The tibial plateau is the flat, expanded top of the shin bone or tibia which makes up the lower half of the knee joint. It is a very important part of the body for load bearing and any disruption of this area can cause abnormalities in alignment of the knee, knee stability and movement especially weight bearing and walking. Early recognition and treatment of this injury is vital to avoid the potential disability which could ensue and the longer term consequences of knee arthritis. More than half the sufferers from this fracture are over fifty years of age.
Older women make up a significant proportion of patients with this fracture, related to the degree of osteoporosis present in this group. More energetic injuries present with this fracture in younger people. When this fracture occurs, the usual method is for a downward force to be acting on the knee joint when it is suddenly pushed into a knock knee posture. Most commonly the outer condyle of the femur crushes down on the tibial condyle below it and presses the bone downwards into a fracture. Motor vehicles injuries are a common reason for this presentation, with falls from a height and sporting injuries also figuring.
Pedestrians who are hit by the bumper of a car in slow speed events make up about a quarter of this patient group as the bumper is at the right height to apply the required forces. Sporting events such as horse riding or falls from a height can also cause this type of fracture. The levels of energy involved in the precipitating events can make a significant difference to the types of fracture which result. Lower energy events more typically cause depression fractures whilst the result of a higher energy occurrence is more likely to be a splitting fracture. The complex nature of these fractures has resulted in many efforts at classification, with Schatzker and co-workers' now accepted.
Assessment of the patient will not only include the state of the bone but the condition of the soft tissues which can also be damaged, the blood vessels, nerves and muscles. Tibial plateau fractures are accompanied in about 50% of cases by damage to the knee menisci (cartilages) and the cruciate ligaments which may require surgery. The medial collateral ligament, the ligament on the inside of the knee, is more vulnerable to damage due to the incident forces being more typically on the outside of the knee in a knock knee direction. Medial plateau fractures result from bigger events as the bone is stronger on that side, with more frequent soft tissue problems.
Surgeons may be happy to accept a range of fracture displacement and pursue conservative or non-operative management in these cases. Lifting the depressed plateau and securing bone graft underneath it may be required if depression exceeds 5mm in depth. Open fractures, where a wound is continuous with the fracture, mean that surgery will be needed, as it is also if the blood supply has been compromised by vessel damage or if compartment syndrome has developed in the lower leg. Less severe fractures can be conservatively managed and if there is severe soft tissue compromise then surgery may have to be postponed.
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.
Treatment of fractures of the tibial plateau is aimed at restoring the stability of the knee joint, its correct alignment and anatomical relationships of the joint along with full movement in the knee so the knee will function well, is painless and will not suffer arthritic change. If the joint is unstable then surgery will have to be performed, holding the fragments with as little movement as possible. In younger patients with good bone quality then internal fixation may be successful, however older patients with poor bone quality may need to be functionally braced or have total knee replacement. - 14130
Older women make up a significant proportion of patients with this fracture, related to the degree of osteoporosis present in this group. More energetic injuries present with this fracture in younger people. When this fracture occurs, the usual method is for a downward force to be acting on the knee joint when it is suddenly pushed into a knock knee posture. Most commonly the outer condyle of the femur crushes down on the tibial condyle below it and presses the bone downwards into a fracture. Motor vehicles injuries are a common reason for this presentation, with falls from a height and sporting injuries also figuring.
Pedestrians who are hit by the bumper of a car in slow speed events make up about a quarter of this patient group as the bumper is at the right height to apply the required forces. Sporting events such as horse riding or falls from a height can also cause this type of fracture. The levels of energy involved in the precipitating events can make a significant difference to the types of fracture which result. Lower energy events more typically cause depression fractures whilst the result of a higher energy occurrence is more likely to be a splitting fracture. The complex nature of these fractures has resulted in many efforts at classification, with Schatzker and co-workers' now accepted.
Assessment of the patient will not only include the state of the bone but the condition of the soft tissues which can also be damaged, the blood vessels, nerves and muscles. Tibial plateau fractures are accompanied in about 50% of cases by damage to the knee menisci (cartilages) and the cruciate ligaments which may require surgery. The medial collateral ligament, the ligament on the inside of the knee, is more vulnerable to damage due to the incident forces being more typically on the outside of the knee in a knock knee direction. Medial plateau fractures result from bigger events as the bone is stronger on that side, with more frequent soft tissue problems.
Surgeons may be happy to accept a range of fracture displacement and pursue conservative or non-operative management in these cases. Lifting the depressed plateau and securing bone graft underneath it may be required if depression exceeds 5mm in depth. Open fractures, where a wound is continuous with the fracture, mean that surgery will be needed, as it is also if the blood supply has been compromised by vessel damage or if compartment syndrome has developed in the lower leg. Less severe fractures can be conservatively managed and if there is severe soft tissue compromise then surgery may have to be postponed.
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.
Treatment of fractures of the tibial plateau is aimed at restoring the stability of the knee joint, its correct alignment and anatomical relationships of the joint along with full movement in the knee so the knee will function well, is painless and will not suffer arthritic change. If the joint is unstable then surgery will have to be performed, holding the fragments with as little movement as possible. In younger patients with good bone quality then internal fixation may be successful, however older patients with poor bone quality may need to be functionally braced or have total knee replacement. - 14130
About the Author:
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Bournemouth, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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