II. Causes

  1. Pedestrian struck by car bumper
    1. Lateral Tibial Plateau Fracture
      1. Valgus blow to lateral aspect of knee directed medially
    2. Medial Tibial Plateau Fracture
      1. Varus blow to medial aspect of knee directed laterally
      2. Less common than lateral Tibial Plateau Fracture (requires greater force to cause Fracture)
  2. Fall from height with axial compression
  3. Twisting injury in Osteoporosis
  4. ACL Tear
    1. Associated intercondylar eminence Fracture

III. Symptoms

  1. Unable to bear weight
  2. Knee Pain
  3. Knee Effusion

IV. Exam

  1. Knee Exam
    1. Assess for signs of open Fracture (overlying Lacerations)
    2. Knee ligamentous stability
  2. Neurovascular exam
    1. Dorsalis pedis pulse
    2. Posterior tibial pulse
    3. Peroneal nerve Sensation (first web space and dorsal foot)
    4. Peroneal nerve motor function (Ankle Dorsiflexion)

V. Imaging

  1. Knee XRay
    1. Initial acute study, although high False Negative Rate
    2. Include tunnel view (notch view) and consider oblique views (with knee internal/external rotation)
  2. Knee CT
    1. Indicated in patients unable to bear weight but with negative or nondiagnostic XRay
    2. Used in preoperative evaluation, with depression width and depth determining management
  3. Knee MRI
    1. Indicated for suspected ligamentous or Meniscal Injury

VI. Types: Schatzker Classification

  1. Type I
    1. Lateral split Fracture without depression or displacement
  2. Type II
    1. Depression Fracture (seen in Osteoporosis)
  3. Type III
    1. Lateral split Fracture with depression
  4. Type IV (least common)
    1. Medial tibia plateau Fracture
    2. Complications are similar to posterior Knee Dislocation, with injury to popliteal artery and peroneal nerve
  5. Type V
    1. Medial and lateral Tibial Plateau Fracture from high mechanism injury
    2. Risk of Compartment Syndrome
  6. Type VI
    1. Medial and lateral Tibial Plateau Fracture extends into tibial diaphysis (and possibly proximal fibula)
    2. Associated with worse prognosis

VII. Precautions

  1. Exclude Compartment Syndrome and neurovascular injury (esp. in high energy injury)
  2. Expect Compartment Syndrome to develop within first 6-12 hours, especially with large swelling
    1. Consider Compartment Pressures with pain on passive lower extremity movement (especially great toe)
  3. Keep overlying skin visible to observe for Skin Tenting, open wounds, Compartment Syndrome
  4. Operative repair when indicated is best done in the first 2 weeks (prior to Hematoma consolidation)

VIII. Management: Orthopedic Referral

  1. Emergent orthopedic surgical intervention
    1. Neurovascular injury
    2. Compartment Syndrome
  2. Urgent orthopedic referral (within 48 hours, or in some cases 5-7 days - per ortho recommendations)
    1. Depressed (>5mm) or displaced Tibial Plateau Fracture with condylar widening >6 mm
    2. Associated ligamentous or Meniscal Injury
    3. Schatzker category 4-6
  3. Routine orthopedic or sports medicine referral (within 5 days)
    1. Non-displaced Fractures without associated injuries

IX. Management: Acute

  1. Immobilize in long leg compressive splint (Jones dressing) or Knee Immobilizer (worn 24 hours/day)
    1. Splint extends from thigh to Metatarsals
    2. Knee in full extension
    3. Ankle at 90 degrees
  2. Non-weight bearing
  3. Ice and elevation

X. Management: Non-surgical management (for non-displaced Fractures)

  1. Days 3-5
    1. Follow-up from acute management as above
    2. Hinged Knee Brace initiated in full extension for 2 weeks
      1. Exception: Intercondylar Fracture should be splinted in 5-10 degrees flexion
    3. Non-weight bearing
    4. Passive range of motion Exercises start in first 2 weeks
  2. Weeks 2-4
    1. Repeat XRay weekly for 3 weeks to confirm Fracture fragment stability
    2. Adjust brace to allow knee flexion gradually to 90 degrees by 4 weeks
    3. Start active range of motion Exercises
  3. Weeks 4-6
    1. Repeat XRay and re-exam every 2-3 weeks
    2. Continue brace and active range of motion Exercises
    3. Referral to physical therapy if knee flexion to 90 degrees not achieved by 4 weeks active range of motion Exercises
    4. Non-weight bearing until XRay demonstrates some measure of healing
  4. Weeks 6-12
    1. Start partial weight bearing with crutch assistance once XRay starts to show healing
    2. Repeat XRay every 2-3 weeks
    3. Repeat exam every 4 weeks
    4. Continue active range of motion Exercises
    5. Continue brace until XRay demonstrates bone union
  5. Weeks 12-18
    1. Discontinue brace and start full weight bearing when XRay demonstrates bone union
    2. Physical therapy for quadriceps strengthening Exercises
    3. Anticipate 18-20 weeks to regain full function

XI. Complications

  1. Knee Collateral Ligament Tear
  2. Meniscal Tear (27-38% of cases)
  3. Tibial Shaft Fracture
  4. Compartment Syndrome (11% of cases)
  5. Vascular injury (popliteal artery or vein injury)
  6. Septic Joint (if open Fracture or ORIF required)
  7. Post-Traumatic Arthritis
    1. Related to joint instability or tibial plateau articular surface defects and irregularity
  8. Decreased knee range of motion
    1. Related to the prolonged immobilization required for management

XII. References

  1. Orman and Ramadorai in Herbert (2016) EM:Rap 16(7): 2-3
  2. Eiff (1998) Fracture Management for Primary Care, W.B. Saunders, p. 184-7
  3. Fields in Eiff (2012) Proximal Tibia Fractures, UpToDate, accessed 6/5/2014
    1. http://www.uptodate.com/contents/proximal-tibial-fractures-in-adults

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