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Basics ⬇

Author(s): Holly J.Benjamin, MD, FAAP, FACSM and SpencerKirk, MD, MS

Description

  • Fracture that includes the articular surface of the medial and/or lateral tibial condyles
  • Synonym(s): tibial plateau fracture
  • First coined a “fender fracture” by Cotton in 1929:
    • 40–60% of tibial plateau fractures involve an automobile hitting a pedestrian. Fracture results from a medially directed force.

Epidemiology

  • Tibial plateau fractures account for ~1% of all fractures and 8% of fractures in the elderly. Elderly are less likely to have meniscal or ligamentous injury.
  • Lateral tibial plateau is smaller and weaker. Fractures of the lateral plateau account for 55–70%.
  • Bilateral plateau fractures account for 11–31%.
  • Medial plateau fractures account for 10–23%.
  • In both sexes, the highest frequency was between the ages of 40 and 60 yr.

Risk-Factors

  • Osteoporosis
  • Perioperative fracture associated with total or unicompartmental knee arthroplasty (2)
  • Sports: skiing, football

Commonly Associated Conditions

  • Tibial plateau fractures often accompany a predictable pattern of associated soft tissue knee injury:
    • Medial tibial plateau fracture: lateral collateral ligament and medial meniscus injuries
    • Lateral tibial plateau fracture: medial collateral ligament and lateral meniscus injuries
    • Anterior cruciate ligament (ACL) injuries can be seen with either medial or lateral plateau fractures. Also see intracondylar eminence fractures.
  • Owing to brisk hemorrhage and swelling, tibial plateau fractures can be associated with acute compartment syndrome.

Diagnosis ⬆ ⬇

  • X-ray: anteroposterior (AP), lateral, oblique; possible tunnel view
  • Magnetic resonance imaging (MRI): indicated for assessment of associated ligamentous or cartilaginous injury
  • Computed tomography (CT) scan: best to assess bone deformity
  • Schatzker classification system for tibial plateau fractures (3,4):
    • Type I: lateral split
    • Type II: lateral split with depression
    • Type III: pure lateral depression
    • Type IV: pure medial depression
    • Type V: bicondylar
    • Type VI: metaphyseal-diaphyseal dissociation
  • Ancillary studies: Knee aspirate may help to reveal the presence of fat globules (indicating osteochondral injury) and to reduce pain.

History

  • An accurate history will help to determine the direction of the force, velocity (high vs. low), and initial deformity produced.
  • Swelling can be immediate or delayed, often indicating osteochondral fracture or internal derangement.

Physical Exam

  • Signs and symptoms:
    • Painful swollen knee
    • Unable to bear weight
    • May have compartment syndrome signs and symptoms (see below)
  • Physical examination:
    • Most accurate way to evaluate the extent of the soft tissue injuries
    • Allows for evaluation of the vascular and neurologic status of the extremity
    • Gives insight into any associated ligamentous injuries and subsequent stability of the extremity
    • Pain and swelling about the knee may be associated with varus or valgus knee deformity.
    • Visible knee deformity indicates a severe injury.
    • Tenderness to palpation is noted over the medial and/or lateral tibial plateau.
    • Associated ligamentous injuries may show tenderness to palpation and instability of the collateral or cruciate ligaments.
    • Key finding is excursion of endpoint movement.
    • Large hemarthrosis usually is present.
    • If not present, it may indicate a torn capsule if the plateau is depressed.
    • Document distal pulses.
    • Check neurologic status with focus on the peroneal nerve and tendon function.
    • Check for abrasions or possible open fracture.
    • Watch for compartment syndrome findings:
      • Pain out of proportion to the physical examination findings
      • Pressure or tightness in the compartment
      • Pallor
      • Paresthesias
      • Paralysis: sign of cell death and need for immediate compartment release

Differential Diagnosis

  • Intercondylar eminence fracture ± ACL tear: Segond sign on plain film indicates lateral capsule avulsion.
  • Collateral ligament avulsion
  • Tibial tubercle avulsion
  • Proximal fibular fracture
  • Patella fracture
  • Hemarthrosis from patellar dislocation, ACL tear, or meniscal tear (if in the red or red-white zone)
  • Stress fracture
  • Physeal injury (pediatric)

Diagnostic Tests & Interpretation

  • Standard radiographs in AP, lateral, and two oblique views:
    • Initial x-rays may miss a small tibial plateau fracture.
    • High index of suspicion must be maintained based on mechanism of injury, presence/absence of an effusion, and joint instability.
    • Series provides information allowing for accurate assessment of the fracture pattern:
      • Internal oblique view best assesses the lateral plateau.
      • External oblique view best assesses the medial plateau.
      • Tunnel view helpful if suspicious for intercondylar eminence fractures
      • Lateral view demonstrates presence of depression:
        • Medial side is concave.
        • Lateral side is convex.
    • Posterior collateral ligament injury may show avulsion fracture.
  • CT scan:
    • Image of choice if negative films but high index of suspicion for fracture
      ALERT

      Bicondylar tibial plateau fracture all need CT imaging.

