At the upper end of the tibia is the tibial plateau, an expanded and flat open area of bone which forms the lower part of the knee joint. The plateau has a vital role to play in weight bearing and if this surface is damaged then this can adversely affect the stability, alignment and movement of the knee in gait and standing. These fractures need to be identified early and correctly so that correct treatment can limit any disability and forestall the chances of secondary knee arthritis. Patients in this group fall over 50% of the time into the over 50s age group.

A large group which suffer this type of fracture is older women who already have some degrees of osteoporotic change in the area. Younger people with this presentation more likely result from more high energy events. The usual way these fractures occur is for a sideways force to be applied to the knee (often in a knock knee direction) while the knee is weight bearing with a downward force also applied. The lateral condyle (most commonly) is then squashed down by the large femoral condyle on that side. Sports injuries and falling from a height can result in this injury but it is much more common secondary to a road accident.

Over a quarter of these injuries come from pedestrians being hit by the bumper of a car at relatively slow speeds, the bumper applying the force at a level very close to a typical knee height. Other causes can be a fall from a height or activity related such as horse riding. Fractures may vary in resulting from high or low levels of incident energy, with low energy accidents resulting in the bone been squashed down (depression fracture) and high energy events resulting in splits in the bone at various angles. Because of the complexity of presentation most surgeons accept a classification of these fractures into six groups, proposed by Schatzker and co-workers.

Assessment of the patient will not only include the state of the bone but the condition of the soft tissues which can also be damaged, the blood vessels, nerves and muscles. Tibial plateau fractures are accompanied in about 50% of cases by damage to the knee menisci (cartilages) and the cruciate ligaments which may require surgery. The medial collateral ligament, the ligament on the inside of the knee, is more vulnerable to damage due to the incident forces being more typically on the outside of the knee in a knock knee direction. Medial plateau fractures result from bigger events as the bone is stronger on that side, with more frequent soft tissue problems.

It may be appropriate to accept a number of fracture displacement types for non-operative or conservative treatment but if the fracture depression is over 5 millimetres it may be decided to raise up the depressed surface and place a bone graft under it. If the fracture is an open one (with an open wound) then surgery will be required, as it will in cases of damage to the vascular system and in the case of the development of compartment syndrome. If the fracture is not severe then it should be treated conservatively and operation may be avoided, at least temporarily, in cases where extensive soft tissue damage threatens tissue integrity.

On establishing the diagnoses the management plan can begin and this includes treatments aimed at limiting swelling and inflammation such as keeping the part still, resting, elevating the leg and compression of the area. Debridement, the surgical removal of any dying or dead tissue, is essential to ensure the well being of the remaining healthy tissue. Compartment syndrome, where higher and higher pressures develop in the leg compartments, is an emergency for which fasciotomy (surgical release of the tissues) is indicated.

The treatment aim for these tibial plateau fractures is to regain knee stability, re-align the joint and its anatomical relationship and restore full movement, with a good result being a painless and movable knee with no risk of arthritis. Unstable joints will require surgery with good immobilisation of the fracture. Younger people have denser bone and internal fixation may be successful, while older people with weaker bone may need bracing or knee replacement.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Oxford. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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