How to diagnose and treat tibial plateau fractures
Tibial plateau fractures are one of the most common fractures, accounting for about 1.66% of systemic fractures. Tibial plateau fractures are complex injuries caused by high- or low-energy trauma that primarily affect young adults or those in retirement. Tibial plateau fractures are often accompanied by soft tissue injuries of the knee joint, and the specific injury conditions determine the final treatment plan. This article shares the classification, clinical manifestations, diagnosis and treatment of tibial plateau fractures through actual cases, aiming to improve doctors' understanding and ability to deal with the disease.
The tibial plateau is located above the proximal metaphysis of the tibia, with an enlarged shape, which is conducive to the stability of the knee joint, and has more muscles, tendons, and ligaments attached. The cancellous bone is rich, the compact bone is thin, and the ability to resist violence is poor. The upper part of the joint is the platform articular surface, which corresponds to the articular surface of the femoral condyle. The articular surface of the medial tibial platform is larger than that of the lateral one, and the articular surface is concave, while the lateral platform is higher, smaller and convex than the medial one. This should be taken into account when inserting screws from lateral to medial, without entering the medial articular surface. The intercondylar eminence, which is not covered by articular cartilage in the middle of the tibial plateau, is attached by the anterior cruciate ligament. The tibial tuberosity and Gerdy's tuberosity are bony protrusions located below the condyle and are the attachment points of the patellar tendon and iliotibial band, respectively. The proximal tibiofibular joint is located posterolaterally to the lateral tibial condyle. Attached to the fibular head are the peroneal collateral ligament and the biceps femoris, which support the lateral tibial condyle. The peripheral portion of the tibial plateau is covered by menisci, with the lateral meniscus covering a larger area than the medial one.
There are many classification methods for tibial plateau fractures, but no one classification can cover all fracture types seen clinically. In clinical practice, the widely used Schatzker classification method is used to classify tibial plateau fractures.
Type Ⅰ: simple split fracture of the lateral condyle. A typical wedge-shaped non-comminuted fracture fragment is split outward and downward, and this type of fracture is common in young patients without osteoporosis. If there is displacement, it can be fixed with two transverse cancellous bone screws.
Type II: Lateral condyle split type combined with compression fracture. The lateral cuneiform bone was split and separated, and the articular surface was compressed downwards into the metaphysis. This type of fracture is most common in elderly patients. If the compression exceeds 5-8 mm or there is instability of the knee joint, open reduction should be performed. The metaphyseal bone graft "blocks" the compressed plateau and is secured with cancellous screws and lateral cortical support plates.
Type III: Pure central compression fracture. The articular surface is compressed into the platform, and the lateral cortex is intact, which is prone to occur in osteoporosis. If the compression is severe or the X-ray film of the stress position proves unstable, the compressed articular surface should be raised by bone grafting, and the outer cortical bone should be fixed with a support plate.
Type IV: Fracture of the medial condyle. This type of fracture can be a simple wedge-shaped split or a comminuted, compression fracture, etc., often involving the tibial spine. This fracture tends to varus and should be treated with open reduction, medial support plate, and cancellous bone screw fixation.
Type V: bicondylar fracture. Split tibial plateau on both sides. The distinguishing feature is that the metaphysis and diaphysis remain continuous. The bicondyles were fixed with support plates and cancellous bone screws. It is best to avoid immobilizing both condyles with bulky implants. Studies have confirmed that in the experience of treating tibial plateau fractures, the probability of wound dehiscence or infection is higher after both the medial and lateral sides of bicondylar fractures are fixed with bone plates. Usually, the displaced and severely comminuted tibial condyle fractures can be fixed with supporting plates. If the tibial condyle is less involved, it can be reduced by ligament reduction or percutaneous technique, and fixed with larger cancellous bone screws.
Type VI: plateau fracture with separation of metaphysis and diaphysis. In addition to unicondylar or bicondylar and articular surface fractures, there are also transverse or oblique fractures of the proximal tibia. Due to the separation of the diaphysis and metaphysis, this type of fracture is not suitable for traction treatment. Most of them are treated with supporting plates and cancellous bone screws. If both condyles are fractured, each side should be plated. Some scholars advocate the use of steel pins and wire fixation to treat these difficult fractures.
