Tibial plateau fracture

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Tibial plateau fracture
Other namesFractures of the tibial plateau
TibPlateauBadMark.png
A severe tibial plateau fracture with an associated fibular head fracture
Specialty Orthopedics
Symptoms Pain, swelling, decreased ability to move the knee [1]
Complications Injury to the artery or nerve, compartment syndrome [1]
TypesType I to Type VI [2]
Causes Trauma (fall, motor vehicle collision) [1]
Risk factors Osteoporosis, skiing [2]
Diagnostic method Suspected based on symptoms, confirmed with X-rays and CT scan [1]
Differential diagnosis Patella fracture, fibular fracture, anterior cruciate ligament injury [2]
TreatmentSurgery, splinting [1] [2]
Medication NSAIDs, opioids [1] [2]
Prognosis Arthritis is common [2]
Frequency~1% of fractures [2]

A tibial plateau fracture is a break of the upper part of the tibia (shinbone) that involves the knee joint. [1] This could involve the medial, lateral, central, or bicondylar (medial and lateral). [3] Symptoms include pain, swelling, and a decreased ability to move the knee. [1] People are generally unable to walk. [2] Complication may include injury to the artery or nerve, arthritis, and compartment syndrome. [1]

Contents

The cause is typically trauma such as a fall or motor vehicle collision. [1] Risk factors include osteoporosis and certain sports such as skiing. [2] Diagnosis is typically suspected based on symptoms and confirmed with X-rays and a CT scan. [1] Some fractures may not be seen on plain X-rays. [2]

Pain may be managed with NSAIDs, opioids, and splinting. [1] [2] In those who are otherwise healthy, treatment is generally by surgery. [1] Occasionally, if the bones are well aligned and the ligaments of the knee are intact, people may be treated without surgery. [2]

They represent about 1% of broken bones. [2] They occur most commonly in middle aged males and older females. [4] In the 1920s they were called a "fender fracture" due to their association with people being hit by a motor vehicle while walking. [2]

Signs and symptoms

Tibial plateau fractures typically presents with knee effusion, swelling of the knee or fragmentation of the tibia which leads to loss of its normal structural appearance. Blood in the soft tissues and knee joint (hemarthrosis) may lead to bruising and a doughy feel of the knee joint. Due to the tibial plateau's proximity to important vascular (i.e. arteries, veins) and neurological (i.e. nerves such as peroneal and tibial) structures, injuries to these may occur upon fracture. A careful examination of the neurovascular systems is imperative. A serious complication of tibial plateau fractures is compartment syndrome in which swelling causes compression of the nerves and blood vessels inside the leg and may ultimately lead to necrosis or cell death of the leg tissues. [5]

Cause

Tibial plateau fractures may be divided into low energy or high energy fractures. Low energy fractures are commonly seen in older females due to osteoporotic bone changes and are typically depressed fractures. High energy fractures are commonly the result of motor vehicle accidents, falls or sports related injuries. These causes constitute the majority of tibial plateau fractures in young individuals. [6]

Mechanism

Fractures of the tibial plateau are caused by a varus (inwardly angulating) or valgus (outwardly angulating) force combined with axial loading or weight bearing on knee. The classically described situation in which this occurs is from a car striking a pedestrian's fixed knee ("bumper fracture"). However, most of these fractures occur from motor vehicle accidents or falls. Injury can be due to a fall from height in which knee forced into valgus or varus. The tibial condyle is crushed or split by the opposing femoral condyle, which remains intact. The knee anatomy provides insight into predicting why certain fracture patterns occur more often than others. The medial plateau is larger and significantly stronger than the lateral plateau. Also, there is a natural valgus or outward angulation alignment to the limb which coupled with the often valgus or outwardly angulating force on impact will injure the lateral side. This explains how 60% of plateau fractures involve the lateral plateau, 15% medial plateau, 25% bicondylar lesions. Partial or complete ligamentous ruptures occur in 15-45%, meniscal lesions in about 5-37% of all tibial plateau fractures. [7]

Diagnosis

In all injuries to the tibial plateau radiographs (commonly called x-rays) are imperative. Computed tomography scans are not always necessary but are sometimes critical for evaluating degree of fracture and determining a treatment plan that would not be possible with plain radiographs. [8] Magnetic Resonance images are the diagnostic modality of choice when meniscal, ligamentous and soft tissue injuries are suspected. [9] [10] CT angiography should be considered if there is alteration of the distal pulses or concern about arterial injury.

