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Tibial Plateau Fracture, Emergency Medicine

Basics

Description

- Type 6: - Bicondylar, grossly comminuted fracture of the plateau - Diaphyseal " “metaphyseal dissociation - Same associated injuries as types 4 and 5

- Decision tools for the use of radiography: - Ottawa knee rules (highly sensitive): Knee radiographs are indicated if any of the following are present: - Age >55 yr - Tenderness of the fibular head - Inability to flex to 90 ‚ ° - Isolated patellar tenderness - Inability to transfer weight for 4 steps both immediately after the injury and in the ED - Limping is allowed.

- Neurovascular exam: - High-energy mechanism carries risk for neurovascular injury and compartment syndrome - Watch for unrelenting pain, muscle weakness, tense muscle swelling, hypesthesia or anesthesia, pain with passive stretch of muscles - Check popliteal, posterior tibial, and dorsalis pedis pulses - Check integrity of peroneal nerve: - Ankle and great toe dorsiflexion - Sensation in dorsal web space between great and 2nd toes

- CT used to reveal occult fracture(s) not seen on plain film & further characterize known fracture - MRI used for identifying soft tissue injuries (ligamentous and meniscal injuries) - Arteriography helpful in localizing the injured area but should not delay revascularization and is indicated if: - High-energy mechanism - Schatzker type 4, 5, or 6 fracture - Alteration in distal pulses - Expanding hematoma - Bruit - Injury to anatomically related nerves

- Compartment pressure measurements are indicated if: - Pain not over fracture site - Pain on passive stretch - Paresthesias - Decreased distal pulses - Intracompartmental pressures >30 mm Hg are an indication for emergent orthopedic consultation

- Nonweight bearing - Pain control - Nondisplaced fractures or minimally displaced (<8 mm) lateral plateau fractures without ligamentous injury: - Aspiration of hemarthrosis and injection of local anesthetic - Exam for ligamentous instability - If knee is stable: - Compressive dressing - Ice and elevation for 48 hr - No weight bearing/crutches

- Open fractures: - Remove contaminants - Apply moist sterile dressing - Assess tetanus immunity - Antibiotics - Early administration of antibiotic, within 2 " “3 hr - Orthopedics consult for early surgical debridement

  • Synonym: Tibial condylar fracture
  • Fracture or depression of the proximal tibial articulating surface
  • Valgus or varus force applied in combination with axial loading onto tibial plateau

Schatzker Classification of Plateau Fractures

  • Type 1:Split fracture of the lateral tibial plateau without depression of the plateau
  • Type 2:Split fracture and depression of lateral tibial plateauAssociated with lateral meniscus injury
  • Type 3:Central depression of the lateral plateauInjuries may be unstable
  • Type 4:Split of the medial tibial plateauCan cause damage to other structures:Popliteal vesselsPeroneal nerveMCLLateral meniscusLateral collateral ligamentCruciate ligamentsTibial spinesCompartment syndrome
  • Type 5:Bicondylar tibial plateau fractureSame associated injuries as type 4
  • Type 6:Bicondylar, grossly comminuted fracture of the plateauDiaphyseal " “metaphyseal dissociationSame associated injuries as types 4 and 5

Etiology

  • Mechanism of injury:Types 1 & 2 from a valgus force with axial loading, generally a low-energy injuryAssociated with contact sports, twisting motions (e.g., skiing) or classically, pedestrians struck by a vehicle bumperType 3 are low-energy injuries in osteopenic boneTypes 4 " “6 are high-energy injuries usually from motor vehicle/cycle collisions and falls from height causing medial plateau fracturesAssociated with neurovascular injuries
  • Age associatedType 1: Younger patients with cancellous bone of the plateau resists depression.Types 2 & 3: Depression fractures seen in osteopenic older bones

Tibial plateau fractures are rare in children because of the dense cancellous bone of the tibial plateau ‚

Diagnosis

Signs and Symptoms

  • Painful swollen knee
  • Inability to bear weight
  • Knee effusion (hemarthrosis)
  • Active and passive range of motion limited
  • Tender along the proximal tibia and joint line
  • Possible varus or valgus deformity of the knee
  • Possible joint instability due to associated ligamentous injury

