Tibial Plateau Fractures Workup
- Author: Srinivasa Vidyadhara, MBBS, MS, DNB; Chief Editor: Thomas M DeBerardino, MD more...
For a discussion of the challenges in radiologic diagnosis and evaluation of tibial plateau fractures, see Dennan.
Most tibial plateau fractures are easy to identify on standard anteroposterior (AP) and lateral projections of the knee. Lateral views should not be considered adequate if a rotational component obscures the visualization of the femoral condyles as a single unit. Rotational malalignment can lead to missed zones of injury and an inaccurate estimation of the degree of articular depression.
With minimally displaced vertical split fractures, the fracture line often lies in an oblique plane and is therefore not visible on an AP or lateral radiograph. Oblique projections should be added if a nondisplaced tibial plateau fracture is suspected but not seen on the standard projections.
The following subtle radiologic signs may indicate the presence of an underlying plateau fracture:
Lipohemarthrosis - The presence of a fat/fluid level in the suprapatellar recess on the horizontal-beam lateral projection of the knee indicates that a fracture has occurred and has allowed fatty marrow to enter the joint
Increased trabecular density beneath the lateral plateau on an AP film - The medial tibial condyle normally has greater trabecular density because it bears more body weight
Nonalignment of the femoral condyles and tibia on the AP view
An AP projection of the knee, angled 15° caudally (tibial plateau view), can provide a more accurate assessment of the depth of plateau surface depression.
Traction radiographs provide a clearer image of the fracture configuration after anatomic alignment is restored. Areas of bone loss resulting from comminution can be mapped, and the appropriate size and length of the necessary implants can be ascertained.
Corresponding views of the uninjured knee and extremity are necessary for each patient to receive accurate restoration of length and alignment of the leg.
By acquiring thin axial slices through the knee and reconstructing the image data in the sagittal and coronal planes, computed tomography (CT) provides more detailed information. The information obtained from a CT scan can help determine the best surgical approach based on the fracture planes seen on the computer images. Three-dimensional spiral CT reconstructions yield a better and more accurate demonstration of the tibial plateau fracture. They present the anatomy in the view the surgeon will see when surgery is performed.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) is acknowledged as a reliable and accurate tool for assessing meniscal, collateral, and cruciate ligamentous injury, as well as for identifying occult fractures of the tibial plateau.
A bone bruise is indicated by epiphyseal and metaphyseal changes in T1- and T2-weighted images. The signals indicate normal articular and cortical bone changes and reflect changes in bone marrow. They are thought to represent edema, hyperemia, hemorrhage, and microfracture. Plateau fractures may be visualized on MRIs, even when plain film radiographs are normal.
A major advantage that MRI has over CT is that MRI does not use ionizing radiation. Disadvantages include the higher cost and greater time needed to complete the study (25 minutes for MRI vs 20 seconds for CT), which means that motion artifact can be a problem.
Agnew SG. Tibial plateau fractures. Oper Tech Orthoped. 1999. 9(3):197-205.
Burrows HJ. Fractures of the lateral condyle of the tibia. J Bone Joint Surg Br. 1956 Aug. 38-B(3):612-3. [Medline].
Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am. 1973 Oct. 55(7):1331-50. [Medline].
Sarmiento A. Functional bracing of tibial and femoral shaft fractures. Clin Orthop Relat Res. 1972 Jan-Feb. 82:2-13. [Medline].
Maripuri SN, Rao P, Manoj-Thomas A, Mohanty K. The classification systems for tibial plateau fractures: how reliable are they?. Injury. 2008 Oct. 39(10):1216-21. [Medline].
Hohl M, Luck JV. Fractures of the tibial condyle; a clinical and experimental study. J Bone Joint Surg Am. 1956 Oct. 38-A(5):1001-18. [Medline].
Hohl M. Tibial condylar fractures. J Bone Joint Surg Am. 1967 Oct. 49(7):1455-67. [Medline].
Moore TM. Fracture--dislocation of the knee. Clin Orthop Relat Res. 1981 May. (156):128-40. [Medline].
Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968--1975. Clin Orthop Relat Res. 1979 Jan-Feb. (138):94-104. [Medline].
Weaver MJ, Harris MB, Strom AC, Smith RM, Lhowe D, Zurakowski D, et al. Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures. Injury. 2011 Dec 9. [Medline].
Dennan S. Difficulties in the radiological diagnosis and evaluation of tibial plateau fractures. Radiography. 2004. 10:151-8.
Mustonen AO, Koivikko MP, Lindahl J, Koskinen SK. MRI of acute meniscal injury associated with tibial plateau fractures: prevalence, type, and location. AJR Am J Roentgenol. 2008 Oct. 191(4):1002-9. [Medline].