Classification

Physicians use classification types to assess the degree of injury, treatment plan and predict prognosis. Multiple classifications of tibial plateau fractures have been developed. Currently, the Schatzker classification system is the most widely accepted and used. [9] It is composed of six condyle fracture types classified by fracture pattern and fragment anatomy. [11] Each increasing numeric fracture type denotes increasing severity. The severity correlates with the amount of energy imparted to the bone at the time of injury and prognosis.

Schatzker classification for tibial plateau fracture: [12]

This is a wedge-shaped pure cleavage fracture and involves a vertical split of the lateral tibial plateau. It is usually the result of a low energy injury in young individuals with normal mineralization. May be caused by a valgus force combined with axial loading that leads to the lateral femoral condyle being driven into the articular surface of the tibial plateau. Represent 6% of all tibial plateau fractures.

This is a combined cleavage and compression fracture and involves vertical split of the lateral condyle combined with depression of the adjacent load bearing part of the condyle. Caused by a valgus force on the knee; it is a low energy injury, typically seen in individuals of the 4th decade or older with osteoporotic changes in bone. Most common, and make up 75% of all tibial plateau fractures. There is a 20% risk of distraction injuries to the medial collateral ligament. May include distraction injury to the medial collateral ligament or anterior cruciate ligament.

Lateral Tibial Plateau fracture XRay with Depression Lateral Tibial Plateau fracture XRay with Depression.jpg
Lateral Tibial Plateau fracture XRay with Depression

This is a pure compression fracture of the lateral or central tibial plateau in which the articular surface of the tibial plateau is depressed and driven into the lateral tibial metaphysis by axial forces.3 A low energy injury, these fractures are more frequent in the 4th and 5th decades of life and individuals with osteoporotic changes in bone. They are extremely rare. Can be further divided into two subtypes: IIIA Compression Fracture of the lateral tibial plateau IIIB Compression Fracture of the central tibial plateau May result in joint instability.

This is a medial tibial plateau fracture with a split or depressed component. It is usually the result of a high energy injury and involves a varus force with axial loading at the knee. Represent 10% of all tibial plateau fractures. There is high risk of damage to the popliteal artery and peroneal nerve and therefore carry a worse prognosis. May include distraction injuries to lateral collateral ligament, fibular dislocation/fracture, posterolateral corner.

Consists of a split fracture of the medial and lateral tibial plateau. It is usually the result of a high energy injury with complex varus and valgus forces acting upon the tibial plateau. May include injuries to the anterior cruciate ligament and collateral ligaments. Make up 3% of all tibial plateau fractures.

Main feature of this type of fracture is a transverse subcondylar fracture with dissociation of the metaphysis from the diaphysis. The fracture pattern of the condyles is variable and all types of fractures can occur. This is a high energy injury with a complex mechanism that includes varus and valgus forces. Up to 33% of these fractures may be open, often with extensive soft tissue injuries and risk of compartment syndrome. Represents 20% of all tibial plateau fractures.

