Knee trauma

Question 1

What is a tibial plateau fracture?

Answer 1

The tibial plateau most commonly fractures following high-energy trauma, such as a fall from height or a road traffic accident, from the impaction of the femoral condyle onto the tibial plateau. Less commonly they can occur in elderly patients following a fall, especially those with osteoporosis.

It is typically a varus-deforming force, meaning that the lateral tibial plateau is more frequently fractured than the medial side. They are often found alongside other bony and soft tissue injuries, such as meniscal tears or cruciate or collateral ligament injury.

It is important to recognise that this is a significant injury, as there is disruption of the congruence of the articular surface that, if left, will lead to rapid degenerative change within the knee.

Question 2

What are the clinical features of the tibial plateau?

Answer 2

Patients will present following a history of trauma. A clear history of the mechanism of injury is important, as an injury through axial loading or high-impact injuries will increase the likelihood of a tibial plateau fracture.

Patients will present with sudden onset pain in the affected knee, being unable to weight-bear, and swelling of the knee*.

On examination, significant swelling will be evident, alongside tenderness over the medial or lateral aspects of the proximal tibia, with potential ligament instability (albeit not clinically assessed initially, due to the pain it would cause).

Ensure to check peripheral neurovascular status of the patient, as neurovascular injuries (such as popliteal vessel dissection or common fibular nerve damage) are an important association of high grade injuries.

Fracture blisters

Soft tissue damage

Question 3

What is the treatment for a tibial plateau fracture?

Answer 3

Management
Conservative Management
Non-operative management can be trialled in uncomplicated tibial plateau fractures (including no evidence of ligamentous damage, tibial subluxation, or articular step <2mm)

These can typically be treated with a hinged knee brace and non- or partial-weight bearing for around 8-12 weeks, alongside ongoing physiotherapy and suitable analgesia.

Bracing

Operative Management
Operative management is typically warranted in complicated tibial plateau fractures*, or any evidence of open fracture or compartment syndrome. Any form of medial tibial plateau fractures may also require surgical intervention, even if undisplaced, as they have a great potential for displacement.

Open reduction and internal fixation (ORIF) is the mainstay of most tibial plateau fractures, with the aim to restore the joint surface congruence and ensure joint stability. Any metaphyseal gaps can be filled with bone graft or bone substitute.

Postoperatively, a hinged knee brace is fitted with early passive range of movement but limited or non-weight bearing for around 8-12 weeks months is typically required.

Cast

Plating on 1 side or both sides

Frame

Question 4

What are the complications from a tibial plateau?

Answer 4

Stiffness

Compartment syndrome

Arthritis