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Tibial Plateau Fracture
Aka: Tibial Plateau Fracture
- See Also
- Knee Pain
- Knee Injury
- Causes
- Pedestrian struck by car bumper
- Lateral Tibial Plateau Fracture
- Valgus blow to lateral aspect of knee directed medially
- Medial Tibial Plateau Fracture
- Varus blow to medial aspect of knee directed laterally
- Less common than lateral Tibial Plateau Fracture (requires greater force to cause Fracture)
- Fall from height with axial compression
- Twisting injury in Osteoporosis
- ACL Tear
- Associated intercondylar eminence Fracture
- Symptoms
- Unable to bear weight
- Knee Pain
- Knee Effusion
- Exam
- Knee Exam
- Assess for signs of open Fracture (overlying Lacerations)
- Knee ligamentous stability
- Neurovascular exam
- Dorsalis pedis pulse
- Posterior tibial pulse
- Peroneal nerve Sensation (first web space and dorsal foot)
- Peroneal nerve motor function (Ankle Dorsiflexion)
- Imaging
- Knee XRay
- Initial acute study, although high False Negative Rate
- Include tunnel view (notch view) and consider oblique views (with knee internal/external rotation)
- Knee CT
- Indicated in patients unable to bear weight but with negative or nondiagnostic XRay
- Used in preoperative evaluation, with depression width and depth determining management
- Knee MRI
- Indicated for suspected ligamentous or Meniscal Injury
- Types: Schatzker Classification
- Type I
- Lateral split Fracture without depression or displacement
- Type II
- Depression Fracture (seen in Osteoporosis)
- Type III
- Lateral split Fracture with depression
- Type IV (least common)
- Medial tibia plateau Fracture
- Complications are similar to posterior Knee Dislocation, with injury to popliteal artery and peroneal nerve
- Type V
- Medial and lateral Tibial Plateau Fracture from high mechanism injury
- Risk of Compartment Syndrome
- Type VI
- Medial and lateral Tibial Plateau Fracture extends into tibial diaphysis (and possibly proximal fibula)
- Associated with worse prognosis
- Precautions
- Exclude Compartment Syndrome and neurovascular injury (esp. in high energy injury)
- Expect Compartment Syndrome to develop within first 6-12 hours, especially with large swelling
- Consider Compartment Pressures with pain on passive lower extremity movement (especially great toe)
- Keep overlying skin visible to observe for Skin Tenting, open wounds, Compartment Syndrome
- Operative repair when indicated is best done in the first 2 weeks (prior to Hematoma consolidation)
- Management: Orthopedic Referral
- Emergent orthopedic surgical intervention
- Neurovascular injury
- Compartment Syndrome
- Urgent orthopedic referral (within 48 hours, or in some cases 5-7 days - per ortho recommendations)
- Depressed (>5mm) or displaced Tibial Plateau Fracture with condylar widening >6 mm
- Associated ligamentous or Meniscal Injury
- Schatzker category 4-6
- Routine orthopedic or sports medicine referral (within 5 days)
- Non-displaced Fractures without associated injuries
- Management: Acute
- Immobilize in long leg compressive splint (Jones dressing) or Knee Immobilizer (worn 24 hours/day)
- Splint extends from thigh to Metatarsals
- Knee in full extension
- Ankle at 90 degrees
- Non-weight bearing
- Ice and elevation
- Management: Non-surgical management (for non-displaced Fractures)
- Days 3-5
- Follow-up from acute management as above
- Hinged Knee Brace initiated in full extension for 2 weeks
- Exception: Intercondylar Fracture should be splinted in 5-10 degrees flexion
- Non-weight bearing
- Passive range of motion Exercises start in first 2 weeks
- Weeks 2-4
- Repeat XRay weekly for 3 weeks to confirm Fracture fragment stability
- Adjust brace to allow knee flexion gradually to 90 degrees by 4 weeks
- Start active range of motion Exercises
- Weeks 4-6
- Repeat XRay and re-exam every 2-3 weeks
- Continue brace and active range of motion Exercises
- Referral to physical therapy if knee flexion to 90 degrees not achieved by 4 weeks active range of motion Exercises
- Non-weight bearing until XRay demonstrates some measure of healing
- Weeks 6-12
- Start partial weight bearing with crutch assistance once XRay starts to show healing
- Repeat XRay every 2-3 weeks
- Repeat exam every 4 weeks
- Continue active range of motion Exercises
- Continue brace until XRay demonstrates bone union
- Weeks 12-18
- Discontinue brace and start full weight bearing when XRay demonstrates bone union
- Physical therapy for quadriceps strengthening Exercises
- Anticipate 18-20 weeks to regain full function
- Complications
- Knee Collateral Ligament Tear
- Meniscal Tear (27-38% of cases)
- Tibial Shaft Fracture
- Compartment Syndrome (11% of cases)
- Vascular injury (popliteal artery or vein injury)
- Septic Joint (if open Fracture or ORIF required)
- Post-Traumatic Arthritis
- Related to joint instability or tibial plateau articular surface defects and irregularity
- Decreased knee range of motion
- Related to the prolonged immobilization required for management
- References
- Orman and Ramadorai in Herbert (2016) EM:Rap 16(7): 2-3
- Eiff (1998) Fracture Management for Primary Care, W.B. Saunders, p. 184-7
- Fields in Eiff (2012) Proximal Tibia Fractures, UpToDate, accessed 6/5/2014
- http://www.uptodate.com/contents/proximal-tibial-fractures-in-adults