What is Tibial Plateau Fractures?
Tibial plateau fractures, which make up about 1% of all fractures, usually occur due to high-impact events. These fractures can also cause damage to nearby parts such as blood vessels, nerves, ligaments, menisci (cushions between knee bones), and surrounding areas. If the tibial plateau fracture is small and there’s no other associated injury, it can often be treated without surgery. However, these fractures usually need an orthopedic specialist’s consultation and likely, surgical treatment.
What Causes Tibial Plateau Fractures?
The main ways that tibial plateau fractures occur involve a sideways or up-and-down force, with or without an additional downward force. The tibial plateau can break on its outer side, inner side, or on both sides. The outer side is most often broken, usually due to a direct hit to the outer side of the knee.
Inner side breaks require much more force and usually happen due to serious accidents like falling from a high place, car crashes, or other traumatic incidents. In such high-energy situations, it’s more common to see fractures on both sides of the tibial plateau rather than just on the inner side.
Tibial plateau fractures caused by less violent incidents are more likely to happen in older people or those with weak bones due to conditions like osteoporosis.
Risk Factors and Frequency for Tibial Plateau Fractures
Tibial plateau fractures, which make up about 1% of all fractures, occur at a rate of 10.3 cases per 100,000 people every year. Most people who experience these types of fractures are around 52.6 years old. Men under 50 are often more likely to get these fractures through high-energy accidents, often along with soft tissue injuries, while women over 70 are prone to get these fractures due to falls. In general, men are more likely to sustain tibial plateau fractures than women.
- Tibial plateau fractures represent 1% of all fractures.
- Every year, there are about 10.3 cases per 100,000 people.
- The average age of a patient with a tibial plateau fracture is 52.6 years.
- Men under 50 are more likely to get these fractures from high-energy accidents often with soft tissue injuries.
- Women over 70 tend to get these fractures due to falls.
- Generally, men are more prone to tibial plateau fractures than women.
Signs and Symptoms of Tibial Plateau Fractures
A tibial plateau fracture is a type of knee injury. You should suspect this in individuals who have knee pain, swelling, possible changes to the shape of their knee, and a history of injury or known risk factors for this kind of fracture. These fractures can often be associated with high intensity injuries, requiring a thorough assessment and stabilization of the patient’s overall condition.
Examination of the knee should involve comparing with the other knee (assuming it’s uninjured). A comprehensive physical examination should focus on the following aspects:
- Skin: Check the skin all the way around the knee for an open fracture, cuts, or puncture wounds.
- Knee effusion: If the knee is significantly swollen, it can be drained to check for bleeding into the joint, or signs of fractured bone floating in the knee fluid.
- Neurovascular exam: Sensation, muscle function, and pulses in the lower leg should be assessed. If pulses are uneven between the legs, further tests like Ankle-brachial indices may be needed.
- Compartments: Feel all the compartments of the leg. If any compartment is firm or tight, this could indicate compartment syndrome, which can be confirmed by measuring the pressure within.
- Laxity tests: If the knee moves more than 10 degrees side to side, this could suggest a tear in the ligaments. Laxity below the knee could indicate a displaced fracture.
- Range of Motion: It can be difficult to assess movement and strength due to pain, but an attempt should be made to gauge this.
Testing for Tibial Plateau Fractures
If your doctor suspects there might be a problem with your leg, they may want a closer look at your bone fragments. For this, they’ll use imaging methods such as X-rays, CT scans or MRI scans.
X-rays are able to show the front and side views of your leg bones. They can help point out areas of your bone that are compressed, misplaced, or sunk. Plus, they can help spot any fractures at the back of your leg. Other optional views can include angled views and views of the top of your shin bone (tibial plateau). These can be useful in figuring out how much the bony surface has sunk. However, these views are not necessary if a CT scan is being used. It is also important to note that ordinary X-rays might miss to detect a fracture of the shin bone’s plateau with 85% likelihood. Therefore, if a fracture is highly suspected and x-ray findings are negative, then a CT scan is recommended. X-rays can also help in identifying any possible injuries to the knee’s outer side or the back knee ligament. They can do so by identifying if the bony surface has sunk more than 6mm and/ or if it has widened more than 5mm.
CT scans are good at determining how much the bone’s surface has sunk and how many bone fragments have formed due to fractures. They also help in showing the pattern of the fracture, the shape of the broken bone fragment, the size, and location, which is important when planning a surgery. In addition, if fat and blood have entered your knee joint, this can indicate a hidden fracture. A CT scan may even make a change in how your doctor plans to treat your fracture based on the initially taken X-rays.
As for an MRI scan, it is used to check for any injuries in the knee meniscus or ligaments.
Your doctor should take a look at the fracture lines, any misplacement, any sinking of the shin bone’s plateau, and any possible ligament or meniscal injuries.
