Practice Essentials

Fractures of the knee include fractures of the patella, femoral condyles, tibial eminence, tibial tuberosity, and tibial plateau.^{[1, 2]} Direct and indirect forces can cause these fractures, including trauma (direct or indirect), chronic stress, or pathologic conditions. Obtain anteroposterior, lateral, and oblique radiographs of the knee.^{[3, 4]} Arthrocentesis may be of diagnostic and therapeutic benefit for tense effusions. The presence of blood and glistening fat globules indicates lipohemarthrosis, which is pathognomonic for intraarticular knee fracture.

Document the neurovascular status. Apply a sterile dressing to open wounds. Splint the injury. Administer parenteral analgesics for isolated extremity injury. The goal of treatment is a stable, aligned, mobile, and painless knee joint to minimize risk of posttraumatic osteoarthritis.^[5]Orthopedic referral is recommended for all knee fractures. Nondisplaced fractures may be splinted, with orthopedic follow-up care within a few days. Displaced or open fractures require prompt orthopedic consultation.

A good prognosis is expected with patellar and tibial spine or tubercle fractures. A fair prognosis is expected with tibial plateau and femoral condyle fractures. A prospective study in patients with tibial plateau fractures showed that only 14% of patients recover full quadriceps muscle strength 1 year after injury and 20% will have residual knee stiffness after 1 year.^[6]

