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
SymptomsPain, 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] 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. [3] 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 soft tissues and inability to bear weight. The knee may be deformed due to displacement and/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.[ citation needed ]

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.[ citation needed ]

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 pleateau. 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 pleateau, 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. [4]

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. [5] Magnetic Resonance images are the diagnositic modality of choice when meniscal, ligamentous and soft tissue injuries are suspected. [6] [7] 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. [6] It is composed of six condyle fracture types classified by fracture pattern and fragment anatomy. [8] 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:[ citation needed ]

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.

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 mataphysis 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.

Treatment

Repair of a tibial plateau fracture TibPlatRepair.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.[ citation needed ]

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. [9]

Related Research Articles

Knee Region around the kneecap

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.

Tibia

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, and it connects the knee with the ankle bones. The tibia is found on the medial side of the leg next to the fibula and closer to the median plane or centre-line. The tibia is connected to the fibula by the interosseous membrane of the 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 next to the femur. The leg bones are the strongest long bones as they support the rest of the body.

Fibula

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 slenderest 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.

Ankle Region where the foot and the leg meet

The ankle, or the talocrural region, is the region 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.

Posterior cruciate ligament 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.

Anterior cruciate ligament 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 2 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 degrees and 90 degrees of knee flexion. The ACL is the most injured ligament of the four located in the knee.

Bone fracture

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of the bone. In more severe cases, the bone may be broken into several pieces. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

Segond fracture 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.

Medial meniscus

The medial meniscus is a fibrocartilage semicircular band that spans the knee joint medially, located between the medial condyle of the femur and the medial condyle of the tibia. It is also referred to as the internal semilunar fibrocartilage. The medial meniscus has more of a crescent shape while the lateral meniscus is more circular. The anterior aspects of both menisci are connected by the transverse ligament. It is a common site of injury, especially if the knee is twisted.

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.

Stifle joint

The stifle joint is a complex joint in the hind limbs of quadruped mammals such as the sheep, horse or dog. It is the equivalent of the human knee and is often the largest synovial joint in the animal's body. The stifle joint joins three bones: the femur, patella, and tibia. The joint consists of three smaller ones: the femoropatellar joint, medial femorotibial joint, and lateral femorotibial joint.

Unhappy triad injury to the anterior cruciate ligament, medial collateral ligament, and meniscus

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.

Coronary ligament of the knee

The coronary ligaments of the knee are portions of the joint capsule which connect the inferior edges of the fibrocartilaginous menisci to the periphery of the tibial plateaus.

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.

Crus fracture

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

Posterolateral corner injuries of the knee are injuries to a complex area formed by the interaction of multiple structures. Injuries to the posterolateral corner can be debilitating to the person and require recognition and treatment to avoid long term consequences. Injuries to the PLC often occur in combination with other ligamentous injuries to the knee; most commonly the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). As with any injury, an understanding of the anatomy and functional interactions of the posterolateral corner is important to diagnosing and treating the injury.

Medial knee injuries

Medial knee injuries are the most common type of knee injury. The medial ligament complex of the knee is composed of the superficial medial collateral ligament (sMCL), deep medial collateral ligament (dMCL), and the posterior oblique ligament (POL). These ligaments have also been called the medial collateral ligament (MCL), tibial collateral ligament, mid-third capsular ligament, and oblique fibers of the sMCL, respectively. This complex is the major stabilizer of the medial knee. Injuries to the medial side of the knee are most commonly isolated to these ligaments. A thorough understanding of the anatomy and function of the medial knee structures, along with a detailed history and physical exam, are imperative to diagnosing and treating these injuries.

Intercondylar area

The intercondylar area is the separation between the medial and lateral condyle on the upper extremity of the tibia. The anterior and posterior cruciate ligaments and the menisci attach to the intercondylar area.

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

Index of trauma and orthopaedics articles Wikipedia index

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 "Fractures of the Proximal Tibia (Shinbone)". OrthoInfo - AAOS. Archived from the original on 17 June 2017. Retrieved 15 October 2017.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Bracker, Mark D. (2012). The 5-Minute Sports Medicine Consult. Lippincott Williams & Wilkins. p. 242. ISBN   9781451148121. Archived from the original on 2017-10-15.
  3. Karadsheh, Mark. "Tibial Plateau Fractures". www.orthobullets.com. Archived from the original on 28 June 2017. Retrieved 15 October 2017.
  4. Clifford R. Wheeless III, MD. Wheeless' Textbook of Orthopaedics. Duke University Medical Center's Division of Orthopedic Surgery. Data Trace Internet Publishing, LLC. Archived from the original on 2008-03-29.CS1 maint: uses authors parameter (link)
  5. "K. Markhardt, MD. Schatkzker Classification of Tibial Plateau Fractures: Use of CT and MR Imaging Improves Assessment. Radiographics 2009".Cite journal requires |journal= (help)
  6. 1 2 Scuderi G, Tria A (2010). The Knee: A Comprehensive Review. 1 edition. World Scientific Publishing Company. pp. 209–301.
  7. Barrow B (1994). "Tibial Plateau Fractures: Evualuation with MR Imaging". Radiographics. 14 (3): 553–9. doi: 10.1148/radiographics.14.3.8066271 . PMID   8066271.
  8. Zeltser D, Leopold S (2013). "Classifications in Brief: Schatzker Classification of Tibial Plateau Fractures". Clinical Orthopaedics and Related Research. 471 (2): 371–374. doi:10.1007/s11999-012-2451-z. PMC   3549155 . PMID   22744206.
  9. Pires R (2013). "Epidemiological study on tibial plateau fractures at a level I trauma center". Acta Ortop Bras. 21 (2): 109–15. doi:10.1590/S1413-78522013000200008. PMC   3861961 . PMID   24453653.
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