High Yield Topics

Fracture, Tibial Plateau

By admin



Ovid: 5-Minute Sports Medicine Consult, The


Fracture, Tibial Plateau
Ramon Ylanan
Steve Kroll
Basics
Pediatric Considerations
  • Tibial plateau fractures are rare in children because of the dense cancellous bone of the tibial plateau (1).
  • Schatzker classification system:
    • Type 1 is a split-off fracture of the lateral tibial plateau without compression of the plateau (2).
      • Occurs in younger patients where the plateau resists depression (2)
      • Usually occurs from a valgus force to the knee in combination with axial load
    • Type 2 is a combination of a split fracture and depression of all or a portion of the remaining lateral plateau. The mechanism is similar to the preceding, but these patients tend to be older and have weaker bones; the plateau can be depressed by the femoral condyle (2).
    • Type 3 is a local depression of the articulating surface of the lateral plateau (2).
    • Type 4 is a fracture/depression of the medial plateau (2).
      • It requires much more force for this injury to occur (2).
      • Be suspicious for other concomitant injuries, such as damage to the popliteal artery, peroneal nerve, lateral collateral ligament, medial meniscus, and cruciate ligaments
    • Type 5 is a bicondylar fracture (2). High-impact injury associated with popliteal vessel injury, peroneal nerve injury, and possible development of compartment syndrome
    • Type 6 is a bicondylar, grossly comminuted fracture involving both the plateau and the metaphysis (2). Occurs from a violent force, usually a fall from a height; it is typically associated with neurovascular compromise and compartment syndrome.
  • Cautions:
    • With high-energy mechanisms, associated major life-threatening injuries take precedence.
    • Immobilize to prevent further neurologic or vascular injury.
Description
  • Fracture or depression of the proximal tibial articulating surface
  • Also referred to as tibial condylar fractures
  • Valgus or varus force applied in combination with axial loading (3):
    • A pedestrian struck by an automobile (fender fracture, where the bumper of a vehicle strikes the lateral aspect of the proximal tibia) is the most common mechanism of injury.
      • This usually results in splitting or depression of the lateral plateau.
      • The younger the patient, the more resistant the plateau is to depression.
      • Elderly patients present more often with depression-type fractures.
    • Fall from a height causing femoral condyles to impact on tibial surface
    • Violent twisting force, eg, skiing
  • Medial plateau fractures are much less common and require significant force to occur (3). Associated injuries include ligamentous damage (lateral collateral, posterior cruciate, and medial meniscus) and neurovascular injury (peroneal nerve and popliteal vessels) to that knee.
Epidemiology
Incidence
  • ∼1% of all fractures (4).
  • Of tibial plateau fractures, ∼55–70% are lateral, 10–23% are medial, and 11–31% are bicondylar (4).
  • Rate of associated ligamentous injury varies from 7–15.7% (5).
Diagnosis
Pediatric Considerations
  • Include oblique views as part of routine radiography (6).
  • Neurovascular examination:
    • High-energy mechanism (medial plateau or bicondylar fractures) carries risk of neurovascular damage and compartment syndrome.
    • Check popliteal, posterior tibial, and dorsalis pedis arterial pulses.
    • Check integrity of peroneal nerve and ankle and toe dorsiflexion and sensation in the webspace between the great and second toes.
  • Plain radiography:
    • Anteroposterior and lateral views of the knee and proximal tibia
    • Include oblique views
    • Cross-table lateral view may demonstrate lipohemarthrosis (fat-fluid level).
    • Pay attention to areas of ligamentous attachment, where avulsion fractures may take place, ie, medial and lateral femoral condyles, intercondylar eminence, and fibular head.
Physical Exam
  • Painful, swollen knee
  • Inability to bear weight on the injured leg
  • Knee effusion (hemarthrosis)
  • Decreased (both active and passive) range of motion (ROM) of the knee
  • Tenderness along the proximal tibia (either medial or lateral tibial plateau)
  • Possible varus or valgus deformity of the knee
  • Possible joint instability owing to associated ligamentous injury
Diagnostic Tests & Interpretation
Imaging
  • Tibial plateau view–anteroposterior (AP) view with the knee in 10–15 degrees of flexion helps to visualize depressions (6).
  • Oblique: Internal and external: May help to determine the location and degree of depression that may not apparent on other films (6)
  • MRI can be used to better view soft tissue injuries and classify using the Schatzker system, especially in the pediatric population (6).
  • CT scan: May help to determine the size of the fracture and depression of the fragments (6)
  • Angiography is indicated if:
    • High-energy mechanism
    • Schatzker type 4, 5, or 6 fracture
    • Alteration in distal pulses
    • Expanding hematoma
    • Bruit
    • Injury to anatomically related nerves

