Tibial Plateau Fractures


Article Author:
Saloni Malik


Article Editor:
Naomi Rosenberg


Editors In Chief:
Dustin Constant
Donald Kushner


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Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/18/2019 3:15:09 AM

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 operation 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. 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.[3][4]

Once the extent of the injury has been visualized, tibial plateau fractures are classified based on the Schatzker Classification system, summarized below:

  • Schatzker I: Lateral split fracture
  • Schatzker II: Lateral split-depressed fracture
  • Schatzker III: Lateral pure depression fracture
  • Schatzker IV: Medial condyle fracture
  • Schatzker V: Bicondylar plateau fracture
  • Schatzker VI: Metaphyseal-diaphyseal dissociation

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 to 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 more immediate attention, ORIF may be delayed and bridging external fixation may be performed as a temporizing measure.[7]

Prognosis

Higher energy mechanisms of trauma are associated with poor outcomes. 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 profoundly.[8][9][10][11]. For patients whose jobs require a high degree of mobility, a tibial plateau fracture may significantly delay return to employment.[12]


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Tibial Plateau Fractures - Questions

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Which bone is associated with a bumper fracture?



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A 30-year-old woman was a front-seat passenger in a motor vehicle collision and presented with severe pain and swelling of the right knee. She is unable to bear weight on the right, and the range of motion of the right knee is limited. Distal pulses are diminished on the right side. The physical exam is otherwise normal, and an anterior-posterior plain radiograph taken at the bedside shows significant soft tissue swelling but no apparent osseous injury. Which of the following statements is correct?



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A 48-year-old man presents with severe left knee pain and swelling after falling from a second-story scaffolding and landing on his feet. He is unable to bend the left knee or bear weight on the left leg. CT of the left knee shows a bicondylar tibial plateau fracture with depression of the tibial plateau. Which of the following describes appropriate management of this injury?



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A 37-year-old male presents to the clinic two weeks after open reduction and internal fixation of a Schatzker V fracture sustained in a motor vehicle collision. He works in a warehouse and climbs stairs often as part of his job. Which of the following statements is appropriate regarding postoperative care of this injury?



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Tibial Plateau Fractures - References

References

A review of the management of tibial plateau fractures., Mthethwa J,Chikate A,, Musculoskeletal surgery, 2017 Oct 17     [PubMed]
Complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported QOL: a prospective observational study of 46 complex tibial fractures treated with a ring fixator., Elsoe R,Larsen P,Petruskevicius J,Kold S,, Strategies in trauma and limb reconstruction (Online), 2017 Nov 4     [PubMed]
Treatment of closed tibial fractures., Schmidt AH,Finkemeier CG,Tornetta P 3rd,, Instructional course lectures, 2003     [PubMed]
MRI of acute meniscal injury associated with tibial plateau fractures: prevalence, type, and location., Mustonen AO,Koivikko MP,Lindahl J,Koskinen SK,, AJR. American journal of roentgenology, 2008 Oct     [PubMed]
MR findings in patients with acute tibial plateau fractures., Colletti P,Greenberg H,Terk MR,, Computerized medical imaging and graphics : the official journal of the Computerized Medical Imaging Society, 1996 Sep-Oct     [PubMed]
Complex fractures of the tibial plateau., Ziran BH,Hooks B,Pesantez R,, The journal of knee surgery, 2007 Jan     [PubMed]
Mid- to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures., van Dreumel RL,van Wunnik BP,Janssen L,Simons PC,Janzing HM,, Injury, 2015 Aug     [PubMed]
Population-Based Epidemiology of Tibial Plateau Fractures., Elsoe R,Larsen P,Nielsen NP,Swenne J,Rasmussen S,Ostgaard SE,, Orthopedics, 2015 Sep     [PubMed]
Tibial plateau fractures. Management and expected results., Tscherne H,Lobenhoffer P,, Clinical orthopaedics and related research, 1993 Jul     [PubMed]
The long-term functional outcome of operatively treated tibial plateau fractures., Stevens DG,Beharry R,McKee MD,Waddell JP,Schemitsch EH,, Journal of orthopaedic trauma, 2001 Jun-Jul     [PubMed]
Gait characteristics and quality of life perception of patients following tibial plateau fracture., Warschawski Y,Elbaz A,Segal G,Norman D,Haim A,Jacov E,Grundshtein A,Steinberg E,, Archives of orthopaedic and trauma surgery, 2015 Nov     [PubMed]
Functional outcome after tibial plateau fracture osteosynthesis: a mean follow-up of 6 years., Timmers TK,van der Ven DJ,de Vries LS,van Olden GD,, The Knee, 2014 Dec     [PubMed]

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