Imaging Studies

Radiography

Radiographs of the knee, tibia/fibula, and ankle should be obtained as indicated (see the image below). Pedestrians struck by motor vehicles with lower extremity fractures have a high incidence of concomitant spine, chest, or intra-abdominal injuries.^[24]These patients may need additional radiographic tests to rule out these injuries when clinically indicated.

Radiograph demonstrating a displaced tibial shaft fracture with associated fibula fracture.

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Computed tomography

Computed tomography (CT) is indicated for severely injured patients if diagnostically sufficient radiographs of the knee cannot be obtained.^{[25, 26]}

For patients with tibial plateau fractures, tibial plafond fractures, and maisonneuve fractures, CT can assist evaluation of fracture extent.^[27] In a study of CT evaluation of characteristics of tibial plateau fractures, the diagnostic accuracy of fracture characteristics ranged from 70 to 89% for (1) a posteromedial component, (2) a lateral component, (3) a tibial tubercle component, and (4) a tibial spine (central) component.^[28]

(See the CT images of tibial plateau fractures below.)

$Tibial plateau fractures. CT image through the tib$ Tibial plateau fractures. CT image through the tibial plateau shows a fracture of the posterior aspect of the lateral tibial plateau, which is the source of the lipohemarthrosis.

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$Tibial plateau fractures. Coronal reformatted CT.$ Tibial plateau fractures. Coronal reformatted CT. This image demonstrates a bicondylar fracture of the tibial plateau along with a fracture of the tibial diaphysis, a Schatzker VI fracture. Note the articular incongruity.

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In tibial plateau fractures, radiographs may underestimate the degree of articular depression when compared to CT. This is important because patients with articular depression greater than 3 mm may be considered for surgery.

Ultrasonography

Point-of-care ultrasound has demonstrated promise for identifying long bone fractures and for confirming proper reduction.^[29] Sensitivity has been found to be as high as 99% in identifying long bone fractures.^[30] Sensitivity for adequate reduction has ranged from 94 to 100%.^[29]

For stress fractures

Radiographic findings usually are seen after 2-8 weeks of symptoms; radiographs may not be very sensitive during early stages of symptoms.

Radionucleotide scanning and MRI are more sensitive than radiography in diagnosing stress fractures and stress injuries.

Treatment & Management

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Media Gallery

Shown is an intra-articular fracture of the medial condyle of the tibial plateau.
Standard anteroposterior radiograph of a tibial shaft fracture with intramedullary nail fixation. Note the commonly associated fibular fracture that is also apparent.
Radiograph demonstrating a displaced tibial shaft fracture with associated fibula fracture.
Type II tibial plateau fracture in a young active adult with good bone stock treated with percutaneous elevation and cannulated cancellous screw fixation without bone grafting.
Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous elevation, bone grafting, and cancellous screw fixation.
Tibial plateau fractures. Line drawings of Schatzker types I, II, and III tibial plateau fractures. Type I consists of a wedge fracture of the lateral tibial plateau, produced by low-force injuries. Type II combines the wedge fracture of the lateral plateau with depression of the lateral plateau. Type III fractures are classified as those with depression of the lateral plateau but no associated wedge fracture.
Tibial plateau fractures. Line drawings of Schatzker types IV, V, and VI tibial plateau fractures. Type IV is similar to type I fracture, except that it involves the medial tibial plateau as opposed to the lateral plateau. Greater force is required to produce this type of injury. Type V fractures are termed bicondylar and demonstrate wedge fractures of both the medial and lateral tibial plateaus. Finally, type VI fractures consist of a type V fracture along with a fracture of the underlying diaphysis and/or metaphysis.
Tibial plateau fractures. CT image through the tibial plateau shows a fracture of the posterior aspect of the lateral tibial plateau, which is the source of the lipohemarthrosis.
Tibial plateau fractures. Axial CT image through the tibial shows a fracture through the lateral tibial plateau with slight diastasis between the fragments. This is a Schatzker II injury.
Tibial plateau fractures. Coronal reformatted CT. This image demonstrates a bicondylar fracture of the tibial plateau along with a fracture of the tibial diaphysis, a Schatzker VI fracture. Note the articular incongruity.
Classification of tibial tuberosity fractures.

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Author

Jonathan E Dangers, MD, MPH Assistant Professor, Associate Director, Department of Emergency Medicine, University of Kansas School of Medicine

Jonathan E Dangers, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, 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.

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.

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.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, 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.

Additional Contributors

Thomas M Cooper, MD Resident Physician, Department of Emergency Medicine, University of Kansas Medical Center

Thomas M Cooper, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Emergency Physicians, Society of Critical Care Medicine, Emergency Medicine Residents' Association

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.