Tibial Plateau Fractures

Original Editors - Jentel Van De Gucht

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Definition/Description 

Lateral tibial plateau fracture

Tibial plateau fractures are complex injuries of the knee. The tibial plateau is one of the most critical load-bearing areas in the human body. Early detection and appropriate treatment of these fractures are essential in minimizing patient's disability in range of movement, stability and reducing the risk of documented complications.

The fractures are classified according the Schatzker classification system. It divides tibial plateau fractures into six types:
• Schatzker I: lateral tibial plateau fracture without depression
• Schatzker II: lateral tibial plateau fracture with depression
• Schatzker III: compression fracture of the lateral (IIIa) or central (IIIb) tibial plateau
• Schatzker IV: medial tibial plateau fracture
• Schatzker V: bicondylar tibial plateau facture
• Schatzker VI: tibial plateau fracture with diaphyseal discontinuity

A type I fracture is a wedge-shaped pure cleavage fracture of the lateral tibial plateau, with a displacement or depression less than 4mm. They are caused by the lateral femoral condyle being driven into the articular surface of the tibial plateau.

Type II is a fracture with a combined cleavage and compression of the lateral tibial plateau, a type I fracture with a depressed component. There is a depression greater than 4mm.

A Schatzker type III fracture is a pure compression fracture of the lateral tibial plateau in which the articular surface of the tibial plateau is depressed and driven into the lateral tibial metaphysis by axial forces. Type III fractures are divided into two subgroups: those with lateral depression (type IIIA) and those with central depression (type IIIB).

Type IV is a medial tibial plateau fracture with a split or depressed component. These fractures occur as a result of varus forces combined with axial loading in a hyperflexed knee. Type IV fractures have the worst prognosis.

Type V fracture consists of a wedge fracture of the medial and lateral tibial plateau, often with an inverted “Y” appearance. Articular depression is typically seen in the lateral plateau and might be associated with a fracture of the intercondylar eminence.

Type VI is a bicondylar fracture with a dislocation of the metaphysis from the diaphysis.This pattern results from high-energy trauma and diverse combinations of forces. (Level of Evidence 1a)

The first three types are mostly the result of low energy injury, the three others of high energy injury. The magnitude of the force determined the degree of fragmentation and the degree of displacement.
Tibial plateau fractures are often associated with anterior cruciate ligament, collateral ligaments (MCL and/or LCL), menisci and articular cartilage injuries

Clinically Relevant Anatomy

The proximal end of the tibia terminates in a broad, flat region called the tibial plateau.The intercondylar eminence runs down the midline of the plateau, seperating the medial and lateral condyles of the tibia. The two condyles form a flat, broad surface for articulation with medial and lateral condyles of the femur.

Epidemiology /Etiology 

Tibial plateau fractures are typically caused by a strong force on the lower leg with the leg in varus or valgus position, or simultaneous vertical stress and flexion of the knee.

Commonly seen in road traffic accidents, sports accidents with a high velocity such as skiing, horse riding and certain water sports.

Due to the nature of injury soft tissue trauma is likely such as ligament rupture and needs to be considered when managing.

Characteristics/Clinical Presentation

• Swelling
• Inability to weight bare
• Bruising
• Reduced range of movement of the knee
• History of trauma
• Pain

Differential Diagnosis

Tibial plateau fractures are common intra-atricular injury for which CT-scans are routinely used for pre-operative planning to rule out other pathology. Approximately 50% of the knees with closed tibial plateau fractures have injuries of the menisci and cruciate ligaments that usually require surgical repair.

Diagnostic Procedures 

Radiographic evaluation of these fractures involves four views: anteroposterior, lateral, internal oblique and external oblique. Computed tomography (CT) is of great value for determining the location and magnitude of the joint depression, however MRI has been shown to classify and assist management of the fracture best.

Between Schatzker I and II there is not a clear visible difference on X ray.
An anteroposterior radiograph with the knee angled 15° caudally (tibial plateau view) can provide a more accurate assessment of the depth of plateau surface depression. Traction radiographs give a clearer image of the fracture configuration after anatomic alignment is restored. CT scans give more detailed information in 3D of the fracture. This helps to choose the best treatment.
When there is a presumption of damage of the soft tissue, an MRI scan must be done

Outcome Measures

Since the tibial plateau involves a major weight bearing joint, the outcome is tied significantly to the resultant alignment and articular congruity after fracture healing with or without surgical intervention. If the joint is stable with good alignment, articular congruity and no loss of joint motion, good results can be expected. If infection, nonunion, cartilage injury or associated soft tissue injuries are not addressed, the functional outcome for the patient will be lower.

It has been reported that higher Schatzker valued fracture produce poorer outcomes due to the extent of trauma along with soft tissue damage is likely.

Measureable outcome measures that can be used are:

1. Imaging - one year post fracture or further can assess extent of healing
2. Knee range of movement
3. Quality of life score - such as the Musculo-skeletal functional assessment
4. Level of Mobility
   

Examination

There has yet to be a gold standard for accurately predicting the presence of soft tissue injuries in tibial plateau fractures. However, there have been recent studies that have employed preoperative magnetic resonance imaging (MRI) or operative arthroscopy to evaluate the extent of tissue damage.