    • Provides cross-sectional and sagittal assessment of the fracture pattern
    • Reveals extent and position of the fracture lines
    • Allows visualization of areas of depression (AP and lateral planes)
    • If necessary, three-dimensional reconstructions can be provided to enhance the understanding of the fracture.
  • MRI: allows for assessment of associated ligamentous injuries; may not show fracture well
  • Arteriography:
    • Should be considered in any tibial plateau fracture where the stability of the joint is in question
    • Also may use ankle brachial index (ABI); if <0.8, then indicates arterial insult
    • Medial plateau fractures have a high incidence of vascular insult (owing to greater energy injuring force).
    • Arteriography/ABI should be performed and documented in most instances.
    • Presence of a palpable pulse does not exclude the possibility of intimal tear.
    • May lead to intraoperative occlusive thrombosis that could jeopardize the extremity

Treatment ⬆ ⬇

  • No more than 5 mm (0.5 cm) of depression/displacement is acceptable for conservative treatment.
  • Emergency department (ED) treatment:
    • Acute treatment:
      • Non–weight-bearing or toe-touch weight-bearing
      • Long leg splint with knee in full extension, ankle splinted at 90 degrees if instability or dislocation present
      • Hinged knee brace with 0 to 90 degrees of motion preferred for stable fracture
      • Ice, elevation
      • Pain management as needed. Acetaminophen, ice, and elevation are first line with limited use of narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs).
      • If plain films show <5 mm of displacement, then nonoperative management is acceptable.

Medication

  • Conflicting evidence regarding safety of NSAIDs for pain management. Use caution if high risk for nonunion (5).
  • Use total range of motion (TROM) brace locked in extension, and make the patient non–weight-bearing if pain control is difficult and to promote fracture healing.

Additional Therapies

  • Patient’s age, medical condition, history of osteoporosis, and expected level of activity should be taken into consideration on a case-by-case basis in terms of operative versus nonoperative management.
  • There are no specific recommendations regarding patient age or comorbid arthritis to dictate operative versus nonoperative management.
  • Nonoperative treatment is possible with hinged TROM-style bracing and strict non–weight-bearing for 4 to 6 wk if:
    • Under adequate sedation, there is no varus/valgus instability through a full arc of motion.
    • The fracture shows no elements of depression or <5 mm of displacement.

Issues for Referral

  • Emergent referral and treatment if there is associated acute compartment syndrome and/or vascular injury
  • Referral recommended within 48 hr if fracture is depressed or displaced (≥5 mm) or associated with significant ligament/meniscal injuries
  • Key to good outcome is early range of motion (ROM) and non–weight-bearing compliance.
  • Important to encourage quadriceps strengthening after bracing discontinued
  • Physical therapy: warranted once evidence of fracture healing (4 to 6 wk); vital if <90 degrees flexion by 4 wk