Hohl and Moore is an alternative classification for tibial plateau fractures. The 5 types are:

This can be either the lateral or medial aspect of the plateau, this differs from Schatzker I which is a split fracture of the lateral plateau and Schatzker IV which is a split

This can be either the entire medial or lateral condyle, differs from Schatzker V which involves both tibial condyles (medial and lateral)

Treatment

Repair of a tibial plateau fracture Ryan Parent Tibial Plateau.png
Repair of a tibial plateau fracture

Pain may be managed with NSAIDs, opioids, and splinting. [1] [2] In those who are otherwise healthy, treatment is generally by surgery. [1] Occasionally, if the bones are well aligned and the ligaments of the knee are intact, people may be treated without surgery. [2] The surgery usually involves reducing the fractured fragments of the tibia plateau to their anatomical position and fixing them in place with screws only or fixed angle anatomical plates ensuring absolute stability. Implant selection is based on the type of injury. Generally, simple or incomplete fractures (Schatzker type 1) of the plateau are compressed with 6.5mm partially threaded cancellous screws. Complex type fractures will require a plate for enhanced stability. As the tibia condyles articulate with the femur (thigh bone) to form knee joint, any incongruity in the articular surface is unacceptable as it leads to early arthritis. Prolonged immobilization of the knee joint is also not recommended which result in stiffness of the joint and difficult recovery. Following a tibial plateau fracture, the patient is at risk for arthritis. This is referred to as post-traumatic arthritis. The more displaced the joint intra-articular surface is, the more likely post-traumatic arthritis is to occur. This occurs due to injury to the joint surface cartilage. When cartilage is damaged, arthritis can occur. [13] It's currently debated what role primary total knee arthroplasty (Joint Prosthesis) plays in the treatment of tibial plateau fractures. Although accompanied with risks small studies have shown promising results. [14]

Surgery

A tibial plateau fracture requires orthopaedic surgical intervention for treatment. After X-ray and CT scans confirm fracture, Open Reduction Internal Fixation (ORIF) with medial and/or lateral plateau fixation is done. There are 5 different approaches that are most commonly used. [15]

These are: anterolateral, posteromedial, posterolateral, posterior, and dual plate fixation.

Epidemiology

Tibial plateau fractures constitute 1% of all fractures. Peak age is 30–40 years old in men and 60–70 in women. Approximately half of the people who sustain a tibial plateau fracture are aged over 50 years old. [16]

Related Research Articles

<span class="mw-page-title-main">Knee</span> Leg joint in primates

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

<span class="mw-page-title-main">Tibia</span> Leg bone in vertebrates

The tibia, also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates ; it connects the knee with the ankle. The tibia is found on the medial side of the leg next to the fibula and closer to the median plane. The tibia is connected to the fibula by the interosseous membrane of leg, forming a type of fibrous joint called a syndesmosis with very little movement. The tibia is named for the flute tibia. It is the second largest bone in the human body, after the femur. The leg bones are the strongest long bones as they support the rest of the body.

<span class="mw-page-title-main">Fibula</span> Leg bone in vertebrates

The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity is small, placed toward the back of the head of the tibia, below the knee joint and excluded from the formation of this joint. Its lower extremity inclines a little forward, so as to be on a plane anterior to that of the upper end; it projects below the tibia and forms the lateral part of the ankle joint.

<span class="mw-page-title-main">Ankle</span> Region where the foot and the leg meet

The ankle, the talocrural region or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.

<span class="mw-page-title-main">Posterior cruciate ligament</span> One of four major ligaments of the knee

The posterior cruciate ligament (PCL) is a ligament in each knee of humans and various other animals. It works as a counterpart to the anterior cruciate ligament (ACL). It connects the posterior intercondylar area of the tibia to the medial condyle of the femur. This configuration allows the PCL to resist forces pushing the tibia posteriorly relative to the femur.

<span class="mw-page-title-main">Anterior cruciate ligament</span> Type of cruciate ligament in the human knee

The anterior cruciate ligament (ACL) is one of a pair of cruciate ligaments in the human knee. The two ligaments are also called "cruciform" ligaments, as they are arranged in a crossed formation. In the quadruped stifle joint, based on its anatomical position, it is also referred to as the cranial cruciate ligament. The term cruciate translates to cross. This name is fitting because the ACL crosses the posterior cruciate ligament to form an "X". It is composed of strong, fibrous material and assists in controlling excessive motion. This is done by limiting mobility of the joint. The anterior cruciate ligament is one of the four main ligaments of the knee, providing 85% of the restraining force to anterior tibial displacement at 30 and 90° of knee flexion. The ACL is the most injured ligament of the four located in the knee.

