Tibial plateau fracture

Refers to a bone fracture or break in the continuity of the bone occurring in the proximal part of the tibia.

A tibial plateau fracture affects the knee joint, stability and motion.

The tibial plateau is a critical weight-bearing area located on the upper tibia.

The tibial plateau is composed of two slightly concave condyles, the medial condyle and lateral condyle, separated by an intercondylar eminence and the sloping areas in front and behind it.

The tibial plateau can be divided into three areas: the medial tibial plateau, the lateral plateau and the (the part of the tibial plateau that is nearer to the central plateau.

The medial plateau center contains medial condyle.

The lateral plateau is farthest away from the center of the body and contains the lateral condyle.

The central tibial plateau is located between the medial and lateral pleateaus and contains intercondylar eminence.

Injury lesions may be restricted to the tibia or may have significant soft tissue injury as well as meniscal and ligamentous injuries to the knee.

A typical tibial plateau fracture involves either cortical interruption, depression or displacement of the articular surfaces of the proximal tibia without significant injury to the capsule or ligaments of the knee.

Tibial plateau fractures typically presents with knee effusion, swelling of the knee soft tissues and inability to bear weight.

The knee may be deformed due to displacement and/or fragmentation of the tibia which leads to loss of its normal structural appearance.

Due to the tibial plateau’s proximity to important arteries, veins and peroneal and tibial nerve structures, injuries to these may occur upon fracture.

A serious complication of tibial plateau fractures is compartment syndrome in which swelling causes compression of the nerves and blood vessels inside the leg and may ultimately lead to necrosis or cell death of the leg tissues.

Tibial plateau fractures are divided into low energy or high energy fractures .

Low energy fractures are commonly seen in older females due to osteoporotic bone changes and are typically depressed fractures.

High energy fractures are commonly the result of motor vehicle accidents, falls or sports related injuries.

High energy fractures constitute the majority of tibial plateau fractures in young individuals.

Fractures of the tibial plateau are caused by inward or outwardly force combined with weight bearing on knee.

The medial plateau is larger and significantly stronger than the lateral pleateau.

60% of tibial plateau fractures involve the lateral pleateau, 15% medial plateau, 25% bicondylar lesions.

Partial or complete ligamentous ruptures occur in 15-45%, meniscal lesions in about 5-37% of all tibial plateau fractures.

In all injuries to the tibial plateau X-rays are required.

Computed tomography scans are sometimes critical for evaluating degree of fracture and determining a treatment plan.

Magnetic resonance images are the diagnositic modality of choice when meniscal, ligamentous and soft tissue injuries are suspected.

CT angiography should be considered if there is concern about arterial injury.

Lipohemarthrosis can occur due to a tibial plateau fracture

Multiple classifications of tibial plateau fractures have been developed: the Schatzker classification system is the most widely accepted and used.

The Schatzker classification system is composed of six condyle fracture types classified by fracture pattern and fragment anatomy.

The fracture severity correlates with the amount of energy imparted to the bone at the time of injury and prognosis.

Schatzker classification for tibial plateau fracture: Type I = Lateral Tibial plateau fracture without depression.

Type I fracture is a wedge-shaped cleavage fracture and involves a vertical split of the lateral tibial plateau.

Type I fractures. are usually the result of a low energy injury in young individuals with normal mineralization.

Type I fractures may be caused by a valgus force combined with axial loading that leads to the lateral femoral condyle being driven into the articular surface of the tibial plateau.

Type I fractures account for 6% of all tibial plateau fractures.

Type II fracture refers to a lateral tibial plateau fracture with depression.

Type II fracture is a combined cleavage and compression fracture and involves vertical split of the lateral condyle combined with depression of the adjacent load bearing part of the condyle.

Type II fracture is caused by a valgus force on the knee.

Type II fracture is a low energy injury, primarily seen in individuals of the 4th decade or older with osteoporosis.

Type II fracture is the most common type , and make up 75% of all tibial plateau fractures.

There is a 20% risk of distraction injuries to the medial collateral ligament

Type III: Focal depression of articular surface with no associated split is a pure compression fracture of the lateral or central tibial plateau in which the articular surface of the tibial plateau is depressed and driven into the lateral tibial mataphysis by axial forces.

Type III fractures result from a low energy injury.

Type III fractures are more frequent in the 4th and 5th decades of life and in individuals with osteoporosis.

Type III fractures are extremely rare.

Type III fractures are divided into two subtypes: IIIA Compression Fracture of the lateral tibial plateau and IIIB Compression Fracture of the central tibial plateau

Type III fractures may result in joint instability.

Type IV fractures are of the medial tibial plateau, with or without depression and may involve tibial spines and is associated soft tissue injuries.

Type IV fracture is usually the result of a high energy injury and involves a varus force with axial loading at the knee.

Type IV fractures represent 10% of all tibial plateau fractures.

In Type IV fractures there is a high risk of damage to the popliteal artery and peroneal nerve.

Type IV fractures may include distraction injuries to lateral collateral ligament, fibular dislocation/fracture, posterolateral corner.

Type V fractures are bicondylar tibial plateau fractures.

It onsists of a split fracture of the medial and lateral tibial plateau.

Type V fractures are usually the result of a high energy injury with complex varus and valgus forces acting upon the tibial

Type V fractures may include injuries to the anterior cruciate ligament and collateral ligaments.

Type V fracture make up 3% of all tibial plateau fractures.

Type VI tibial fractures are those with diaphyseal discontinuity.

Main feature of this type of fracture is a transverse subcondylar fracture with dissociation of the metaphysis from the diaphysis.

Type VI fracture pattern of the condyles is variable and all types of fractures can occur.

Type V fractures are a high energy injury process with a complex mechanism that includes varus and valgus forces.

Up to 33% of type V fractures may be open, often with extensive soft tissue injuries and risk of compartment syndrome.

Type V fractures represents 20% of all tibial plateau fractures.

Treatment of a tibial plateau fracture is aimed at achieving a stable, aligned, mobile and painless joint and to minimize the risk of post-traumatic osteoarthritis.

Operative or non-operative treatment plans are considered based on criteria such as patient characteristics, severity, risk of complications, fracture depression and displacement, degree of injury to ligaments and menisci, vascular and neurological compromise.

Tibial plateau fractures constitute 1% of all fractures.

Peak age is 30–40 years old in men and 60-70 in women.

Approximately half of the patients who sustain a tibial plateau fracture are aged over 50 years old.

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