Tibial Plateau Fractures
Posted on January 4, 2010
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The expansion of the flat upper end of the tibia which makes up the distal half of the knee joint is known as the tibial plateau. The plateau is an essential part of the weight bearing function of the knee joint and if compromised can severely affect the movement, stability and alignment of the knee, interfering with gait. The fracture should be recognised early and treated accordingly so that the chances of post-traumatic knee arthritis and disability are minimised. Over half the patients in this category are in their fifties or older.
A large group which suffer this type of fracture is older women who already have some degrees of osteoporotic change in the area. Younger people with this presentation more likely result from more high energy events. The usual way these fractures occur is for a sideways force to be applied to the knee (often in a knock knee direction) while the knee is weight bearing with a downward force also applied. The lateral condyle (most commonly) is then squashed down by the large femoral condyle on that side. Sports injuries and falling from a height can result in this injury but it is much more common secondary to a road accident.
Pedestrians who are hit by the bumper of a car in slow speed events make up about a quarter of this patient group as the bumper is at the right height to apply the required forces. Sporting events such as horse riding or falls from a height can also cause this type of fracture. The levels of energy involved in the precipitating events can make a significant difference to the types of fracture which result. Lower energy events more typically cause depression fractures whilst the result of a higher energy occurrence is more likely to be a splitting fracture. The complex nature of these fractures has resulted in many efforts at classification, with Schatzker and co-workers’ now accepted.
Patient assessment does not concentrate solely on the state of the bony structures but includes the soft tissues in the local area including nerves, muscles and blood vessels. Cruciate ligament and cartilage (meniscal) injuries accompany around half of the number of tibial plateau fractures and these may require separate surgical intervention. The medial collateral ligament, on the inside of the knee joint, is more at risk from the injuring forces as they often hit the knee laterally and force it into a knock knee position. More severe events can fracture the medial plateau and this is accompanied by higher rates of soft tissue damage.
Surgeons may be happy to accept a range of fracture displacement and pursue conservative or non-operative management in these cases. Lifting the depressed plateau and securing bone graft underneath it may be required if depression exceeds 5mm in depth. Open fractures, where a wound is continuous with the fracture, mean that surgery will be needed, as it is also if the blood supply has been compromised by vessel damage or if compartment syndrome has developed in the lower leg. Less severe fractures can be conservatively managed and if there is severe soft tissue compromise then surgery may have to be postponed.
On establishing the diagnoses the management plan can begin and this includes treatments aimed at limiting swelling and inflammation such as keeping the part still, resting, elevating the leg and compression of the area. Debridement, the surgical removal of any dying or dead tissue, is essential to ensure the well being of the remaining healthy tissue. Compartment syndrome, where higher and higher pressures develop in the leg compartments, is an emergency for which fasciotomy (surgical release of the tissues) is indicated.
Treatment of fractures of the tibial plateau is aimed at restoring the stability of the knee joint, its correct alignment and anatomical relationships of the joint along with full movement in the knee so the knee will function well, is painless and will not suffer arthritic change. If the joint is unstable then surgery will have to be performed, holding the fragments with as little movement as possible. In younger patients with good bone quality then internal fixation may be successful, however older patients with poor bone quality may need to be functionally braced or have total knee replacement.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Coventry, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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