Clinical Presentation

Accousti WK, Willis RB. Tibial eminence fractures. Orthop Clin North Am. 2003 Jul. 34(3):365-75. [Medline].
Wiss DA, Watson JT, Johnson EE. Fractures of the knee. Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996. 1919-2001.
Walker CW, Moore TE. Imaging of skeletal and soft tissue injuries in and around the knee. Radiol Clin North Am. 1997 May. 35(3):631-53. [Medline].
Lazaro LE, Wellman DS, Klinger CE, Dyke JP, Pardee NC, Sculco PK, et al. Quantitative and qualitative assessment of bone perfusion and arterial contributions in a patellar fracture model using gadolinium-enhanced magnetic resonance imaging: a cadaveric study. J Bone Joint Surg Am. 2013 Oct 2. 95(19):e1401-7. [Medline].
Forman JM, Karia RJ, Davidovitch RI, Egol KA. Tibial Plateau Fractures with and without Meniscus Tear - Results of a Standardized Treatment Protocol. Bull Hosp Jt Dis (2013). 2013. 71(2):144-51. [Medline].
Gaston P, Will EM, Keating JF. Recovery of knee function following fracture of the tibial plateau. J Bone Joint Surg Br. 2005 Sep. 87(9):1233-6. [Medline].
Bharam S, Vrahas MS, Fu FH. Knee fractures in the athlete. Orthop Clin North Am. 2002 Jul. 33(3):565-74. [Medline].
Kevin H. Latz, M.D. Patellar Fractures. www.posna.org. Available at https://posna.org/Physician-Education/Study-Guide/Patella-Fractures.
Petrie J, Sassoon A, Langford J. Complications of patellar fracture repair: treatment and results. J Knee Surg. 2013 Oct. 26 (5):309-12. [Medline].
Carter K, Nesper A, Gharahbaghian L, Perera P. Ultrasound Detection of Patellar Fracture and Evaluation of the Knee Extensor Mechanism in the Emergency Department. West J Emerg Med. 2016 Nov. 17 (6):814-816. [Medline].
Luo TD, Marino DV, Pilson H. Patella Fractures. 2020 Jan. [Medline]. [Full Text].
Vestermark GL, Odum SM, Springer BD. Early femoral condyle insufficiency fractures after total knee arthroplasty: treatment with delayed surgery and femoral component revision. Arthroplast Today. 2018 Jun. 4 (2):249-253. [Medline]. [Full Text].
Plett SK, Hackney LA, Heilmeier U, Nardo L, Yu A, Zhang CA, et al. Femoral condyle insufficiency fractures: associated clinical and morphological findings and impact on outcome. Skeletal Radiol. 2015 Aug 20. [Medline].
Zhang Q, Yang J, Zhao G, Zheng D, Zhou X, Xu N, et al. A new technique for arthroscopic reduction and fixation of displaced tibial intercondylar eminence fractures, using suture anchor and EndoButton system. J Orthop Surg (Hong Kong). 2017 Jan. 25 (1):2309499016685011. [Medline]. [Full Text].
Kushner RL, Massey P. Tibial Tubercle Avulsion. 2020 Jan. [Medline]. [Full Text].
Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury. 2018 Dec. 49 (12):2252-2263. [Medline]. [Full Text].
J. L. Marsh, Matthew D. Karam. Tibial Plateau Fractures. www.otaonline.org. Available at https://otaonline.org/book/952/chapter/53360394/tibial-plateau-fractures.
Sanal HT, Krestan C, Schurz M. Imaging Following Fractures of and Around the Knee. Semin Musculoskelet Radiol. 2018 Sep. 22 (4):457-463. [Medline].
Gray SD, Kaplan PA, Dussault RG. Acute knee trauma: how many plain film views are necessary for the initial examination?. Skeletal Radiol. 1997 May. 26(5):298-302. [Medline].
Davis DS, Post WR. Segond fracture: lateral capsular ligament avulsion. J Orthop Sports Phys Ther. 1997 Feb. 25(2):103-6. [Medline].
Hall FM, Hochman MG. Medial Segond-type fracture: cortical avulsion off the medial tibial plateau associated with tears of the posterior cruciate ligament and medial meniscus. Skeletal Radiol. 1997 Sep. 26(9):553-5. [Medline].
Hardy JR, Chimutengwende-Gordon M, Bakar I. Rupture of the quadriceps tendon: an association with a patellar spur. J Bone Joint Surg Br. 2005 Oct. 87(10):1361-3. [Medline].
Nichol G, Stiell IG, Wells GA. An economic analysis of the Ottawa knee rule. Ann Emerg Med. 1999 Oct. 34(4 Pt 1):438-47. [Medline].
Stiell IG, Wells GA, Hoag RH. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA. 1997 Dec 17. 278(23):2075-9. [Medline].
Molenaars RJ, Mellema JJ, Doornberg JN, Kloen P. Tibial Plateau Fracture Characteristics: Computed Tomography Mapping of Lateral, Medial, and Bicondylar Fractures. J Bone Joint Surg Am. 2015 Sep 16. 97 (18):1512-20. [Medline].
Mustonen AO, Koskinen SK, Kiuru MJ. Acute knee trauma: analysis of multidetector computed tomography findings and comparison with conventional radiography. Acta Radiol. 2005 Dec. 46(8):866-74. [Medline].
Aponte EM, Novik JI. Identification of lipohemarthrosis with point-of-care emergency ultrasonography: case report and brief literature review. J Emerg Med. 2013 Feb. 44 (2):453-6. [Medline].
Newton EJ, Love J. Emergency department management of selected orthopedic injuries. Emerg Med Clin North Am. 2007 Aug. 25(3):763-93, ix-x. [Medline].
Roberts DM, Stallard TC. Emergency department evaluation and treatment of knee and leg injuries. Emerg Med Clin North Am. 2000 Feb. 18(1):67-84, v-vi. [Medline].
Lee TC, Huang HT, Lin YC, Chen CH, Cheng YM, Chen JC. Bicondylar tibial plateau fracture treated by open reduction and fixation with unilateral locked plating. Kaohsiung J Med Sci. 2013 Oct. 29(10):568-77. [Medline].
Arvanitakis AV, Mian KC, Kreienkamp R, Rhoades CE. Tibial Plateau Fracture Following Low Energy Fall in the Rocky Mountains. Kans J Med. 2019 Aug. 12 (3):91-93. [Medline]. [Full Text].
Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg. 2007 Dec. 73(12):1199-209. [Medline].
Herman MJ, Martinek MA, Abzug JM. Complications of tibial eminence and diaphyseal fractures in children: prevention and treatment. Instr Course Lect. 2015. 64:471-82. [Medline].
Pandya NK, Edmonds EW, Roocroft JH, Mubarak SJ. Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment. J Pediatr Orthop. 2012 Dec. 32 (8):749-59. [Medline].
Kilgore KP. The knee. Emergency Management of Skeletal Injuries. St Louis, Mo: Mosby-Year Book; 1995. 439-99.
Koval KJ, Zuckerman JD. Lower extremity fractures and dislocations. Handbook of Fractures. 2002. 210-234.
Sanders AK, Boggess BR, Koenig SJ. Medicolegal issues in sports medicine. Clin Orthop Relat Res. 2005 Apr. 38-49. [Medline].
Mustonen AO, Koskinen SK, Kiuru MJ. Acute knee trauma: analysis of multidetector computed tomography findings and comparison with conventional radiography. Acta Radiol. 2005 Dec. 46(8):866-74. [Medline].
Thomas AL, Wilson RH, Thompson TL. Quadriceps avulsion through a bipartite patella. Orthopedics. 2007 Jun. 30(6):491-2. [Medline].

Media Gallery

of 0

Author

Mark Steele, MD Professor, Department of Emergency Medicine, Chief Medical Officer, Truman Medical Center, University of Missouri-Kansas City School of Medicine

Mark Steele, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey G Norvell, MD, MBA, RDMS Associate Professor, Program Director, Department of Emergency Medicine, University of Kansas Medical Center

Jeffrey G Norvell, MD, MBA, RDMS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.