History

  • Hit to lateral knee
  • Fall from a height with axial load
  • Twisting injury

Physical Exam

  • Decision tools for the use of radiography:Ottawa knee rules (highly sensitive): Knee radiographs are indicated if any of the following are present:Age >55 yrTenderness of the fibular headInability to flex to 90 ‚ °Isolated patellar tendernessInability to transfer weight for 4 steps both immediately after the injury and in the EDLimping is allowed.Pittsburgh knee rule (highly sensitive and specific): Knee radiographs are indicated in fall or blunt trauma when the following are present:Age <12 or >55 yrInability to bear full weight for 4 steps in the EDLimping is not allowedPittsburgh knee rule should be applied with caution to patients <18 yr old
  • Neurovascular exam:High-energy mechanism carries risk for neurovascular injury and compartment syndromeWatch for unrelenting pain, muscle weakness, tense muscle swelling, hypesthesia or anesthesia, pain with passive stretch of musclesCheck popliteal, posterior tibial, and dorsalis pedis pulsesCheck integrity of peroneal nerve:Ankle and great toe dorsiflexionSensation in dorsal web space between great and 2nd toes

Diagnosis Tests & Interpretation

Imaging

  • Plain radiography:Tibial plateau view:Anteroposterior (AP) view angled at 10 " “15 ‚ ° of flexion to evaluate the tibial spines, fracture lines extending into the joint, and depressionsSunrise view of the patella:Useful in identifying fractures of the patella not visualized on AP or lateral viewsCross-table lateral view:To evaluate the medial plateau and reveal lipohemarthrosis (fat " “fluid level)Oblique view:To identify fractures not apparent on other films and provide more information on fracture patternsPay attention to areas of ligamentous attachment where avulsion fractures may take place:Medial and lateral femoral condylesTibial spine (intercondylar eminence)Fibular head
  • CT used to reveal occult fracture(s) not seen on plain film & further characterize known fracture
  • MRI used for identifying soft tissue injuries (ligamentous and meniscal injuries)
  • Arteriography helpful in localizing the injured area but should not delay revascularization and is indicated if:High-energy mechanismSchatzker type 4, 5, or 6 fractureAlteration in distal pulsesExpanding hematomaBruitInjury to anatomically related nerves

Diagnostic Procedures/Surgery

  • Arthrocentesis to look for fat globules and bone marrow elements indicative of intra-articular fracture:Indication to do procedure: Effusion present without fracture on plain radiographs
  • Compartment pressure measurements are indicated if:Pain not over fracture sitePain on passive stretchParesthesiasDecreased distal pulsesIntracompartmental pressures >30 mm Hg are an indication for emergent orthopedic consultation

Differential Diagnosis

  • Knee dislocation
  • Proximal fibular fracture
  • Femoral condyle fracture
  • Patellar fracture
  • Tibial subcondylar fracture
  • Tibial tuberosity fracture
  • Tibial spine fracture
  • Cruciate ligament tears
  • Collateral ligament tears
  • Meniscal tears

Include oblique views as part of routine radiography ‚

Treatment

Pre-Hospital

Cautions: ‚

  • In high-energy mechanisms, associated major injuries take precedence
  • Immobilize to prevent further neurologic or vascular injury

Initial Stabilization/Therapy

  • Stabilization of the multiple-injury trauma patient
  • Long leg splint in full extension
  • Ice
  • Elevation
  • Frank dislocations with vascular compromise may need immediate reduction in ED

Ed Treatment/Procedures

  • Nonweight bearing
  • Pain control
  • Nondisplaced fractures or minimally displaced (<8 mm) lateral plateau fractures without ligamentous injury:Aspiration of hemarthrosis and injection of local anestheticExam for ligamentous instabilityIf knee is stable:Compressive dressingIce and elevation for 48 hrNo weight bearing/crutchesKnee is unstable if fracture is causing vascular injury or compartment syndromeUrgent orthopedic consultation is warranted in the unstable knee
  • Open fractures:Remove contaminantsApply moist sterile dressingAssess tetanus immunityAntibioticsEarly administration of antibiotic, within 2 " “3 hrOrthopedics consult for early surgical debridement