Medical Management

For these fractures, preoperative planning is fundamental. The clinical history, trauma mechanism, age and associated comorbidities influence the treatment decisions. In the physical examination, the soft-tissue envelope, neurovascular functioning and associated lesions should be assessed so that the intervention will be appropriate.

Management of these fractures consists of using comprehensive classification systems that are easily reproducible and have prognostic value, thereby making it conceptually easier to define tactics and surgical accesses.

The primary aim of fracture treatment is to restore the congruence of the articular surface and ensure mechanical axis alignment. Any deviations from anatomical condylar position or ligamentous instabilities may lead to an increased likelihood of degenerative osteoarthritis and subsequent reduced functional abilities.

Commonly managed by Open Reduction and Internal Fixation (ORIF).

In some more complex cases fractures can be managed by external fixation followed by further ORIF at a later time.

Post tibial plateau fracture osteoarthritis is common (approximately one third) due to the articular surface being involved despite the age of the patient.

Physical Therapy Management

The physical therapist must consider both the patients subjective response to injury and the physiological mechanisms of tissue healing; both are essential in relation to a patient's return to optimal performance.

As a preface to discussion of the goals of treatment during injury rehabilitation, two points must be made. First, healing tissue must not be overstressed. During tissue healing, controlled therapeutic stress is necessary, but too much stress can damage new structures and slow the patient’s rehabilitation. Second, the patient must meet specific objectives to progress from one phase of healing to the next. These objectives may depend on ROM, strength, or activity. It is the responsibility of the physical therapist to establish these guidelines.

After a fracture, physical therapy may be required to help ensure return to optimum function as quickly as possible.

Tibial plateau fractures are notoriously difficult to manage, particularly when there is a medial or posteromedial component. The treatment for tibial plateau fractures aims to achieve anatomical reduction of the joint surface and stable osteosynthesis in order to enable early mobilization, so as to prevent complications such as joint stiffness and post-traumatic arthrosis.^[12]

After 10 to 12 weeks the bone is expected to be healed. The goals of the physical therapy are to restore the range of motion as early as possible, to improve and restore the strength of the muscles and to restore the stability of the knee. After surgical treatment the indications to start passive mobilization are 0° extension and 90° flexion of the knee. The patient may not bear weight on his leg for 3 months.

From the day of the injury to one week after, early range of motion is very important. Active and active-assistive flexion and extension of the knee are allowed while protecting the knee from varus and valgus, once the pain has subsides. This is done in a sitting position. Initially 40° to 60° flexion are allowed. After one week it is possible to increase to 90° flexion. Sometimes a continuous passive motion machine is used. Gentle ankle isotonics without resistance and gluteal exercises are prescribed to strength muscles.

After 2 weeks the patient must be able to do active and active-assistive range of motion exercises, obtaining 0° to at least 90° of knee flexion. The patient may start with isometric exercises to the quadriceps at the end of 2 weeks and continue gluteal exercises.

Also from the fourth to the sixth week active and active-assistive range of motion exercises, obtaining 0° to at least 90° of knee flexion must be done. At the end of week 6 gentle passive range of motion is allowed. Active and passive range of motion of the ankle and hip can begin. From now on we can start with isometric hamstring exercises and continue with isometric exercises of the quadriceps and isotonics to strength the muscles of the ankle.

From the eighth to the twelfth week, when the fracture appears stable and there is no collateral ligament injury or instability, we can start bearing partial weight on crutches. The patient must be able to do full extension and at least 90° of flexion. From now on resistive exercises to the quadriceps, hamstrings and ankle musculature are prescribed. The number of repetitions can increase gradually. At the end of the twelfth week, weight bearing activities are started.

From the twelfth to the sixteenth week the patient is fully weight bearing and should be weaned off assistive devices. Muscle strength exercises must be continued and resistive exercise are increased progressively. The range of motion is still at least full extension and 90° of flexion. (Level of Evidence 1a), (Level of Evidence 5), (Level of Evidence 2b)

Resources

Musculo-skeletal functional assessment questionnaire

Clinical Bottom Line

Tibial plateau fractures do not occur frequently. They comprise approximately 1% of all fractures. These fractues are typically caused by high energy trauma, but they can also occur due low energy trauma (e.g. slip and fall). The fractures are classified according the Schatzker classification system. It divides tibial plateau fractures into six types: Shatzker I-VI. Clinical presentation of tibial plateau fractures are swelling, pain, limited range of motion and bruising may be seen over the skin. The medical management are not the same for all fractures. As said before, tibial plateau fractures are divided in six categories. Treatment of these fractures is governed by the vascularity (local tissue and distal), the condition of the soft tissues, and the presence or absence of compartment syndrome. Treatment can be operative and non-operative. Physical therapy is very important, but depends on the patient and his condition. Patients who have tibial plateau fractures experience edema, pain, loss of ROM, strength and function, all of which are indications for physical therapy. For acute trauma, consisting early ROM is very important. For sub-acute trauma we must concentrate on the pain, edema, knowledge of the patient, ROM, strength, balance and proprioception.