How to Diagnose and Treat 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.

Treatment

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.