Q: A friend of mine fell skiing and you had to surgically fix their tibial plateau fracture. What sort of fracture is this and are these common injuries?
I see tibial plateau fractures fairly frequently here in ski country. Tibial plateau fractures are fractures involving the top of the tibia or shin bone. They can be serious injuries because they entail disruption of not only bone but also disruption of the coating or articular cartilage on the top of the tibia. Remember that the knee joint is a hinge joint in which the cartilage surface on the top of the tibial plateau articulates with the cartilage surface on the end of the femur.
I see these injuries most commonly in skiers. In these injuries, there is usually a sudden rotational force whereby the femur acts like a hammer and punches down a portion of the cartilage and bone on the top of the tibial plateau. The majority of tibial plateau fractures involve the lateral or outer portion of the tibia. This is due to the fact that our legs are more susceptible to forces that load the outside of the knee and also because the bone is typically weaker and less dense on the lateral side of the tibial plateau compared to the medial side. In younger patients with denser, stronger bone, there is more energy required to break the bone and the plateau usually splits. In older patients with softer, less dense bone, less energy is required to fracture and the bone and cartilage are typically crushed and depressed. The more energy involved in the injury, the more displaced and shifted the fracture is. In rare cases, the nerves and blood vessels to the foot can also be injured.
Most patients who have these injuries report hearing and/or feeling a pop and having immediate pain and swelling. This is not unlike what people report to me after they tear their ACL. There is usually immediate swelling and pain. Patients are normally not able to bear weight on the knee due to pain.
These patients usually come to the emergency room and there I obtain radiographs and a CT scan. A three-dimensional reconstruction CT scan is very helpful in showing all the different fracture lines and the location of the displaced pieces so that the surgeon can do a better job of putting the displaced pieces back where they belong.
If a tibial plateau fracture is displaced less than 2-3 mm, then it does not need surgery and the patient should do well. However, in most of these injuries the bone and cartilage are displaced more than this and these need surgery to try to restore the normal cartilage surface of the tibial plateau. Some of these fractures can be treated arthroscopically through small, minimally invasive incisions. However, most of these fractures are badly displaced and need to be fixed through a moderate-sized incision. After surgically restoring the depressed bone and cartilage fragments back to their normal position, hardware is applied to the tibial plateau to hold these fragments in place so that they heal in the proper position. Orthopedic implant companies now make pre-contoured locking plates to fix these fractures which have helped surgeons a great deal. These plates are lower profile than the big old bulky plates used in years past and the newer plates are stronger and fit the normal contour of the tibial plateau better.
After surgery, patients cannot put any weight on the affected leg for eight to 10 weeks. However, I get these patients in physical therapy right away to work on knee range of motion so that we can limit stiffness in the knee joint. There is no cast, but patients are placed in a knee brace for eight weeks. This brace also allows for the medial collateral ligament to heal, as it is often torn with these lateral tibial plateau fractures.
Although tibial plateau fractures are more serious fractures given that they involve the cartilage surface of the knee joint, patients can recover and get back to all their activities.
Dr. Rick Cunningham is a Knee and Shoulder Sports Medicine Specialist with Vail-Summit Orthopaedics. He is a physician for the U.S. Ski Team and chief of surgery at Vail Valley Medical Center. Do you have a sports medicine question you’d like him to answer in this column? Visit his website at www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit www.vsortho.com.