P.261


Diagnostic Procedures/Surgery
  • Compartment pressures if suspected compartment syndrome:
    • Pain not over fracture site
    • Pain on passive stretch
    • Paresthesias
    • Abnormality of pulses
    • Pressures >30 mm Hg are an indication for fasciotomy.
  • Arthrocentesis to look for fat globules if mechanism strongly suggests that fracture and effusion are present without x-ray findings
Differential Diagnosis
  • Knee dislocation
  • Cruciate ligament tears/avulsion
  • Meniscal tears
  • Quadriceps tendon rupture
  • Patellar fracture
  • Patellar dislocation
Treatment
Pre-Hospital
  • ABCs/ATLS protocol in multiple-trauma victim
  • Long-leg splint
  • Ice
  • Elevation
ED Treatment
  • Non-weight-bearing
  • Pain control
  • Nondisplaced fractures or minimally displaced lateral plateau fractures without ligamentous injury:
    • Aspiration of hemarthrosis and injection of local anesthetic
    • Examination for ligamentous instability
    • If knee is stable:
      • Compressive dressing
      • Ice and elevation for 48 hr
      • Non-weight-bearing/crutches
    • Early orthopedic follow-up if knee is not stable
  • Blokker and colleagues recommended open reduction with internal fixation (ORIF) for fractures with >5 mm of depression or 1 mm of displacement (5).
  • Open fractures:
    • Remove contaminants.
    • Apply moist sterile dressing.
    • Assess tetanus immunity.
    • Antibiotics
    • Emergent orthopedic consultation
In-Patient Considerations
Admission Criteria
  • Open fractures for débridement, irrigation, and IV antibiotics
  • Comminuted bicondylar fractures for traction
  • High-energy mechanism for observation of neurovascular status
  • Suspected compartment syndrome
  • Pain control (7)
Discharge Criteria
  • Nondisplaced fractures
  • Minimally displaced, stable fractures of the lateral plateau
Ongoing Care
Nonoperative management:
  • Fractures with <5 mm of depression or 1 mm displacement (5)
  • Non-weight-bearing and early ROM are critical (3).
  • Average time to heal is 12–20 wks (3).
  • Timetables:
    • Initially, patient in brace with full extension for 10–14 days (3)
    • Begin gradual ROM, with goal of 90 degrees of flexion by 4 wks (3).
    • Non-weight-bearing for 4–6 wks or until radiographic evidence of healing is noted; then may proceed with partial weight-bearing with crutch assistance (3)
    • Follow-up every 2–3 wks, repeating radiographs at each visit to document healing (3)
  • Formal physical therapy early can help to restore function (3).
  • Hinged knee brace for support should be used during the healing process (3).
References
1. Rang M. Children's fractures. 2d ed. Philadelphia: JB Lippincott, 1984.
2. Simon RR, Sherman SC, Koenigsknecht SJ. Proximal Tibia Fractures. In: Simon RR, Sherman SC, Koenigsknecht eds. Emergency orthopedics: the extremities 5th ed. Norwalk CT: Appleton and Lange, 2007:396–403.
3. Eiff MP, Hatch RL, Calmbach WL: Fracture management for primary care. Saunders. 2003:269–273.
4. Wiss DA, Watson JT, Johnson EE. Fractures of the knee. In: Rockwood CA, Green DP, Bucholz RW, et al. eds. Rockwood and Green's fractures in adults. 4th ed. Philadelphia: Lippincott-Raven, 1996:1593–1652.
5. Blokker CP, Rorabeck CH, Bourne RB. Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop Relat Res. 1984:193–199.
6. Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics. 2009;29:585–597.
7. Torrey SB. Lower extremity and pelvis trauma. In: Barkin ed. Pediatric emergency medicine. St. Louis: CV Mosby. 1992:357–365.
Additional Reading
Wheeless III, Clifford R. January 18, 2008. [http://www.wheelessonline.com/ortho/tibial_plateau_fractures]
Codes
ICD9
823.00 Closed fracture of upper end of tibia


Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More