Tibial Plateau Fractures
Tibial plateau fractures are common ski injuries. On a given winter weekend of taking orthopedic emergency room call, I will see several of these on average. Patients usually describe a sudden twisting type force to the knee while skiing and may also report hearing or feeling a pop, and having swelling and pain.
Tibial plateau fractures are fractures of the top part of the tibia or lower leg bone. The knee joint is made up of the bottom end of the femur gliding on the top part of the tibial plateau. The top of the tibia and the bottom of the femur are covered in white, articular cartilage, much like the cartilage on the end of a chicken bone. When one fractures the tibial plateau, they not only break the bone of the tibia but also crack this white coating cartilage. This is what makes these injuries more severe than simply breaking the mid shaft of the tibia or a so called “boot top fracture.”
Depending on the amount of energy that caused the fracture and the age of the patient and relative density of one’s bone, the tibial plateau can break as one clean split, or in worse cases, the cartilage and bone can be splintered into many small pieces. I typically see split fractures of the tibial plateau in young patients, whereas in older patients, the bone and cartilage are typically more depressed and in multiple fragments. However, it is not uncommon to see a young person suffer a terribly depressed and multi-part fracture of the tibial plateau from landing a big jump “flat” in the terrain park. In these cases, patients can fracture both the medial and lateral tibial plateaus. In these high energy fractures, there can be severe associated soft tissue, nerve and even blood vessel damage and some of these injuries are limb threatening.
In the emergency room, we obtain xrays but once the diagnosis of a tibial plateau fracture is made, then a thin cut 3D CT scan of the knee is obtained. This shows in detail all the fracture lines and the amount of displacement of the bone fragments.
If there is not too much soft tissue swelling, these fractures can be surgically repaired right after the injury. In surgery, an incision is made over the fracture site and the fractured fragments of bone and cartilage are re-aligned as best as possible and are then held in place with a low profile, anatomically contoured metal plate and screws that lock into the plate at fixed angles. There is typically voids left in the bone due to the bone being compressed and then lifted back up into place in surgery and these bone voids are filled with cadaver bone which provides a latticework over which the patients bone can grow. Patients can have associated meniscal tears that are also repaired at the time of surgery.
Patients are usually in the hospital for a few days for pain control, nursing care, and physical therapy. In most cases, the patient cannot put any weight on the knee for at 8-12 weeks or else the bone and cartilage fragments might be pushed back down and displace once again. During the first 8 weeks, physical therapy is critical in order to start knee range of motion and prevent stiffness in the knee. Patients are also placed on a blood thinner medicine to prevent blood clots from forming after surgery.
Long term, patients can do reasonably well but there is an increased risk for having some residual stiffness in the knee. Some patients with more severe fractures may develop posttraumatic arthritis and associated pain and swelling. However, many patients are able to resume many of the activities that they enjoy once they heal their tibial plateau fracture and get their strength back.