Fractures of the Tibial Plateau



Posted: Tuesday, December 15, 2009

by Jonathan Blood Smyth

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.

A large group which suffer this type of fracture is older women who already have some degrees of osteoporotic change in the area. Younger people with this presentation more likely result from more high energy events. The usual way these fractures occur is for a sideways force to be applied to the knee (often in a knock knee direction) while the knee is weight bearing with a downward force also applied. The lateral condyle (most commonly) is then squashed down by the large femoral condyle on that side. Sports injuries and falling from a height can result in this injury but it is much more common secondary to a road accident.

Over a quarter of these injuries come from pedestrians being hit by the bumper of a car at relatively slow speeds, the bumper applying the force at a level very close to a typical knee height. Other causes can be a fall from a height or activity related such as horse riding. Fractures may vary in resulting from high or low levels of incident energy, with low energy accidents resulting in the bone been squashed down (depression fracture) and high energy events resulting in splits in the bone at various angles. Because of the complexity of presentation most surgeons accept a classification of these fractures into six groups, proposed by Schatzker and co-workers.

On assessment the surgeon will not only assess the fracture itself but the health of the surrounding tissues such as the local muscles, nerves and blood vessels. Around half of tibial plateau fractures may have accompanying injuries to the cruciate ligaments and the cartilages (menisci) which may need surgical intervention themselves. Due to the typical force being in a knock knee direction the medial collateral ligament is more likely to suffer damage than the lateral. Fractures of the medial plateau usually involve more forceful injuries due to the stronger bony areas and this can increase the risk of soft tissue complications.

It may be appropriate to accept a number of fracture displacement types for non-operative or conservative treatment but if the fracture depression is over 5 millimetres it may be decided to raise up the depressed surface and place a bone graft under it. If the fracture is an open one (with an open wound) then surgery will be required, as it will in cases of damage to the vascular system and in the case of the development of compartment syndrome. If the fracture is not severe then it should be treated conservatively and operation may be avoided, at least temporarily, in cases where extensive soft tissue damage threatens tissue integrity.

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.

The treatment aim for these tibial plateau fractures is to regain knee stability, re-align the joint and its anatomical relationship and restore full movement, with a good result being a painless and movable knee with no risk of arthritis. Unstable joints will require surgery with good immobilisation of the fracture. Younger people have denser bone and internal fixation may be successful, while older people with weaker bone may need bracing or knee replacement.

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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