lower leg, located medially to the fibula. The proximal part of the bone compromises the distal part of the knee joint. The tibial plateau has two articular surfaces, the medial and lateral tibial condyles, also called the medial and lateral plateaus. The medial tibial condyle bears 60% of the knee’s weight and is a thicker structure. It is concave in shape and located slightly more distally compared to the lateral tibial condyle. The lateral tibial condyle is convex in shape, thinner, weaker, and more proximal than the medial tibial condyle. The intercondylar eminence is a bony structure between the two condyles that serves as an attachment point for the anterior cruciate ligament.
Fascia separates the lower leg into four compartments containing muscle, vessels, and nerves. The anterior, posterior and deep compartments border the tibia and are at risk for compartment syndrome with tibial fractures.
The ligaments and menisci of the knee joint are also in contact with the proximal tibia and are at risk for injury associated with tibial fractures.
Vascular injury is also a complication of proximal tibial fractures; the popliteal artery runs posterior to the knee, and branches into the anterior and posterior tibial artery.
History and Physical
Tibial plateau fractures should be suspected in patients presenting with knee pain, possible deformity, edema, and a significant mechanism of injury or risk factors that predispose to orthopedic injuries.
Patients with very high energy mechanisms of injury may present to the trauma bay and undergo complete ATLS evaluation, and prioritization should always be given to evaluating ABCs and stabilizing the patient. A pulseless distal extremity is an orthopedic emergency. Complete physical exam of a potential tibial fracture should include an examination of the entire knee, comparison to the contralateral (presumably uninjured) knee, with special attention to the following:
- Skin: The skin should be examined circumferentially to evaluate for an open fracture, lacerations, or puncture wounds.
- Knee effusion: If there is a significant effusion, the knee may be aspirated to evaluate for hemarthrosis, and for the presence of lipids or bone marrow elements, suggesting intraarticular fracture.
- Neurovascular exam: Sensation, motor function, and distal pulses should be assessed. There should be a low threshold to measure Ankle-brachial indices should there be a difference in pulses between extremities.
- Compartments: All compartments should be palpated; a firm, tense compartment suggests compartment syndrome, which can be further evaluated by measuring intracompartmental pressure.
- Laxity tests: More than 10 degrees of laxity at the joint line with varus/valgus stress testing suggests a tear of the collateral ligaments. Laxity below the joint line is indicative of a displaced fracture.
- The range of motion: Range of motion and strength may be very difficult to assess secondary to pain.
Evaluation
Plain radiographs should include anterior-posterior, lateral, and intercondylar notch views. However, tibial plateau fractures can be difficult to see on plain films, with a sensitivity of 85%.[1] These injuries are associated with significant morbidity, and frequently require operative management, therefore if there is a high degree of suspicion for tibial plateau fractures and negative plain radiographs, CT or MRI should be used. The knee joint should be evaluated for fracture lines, displacement, depression of the tibial plateau, and associated ligamentous or meniscal injury.
Tibial plateau fractures are classified based on the Schatzker Classification system, summarized below:
- Schatzker I: Lateral plateau split fracture
- Schatzker II: Lateral plateau split-depressed fracture
- Schatzker III: Lateral plateau pure depression fracture
- Schatzker IV: Medial plateau fracture
- Schatzker V: Bicondylar plateau fracture
- Schatzker VI: Metaphyseal-diaphyseal dissociation
Either CT or MRI can better demonstrate the extent of plateau depression and comminution than plain radiographs, and may be helpful in surgical planning should this management be indicated. CT scans are typically faster and easier to obtain in an acute setting. However, MRI can identify meniscal and ligamentous injury while CT cannot. Lateral meniscal tears are more common in Schatzker type II fractures, while medial meniscus tears are most common in Schatzker type IV plateau fractures. ACL injuries are most commonly associated with Schatzker type IV and VI fractures. Vascular injuries are commonly seen in Schatzker type IV fracture-dislocations [3], [4].
Treatment / Management
Non-Operative Management
Tibial plateau fractures most commonly require orthopedic consultation. These injuries may be managed non-operatively only if there is absolutely no displacement, depression of the tibial plateau, comminution, or associated ligamentous or meniscal injury. These typically occur with low energy mechanisms. Fractures appropriate for non-operative management may be placed in a hinged knee brace and made non-weight bearing. The patient should be re-evaluated weekly with plain radiographs for 3 weeks following injury, and assuming there is no further injury or displacement, may be transitioned to imaging biweekly or every three weeks. Typically patients will be non-weight bearing for 6 weeks, with partial weight bearing permitted after bony callus is demonstrated on radiographs. The patient should remain in the brace until radiographic healing is complete, which may take up to 12 weeks. Physical therapy may begin at this time, and patients may not regain full function until 16 to 20 weeks or longer. Return to activities requiring prolonged weight bearing and stress such as certain sports should not occur until healing is nearly complete, with the affected extremity demonstrating more than 90% of the strength of the unaffected extremity. [1] [5], [6], [7].
Operative Management
Open reduction with internal fixation (ORIF) is recommended for tibial fractures with significant articular step-off, condylar widening, ligamentous instability, and for Schatzer IV, V, and VI injuries. If the injury is too comminuted for internal fixation, external fixation with limited open/percutaneous fixation of the articular segment may be performed. If there is significant soft tissue injury, or if the patient has sustained other serious injuries that require damage control orthopedics, ORIF may be delayed and bridging external fixation may be performed as a temporizing measure.[7]
Differential Diagnosis
Tibial plateau fractures commonly present with knee deformity and effusion. It is important to evaluate for other possible intra-articular fractures such as the distal femur and tibial spine. The diagnosis for tibial plateau fractures is made with plain radiographs and CT scan. Additional soft tissue injuries to the medial and lateral meniscus, ACL, and the collateral ligaments should all be considered [8].
Prognosis
Many studies have shown that after open reduction internal fixation of any type of tibial plateau fracture is associated with decreased functional outcomes. However, when evaluating for post-traumatic knee arthritis on plain radiographs, this did not correlate with functional outcome. Studies have shown that higher energy mechanisms of trauma are associated with poor outcomes [9].
Complications
Long-term complications of tibial plateau fractures include an inability to regain normal gait, osteoarthritis of the knee, ankle osteoarthritis secondary to an abnormal gait, and chronic pain; these problems may affect the quality of life [9], [10], [11], [12]. For patients whose jobs require a high degree of mobility, a tibial plateau fracture may significantly delay return to employment [13].
Deterrence and Patient Education
It is important to educate patients about tibial plateau fractures when discussing operative and non-operative treatment regarding prognosis as above. Prompt outpatient orthopedic surgery follow up is extremely important.
Enhancing Healthcare Team Outcomes
Tibial plateau fractures are bet managed by an interprofessional team that includes orthopedic nurses and therapists. An orthopedic consult is essential in all cases to determine the type of treatment. Most patients need extensive rehabilitation to regain muscle strength and function. The outcomes in most cases are good but return to sports may be delayed for months.