Tibial plateau fracture
Encyclopedia
A tibial plateau fracture is a bone fracture
or break in the continuity of the bone occurring in the proximal part of the tibia
or shinbone called the tibial plateau; affecting the knee joint, stability and motion.
The tibial plateau is a critial weight-bearing area located on the upper extremity of the tibia
and is composed of two slightly concave condyles (medial condyle
and lateral condyle
) separated by an intercondylar eminence and the sloping areas in front and behind it. It can be divided into three areas: the medial tibial plateau (the part of the tibial plateau that is nearer to the center of the body and contains medial condyle), the lateral plateau (the part of the tibial plateau that is farthest away from the center of the body and contains the lateral condyle) and the central tibial plateau (located between the medial and lateral pleateaus and contains intercodylar eminence).
Depending on the injury pattern, lesions may be restricted to the tibia or may have significant soft tissue
injury as well as meniscal
and ligamentous
injuries to the knee. However, a standard tibial plateau fracture involves either cortical interruption, depression or displacement of the articular surfaces of the proximal tibia without significant injury to the capsule or ligaments of the knee.
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.
) may lead to bruising and a doughy feel of the knee joint. Due to the tibial plateau's proximity to important vascular (ie arteries, veins) and neurological (ie nerves such as peroneal and tibial) structures, injuries to these may occur upon fracture. A careful examination of the neurovascular systems 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.
(inwardly angulating) or valgus
(outwardly angulating) force combined with axial loading or weight bearing on knee. The classically described situation in which this occurs is from a car striking a pedestrian's fixed knee ("bumper fracture"). 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 pleateau. 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.4 This explains how 60% of plateau fractures involve the lateral pleateau, 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.
Schatzker classification for tibial plateau fracture:
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 beign driven into the articular surface of the tibial plateau. Represent 6% of all tibial plateau fractures.
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, tipically seen in individuals of the 4th decade or older with osteoporotic changes in bone. Makes up 25% 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 cruiciate ligament.
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 mataphysis by axial forces.3 A low energy injury, these fractures are more frequen in the 4th and 5th decades of life and individuals with osteoporotic changes in bone. They repersent 36% of all tibial plateau fractures.
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.
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. Reperesent 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.
Consists of a split fracture of the medial and lateral tibial plateau. It is usually the result of a 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.
Main feature of this fracutre 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.3 This is a high energy injury with complex mechanism that includes varus and valgus forces. Up to 33% of these fractures may be open often with extensive soft tissue injuries with risk of compartment syndrome. Represent 20% of all tibial plateau fractures.
scans are not always neccesary but are sometimes critical for evaluating degree of fracture and determining a treatment plan that would not be possible with plain radiographs. Magnetic Resonance images
are the diagnositic modality of choice when meniscal, ligamentous and soft tissue injuries are suspected. CT artetriography should be considered if there is alteration of the distal pulses or concern about arterial injury.
Bone fracture
A bone fracture is a medical condition in which there is a break in the continuity of the bone...
or break in the continuity of the bone occurring in the proximal part of the tibia
Tibia
The tibia , shinbone, or shankbone is the larger and stronger of the two bones in the leg below the knee in vertebrates , and connects the knee with the ankle bones....
or shinbone called the tibial plateau; affecting the knee joint, stability and motion.
The tibial plateau is a critial weight-bearing area located on the upper extremity of the tibia
Upper extremity of tibia
The upper extremity of the tibia is large, and expanded into two eminences, the medial condyle and lateral condyle.-Facets:The superior articular surface presents two smooth articular facets....
and is composed of two slightly concave condyles (medial condyle
Medial condyle of tibia
The medial condyle is the medial portion of the upper extremity of tibia.It is the site of insertion for the Semimembranosus muscle....
and lateral condyle
Lateral condyle of tibia
The lateral condyle is the lateral portion of the upper extremity of tibia.It serves as the insertion for the Biceps femoris muscle....
) separated by an intercondylar eminence and the sloping areas in front and behind it. It can be divided into three areas: the medial tibial plateau (the part of the tibial plateau that is nearer to the center of the body and contains medial condyle), the lateral plateau (the part of the tibial plateau that is farthest away from the center of the body and contains the lateral condyle) and the central tibial plateau (located between the medial and lateral pleateaus and contains intercodylar eminence).
