Tibial Head Fracture

What is a tibial plateau fracture?

The term tibial plateau fracture refers to a broken tibia bone close to the knee joint.  

The tibia, also called the shinbone in medical terms, makes up the lower leg together with the fibula. Along with the femur and indirectly with the fibula, the tibial head constitutes the knee joint. Therefore, the bone plays a major role in the stability of the lower leg. 

The tibia can break at various points as well as in combination with the fibula or alone. A tibial plateau fracture occurs near the knee joint.  

Tibial plateau fractures can be classified into particular fracture types clinically. The decisive factors are, on the one hand, the severity of the fracture and, on the other hand, whether the knee joint has been affected by the injury. In addition, dislocation fractures are differentiated. In such case, the tibial plateau is displaced from the knee joint, referred to as dislocation.  

This classification is crucial for choosing the correct therapy.

What are the causes of a tibial plateau fracture?

A tibial plateau fracture can have a variety of causes, but usually traumatic events lead to fractures of the tibial plateau. In most cases, a strong force from the side is acting on the knee joint together with a twisting movement.  

Young patients, especially men, often sustain fractures due to traffic accidents or sports injuries. One typical accident mechanism is the impact of a car on the side of a pedestrian's knee. This often causes so-called comminuted fractures involving multiple bone fragments, as well as severe damage to the adjacent soft tissue.  

In elderly patients, falling on the knee joint can cause such fractures. In this case, females are more likely to be affected than males.

Symptoms of tibial plateau fracture

Patients who suffer tibial plateau fractures mainly complain of severe pain, which gets worse with movement. There is also swelling, bruising, and palpable or even visible deformity as a result of the fracture. A phenomenon called crepitation is another fracture sign, where bone fragments grind against each other and cause a creaking sound.  

Soft tissue damage, particularly to the knee joint, like tears of ligamentous structures or menisci, is not rare and can produce more pain, restricted movement or more specific signs like joint effusions. Since tibial plateau fractures usually occur as a result of trauma, there are many patients who are brought to a hospital emergency room with a general inability to walk or stand.

How is a tibial plateau fracture diagnosed?

The first step is to take a thorough patient history and determine the exact history of the accident. This is followed by a physical examination of the knee joint as well as a test of the intact sensitivity, blood circulation and motor function of the affected leg.  

Subsequently, an X-ray of the knee joint is obtained. For more complicated fractures, a CT scan is also initiated especially if the fracture requires surgery.  

Further imaging modalities will depend on potential additional injuries such as soft tissue damage. For instance, an ultrasound or MRI examination may be performed to check the ligamentous structures of the knee joint.  

For every fracture, but particularly for complicated ones, circulatory disturbances and nerve injuries always have to be ruled out.

What is the treatment for a tibial plateau fracture?

Generally, the fracture can be managed conservatively or surgically. Each treatment is intended to reduce pain with the shortest possible immobilization time, to restore functional mobility and resilience, and to achieve a correct axial and joint position. 

Conservative therapy 

Purely conservative treatments are carried out if individual patient factors make surgery inadvisable, such as general health, expected wound healing disorders, or certain associated diseases. 

Moreover, a tibial plateau fracture itself may fulfill certain requirements to offer a good chance of recovery without surgery. Simple, stable fractures with no involvement of the knee joint and without substantial soft tissue damage can normally be expected to have a good chance of successful conservative treatment. 

At first, thrombosis prophylaxis is started and must be maintained until the leg is fully weight-bearing. If the fracture is slightly displaced, a so-called reduction has to be carried out first, ensuring that the bone fragments are correctly aligned again.  

Both the upper and lower leg are then immobilized with a split plaster splint to prevent tissue damage in case of any swelling. After a certain period of time, a cast can be applied to the entire leg or the patient can be fitted with a special walking cast.

Once the pain eases, the patient can start with passive weight-bearing and later also active weight-bearing. As part of physiotherapeutic care, the intensity of the load is continuously increased. To ensure a reasonable adaptation of the load, regular follow-up checks by means of X-ray examinations are important. 

