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Tibial Plateau Fractures

January 4th, 2010

The expansion of the flat upper end of the tibia which makes up the distal half of the knee joint is known as the tibial plateau. The plateau is an essential part of the weight bearing function of the knee joint and if compromised can severely affect the movement, stability and alignment of the knee, interfering with gait. The fracture should be recognised early and treated accordingly so that the chances of post-traumatic knee arthritis and disability are minimised. Over half the patients in this category are in their fifties or older.

A large group which suffer this type of fracture is older women who already have some degrees of osteoporotic change in the area. Younger people with this presentation more likely result from more high energy events. The usual way these fractures occur is for a sideways force to be applied to the knee (often in a knock knee direction) while the knee is weight bearing with a downward force also applied. The lateral condyle (most commonly) is then squashed down by the large femoral condyle on that side. Sports injuries and falling from a height can result in this injury but it is much more common secondary to a road accident.

Around 25% of this kind of injury is secondary to a person being hit by a slow speed car at roughly the height of the knee joint, the bumper being the primary contact point. Falling from a height or sporting activities including horse riding can also result in this fracture. A fracture may result from a low energy event or a high energy event, depression fractures being more common from lower energy contacts and splitting fractures more common in higher energy involvement. This type of fracture can present in many complex ways and Schatzker and co workers have proposed a classification into six subtypes which is widely used.

On assessment the surgeon will not only assess the fracture itself but the health of the surrounding tissues such as the local muscles, nerves and blood vessels. Around half of tibial plateau fractures may have accompanying injuries to the cruciate ligaments and the cartilages (menisci) which may need surgical intervention themselves. Due to the typical force being in a knock knee direction the medial collateral ligament is more likely to suffer damage than the lateral. Fractures of the medial plateau usually involve more forceful injuries due to the stronger bony areas and this can increase the risk of soft tissue complications.

A range of displacements of the fracture may be acceptable for conservative, non operation, treatment but if the fracture is depressed more than five millimetres the surgeon may decide to lift up the joint surface and bone graft below it. Surgery is essential in fractures to this area which are open (there is a wound connecting to the fracture), cases where compartment syndrome is present and evidence of damage to the blood vessels. Operation is not advised in cases where the fracture is not severe enough and where the soft tissues are too badly damaged to make internal fixation wise.

Once the diagnosis has been established treatment can be started and this can include treatments to reduce inflammation and swelling such as rest, immobilisation, local compression and elevation of the leg. Cutting away any dead or dying tissues, a procedure known as debridement, is very important to maintain the health of the remaining viable tissues. If there is any sign of inappropriately high pressure developing in part of the leg, known as compartment syndrome, the treatment is immediate fasciotomy by opening of the tissue compartments.

The treatment aim for these tibial plateau fractures is to regain knee stability, re-align the joint and its anatomical relationship and restore full movement, with a good result being a painless and movable knee with no risk of arthritis. Unstable joints will require surgery with good immobilisation of the fracture. Younger people have denser bone and internal fixation may be successful, while older people with weaker bone may need bracing or knee replacement.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Oxford. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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