Tibial Plateau Fracture

Clinical Features

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.

*This represents a lipohaemarthrosis and is an important clinical and radiological feature to recognise

Differential Diagnosis

For patients presenting with knee pain following trauma, other differentials to consider are knee dislocation, other knee fractures (including patella or distal femur), meniscal injuries, ligamentous injuries, patella dislocation, or patella/quadriceps tendon rupture.

Investigations

The first line investigation for a suspected plateau fracture is plain film radiographs (anteroposterior and lateral), often features on radiograph are subtle (Fig. 2). There will also be a lipohaemarthrosis present.

CT scanning is needed in almost all cases (Fig. 3), apart from undisplaced fractures. This help both in assessment of severity, as well as surgical planning.

*It is important to recognise that the presence of fat in the joint indicates that there is an intra-articular fracture present (e.g. tibial plateau, patella, distal femur)

James Heilman, MD [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Figure 2
Plain radiograph showing tibial plateau fracture

Classification

Tibial plateau fractures can be classified through the Schatzker Classification

Table 1 – Schatzker Classification for tibial plateau fractures

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.

James Heilman, MD [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Figure 3
CT imaging demonstrating lipohaemarthrosis due to a tibial plateau fracture

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.

External fixation with delayed definitive surgery is indicated in cases of significant soft tissue injury, polytrauma and highly comminuted fractures where an immediate ORIF may not be suitable.

*Complicated fractures include those demonstrating an articular step ≥2mm, angular deformity ≥10 degrees, any metaphyseal-diaphyseal translation, ligamentous injury requiring repair, or those with associated tibial fractures

Complications

The main long-term complication following a tibial plateau fracture is post-traumatic osteoarthritis to the affected joint.