Clinical Presentation and Diagnosis
1. Symptoms and signs:
Tibial plateau fractures with no displacement or slight displacement have mild post-injury symptoms and must be differentiated from simple knee ligament injuries. When the violence is severe, there is hemorrhage in the knee joint cavity, obvious swelling and genu varus or valgus deformity. At the same time, attention should be paid to non-common peroneal nerve and popliteal vessel injury. In addition, it should be emphasized that plateau fractures can be associated with knee collateral ligament, meniscus, and cruciate ligament injuries.
2. Imaging examination:
X-rays can help confirm the diagnosis. CT is beneficial to understand the fracture displacement from the axial position, and CT three-dimensional reconstruction imaging can intuitively observe the fracture displacement and fracture type from different angles. MRI can detect and understand occult fractures, meniscal and ligament injuries. Arteriography is of great significance in judging patients with suspected vascular injury, and ultrasonography cannot reliably evaluate the degree of vascular injury, such as vascular intimal tear.
The goals of treating a tibial plateau fracture are to achieve a stable, well-mobilized, pain-free knee and to minimize the potential for post-traumatic osteoarthritis. The choice of treatment depends on the patient's injury, the type of fracture, and the physician's clinical experience. Conservative treatment can be adopted for elderly patients with small fracture displacement. Surgical treatment is often complicated and difficult, requiring certain experience and internal fixation techniques.
1. Non-surgical treatment:
Conservative treatment includes closed reduction, bone distraction, or cast immobilization. The danger of surgical treatment is avoided as much as possible, but it is easy to cause knee joint stiffness and malalignment. It is mainly suitable for lateral plateau fractures caused by low-energy injuries. Relative indications also include: non-displaced or incomplete plateau fractures; mildly displaced stable lateral plateau fractures; unstable lateral plateau fractures in some elderly patients with osteoporosis; patients with severe medical diseases.
Conservative treatment can also use a knee brace that can control the movement according to the situation. According to the clinical symptoms, signs and radiological manifestations of fracture healing, fracture brace or knee hinge brace can be used for 3 to 6 weeks after injury, but weight bearing should be avoided until the fracture is firmly healed.
2. Surgical treatment:
When the platform collapses or "steps", there is still no unified opinion on whether to adopt conservative treatment or surgical treatment. It is generally believed that if the platform collapse exceeds 3mm or 4mm, surgery must be performed to restore the anatomy of the articular surface and firm internal fixation. For unstable and malaligned tibial plateau fractures with displacement and "steps", open reduction and internal fixation or external fixation can be selected for treatment. For some less serious Schatzker fractures, arthroscopy-assisted microscopic invasive treatment. Internal fixation includes bone plate internal fixation and absorbable screw internal fixation.
There are anatomical bone plates and locking bone plates. Absorbable screws can achieve the same reduction and fixation effect as metal internal fixation devices in the treatment of tibial plateau fractures, but the indications must be properly mastered. The external fixator needs combined bilateral or annular external fixation.
Absolute indications for surgery include: open tibial plateau fractures; tibial plateau fractures with compartment syndrome; and acute vascular injury.
Relative indications include: lateral plateau fractures that can lead to joint instability; medial fractures that are more displaced; and mostly displaced bicondylar fractures of the tibial plateau.
 Epidemiology of Clinical Orthopedic Trauma (3rd Edition), Author: Zhang Yingze, Publisher: People's Medical Publishing House, Publication Date: 2018/10/1, ISBN: 9787117271080.
 Fracture Operation and Skills (Second Edition), Author: Wang Manyi, Publisher: People's Medical Publishing House, Publication Date: 2016/10/1, ISBN: 9787117232777.
 Tutorial of Orthopedics, Author: Yang Shuhua, Publisher: People's Health Publishing House, Publication Date: 2014/8/1, ISBN: 9787117189712.
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Post time: Aug-22-2023