In this review article the authors summarise current understanding of the many issues of tibial plateau fractures. The article is quite easy to read and you can find the online original if you click the link above.
High- or Low-energy trauma?
Tibial plateau fractures may result from both high energy and low energy accidents, but complex fractures are generally related to high energy insults. However, because older patients may have weak bones because of osteoporosis, even low energey impacts in this patient group may result in quite complex fracture patterns. Soft tissue damage tends to be worse in high energy incidents, but may similarly be quite significant even in the low energy group.
Does age matter?
The authors point out that tendency for this fracture to occur in two age groups - young adults and 'third age' adults - raises questions about what is the best approach to management in these two groups. With limb fractures in general one must pay attention to fracture reduction, limb alignment, knee stability and range of motion, but in the older patient in particular an imperfect reduction may still result in acceptable return to function.
Assessment of associated soft tissue injury
Soft tissue damage related to a tibial plateau fracture may be substantial the authors stress, particularly if the blood supply to the limb has been compromised by local tissue swelling and inflammation, which may then result in skin blistering and damage to muscles remote from the fracture site. Attention to the soft tissues should be prioritised, usually by urgent limb immobilisation in a splint and cold (cryo) therapy, and the bony injury itself only dealt with once the soft tissues are out of danger. In complex cases the joint can be 'splinted' using an external fixator, and definitive surgery on the fracture undertaken only once the soft tissues have settled down.
Diagnosis and classification
Initial X-ray views should be in different planes - AP (anteroposterior), lateral and oblique, but a CT scan should be undertaken early as it is somewhat more accurate in assessing fragment displacement and an MRI scan is also useful for identifying associated soft tissue problems such as meniscal and ligament tears. The authors refer to a 2005 study by Gardner et al who analysed over 100 patients with various kinds of tibial plateau fracture and found that "99% presented associated soft-tissue injuries and 77% a complete anterior cruciate ligament (ACL) or LCL injury, whereas 81% presented with a significant lateral meniscal tear and 44% a medial meniscus tear."
Tibial plateau fractures are generally classified using the Schatzker Classification system, but there is also an AO/OTA system of classification. Neither is apparently fully perfect, and the authors suggest that considering the top of the tibia as being composed of 'three columns', with fractures described according to how many of the columns are affected, has improved understanding of how to manage these fractures.
Surgery - indications and technique
As a general pronciple, tibial plateau fractures will require surgery, but operation may depend upon the patient's fitness for surgery, their ability to follow a rehabilitation regime and the nature and extent of soft tissue injuries. Depressed segments can be elevated and bone wedged underneath to hold the position until healing takes place. For displaced fragments, these surgeons would generally choose between a percutaneous, arthroscopically-assisted technique or an open technique to achieve an anatomical reduction of the fragments and fixation of the same so that the patient can begin to mobilise the joint. In complex situations staged open reduction and internal fixation is optimal, but some surgeons like to use an external fixator to give them control of the situation over time. They go into considerable technical detail which is interesting reading.
They explain that the complexity of the fracture does not necessarily correlate with the outcome, but results are seldom perfect and only half of the patients that played sport went back to their previous sporting activity level and osteoarthritis is a common long term problem leading often to total knee replacement.