Conservative treatment of tibial plateau fractures is rarely used, as it is usually associated with complications. In some cases, if the fracture does not heal well or in the wrong position, surgery may become necessary after all.  

Particularly for older or seriously ill patients, conservative therapy provides the opportunity of treating the fracture without a high-risk operation. The benefits must always be weighed against the risks.

Surgical therapy 

There are many indications for surgery. All open fractures, vascular and nerve injuries, as well as soft tissue injuries are considered emergency surgical treatment. Generally, unstable fractures as well as fractures with joint involvement and irregular joint surfaces make surgery necessary. 

A number of procedures are employed, depending on the type of fracture.  

Simple fractures are most often managed with screws and can even be operated on in a minimally invasive fashion using arthroscopy. Besides reduced tissue damage, another advantage is that damaged ligaments or menisci can be repaired at the same time. 

So-called impression fractures are fractures where external force has depressed parts of the bone. A special ram technique is used here, during which the depressed bone is practically pushed up again from below, so that the normal bone edge is restored. Bone defects can subsequently be filled with bone material extracted directly from the iliac crest.  

For more complex fractures, plate systems are used more frequently, allowing several fragments to be screwed together. Such plates are specially shaped to fit the tibia and are secured with a variety of screws.  

Follow-up care and chance of cure  

A typical follow-up regimen after surgery is to rest the affected leg for a period of 6-12 weeks. Subsequently, X-ray follow-up checks dictate the extent to which weight-bearing activities should be increased or adjusted.  

Patients are provided with an individualized follow-up treatment regimen after a tibial plateau fracture, specifying the exact weight-bearing and range of motion.  

For a successful therapy, early mobilization in the context of physiotherapy is essential. At first, the affected extremity is exercised passively, for instance with a special motion splint.  Later on, walking exercises and lymphatic drainage are introduced, and active training is continuously increased in accordance with progress monitoring. Static holding exercises can also train the musculature.  

The degree to which movement and weight-bearing are possible again depends to a great extent on the type of fracture, the selected therapy and the individual patient's circumstances. The general guideline is for the leg to be stable for movement in the first six weeks and stable for weight-bearing again from the 7th week onwards.  

With proper management, both conservative and surgical treatment can achieve very good results.

Complications of a tibial plateau fracture 

In principle, every tibial plateau fracture bears risks and various complications may develop. Above all, these include nerve damage, circulatory disturbances or infections. Following operative treatment of the fracture, there is also a risk of thrombosis.  

A feared complication of fractures in the lower leg and knee area is the so-called compartment syndrome. This involves severe pressure within a muscle compartment of the lower leg caused by bleeding or swelling, for example. As a result, nerves can be severely and irreversibly damaged, so that the fastest possible surgical therapy must be initiated.   

A detailed diagnosis, in which above all the blood circulation and the integrity of the nerves are tested, enables the early detection and adequate treatment of the complications of a tibial plateau fracture.

Late consequences of a tibial plateau fracture 

As tibial plateau fractures are frequently complicated fractures arising from major accidents, there may be a number of late complications even after treatment has been completed.  

Particularly in the case of complex fractures or severe trauma, these include misalignment, joint instability, or loss of function. One common late complication following a tibial plateau fracture is post-traumatic gonarthrosis.  

Gonarthrosis refers to joint wear and tear with loss of protective cartilage in the knee joint. Although this is part of the natural aging process, it can be favored by the fracture that has taken place.  

Damage to the cartilage caused by the fracture or a malposition of the knee joint can be the reason for this. As a result, there is an unbalanced load on the joint and arthrosis develops.  

Regular checks should be carried out after a tibial plateau fracture in order to recognize and treat possible late complications at an early stage.

Which doctors and clinics specialize in the treatment of a tibial plateau fracture?  

The optimal treatment of tibial plateau fractures is provided by specialists in orthopedics and trauma surgery. For more serious fractures requiring surgery, they should be specialists with a surgical focus.

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