Tibial Plateau Fractures

Question 1

Tibial plateau fractures are due to …-energy trauma in the young and …-energy falls in the elderly.

Answer 1

Tibial plateau fractures are due to high-energy trauma in the young and low-energy falls in the elderly.

Question 2

The tibial plateau refers to the proximal … surface of the tibia, which forms the knee joint with the …

Answer 2

The tibial plateau refers to the proximal articular surface of the tibia, which forms the knee joint with the femur.

Question 3

Tibial plateau fractures have a bimodal distribution, classically presenting in …. in their 40s and … in their 70s. The incidence of these fractures is around 10.3 per 100,000 annually.

Answer 3

Tibial plateau fractures have a bimodal distribution, classically presenting in males in their 40s and females in their 70s. The incidence of these fractures is around 10.3 per 100,000 annually.

Question 4

Tibial plateau fractures occur secondary to …. injuries

Answer 4

Tibial plateau fractures occur secondary to traumatic injuries

Question 5

Mechanisms of tibial plateau fractures

Answer 5

Fracture of the tibial plateau can arise from a valgus force, which describes an outside force pushing the knee inwards along a coronal plane. Alternatively, a fracture can arise from a varus force, which describes an inside force pushing the knee outwards along a coronal plane.

Question 6

The medial tibial plateau bears …% of the load through the knee. The medial condyle is generally larger, stronger and transmits more weight compared to the lateral condyle. The lateral tibial condyle is … in shape, compared to the … medial side.

Answer 6

The medial tibial plateau bears 60% of the load through the knee. The medial condyle is generally larger, stronger and transmits more weight compared to the lateral condyle. The lateral tibial condyle is convex in shape, compared to the concave medial side.

Question 7

A unicondylar fracture refers to a fracture of one of the condyles, the … condyle is more frequently affected. A bicondylar fracture refers to a fracture of both condyles.

Answer 7

A unicondylar fracture refers to a fracture of one of the condyles, the lateral condyle is more frequently affected. A bicondylar fracture refers to a fracture of both condyles.

Question 8

Aspects of the anatomy of the tibial plateau can affect the response to a fracture, these include:

Answer 8

Muscular attachments: the large muscular attachments on the tibial plateau can contribute to fragment displacement following trauma.
Joint surface: the incongruent joint surface increases the risk of post-traumatic arthritis.
Soft tissue: injuries to the surrounding soft tissue can contribute to joint instability.

Question 9

Features of tibial plateau fractures: (5)

Answer 9

Pain
Swelling: typically due to marked haemarthrosis (blood within the joint) and soft tissue swelling. It is important to ensure muscular compartments are soft on palpation during examination
Reduced mobility
Deformity: may be open fracture, it is important to inspect the leg circumferentially
Neurovascular supply: essential to ensure the leg is well perfused and sensation remains intact.

Question 10

Imaging modality for suspected tibial plateau fractures

Answer 10

X-rays are typically diagnostic, CT scans have a role in surgical planning.

Question 11

Plain film radiograph of knee - what to do in suspected tibial plateau fracture

Answer 11

Plain film radiograph of knee: get anterior-posterior (AP), lateral and plateau views*. Look out for lipohaemoarthrosis (fat and fluid within the joint) on the lateral view, which suggests an intra-articular fracture. Plain X-ray may miss subtle fractures, where sufficient suspicion exists a CT or MRI should be arranged.

Question 12

The … classification is commonly used to describe tibial plateau fractures.

Answer 12

The Schatzker classification is commonly used to describe tibial plateau fractures.

Question 13

The Schatzker classification is commonly used to describe … … fractures.

Answer 13

The Schatzker classification is commonly used to describe tibial plateau fractures.

Question 14

The principle of management of tibial plateau fracture is to restore …. ….

Answer 14

The principle of management is to restore joint stability.

Question 15

The management of a tibial plateau fracture, like most acute fractures, involves analagesia and acute .. the joint followed by non-operative (conservative) or operative management.

Answer 15

The management of a tibial plateau fracture, like most acute fractures, involves analagesia and acute stabilisation of the joint followed by non-operative (conservative) or operative management.

Question 16

Acute management of a tibial plateau fracture

Answer 16

Consider the mechanism of injury, presenting state and other associated injuries - is a trauma call required? Complete a head-to-toe assessment in all patients.

Patients should be given appropriate analgesia placed in a brace or above knee plaster of Paris (POP) backslab. They should be made non-weight bearing and elevation should be encouraged.

All patients should be referred to and discussed with orthopaedics.

Question 17

Closed tibial plateau fractures - Nonoperative management

Answer 17

generally involves a hinged knee brace. Can partial weight bear for 8-12 weeks. Indications for non-operative management include non-ambulant patients or minimally displaced fractures with non-injured ligaments (varus/valgus stability)

Question 18

Closed tibial plateau fractures - Operative management

Answer 18

open reduction and internal fixation (ORIF). Indications for operative management include an articular step (depression in the surface) >3mm, condylar widening >5mm or gross instability.

Question 19

Open tibial plateau fracture management

Answer 19

If an open injury, macroscopic debris should be removed and medical photography arranged, no washout should be completed in AE. Dress with saline-soaked gauze and urgently refer to orthopaedics/plastic surgery. The risk of compartment syndrome should be considered and anticipated.

Initial management is as per BOAST guidelines. The risk of compartment syndrome should be considered and anticipated.

External fixators are often used as a temporising measure in severe open fractures with contamination. Staged procedures to wash, debride and later fix the fracture can be arranged.

Question 20

A number of complications may follow a tibial plateau fracture and surgical fixation (3)

Answer 20

Early osteoarthritis
Non-union/ mal-union
Post-operative infection