MANUAL MINORS
A tibial plateau fracture is an injury affecting the upper part of the tibia, forming the base of the knee joint. This fracture compromises the area where the femur and tibia articulate, making it crucial for knee stability and movement.
These fractures often occur from high-energy trauma, such as car accidents or falls from heights, although in individuals with osteoporosis, they may result from minor trauma. Tibial plateau fractures can be intra-articular, increasing the risk of complications such as post-traumatic osteoarthritis.
Diagnosis
Patients with a tibial plateau fracture present with severe pain, swelling, inability to bear weight, and often visible knee deformity. Joint effusion or bruising may also be present. The diagnosis is confirmed with knee X-rays (anteroposterior, lateral, and oblique views), which help visualise the fracture and assess displacement.
In many cases, a computed tomography (CT) scan is necessary to better evaluate the fracture pattern, especially if the joint surface is involved. Magnetic resonance imaging (MRI) may be helpful in assessing associated ligament and meniscus injuries.
Differential Diagnosis
Condition | Key Differentiation |
|---|---|
Patellar Fracture | Affects the patella, not the proximal tibia; patient may have difficulty extending the knee. |
Supracondylar Fracture | Affects the distal femur, with pain and deformity above the knee. |
Meniscus Injury | Knee pain without visible fracture on imaging; joint locking may be present. |
Knee Dislocation | Joint displacement, usually involving ligament injuries. |
Bone Contusion | Pain with oedema seen on MRI, but no fracture visible on X-rays. |
Emergency Management
Initial management includes immobilising the affected limb with a splint or immobiliser to prevent movement and reduce pain. Analgesia, typically with NSAIDs or opioids, is administered, and in severe cases, the possibility of an open fracture or neurovascular damage is evaluated.
The patient should be stabilised, and in cases of open fractures, antibiotics and tetanus prophylaxis are administered. In the emergency department, it is crucial to assess the arteries (especially the popliteal artery) and nerves due to the risk of vascular or neurological compromise.
Definitive Treatment
Definitive treatment depends on the degree of displacement and joint stability
Conservative Treatment
Non-displaced or minimally displaced fractures (less than 3 mm) can be managed conservatively with immobilisation and restricted weight-bearing. This involves using a splint or knee immobiliser for several weeks, followed by physiotherapy to regain the range of motion.
Surgical Treatment
Surgical treatment is indicated for displaced, unstable fractures or those affecting joint congruence. Surgical options include:
Internal Fixation with Plates and Screws: This is the most common technique to restore alignment and joint stability. An open reduction is performed to align the bone fragments, followed by fixation with plates and screws.
Arthroscopy: In fractures involving the joint surface, arthroscopy can help assess and treat associated meniscal or ligament injuries.
Bone Grafts: In fractures with significant depression of the tibial plateau, bone grafts may be used to reconstruct the joint surface.
Rehabilitation
Rehabilitation is essential to restore knee function. After treatment, passive exercises are started to improve the range of motion.
Weight-bearing on the affected leg is usually restricted for 8-12 weeks, depending on the type and stability of the fracture. Intensive physiotherapy is crucial for strengthening the leg muscles and restoring full mobility.
Regular radiological follow-up is necessary to ensure proper fracture healing and to avoid complications such as post-traumatic osteoarthritis, joint stiffness, or malunion (improper healing).
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