Surgery/Other Procedures

  • The goals of treating an intra-articular fracture of the tibia are to preserve pain-free joint mobility, stability, axial alignment, and articular cartilage congruity and avoid posttraumatic osteoarthritis.
  • Best accomplished by anatomic reduction of the joint surface and restoration of axial alignment
  • Intra-articular fractures, regardless of open or closed treatment, must be mobilized quickly to achieve the best ROM.
  • Only percutaneous or open reduction and stable fixation allow early motion without loss of articular cartilage.
  • Fractures treated initially by closed reduction often will show persistent displacement of articular cartilage fragments.
  • If open reduction cannot be achieved owing to mitigating circumstances, then treatment should consist of skeletal traction and early mobilization.
  • Bicondylar tibial plateau fractures are best managed with locked plating in favor of external fixation (6).
  • Absolute surgical indications:
    • Open fractures
    • Acute compartment syndrome
    • Acute vascular injury
  • Total knee replacement may be necessary in complex patterns in specific patient populations.
  • Timing of surgery: immediate if open fractures, associated compartment syndrome, and fractures with associated vascular injuries
  • Careful evaluation of fractures with tomography/CT scan/MRI is recommended:
    • Delay of 24 to 48 hr will not compromise the outcome.
    • Evaluation for soft tissue injury is important.
  • Patients delayed >48 hr can be placed in skeletal traction.
  • Postoperative management:
    • Depends on the degree of stability achieved with fixation and the findings at surgery
    • If stable, early motion by continuous passive motion (CPM) is beneficial.
    • Motion from full extension to 40 to 60 degrees of flexion on postoperative night 1.
    • CPM is increased to 90 degrees as quickly as possible.
    • If CPM is not available, immobilization of the knee in 60 to 90 degrees of flexion is recommended for the first 48 to 72 hr, followed by active motion.
    • Immobilization in flexion greatly affects postoperative motion.
    • Non–weight-bearing ambulation is encouraged postoperatively.
    • Stable type I to V fractures may start partial weight-bearing at 8 wk.
    • More comminuted fractures should be held non–weight-bearing for 10 to 12 wk.
    • Early motion and non–weight-bearing are critical keys to long-term success.

Ongoing Care ⬆ ⬇

Prognosis

  • High rate of osteoarthritis associated with tibial plateau fractures (7)
  • Prognosis for full return of motion in the presence of osteoarthritis is poor.
  • Outcomes are generally better in younger patients.

Complications

  • Compartment syndrome (preoperative and postoperative); most common significant short-term complication
  • Posttraumatic osteoarthritis
  • Infection
  • Wound slough
  • Loss of ROM
  • Loss of normal gait pattern
  • Fixation failure
  • Loss of articular reduction
  • Malunion
  • Nonunion (rare)
  • Deep vein thrombosis
  • Pseudoarthrosis

Additional Reading ⬆ ⬇

  • Elsoe R, Larsen P, Nielsen NP, et al. Population-based epidemiology of tibial plateau fractures. Orthopedics. 2015;38(9):e780–e786.
  • Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev. 2017;1(5):225–232.
  • Stanitski CL, Harvell JC, Fu F. Observations on acute knee hemarthrosis in children and adolescents. J Pediatr Orthop. 1993;13(4):506–510.

References ⬆ ⬇

  1. Gardner MJ, Yacoubian S, Geller D, et al. The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma. 2005;19(2):79–84.
  2. Kim KI, Egol KA, Hozack WJ, et al. Periprosthetic fractures after total knee arthroplasties. Clin Orthop Relat Res. 2006;446:167–175.
  3. Schatzker J.Tibial plateau fractures. In: Browner B, Jupiter JB, Levine AM, et al, eds. Skeletal Trauma. Philadelphia, PA: WB Saunders; 1992:1745–1769.
  4. Eiff MP, Hatch R. Patellar, tibial, and fibular fractures. In: Fracture Management for Primary Care. 3rd ed. Philadelphia, PA: Elsevier; 2012:234–243.
  5. Marquez-Lara A, Hutchinson ID, Nuñez F Jr, et al. Nonsteroidal anti-inflammatory drugs and bone-healing: a systematic review of research quality. JBJS Rev. 2016;4(3). doi:10.2106/JBJS.RVW.O.0005.
  6. Krupp RJ, Malkani AL, Roberts CS, et al. Treatment of bicondylar tibia plateau fractures using locked plating versus external fixation. Orthopedics. 2009;32(8). doi:10.3928/01477447-20090624-11.
  7. Ding C, Cicuttini F, Jones G. Tibial subchondral bone size and knee cartilage defects: relevance to knee osteoarthritis. Osteoarthritis Cartilage. 2007;15(5):479–486.

Clinical Pearls ⬆

  • Need to have a high index of suspicion with ligamentous injury, especially in the setting of large swelling shortly after injury
  • Although tibial plateau fractures have a low overall incidence, these injury patterns must be thought of in trauma owing to the risk of associated vascular insult (see discussion on arteriography under “Diagnostic Tests & Interpretation”).
  • Liberal use of advanced imaging is encouraged for full understanding of the extent of the injury, although x-ray evaluation is still considered the “gold standard” for imaging assessment.
  • Consider compartment syndrome both pre- and postoperatively as a potential complication.
  • The keys—both for early treatment and for long-term reasonable prognosis—lie in compliance with non–weight-bearing and ROM.
  • Anticipate the development of osteoarthritis, and educate these patients accordingly.