Tibial Plateau Fracture - Clinical Features, Diagnosis, and Treatment

Introduction:

Tibial plateau fractures account for one percent of all fractures, which are typically sustained with high-energy mechanisms. These fractures are associated with injury to nearby structures, including vasculature, nerves, and adjacent compartments. Minimal tibial plateau fractures are treated conservatively, while fractures associated with injuries that need orthopedic consultation are treated surgically.

What Is Tibial Plateau Fracture?

A tibial plateau fracture is a fracture involving the upper part of the tibia (shin bone), which involves the knee joint.

What Is the Etiology of Tibial Plateau Fracture?

• Injury to the lateral part of the tibial plateau is due to a blow to the lateral aspect of the knee.

• Injuries to the medial part are due to high-energy mechanisms, including axial load falling from a height and landing on the feet, motor vehicle collisions, and other sources of direct trauma.

• Bicondylar fractures occur due to high-energy mechanisms.

• Tibial fracture with a low-energy mechanism occurs in elderly people.

What Are the Clinical Features of Tibial Plateau Fracture?

1. Comprises one percent of all fractures.

2. Most commonly occurs in males rather than females.

3. Most commonly seen around fifty-two years of age.

4. Men under fifty years of age are likely to sustain this injury through high-energy mechanisms and soft tissue injuries, while women under seventy years of age are likely to sustain this injury due to falls.

5. Pain.

6. Swelling or fragmentation of the tibia leads to the loss of its normal structure.

7. Decreased ability to move the knee.

8. Blood in the soft tissues and knee joint (hemarthrosis)- bruising and doughy feel.

9. A complicated tibial fracture leads to compartment syndrome- swelling causes compression of the nerves and blood vessels inside the leg and cell death (necrosis).

What Is the Anatomy of the Tibial Bone?

• Tibia- weight-bearing bone located medial to the fibula.

• The proximal part of the tibia bone comprises the lateral part of the knee joint.

• The tibial plateau has two articular surfaces- medial and lateral plateaus.

• The medial plateau is thicker and concave in shape.

• The lateral plateau is thinner, weaker, and convex in shape.

• The main mechanism of injury is due to valgus load with or without an axial load.

What Is the Pathophysiology of Tibial Plateau Fracture?

The tibial plateau fracture is an injury that causes the bone to break and injure the cartilage that covers the top end of the bone. The crack may range from a single to shattering into many pieces.

What Are the Risk Factors of Tibial Plateau Fracture?

• Individual with knee pain.

• Individual with possible deformity.

• Individual with edema and suspected mechanism of injury.

How to Classify Tibial Plateau Fracture?

Schatzker Classification:

• Schatzker 1: Lateral plateau split fracture.

• Schatzker 2: Lateral plateau split-depressed fracture.

• Schatzker 3: Lateral plateau pure depression fracture.

• Schatzker 4: Median plateau fracture.

• Schatzker 5: Bicondylar plateau fracture.

• Schatzker 6: Metaphyseal and diaphyseal dissociation.

Hohl and Moore Classification:

• Type 1: Coronal split fracture.

• Type 2: Entire condylar fracture.

• Type 3: Rim avulsion fracture of the lateral tibial fracture.

• Type 4: Rim compression fracture.

• Type 5: Four-part fracture.

How to Diagnose Tibial Plateau Fracture?

Complete physical examination includes an examination of the entire knee in comparison to the contralateral knee with special attention to the following:

• Skin: The skin is examined to evaluate open fractures, lacerations, and puncture wounds.

• Knee Effusion: The knee is examined for hemarthrosis (blood in soft tissues and bone joints) and bone fragments suggesting internal fracture.

• Neurovascular Exam: It is done to evaluate sensation, motor function, and distal pulses.

• Compartments: All compartments should be palpated. A firm, tense compartment suggests compartment syndrome (compression of nerves and blood vessels inside the leg).

• Laxity Tests: More than ten degrees of laxity with valgus stress testing suggests a tear of the collateral ligaments (tissue that connects muscle to bone). Laxity below ten degrees suggests displaced fracture.

• The Range of Motion: The range of motion is difficult to access due to pain.

Other investigations:

• X-ray: Useful in detecting compression, joint malalignment, and depression of the articular surface.

• Computed Tomography: Useful in detecting articular surface depression and comminuted (multiple) fractures.

• Magnetic Resonance Imaging: Useful in detecting pathologies.

What Is the Treatment For Tibial Plateau Fracture?

Non-Operative Management:

1. Indicated in minimally displaced fracture.

2. A fracture occurs due to a low-energy mechanism and no associated injuries.

3. Non-ambulatory individuals.

4. A fractured tibia is placed in a hinged knee brace, and an immediate passive range of motion can be started.

5. Then the individual is instructed to be non-weight-bearing for six to eight weeks.

6. This is followed by partial weight-bearing for the next six weeks and then full weight-bearing as tolerated.

7. Reevaluation weekly with plain radiograph for three weeks following injury to detect further injury and displacement.

8. The individual should remain in the brace until radiographic healing is complete, which takes up to twelve weeks.

9. Physical therapy may begin, but the individual cannot regain full function until sixteen to twenty weeks or longer.

10. Prolonged weight-bearing exercises and playing sports should be avoided until healing is complete.

Operative Management:

• Open reduction and internal fixation.

• External fixation with open fixation of the articular segment.

• Arthroscopically assisted reduction and internal fixation.

• Primary total knee arthroplasty.

What Is the Prognosis?

• Studies have shown that after surgical intervention, the individual is able to do limited functions.

• The factor that influences long-term outcomes is the restoration of joint stability.

• External fixation procedures have a high malunion rate.

• The worst long-term outcomes were reported in individuals with ligament instability and alteration of the limb mechanical axis by more than five degrees.

What Are the Postoperative Complications?

• Infections associated with smoking, lung diseases, bicondylar fractures, and increased intraoperative time.

• Abnormal gait.

• Post-traumatic knee osteoarthritis (inflammation of the bone).

• Post-traumatic ankle osteoarthritis (inflammation of the bone) due to abnormal gait.

• Chronic pain.

• Long-term complications will affect the quality of life, especially for individuals whose job requires a high degree of mobility leading to a delayed return to work.

Conclusion:

It is important to discuss the prognosis of the treatment before doing the procedure. Tibial plateau fractures are best managed by an interprofessional team that comprises orthopedic nurses and therapists. An orthopedic consultation is important to detect the type of fracture and treatment. Prompt orthopedic follow-up is important. Most individuals need extensive rehabilitation to regain muscle strength and function. The outcome is good for most people, but there is a delay in returning to sports.