A 30-year-old man sustained traumatic amputations of three of his left fingers while at work. A heavy object fell when a supporting chain snapped; although he moved quickly, three of his left distal fingers were caught under the object. He was flown to a hospital for definitive hand care.
During the preadmission history and physical, it was noted that the patient had mild right knee pain in addition to his finger injuries. He had experienced no head injury and no loss of consciousness or other complaints. He did not remember injuring his leg, although he said it might have been struck by the falling object; all he could remember was the injury to his fingers.
On physical exam, the only abnormality other than the man’s traumatic finger amputations was mild right knee edema and a small bruised area medially. Initially, he complained of mild pain on palpation and moderate pain with passive range of motion, but range of motion was intact. His pain was worse at the proximal, medial tibial area, and he had mild lateral mid-calf tenderness though no bruising. Distally, his right lower extremity motor and sensory function were intact, and he had no open wounds or skin breakdown. He had 2+ dorsalis pedis pulse and 1+ posterior tibial pulse. The toes were pink and warm with brisk capillary refill. All compartments were soft and compressible.
Upon review of his plain radiographs (three views of the right knee), the patient was noted to have a severely comminuted medial tibial plateau fracture that extended to the midline in the region of the tibial spine, with mild depression of the fracture fragments measuring about 6 mm (see Figures 1a, 1b, and 1c). This would translate into a Schatzker IV classification type1 fracture (see Figure 22,3).
The man was admitted and underwent emergent surgery on his injured left fingers that night. Further diagnostic knee testing was performed, including CT and MRI (see Figures 3 and 4). Three days after admission, the patient underwent open reduction and internal fixation (plating) of the right medial, proximal tibia (see Figure 5). He has done very well since without issue.
Fractures of the tibial plateau occur along the articular, or joint, surface of the proximal tibia. The plateau consists of lateral and medial condylar surfaces. These concave structures function as an articulation point for the cartilaginous menisci and the femoral condyles.4 The medial plateau and condyle are stronger than those of the lateral side, and therefore are less commonly fractured. An elevated intercondylar eminence divides the lateral and medial plateaus, providing an attachment site for the cruciate ligaments.3
The Schatzker classification system1 is most commonly used to describe the types of tibial plateau fractures (as seen in Figure 22,3). Schatzker et al1 divided these injuries into six categories, according to the impact of increased energy exerted onto the bone; the rising classification numbers indicate an increase in complexity and severity and usually a worsening prognosis.
The type I fracture represents a split fracture of the lateral plateau. Typically, a fracture of this type has depression or displacement measuring less than 4 mm.
Type II tibial plateau fractures, the most common Schatzker injury, are lateral plateau fractures with depression noted at the split. Not always evident on plain radiographs, this depression can often be overlooked, and the injury mistaken for a type I fracture. The depression is measured vertically from the lower edge of the medial plateau to the lowest depression point of the lateral plateau.5
Type III fractures, the least common among the Schatzker injuries, are described as pure depression fractures of the lateral plateau. These fractures do not have an appreciable “split” along the plateau and are usually found in older patients with osteopenia.2
The Schatzker type IV injury is a medial fracture with displacement or depression to a portion of the plateau. The fracture may be split or comminuted and may originate in the intercondylar area.
Type V fractures, also known as “bicondylar fractures,” affect both the lateral and medial plateau. An inverted “Y” pattern is frequently seen, and there may be additional involvement of the intercondylar eminence. Type V fractures differ from type VI injuries in that there is no disturbance of the metaphyseal-diaphyseal connection. Thus, type VI fractures also include a transverse component that separates the condyles (metaphysis) of the bone from the shaft (diaphysis). Wide variation is seen among type VI fractures.5
Assessment and Diagnosis
Originally termed “fender fractures” due to their frequent association with automobile injuries, fractures of the tibial plateau account for 1% of all fractures and 8% of fractures in elderly patients.6 Tibial plateau fractures occur when varus or valgus force is combined with axial loading. The fracture itself occurs when the femoral condyle is driven into the lateral or medial plateau. Bicondylar injuries occur when rigorous axial force is sustained in a fully extended knee.
