Tibial Plateau Fractures
The tibial plateau is the top flat surface of the tibia, which is one of the two long bones in the lower leg. Tibial plateau fractures are more common in the elderly, accounting for 8 percent of all fractures in the elderly population. There can be fractures of the medial or lateral plateau of the tibia, with lateral tibial plateau fractures being more often isolated fractures when compared to medial plateau fractures. About 1-3 percent of these fractures are considered open fractures.
The tibial plateau is a joint surface connecting the femur to the lower leg. There are two articular surfaces on this bone with an intercondylar eminence connecting the cruciate ligaments. The medial plateau is stronger than the lateral plateau, which is why there are more lateral plateau fractures. Medial plateau fractures are more associated with high-impact trauma, such as with motor vehicle accidents.
Fractures of the tibial plateau usually require a great force on the area; however, elderly people can fracture this area after a simple fall. A split fracture between the condyles of the bone is common because the bone is otherwise very strong.
Evaluation of Tibial Plateau Fractures
Patients often have a lot of bleeding into the joint. Aspiration of the knee may show fat from inside the bone marrow. A neurovascular evaluation needs to be done because many high-impact injuries leading to fractures in this area result in damage to the popliteal artery. Because these fractures are often caused by direct trauma to the affected area, any laceration seen on the knee could represent an open fracture. Compartment syndrome is possible with this kind of fracture, and ligaments are easily damaged along with the bones.
Ninety percent of these people will have soft tissue injuries along with their fractures. Meniscal tears occur in about half of all of these fractures. Injury to the collateral ligaments or cruciate ligaments happens in 30 percent of cases. Medial fractures are more likely associated with peroneal nerve injuries or popliteal artery injuries.
In most cases, X-rays of the frontal and lateral views can show the fractured areas. Some oblique views can be performed as well. A view with traction can help identify those fractures that are impacted. Stress views under sedation can also help detect collateral ligament ruptures. CT scanning is helpful in showing the degree of fragmentation, and an MRI scan can identify injury to the cruciate ligaments, the meniscus, and the collateral ligaments. If there is a possibility of vascular damage, an angiogram of the knee can be undertaken.
Classification of Tibial Plateau Fractures
There are two classification systems, the Schatzker, and the Moore classification systems. They differ according to displacement and the degree to which the articular surface is involved. Treatment depends on how the fracture is classified, with those involving the articular surgery needing special attention to avoid arthritic changes in the knee.
Treatment of Tibial Plateau Fractures
Treatment can involve surgery or no surgery, depending on the fracture type and expected outcome. Nonsurgical options are used whenever the fracture is nondisplaced, or the patient has severe osteoporosis. The knee is placed in a knee immobilizer with early range of motion exercises and partial weight bearing for up to 12 weeks, followed by a gradual increase in weight bearing as tolerated.
Surgery is used if there is an articular depression of at least one centimeter. If the joint is unstable, it must be treated with surgery. Open fractures and those with compartment syndrome require surgery to correct the fracture segments. The goal is to reconstruct the articular surface and then align the tibia. The fracture can be fixed using plates and screws. Bone grafts may be required to fix areas of lost bone. External fixation is often used in open fractures that need careful attention. There are usually attempts at repairing the meniscus and the ligaments while the fracture is fixed. Arthroscopy can be used to evaluate the articular surfaces to see if they can be repaired or if they are already intact.
After surgery, the patients need to be non-weight bearing with a passive range of motion and active range of motion until partial weight bearing is allowed. Total weight bearing can occur within 8-12 weeks post-injury.
Complications of Tibial Plateau Fractures
Common complications of tibial plateau fractures include the following:
- Arthrofibrosis—this occurs with scarring of the tissue and immobility after surgery.
- Infection—this can happen with open or closed fractures, especially if surgery is ill-timed when the patient is still trying to heal from multiple injuries.
- Compartment syndrome—this can result from excessive swelling to the leg and must be treated with emergency fasciotomies.
- Malunion or nonunion—this can be related to comminuted fractures, implant failure, and unstable fixation.
- Post-traumatic osteoarthritis—this can occur with damage to the joint surfaces at the time of injury.
- Peroneal nerve surgery—lateral tibial plateau fractures can result in this nerve injury most commonly.
- Popliteal artery laceration—this is fortunately fairly rare.
- Avascular necrosis of the small articular fragments—there can be loose bodies of bony or cartilaginous tissue within the joint due to this complication.
Ed Smith is one of Sacramento’s top personal injury lawyers who has handled many tibia fractures over the years. Call me anytime at 916-921-6400 in Sacramento.
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