Basics
Description
- 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 plateau
- Associated with lateral meniscus injury
- Type 3:
- Central depression of the lateral plateau
- Injuries may be unstable
- Type 4:
- Split of the medial tibial plateau
- Can cause damage to other structures:
- Popliteal vessels
- Peroneal nerve
- MCL
- Lateral meniscus
- Lateral collateral ligament
- Cruciate ligaments
- Tibial spines
- Compartment syndrome
- Type 5:
- Bicondylar tibial plateau fracture
- Same associated injuries as type 4
- Type 6:
- Bicondylar, grossly comminuted fracture of the plateau
- Diaphyseal " “metaphyseal dissociation
- Same 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 injury
- Associated with contact sports, twisting motions (e.g., skiing) or classically, pedestrians struck by a vehicle bumper
- Type 3 are low-energy injuries in osteopenic bone
- Types 4 " “6 are high-energy injuries usually from motor vehicle/cycle collisions and falls from height causing medial plateau fractures
- Associated with neurovascular injuries
- Age associated
- Type 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 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.
- 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 yr
- Inability to bear full weight for 4 steps in the ED
- Limping is not allowed
- Pittsburgh knee rule should be applied with caution to patients <18 yr old
- 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
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 depressions
- Sunrise view of the patella:
- Useful in identifying fractures of the patella not visualized on AP or lateral views
- Cross-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 patterns
- Pay attention to areas of ligamentous attachment where avulsion fractures may take place:
- Medial and lateral femoral condyles
- Tibial 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 mechanism
- Schatzker type 4, 5, or 6 fracture
- Alteration in distal pulses
- Expanding hematoma
- Bruit
- Injury 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 site
- Pain on passive stretch
- Paresthesias
- Decreased distal pulses
- Intracompartmental 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 anesthetic
- Exam for ligamentous instability
- If knee is stable:
- Compressive dressing
- Ice and elevation for 48 hr
- No weight bearing/crutches
- Knee is unstable if fracture is causing vascular injury or compartment syndrome
- Urgent orthopedic consultation is warranted in the unstable knee
- 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
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)