Depending on the injury pattern, lesions may be restricted to the tibia or may have significant soft tissue
Soft tissue
In anatomy, the term soft tissue refers to tissues that connect, support, or surround other structures and organs of the body, not being bone. Soft tissue includes tendons, ligaments, fascia, skin, fibrous tissues, fat, and synovial membranes , and muscles, nerves and blood vessels .It is sometimes...
injury as well as meniscal
Meniscus (anatomy)
In anatomy, a meniscus is a crescent-shaped fibrocartilaginous structure that, in contrast to articular disks, only partly divides a joint cavity. In humans it is present in the knee, acromioclavicular, sternoclavicular, and temporomandibular joints; in other organisms they may be present in other...
and ligamentous
Ligament
In anatomy, the term ligament is used to denote any of three types of structures. Most commonly, it refers to fibrous tissue that connects bones to other bones and is also known as articular ligament, articular larua, fibrous ligament, or true ligament.Ligament can also refer to:* Peritoneal...
injuries to the knee. However, a standard tibial plateau fracture involves either cortical interruption, depression or displacement of the articular surfaces of the proximal tibia without significant injury to the capsule or ligaments of the knee.
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 patients who sustain a tibial plateau fracture are aged over 50 years old.Etiology
Tibial plateau fractures may be divided into low energy or high energy fractures . Low energy fractures are commonly seen in older females due to osteoporoticOsteoporosis
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...
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.
Clinical Features
Tibial plateau fractures tipically presents with knee effusion, swelling of the knee soft tissues and inability to bear weight. The knee may be deformed due to diplacement and/or fragmentation of the tibia which leads to loss its normal structural appearance. Blood in the soft tissues and knee joint (hemarthrosisHemarthrosis
Hemarthrosis is a bleeding into joint spaces.-Causes:It usually follows injury but occurs mainly in patients with a predisposition to hemorrhage such as those being treated with warfarin and patients with hemophilia.It can be associated with knee joint arthroplasty.-Treatment:In hemophilia it may...
) may lead to bruising and a doughy feel of the knee joint. Due to the tibial plateau's proximity to important vascular (ie arteries, veins) and neurological (ie nerves such as peroneal and tibial) structures, injuries to these may occur upon fracture. A careful examination of the neurovascular systems imperative. A serious complication of tibial plateau fractures is compartment syndrome
Compartment syndrome
Compartment syndrome is a limb threatening and life threatening condition, defined as the compression of nerves, blood vessels, and muscle inside a closed space within the body . This leads to tissue death from lack of oxygenation due to the blood vessels being compressed by the raised pressure...
in which swelling causes compression of the nerves and blood vessels inside the leg and may ultimately lead to necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
or cell death of the leg tissues.
Mechanism
Fractures of the tibial plateau are caused by a varusVarus deformity
In orthopedics, a varus deformity is a term for the inward angulation of the distal segment of a bone or joint. The opposite of varus is called valgus.The terms varus and valgus always refer to the direction that the distal segment of the joint points....
(inwardly angulating) or valgus
Valgus deformity
In orthopedics, a valgus deformity is a term for outward angulation of the distal segment of a bone or joint. The opposite deformation, medial deviation of the distal bone, is called varus....
(outwardly angulating) force combined with axial loading or weight bearing on knee. The classically described situation in which this occurs is from a car striking a pedestrian's fixed knee ("bumper fracture"). 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 pleateau. 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.4 This explains how 60% of plateau fractures involve the lateral pleateau, 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.
Classification
Physicians use classification types to assess the degree of injury, treatment plan and predict prognosis. Multiple classifications of tibial plateau fractures have been delevoped. Currently, the Schatzker classification system is the most widely accepted and used.3 It is composed of six condyle fracture types classified by fracture pattern and fragment anatomy. 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:
- 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 beign 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, tipically seen in individuals of the 4th decade or older with osteoporotic changes in bone. Makes up 25% 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 cruiciate ligament.
- 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 mataphysis by axial forces.3 A low energy injury, these fractures are more frequen in the 4th and 5th decades of life and individuals with osteoporotic changes in bone. They repersent 36% of all tibial plateau fractures.
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. Reperesent 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 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 fracutre 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.3 This is a high energy injury with complex mechanism that includes varus and valgus forces. Up to 33% of these fractures may be open often with extensive soft tissue injuries with risk of compartment syndrome. Represent 20% of all tibial plateau fractures.
Diagnostic Imaging
In all injuries to the tibial plateau radiographs (commonly called x-rays) are imperative. Computed tomographyComputed tomography
X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...
scans are not always neccesary but are sometimes critical for evaluating degree of fracture and determining a treatment plan that would not be possible with plain radiographs. Magnetic Resonance images
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
are the diagnositic modality of choice when meniscal, ligamentous and soft tissue injuries are suspected. CT artetriography should be considered if there is alteration of the distal pulses or concern about arterial injury.