<span class="mw-page-title-main">Maisonneuve fracture</span> Medical condition

The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of the deep deltoid ligament of the ankle. This type of injury can be difficult to detect.

<span class="mw-page-title-main">Segond fracture</span> Avulsion fracture of the lateral tibial condyle of the knee

The Segond fracture is a type of avulsion fracture from the lateral tibial plateau of the knee, immediately below the articular surface of the tibia.

<span class="mw-page-title-main">Medial collateral ligament</span> Ligament on the inner side of the knee joint

The medial collateral ligament (MCL), also called the superficial medial collateral ligament (sMCL) or tibial collateral ligament (TCL), is one of the major ligaments of the knee. It is on the medial (inner) side of the knee joint and occurs in humans and other primates. Its primary function is to resist valgus forces on the knee.

<span class="mw-page-title-main">Ankle fracture</span> Medical condition

An ankle fracture is a break of one or more of the bones that make up the ankle joint. Symptoms may include pain, swelling, bruising, and an inability to walk on the injured leg. Complications may include an associated high ankle sprain, compartment syndrome, stiffness, malunion, and post-traumatic arthritis.

The knee examination, in medicine and physiotherapy, is performed as part of a physical examination, or when a patient presents with knee pain or a history that suggests a pathology of the knee joint.

<span class="mw-page-title-main">Superior tibiofibular joint</span> Joint in the knee

The superior tibiofibular articulation is an arthrodial joint between the lateral condyle of tibia and the head of the fibula.

<span class="mw-page-title-main">Unhappy triad</span> Medical condition of the knee

The unhappy triad, also known as a blown knee among other names, is an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, "combined anterior cruciate and medial collateral ligament disruptions that were incurred during athletic endeavors" always present with concomitant medial meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.

A bumper fracture is a fracture of the lateral tibial plateau caused by the bumper of a car coming into contact with the outer side of the knee when a person is standing. Specifically, it is caused by a forced valgus applied to the knee. This causes the lateral part of the distal femur and the lateral tibial plateau to come into contact, compressing the tibial plateau and causing the tibia to fracture. The name of the injury is because it was described as being caused by the impact of a car bumper on the lateral side of the knee while the foot is planted on the ground, although this mechanism is only seen in about 25% of tibial plateau fractures.

<span class="mw-page-title-main">Crus fracture</span>

A crus fracture is a fracture of the lower legs bones meaning either or both of the tibia and fibula.

<span class="mw-page-title-main">Medial knee injuries</span> Medical condition

Medial knee injuries are the most common type of knee injury. The medial ligament complex of the knee consists of:

The anterolateral ligament (ALL) is a ligament on the lateral aspect of the human knee, anterior to the fibular collateral ligament.

High tibial osteotomy is an orthopaedic surgical procedure which aims to correct a varus deformation with compartmental osteoarthritis. Since the inception of the procedure, advancements to technique, fixation devices, and a better understanding of patient selection has allowed HTO to become more popular in younger, more active patients hoping to combat arthritis. The idea behind the procedure is to realign the weight-bearing line of the knee. By realigning the knee, the force produced from weight-bearing is shifted from the arthritic, medial compartment to the healthy, lateral compartment. This decrease in force or load in the diseased part of the knee joint decreases knee pain and can delay the development or progression of osteoarthritis in the medial compartment.

In the skeleton of humans and other animals, a tubercle, tuberosity or apophysis is a protrusion or eminence that serves as an attachment for skeletal muscles. The muscles attach by tendons, where the enthesis is the connective tissue between the tendon and bone. A tuberosity is generally a larger tubercle.

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