Medication

Open fractures: Aminoglycoside + Cephalosporin ‚

  • Cefazolin: 2 g IV (peds: 50 mg/kg)
  • Gentamicin: 2 " “5 mg/kg IV (peds: 2.5 mg/kg)
  • Tetanus toxoid if indicated
  • Vancomycin: 1 g IV loading dose (peds: 10 mg/kg) if penicillin allergic

Follow-Up

Disposition

Admission Criteria

  • Open fractures for debridement, irrigation, and IV antibiotics
  • Comminuted, bicondylar fractures for traction
  • High-energy mechanisms for observation of neurovascular status and development of compartment syndrome; may occur 24 or more after injury
  • Pain control

Discharge Criteria

Nondisplaced or minimally displaced, stable fractures of the lateral plateau ‚

Followup Recommendations

Orthopedic follow-up: ‚

  • Long leg splint with ice, elevation, and nonweight-bearing status of affected joint

Pearls and Pitfalls

  • Consider popliteal artery injury with high-energy mechanisms of injury
  • Lipohemarthrosis (blood and fat globules) on arthrocentesis, is pathognomonic for intra-articular knee fracture
  • Tibial plateau fractures, Segond fractures, and Salter " “Harris 1 fractures are easily missed on plain knee radiographs

Additional Reading

  • Berkson ‚ EM, Virkus ‚ WW. High-energy tibial plateau fractures. J Am Acad Orthop Surg. 2006;14(1):20 " “31.
  • Fields ‚ KB, Eiff ‚ P, Grayzel ‚ J. Proximal tibial fractures in adults. UpToDate.com. Nov 2012.
  • Patrick ‚ B, et al. Towards evidence based emergency medicine: PRIVATE best BETs from the Manchester Royal Infirmary. BET1: Predicting the need for knee radiography in the emergency department: Ottawa or Pittsburgh rule? Emerg Med J. 2012;29:77 " “78.
  • Skaggs ‚ DL, Friend ‚ L, Alman ‚ B, et al. The effect of surgical delay on acute infection following 554 open fractures in children. J Bone Joint Surg Am. 2005;87(1):8 " “12.
  • Yao ‚ K, Haque ‚ T. The Ottawa knee rules " “ a useful clinical decision tool. Aust Fam Physician. 2012;41(4):223 " “224.
  • Zeltser ‚ DW, Leopold ‚ SS. Classifications in brief: Schatzker classification of tibial plateau fractures. Clin Orthop Relat Res. 2013;471:371 " “374.

Codes

ICD9

  • 823.00 Closed fracture of upper end of tibia alone
  • 823.10 Open fracture of upper end of tibia alone

ICD10

  • S82.143A Displaced bicondylar fracture of unsp tibia, init
  • S82.143B Displaced bicondylar fx unsp tibia, init for opn fx type I/2
  • S82.146A Nondisplaced bicondylar fracture of unsp tibia, init
  • S82.146B Nondisp bicondylar fx unsp tibia, init for opn fx type I/2
  • S82.141A Displaced bicondylar fracture of right tibia, init
  • S82.141B Displaced bicondylar fx r tibia, init for opn fx type I/2
  • S82.142A Displaced bicondylar fracture of left tibia, init
  • S82.142B Displaced bicondylar fx left tibia, init for opn fx type I/2
  • S82.144A Nondisplaced bicondylar fracture of right tibia, init
  • S82.144B Nondisp bicondylar fx right tibia, init for opn fx type I/2
  • S82.145A Nondisplaced bicondylar fracture of left tibia, init
  • S82.145B Nondisp bicondylar fx left tibia, init for opn fx type I/2

SNOMED

  • 428257007 fracture of tibial plateau (disorder)
  • 428798001 Closed fracture of tibial plateau (disorder)
  • 446980008 Open fracture of tibial plateau (disorder)