From EMRAP Episode:
Take Home Points
❏ Tibial plateau fractures from higher energy mechanisms of injury are at increased risk of compartment syndrome.
❏ If moving the big toe up and down causes significant pain, you should be very concerned for compartment syndrome.
❏ CT scans are useful for determining need for operative intervention.
Diagnosis
How frequently are plain films negative? There isn’t good literature available. However, anecdotally, it happens a lot.
When should we suspect an occult tibial plateau fracture? If the patient has a large effusion and a mechanism consistent with a tibial plateau fracture (for example, the patient was hit from the side by a car), you can obtain oblique views with the knee internally and externally rotated about 15-20 degrees. This can sometimes identify medial or lateral plateau fractures without a CT scan.
Do you need to get a CT scan? This is useful for determining operative repair. CT scans will allow you to determine the amount of depression. Guidelines determine management based on the depth and width of the segment. Sometimes a lateral plateau fracture identified on plain films will have an associated medial plateau fracture identified on CT which will change management.
Missed diagnosis of tibial plateau fractures rarely requires significant surgical intervention. Patients with lateral tibial plateau fractures may have up to 1cm of depression but still do ok. However, continued weight-bearing can worsen the depression.
The tibial plateau is an important part of the knee joint. Tibial plateau fractures are inherently intra-articular. They can cause long term disability due to joint degeneration.
Management
Should we check the compartment pressure? It depends on your consultant. Ramadorai views compartment syndrome as a clinical diagnosis and advises treatment if it is suspected.
Who needs surgery? Depression greater than 5mm of the segment. This is best measured on a CT scan. Condylar widening greater than 6mm. This is associated with increased risk of meniscal injury. Schatzker categories IV, V and VI need to be treated surgically. Any neurovascular injury, compartment syndrome or open fracture needs operative repair.
Elderly patients with multiple comorbid conditions and minimal displacement may be treated nonoperatively.
How should you treat patients who will be managed non-operatively? Patients should be non-weightbearing.
Patients can be placed in a knee immobilizer in the ED. They will need to transition to a knee brace with a hinge as soon as possible. Patients should be evaluated by an orthopedic surgeon within a week.
Range of motion exercises should start within 1-2 weeks. Passive range of motion with physical therapy followed by active range of motion and on to a graduated weight bearing protocol at 6-8 weeks. Should the patient sleep in the knee immobilizer? Yes, for the first few weeks.
Patients with a tibial plateau fracture that will require operative management may be discharged from the ER. You need to make sure they don’t have compartment syndrome or neurovascular injury. They need to follow-up with the orthopedic surgeon in 5-7 days.
Patients with Type IV-VI fractures may require admission for pain control and monitoring.
Consultation and Classification
The Schatzker classification:
o Type I. This is a lateral split fracture. There is no depression or displacement.
o Type II. This is a pure depression fracture. This generally happens in patients with osteoporosis.
o Type III. This is a lateral split with depression. The width and depth of the depression will determine treatment.
o Type IV. This is the most uncommon type. This is a fracture of the medial tibial plateau. These have a high rate of neurovascular injury (involving the popliteal artery and the peroneal nerve) and can be considered equivalent to a knee dislocation.
o Type V. This involves both the medial and lateral columns. These usually stem from high energy injuries. They have a higher risk of compartment syndrome and compromise of the skin.
o Type VI. These are really bad. The fracture involves the medial and lateral plateaus and extends into the diaphysis of the tibia. The proximal fibula may be involved.
What should you say to the consulting orthopedist? You don’t necessarily need to memorize the Schatzker classification system. The most important details are the neurovascular exam, degree of pain and the degree of swelling of the compartments. If the patient is at risk of vascular injury or compartment syndrome, the orthopedic surgeon will need to come in and perform external fixation.
How should you describe the fracture? Is it medial or lateral? Is it bicondylar? Is it significantly depressed? What was the mechanism of injury?
Why is the mechanism of injury important? Higher energy tibial plateau fractures have a higher rate of compartment syndrome. These usually develop within 6-12 hours after the injury. The patient will have significant swelling and tend to have pain with passive motion. If moving the big toe up and down causes significant pain, you should be very concerned for compartment syndrome.