Fractures of the Tibial Plateau

By Jonathan Blood Smyth

At the upper end of the tibia is the tibial plateau, an expanded and flat open area of bone which forms the lower part of the knee joint. The plateau has a vital role to play in weight bearing and if this surface is damaged then this can adversely affect the stability, alignment and movement of the knee in gait and standing. These fractures need to be identified early and correctly so that correct treatment can limit any disability and forestall the chances of secondary knee arthritis. Patients in this group fall over 50% of the time into the over 50s age group.

This fracture is more common in older women which reflects the increased incidence of osteoporotic changes in these patients. If this fracture occurs in younger people then it is likely to be secondary to more energetic injuries. The typical method of fracture in tibial plateau fractures is a force applied to the knee in a knock knee direction with weight bearing loads applied at the same time. The lateral condyle of the femur compresses down on the tibial plateau on the outside and crushes down the bone on that side. Many injuries are related to motor vehicle injuries with a smaller number deriving from sport.

Around 25% of this kind of injury is secondary to a person being hit by a slow speed car at roughly the height of the knee joint, the bumper being the primary contact point. Falling from a height or sporting activities including horse riding can also result in this fracture. A fracture may result from a low energy event or a high energy event, depression fractures being more common from lower energy contacts and splitting fractures more common in higher energy involvement. This type of fracture can present in many complex ways and Schatzker and co workers have proposed a classification into six subtypes which is widely used.

Assessment of the patient will not only include the state of the bone but the condition of the soft tissues which can also be damaged, the blood vessels, nerves and muscles. Tibial plateau fractures are accompanied in about 50% of cases by damage to the knee menisci (cartilages) and the cruciate ligaments which may require surgery. The medial collateral ligament, the ligament on the inside of the knee, is more vulnerable to damage due to the incident forces being more typically on the outside of the knee in a knock knee direction. Medial plateau fractures result from bigger events as the bone is stronger on that side, with more frequent soft tissue problems.

A range of displacements of the fracture may be acceptable for conservative, non operation, treatment but if the fracture is depressed more than five millimetres the surgeon may decide to lift up the joint surface and bone graft below it. Surgery is essential in fractures to this area which are open (there is a wound connecting to the fracture), cases where compartment syndrome is present and evidence of damage to the blood vessels. Operation is not advised in cases where the fracture is not severe enough and where the soft tissues are too badly damaged to make internal fixation wise.

With the diagnosis established the treatment plan can begin with treatment modalities targeted at lowering oedema and inflammation, including limb elevation, tissue compression, immobilisation of the area and resting the part. The removal by surgery of any non-viable dead and dying tissues (debridement) is vital to safeguard the remaining healthy tissues. Fasciotomy may be required to release excessive pressure from one or more of the leg compartments should compartment syndrome threaten the viability of the limb.

Tibial plateau fractures have as a treatment strategy to restore alignment of the knee joint, re-establish full range of movement, and ensure stability of the knee and anatomical alignment. Overall the knee should be painless, movable and free from arthritis. Strong immobilisation of the fracture by surgery is necessary in unstable joints, with the denser bone of younger people allowing this. Functional bracing and total knee replacement may be necessary in older patients who have reduced bone density. - 32188

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