A tibial plateau fracture is a bone fracture or break in the continuity of the bone occurring in the proximal (upper) part of the tibia (shinbone). The tibial plateau is one of the most critical loadbearing areas in the human body. The bone comprising the tibial plateau is cancellous (“crunchy”), as opposed to the thicker cortical bone of the tibial shaft. The composition of the bone is important, because cancellous bone may compress and remain depressed when it is injured. Fractures of the tibial plateau are often associated with injuries to the anterior cruciate ligament, collateral ligaments, menisci and articular cartilage. Tibial plateau fractures affect the knee alignment, joint, stability and movement. Thus, fractures of the tibial plateau are considered quite serious as this upper surface of the bone contains structures which are critical to the knee functioning.
Fractures which involve the tibial plateau range from very small fractures, which are only seen on MRI scans, to those which involve a significant injury, which results in a Humpty-Dumpty appearance of several bone pieces which can be almost impossible to put back together. While those with fractures which only show up on a MRI scan have an excellent outcome and a fairly quick return to activities, those involving significant disruption with multiple pieces of the lateral tibial plateau often have a poor prognosis.
Causes of Tibial Plateau Fracture
A fracture of the upper tibia can occur from stress (minor breaks from unusual excessive activity) or from already compromised bone (as in cancer or infection). Most, however, are the result of trauma (injury). Both low-energy injuries (fall from a height and sports-related trauma) and high-energy injuries (motor vehicle accidents) can cause tibial plateau fractures. Additionally, these fractures may result in improper limb alignment. The upper tibia is also prone to becoming fractured in high speed accidents such as those associated with skiing, horseback riding and certain water sports.
Low-energy fractures are commonly seen in older females, due to osteoporotic bone changes, and are typically depressed fractures. High-energy fractures are commonly seen in young individuals due to their heightened level of activities.
Symptoms of a Tibial Plateau Fracture
A fracture of the upper tibia may result in injury to both the bone and the soft tissues of the knee region. The symptoms of a tibial plateau fracture are:
- Pain when weight is applied
- Deformity around the knee
- Pale, cool foot
- Limited range of motion
- In severe cases, numbness or “pins and needles” in the foot due to nerve damage
Due to the tibial plateau’s proximity to important vascular (i.e., arteries, veins) and neurological (i.e., nerves such as peroneal and tibial) structures, injuries to these nerves may occur upon tibial plateau fracture. Therefore, a careful examination of the neurovascular systems is imperative. 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.
The major goal of the treatment of a tibial plateau fracture is to achieve a stable, aligned, mobile and painless joint, and to minimize the risk of post-traumatic osteoarthritis. The clinical history, trauma mechanism, age and associated comorbidities influence the treatment decisions. Based on severity, risk of complications, fracture depression and displacement, degree of injury to ligaments and menisci, and vascular and neurological compromise, operative or non-operative treatment approaches are recommended by the orthopedic surgeons.
Non-operative treatment approaches for a tibial plateau fracture include the following:
- Plaster cast immobilization
- Skeletal traction
- Functional cast bracing
Operative (surgical) treatment of a tibial plateau fracture includes the following:
- Internal stabilization of the fracture with screws alone or with a combination of plate and screws
- External stabilization with a fixator frame applied around the limb
All high-energy tibial plateau fractures must be immediately checked for soft-tissue integrity. If the skin is damaged due to the broken bones and there is an open wound, there is a risk of infection for the underlying fracture. These fractures may require surgical treatment to cleanse the fracture surfaces and soft tissues to lessen the risk of infection. In cases of severe soft-tissue swelling, the blood supply may be affected to the leg and foot, causing a condition referred to as compartment syndrome. This may require emergency surgery in which vertical incisions (fasciotomy) are made to release the skin and muscle coverings. These incisions are often left open and then closed or covered days or weeks later as the soft tissues recover and swelling resolves. If the condition of the soft tissues is such that the application of a cast or splint would be unwise, an “external fixator” may be considered. With this device, (often temporary) pins are inserted above and below the joint. These pins exit the skin and are connected by bars, which stabilize the knee joint.
In the past, using a long leg cast and traction mobilization were used for some tibial plateau fractures. However, functional cast bracing is now preferred as nonsurgical treatment.
Open or arthroscopic-assisted techniques are considered for fractures with displacement, depression of the condylar surfaces, or both. If surgical treatment is elected to obtain and maintain alignment, several devices may be considered for internal and external fixation.
Internal fixation can be accomplished by means of the following:
- Biologic fixation – screw fixation, minimally invasive plate osteosynthesis, least invasive stabilization system
- Arthroscopic-assisted fixation
- Conventional double plating
In some cases, the condition of the soft tissue is so poor that the use of a plate or rod might threaten it further. External fixation can be accomplished with the following:
- Ilizarov fixator
- Hybrid fixator
- Combination devices may also be employed
Some promising results have been achieved with balloon tibioplasty for depression fractures of the tibial plateau, but long-term results remain to be determined.