Injuries may also include those of the ligaments or menisci, resulting in joint instability. Patients may present with generalized knee pain or difficulty bearing weight after sustaining injuries, such as being struck in a motor vehicle accident, being tackled, or falling from some height.4
Evaluation of a patient with a suspected tibial plateau fracture begins with a detailed history and thorough physical examination. Details regarding the mechanism of injury help to predict the pattern of the fracture and may indicate whether a more focused neurovascular exam is warranted. Low-energy injuries (often seen with Schatzker types I to III) or twisting injuries yield low suspicion for neurovascular injury or compartment syndrome. However, high-energy injuries (seen often with Schatzker types IV through VI) have a greater likelihood of resulting in complicated injuries that must be urgently or emergently treated.5
The popliteal artery is bound posteriorly and distally to the tibial plateau, and the peroneal nerve is located laterally and positioned around the fibular head. It is essential to assess for the popliteal pulse, as well as lateral lower-extremity sensation and the patient’s ability to dorsiflex. Along with motor and neurovascular injuries, presentation with a painful, strikingly swollen knee and difficulty bearing weight may indicate a hemarthrosis. Soft tissue injuries over the knee resulting from direct trauma may require a saline arthrogram to rule out communication into the joint. Furthermore, a thorough ligamentous exam of the knee is helpful in determining the extent of the injuries.3
Compartment syndrome is a serious, emergent complication that can occur with tibial plateau fractures, especially those sustained during high-energy trauma.7 The health care provider must perform serial exams of the lower extremity to assess for classic signs of compartment syndrome. Are the compartments tense or noncompressible? Does the patient have pain with passive stretch or with range of motion of the lower extremity? Is there pallor or paresthesia to the affected limb? Is the pulse weak or absent? Presence of any of the aforementioned symptoms should prompt a high suspicion for compartment syndrome, and the patient must be sent to an emergency department for urgent evaluation.5
For Schatzker types I through III, intervention focuses on the articular cartilage examination and repair. Type IV injuries often include corresponding damage to the popliteal artery and/or peroneal nerve, and types V and VI often have such overlying soft tissue damage that temporary placement of an external fixation device is required before definitive surgical intervention can be performed.8
However, it should be noted that conservative versus surgical treatment is often debated among surgeons for treatment of Schatzker fractures. The management of a tibial plateau fracture depends on the physical demands and health of the patient, the severity of the fracture, the stability of the joint, and the surgeon’s skill set and preferences.4 Operative intervention is generally indicated for fractures with depressions greater than 2 mm (although some surgeons allow up to 1 cm of depression), fractures with joint instability, or open fractures. Injuries with concern for vascular injury or compartment syndrome are also treated both operatively and emergently. Postoperatively, patients will remain non–weight-bearing for eight to 12 weeks after surgery, and in the interim, depending on the surgeon’s preference, may or may not engage in active or passive range of motion of the knee.
Advocates of open reduction and internal fixation (ORIF) argue that this method allows for the fracture reduction and anatomic alignment to be directly examined, but they also acknowledge that this approach compromises a great deal of soft tissue surrounding the proximal tibia.9,10
In order to reduce soft tissue damage, some surgeons favor external fixation. Initial use of this surgical technique results in minimal soft tissue swelling and allows early range of motion. While the external fixation device is in place, there is a risk for pin site infection, and proper site care must be provided.6,11
Generally, the treatment of tibial plateau fractures is considered successful when the fracture reduction is sustained, the patient’s functional capacity and axial loading are restored, and the articular surface is reconstructed. As a rule, nonoperative treatment is reserved for tibial plateau fractures that are minimally depressed or nondisplaced, or for patients with advanced osteoporosis. Under these circumstances, after a non–weight-bearing period of four to eight weeks, patients will begin to perform protected and partial weight bearing using a hinged knee brace.2 Early active range of motion, along with isometric exercises to strengthen the quadriceps, is recommended.
Whether surgical or conservative treatment is chosen, complications of tibial plateau fractures include knee stiffness, wound breakdown and infection, malunion or nonunion, vascular or neurologic injury, prominent or painful hardware, or avascular necrosis of fragmented bone pieces.4
The primary care practitioner must never overlook patients’ complaints of knee pain, especially after varus or valgus stress injuries or axial loading injuries to the knee. The patient may be able to ambulate; however, ordering a radiograph is an easy method for evaluation and for ruling out tibial plateau injuries. If there is any question regarding the presence of fracture with plain radiographs and/or the clinical exam warrants it, CT is an appropriate second diagnostic intervention.
Should a tibial plateau fracture present in a primary care or urgent care setting, thorough examination of neurovascular status and risk for compartment syndrome must be done urgently, followed by a referral to an orthopedic surgeon or emergency department.
1. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto experience, 1968–1975. Clin Orthop Relat Res. 1979;(138): 94-104.
2. Marsh JL. Tibial plateau fractures. In: Bucholz RW, Court-Brown CM, Heckman HD, Tornetta P. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:1780-1831.
3. Egol K, Koval KJ, Zuckerman JD. Tibial plateau. In: Egol K, Koval KJ, Zuckerman JD. Handbook of Fractures. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:455-463.
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5. Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics. 2009;29(2):585-597.
6. Lewis C. Does the mode of fixation of tibial plateau fractures, i.e. external fixation versus internal fixation, influence the time to union? A systematic review of the literature. Eur J Orthopaed Surg Traumatol. 2008;18(5):365-370.
7. Weinlein J, Schmidt A. Acute compartment syndrome in tibial plateau fractures—beware! J Knee Surg. 2010;31(1):9-16.
8. te Stroet MA, Holla M, Biert J, van Kampen A. The value of CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures. Emerg Radiol. 2011;18(4):279-283.
9. Musahl V, Tarkin I, Kobbe P, et al. New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau. J Bone Joint Surg Br. 2009;91(4):426-433.
10. Toro-Arbelaez JB, Gardner MJ, Shindle MK, et al. Open reduction and internal fixation of intraarticular tibial plateau nonunions. Injury. 2007;38(3):378-383.
11. Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fractures of the tibial plateau. J Bone Joint Surg Am. 1995;77(5):661-673.