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Fractures of the Plateau of the Tibia
At the upper end of the tibia is the tibial plateau, an expanded and flat open area of bone which forms the lower part of the knee joint. The plateau has a vital role to play in weight bearing and if this surface is damaged then this can adversely affect the stability, alignment and movement of the knee in gait and standing. These fractures need to be identified early and correctly so that correct treatment can limit any disability and forestall the chances of secondary knee arthritis. Patients in this group fall over 50% of the time into the over 50s age group.
This fracture is more common in older women which reflects the increased incidence of osteoporotic changes in these patients. If this fracture occurs in younger people then it is likely to be secondary to more energetic injuries. The typical method of fracture in tibial plateau fractures is a force applied to the knee in a knock knee direction with weight bearing loads applied at the same time. The lateral condyle of the femur compresses down on the tibial plateau on the outside and crushes down the bone on that side. Many injuries are related to motor vehicle injuries with a smaller number deriving from sport.
Pedestrians who are hit by the bumper of a car in slow speed events make up about a quarter of this patient group as the bumper is at the right height to apply the required forces. Sporting events such as horse riding or falls from a height can also cause this type of fracture. The levels of energy involved in the precipitating events can make a significant difference to the types of fracture which result. Lower energy events more typically cause depression fractures whilst the result of a higher energy occurrence is more likely to be a splitting fracture. The complex nature of these fractures has resulted in many efforts at classification, with Schatzker and co-workers’ now accepted.
On assessment the surgeon will not only assess the fracture itself but the health of the surrounding tissues such as the local muscles, nerves and blood vessels. Around half of tibial plateau fractures may have accompanying injuries to the cruciate ligaments and the cartilages (menisci) which may need surgical intervention themselves. Due to the typical force being in a knock knee direction the medial collateral ligament is more likely to suffer damage than the lateral. Fractures of the medial plateau usually involve more forceful injuries due to the stronger bony areas and this can increase the risk of soft tissue complications.
A range of displacements of the fracture may be acceptable for conservative, non operation, treatment but if the fracture is depressed more than five millimetres the surgeon may decide to lift up the joint surface and bone graft below it. Surgery is essential in fractures to this area which are open (there is a wound connecting to the fracture), cases where compartment syndrome is present and evidence of damage to the blood vessels. Operation is not advised in cases where the fracture is not severe enough and where the soft tissues are too badly damaged to make internal fixation wise.
Once the diagnosis has been established treatment can be started and this can include treatments to reduce inflammation and swelling such as rest, immobilisation, local compression and elevation of the leg. Cutting away any dead or dying tissues, a procedure known as debridement, is very important to maintain the health of the remaining viable tissues. If there is any sign of inappropriately high pressure developing in part of the leg, known as compartment syndrome, the treatment is immediate fasciotomy by opening of the tissue compartments.
Treatment of fractures of the tibial plateau is aimed at restoring the stability of the knee joint, its correct alignment and anatomical relationships of the joint along with full movement in the knee so the knee will function well, is painless and will not suffer arthritic change. If the joint is unstable then surgery will have to be performed, holding the fragments with as little movement as possible. In younger patients with good bone quality then internal fixation may be successful, however older patients with poor bone quality may need to be functionally braced or have total knee replacement.
Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Leeds visit his website.
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Filed under back pain by on Jan 6th, 2010. 
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