Without a doubt, figuring out which type of fracture you have can be complicated. To do this, doctors often use the Schatzker Classification system. This system has six types of fractures. Yet, 10% of all tibial plateau fractures can’t be identified by this classification especially the ones linked with dislocations or knee instability. Hohl and Moore suggested a different classification of the shin bone’s plateau fractures. Other types of imaging like CT or MRI can be more helpful than a simple X-ray in showing how much the bony plateau has sunk or how turned into multiple fragments. They can be particularly useful when surgical management is in consideration. CT scans are often easier to get in an emergency situation. However, MRI scans can be more beneficial in identifying any injuries to the meniscus and ligaments.
Treatment Options for Tibial Plateau Fractures
Successful recovery from fractured shinbone plateau hinges on a few key factors. First, it’s crucial to restore the original alignment and stability of the leg and knee. While it’s also important to realign the fractured bone accurately, this is less critical for overall function. Managing the associated soft tissue injury is also vital. Prevention of further injury to soft tissues is achieved through immobilizing the knee and applying cold therapy.
Non-surgical treatment is usually suitable for fractures that are barely out of place, do not involve ligament injuries, or if the patient is non-ambulatory. The patient is placed in a brace that doesn’t restrict knee movement and can start gentle exercises right away. Weight-bearing is not recommended for 6-8 weeks, followed by gradual introduction to weight-bearing over the next 6 weeks. The patient remains in the brace until the fracture heals, which can take up to 12 weeks. Physical therapy can begin at this stage, however, a full recovery could take 16-20 or more weeks. The return to activities that put prolonged weight and stress on the leg shouldn’t happen until the healing is nearly complete.
Surgical treatment is recommended for more severe fractures, fractures associated with ligament instability or ones that cause the knee joint to be significantly misaligned. The surgical technique is chosen based on the fracture pattern, which could involve various approaches (anterior-lateral, posterior-medial or combined). The main goal of surgery focuses on restoring the joint surface as much as possible, filling bone defects with bone grafts or cement. Afterward, the fracture is stabilized using screws or a plate. Postsurgery, the patient is given a hinged knee brace and recommended to begin gentle exercises. Weight-bearing is not permitted for the first 6 weeks, gradually allowed over the next 6 weeks, and then as tolerated.
In the case of considerably fragmented fractures or dirty wound fractures, external brace with limited internal fixation can be done. This method allows knee movement and reduces harm to the soft tissues. However, this technique is associated with a higher rate of improper bone healing. A two-stage fixation method can be opted for when there are significant soft tissue injuries; this method initially employs a temporary external brace, followed by a definitive internal screw fixation. This process reduces the chances of infection and healing complications. The only drawback is that it can leave the knee stiff.
There are other techniques too, like arthroscopic internal fixation, which can provide similar good results as traditional surgery. In certain patients and with specific fracture patterns, total knee joint replacement could be considered.
What else can Tibial Plateau Fractures be?
If someone has a fracture to the flat top part of their shinbone (called the tibial plateau), it will often cause their knee to change shape and swell. Doctors should also check for potential fractures in nearby areas, such as the lower part of the thigh bone (distal femur) and another part of the shinbone (tibial spine).
For diagnosis, doctors usually use an x-ray and a CT scan. In addition to the fracture, it’s important to examine any injuries to surrounding soft tissues. This includes the two cushion-like structures in the knee (medial and lateral meniscus), the knee’s main stabilizing ligament (ACL), and the ligaments on the sides of the knee (collateral ligaments).
What to expect with Tibial Plateau Fractures
Research has found that individuals who undergo surgery to fix a specific type of break in the shinbone, known as a tibial plateau fracture, tend to experience decreased functionality afterwards. Interestingly, X-ray assessments did not find a link between arthritis after injury and these outcomes.
Higher energy injury types have been found to yield poorer outcomes, with joint stability playing a crucial role in long-term results. Notably, using external devices to fix particularly shattered fractures has been linked to high rates of bone healing in an incorrect position, and there were cases where later joint replacement was necessary in older patients.
The worst long-term results were noticed in cases where there was also ligament instability, removal of the knee pad, or when the alignment of the leg was changed by more than 5 degrees.
Possible Complications When Diagnosed with Tibial Plateau Fractures
There are some factors that have been linked to the likelihood of getting an infection after surgery. These include being male, smoking, having lung diseases, certain bone feature abnormalities, and long surgery times. Compartment syndrome is a severe complication that can occur, and doctors always need to be on the lookout for this.
Tibial plateau fractures, or breaks in the upper part of your shin bone, can have complications that affect a person’s quality of life. This can be especially challenging for people who need a lot of mobility for their job; a fracture in this part of the leg could mean a considerable delay in going back to work. Some long-term issues you might face if you’ve had a tibial plateau fracture include:
- Abnormal walking
- Knee osteoarthritis due to the trauma, which can become more likely with certain knee conditions like meniscectomy, axial malalignment, septic arthritis, and ligament instability.
- Ankle osteoarthritis, which can occur due to the abnormal walking pattern
- Chronic pain
Preventing Tibial Plateau Fractures
It’s essential to explain to patients about breaks in the upper part of the shinbone, known as tibial plateau fractures, when discussing surgical and non-surgical treatment options and expected outcomes. Fast, out-of-hospital visits to an orthopedic specialist for follow-up care are also extremely important.