Tibial plateau fracture
Tibial plateau fracture | |
---|---|
Other names | Fractures of the tibial plateau |
Prognosis | Arthritis is common[2] |
Frequency | ~1% of fractures[2] |
A tibial plateau fracture is a
The cause is typically
Pain may be managed with
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
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.[11]
Diagnosis
In all injuries to the tibial plateau
-
Lipohemarthrosis (presence of fat and blood from bone marrow in the joint space after an intraarticular fracture) seen on X-ray in a person with a subtle tibial plateau fracture
-
Lipohemarthrosis due to a tibial plateau fracture
-
3D reconstruction of a CT image of a tibial plateau fracture
-
Subtle tibial plateau fracture on an AP X ray of the knee
-
Lipohemarthrosis due to a tibial plateau fracture
-
A tibial plateau fracture seen on X-ray
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.[13] It is composed of six condyle fracture types classified by fracture pattern and fragment anatomy.[15] 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:[16]
- Type I = Lateral Tibial plateau fracture without depression.
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.
- Type II = Lateral tibial plateau fracture with depression,
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.
![](http://upload.wikimedia.org/wikipedia/commons/thumb/4/4e/Lateral_Tibial_Plateau_fracture_XRay_with_Depression.jpg/220px-Lateral_Tibial_Plateau_fracture_XRay_with_Depression.jpg)
- Type III: Focal depression of articular surface with no associated split.
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.
- Type IV = Medial tibial plateau fracture, with or without depression; may involve tibial spines; associated soft tissue injuries.
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.
- Type V = Bicondylar tibial plateau fracture,
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.
- Type VI = Tibial plateau fracture with diaphyseal discontinuity
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:
- Type I: Split Fracture
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
- Type II: Entire Condylar Fracture
This can be either the entire medial or lateral condyle, differs from Schatzker V which involves both tibial condyles (medial and lateral)
- Type III: Rim Avulsion Fracture
- Type IV: Rim Depression Fracture
- Type V: Four-part fracture
Treatment
![](http://upload.wikimedia.org/wikipedia/commons/thumb/3/3a/Ryan_Parent_Tibial_Plateau.png/220px-Ryan_Parent_Tibial_Plateau.png)
Pain may be managed with
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.[19]
These are: anterolateral, posteromedial, posterolateral, posterior, and dual plate fixation.
- Anterolateral: anterior to ilio-tibial tract; proximal attachment of tibialis anterior muscle; avoid peroneal nerve around fibular head
- Posteromedial: interval between per anserinus and medial head of the gastrocnemius (calf muscle)
- Posterolateral: biceps femorus and peroneal nerve retracted laterally; lateral gastrocnemius and soleus retracted medially
- Posterior: done with the patient laying on stomach (prone); retract semimembranosus (one of hamstring muscles) until gastrocnemius becomes visible and continue until postero-medial capsule is visualized
- Dual plate fixation: can be used over medial and lateral aspects of plateau; used for bicondylar plateau fractures.
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.[20]
References
- ^ a b c d e f g h i j k l m n o "Fractures of the Proximal Tibia (Shinbone)". OrthoInfo - AAOS. Archived from the original on 17 June 2017. Retrieved 15 October 2017.
- ^ ISBN 978-1-4511-4812-1. Archivedfrom the original on 2017-10-15.
- ^ Karadsheh M. "Tibial Plateau Fractures". www.orthobullets.com. Archived from the original on 28 June 2017. Retrieved 15 October 2017.
- ^ Karadsheh M. "Tibial Plateau Fractures". www.orthobullets.com. Archived from the original on 28 June 2017. Retrieved 15 October 2017.
- PMID 29261932. Archived from the original on 16 November 2023. Retrieved 20 February 2024.)
{{cite journal}}
: CS1 maint: bot: original URL status unknown (link - PMID 29261932. Archived from the original on 16 November 2023. Retrieved 20 February 2024.)
{{cite journal}}
: CS1 maint: bot: original URL status unknown (link - ^ Tibial Plateau Fractures at eMedicine
- ^ "Bumper Fracture of the Knee". www.mdedge.com. Retrieved 13 October 2018.
- ]
- ^ "Skeletal Trauma". www.med-ed.virginia.edu. Retrieved 13 October 2018.
- ^ Clifford R. Wheeless III. 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.
- PMID 19325067.
- ^ a b Scuderi G, Tria A (2010). The Knee: A Comprehensive Review. 1 edition. World Scientific Publishing Company. pp. 209–301.
- PMID 8066271.
- PMID 22744206.
- PMID 22744206.
- S2CID 3310762.
- S2CID 73501709.
- ^ Karadsheh M. "Tibial Plateau Fractures". www.orthobullets.com. Archived from the original on 28 June 2017. Retrieved 15 October 2017.
- PMID 24453653.
External links
![](http://upload.wikimedia.org/wikipedia/en/thumb/4/4a/Commons-logo.svg/30px-Commons-logo.svg.png)