Pernaa K, Koski I, Mattila K, Gullichsen E, Heikkila J, Aho A, et al. Bioactive Glass S53P4 and Autograft Bone in Treatment of Depressed Tibial Plateau Fractures - A Prospective Randomized 11-year Follow-Up. J Long Term Eff Med Implants. 2011. 21(2):139-48. [Medline].
Laible C, Earl-Royal E, Davidovitch R, Walsh M, Egol KA. Infection after spanning external fixation for high-energy tibial plateau fractures: is pin site-plate overlap a problem?. J Orthop Trauma. 2012 Feb. 26(2):92-7. [Medline].
Lubowitz JH, Elson WS, Guttmann D. Part I: Arthroscopic management of tibial plateau fractures. Arthroscopy. 2004 Dec. 20(10):1063-70. [Medline].
Lubowitz JH, Elson WS, Guttmann D. Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures. Arthroscopy. 2005 Jan. 21(1):86-92. [Medline].
Chen XZ, Liu CG, Chen Y, Wang LQ, Zhu QZ, Lin P. Arthroscopy-assisted surgery for tibial plateau fractures. Arthroscopy. 2015 Jan. 31 (1):143-53. [Medline].
Kayali C, Oztürk H, Altay T, Reisoglu A, Agus H. Arthroscopically assisted percutaneous osteosynthesis of lateral tibial plateau fractures. Can J Surg. 2008 Oct. 51(5):378-82. [Medline].
Kumar P, Singh GK, Bajracharya S. Treatment of grade IIIB opens tibial fracture by ilizarov hybrid external fixator. Kathmandu Univ Med J (KUMJ). 2007 Apr-Jun. 5(2):177-80. [Medline].
Craiovan BS, Keshmiri A, Springorum R, Grifka J, Renkawitz T. [Minimally invasive treatment of depression fractures of the tibial plateau using balloon repositioning and tibioplasty : Video article]. Orthopade. 2014 Oct. 43(10):930-3. [Medline].
Yoon RS, Liporace FA, Egol KA. Definitive fixation of tibial plateau fractures. Orthop Clin North Am. 2015 Jul. 46 (3):363-75, x. [Medline].
Krappinger D, Struve P, Smekal V, Huber B. Severely comminuted bicondylar tibial plateau fractures in geriatric patients: a report of 2 cases treated with open reduction and postoperative external fixation. J Orthop Trauma. 2008 Oct. 22(9):652-7. [Medline].
Yu B, Han K, Ma H, Zhang C, Su J, Zhao J, et al. Treatment of tibial plateau fractures with high strength injectable calcium sulphate. Int Orthop. 2008 Aug 13. [Medline].
Lasanianos N, Mouzopoulos G, Garnavos C. The use of freeze-dried cancelous allograft in the management of impacted tibial plateau fractures. Injury. 2008 Oct. 39(10):1106-12. [Medline].
Russell TA, Leighton RK. Comparison of autogenous bone graft and endothermic calcium phosphate cement for defect augmentation in tibial plateau fractures. A multicenter, prospective, randomized study. J Bone Joint Surg Am. 2008 Oct. 90(10):2057-61. [Medline].
Duan XJ, Yang L, Guo L, Chen GX, Dai G. Arthroscopically assisted treatment for Schatzker type I-V tibial plateau fractures. Chin J Traumatol. 2008 Oct. 11(5):288-92. [Medline].
Mills WJ, Barei DP. High-energy tibial plateau fractures: Staged management. Oper Tech Orthoped. 2003. 13(2):96-103.
Chan YS, Chiu CH, Lo YP, Chen AC, Hsu KY, Wang CJ, et al. Arthroscopy-assisted surgery for tibial plateau fractures: 2- to 10-year follow-up results. Arthroscopy. 2008 Jul. 24(7):760-8. [Medline].
Rossi R, Bonasia DE, Blonna D, Assom M, Castoldi F. Prospective follow-up of a simple arthroscopic-assisted technique for lateral tibial plateau fractures: results at 5 years. Knee. 2008 Oct. 15(5):378-83. [Medline].
Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, et al. Complications after tibia plateau fracture surgery. Injury. 2006 Jun. 37(6):475-84. [Medline].
Mehin R, O'Brien P, Broekhuyse H, Blachut P, Guy P. Endstage arthritis following tibia plateau fractures: average 10-year follow up. Can J Surg. 2012 Feb 1. 55(1):003111-3111. [Medline].
Garner MR, Thacher RR, Ni A, Berkes MB, Lorich DG. Elective removal of implants after open reduction and internal fixation of Tibial Plateau fractures improves clinical outcomes. Arch Orthop Trauma Surg. 2015 Aug 12. [Medline].