44F Trauma and Knee Pain • Xray of the Week
Figure 1. What is the important finding on this xray and CT scan.
Figure 2. Lateral x-ray and sagittal CT demonstrating a tibial plateau fracture (red arrows) with a fat fluid level (yellow arrows). There is also a fibular neck fracture (green arrows).
Tibial plateau fractures include a multitude of intraarticular fractures that can be associated with a variety of injuries such as comminution, ligament or meniscal injury, and articular depression (1). They are often associated with motor vehicle accidents or falls. Tibial plateau fractures occur in 10.3 per 100,000 people annually (2). Men younger than 50 had a higher incidence compared to women, with the highest age frequency being between 40 and 60 in both men and women (2). The most common type of tibial plateau fracture is a split-depression unicondylar fracture (AO classification type 41B3) which can be lateral, medial or involving the tibial spines and one of the plateaus. The Schatzker classification system is used for prognosis, management, and pre-operative planning (3), although, some patterns of injury may not fit into this system (4). Other systems include the Luo, Hohl, and AO classifications.
CT and radiographs are essential imaging modalities to assess tibial plateau fractures (5, 7). Radiographs are useful in detection but may underestimate the fractures in as many as 43% of cases, whereas CT allows a more accurate depiction and enables more precise surgical planning (6). Since this is an intra-articular fracture, plain radiographs may show lipohemarthrosis (Fig. 2) in the joint space, even with subtle fractures (8). It is important to differentiate lipohemarthrosis with simple hemearthrosis which can also occur with tibial plateau fractures (10). MR imaging is useful to depict the internal anatomy of the knee as well as evaluating meniscal and ligamentous injuries associated with the fractures (1). While CT and MR may determine articular depression equally well, MR can demonstrate greater amounts of comminution than CT (1) and is more suitable for diagnosing cartilage lesions (3).
Using the Schatzker classification, tibial plateau fractures may be managed non-operatively if they are nondisplaced (type I), while multiple indications exist for internal fixation including, but not limited to, open fractures, compartment syndrome, and an articular step off of more than 3 mm (8,9).
Barrow BA, Fajman WA, Parker LM, Albert MJ, Drvaric DM, Hudson TM. Tibial plateau fractures: evaluation with MR imaging. Radiographics. 1994;14(3):553-559. doi:10.1148/radiographics.14.3.8066271
Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE. Population-Based Epidemiology of Tibial Plateau Fractures. Orthopedics. 2015;38(9):e780-e786. doi:10.3928/01477447-20150902-55
Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics. 2009;29(2):585-597. doi:10.1148/rg.292085078
Molenaars RJ, Mellema JJ, Doornberg JN, Kloen P. Tibial Plateau Fracture Characteristics: Computed Tomography Mapping of Lateral, Medial, and Bicondylar Fractures. J Bone Joint Surg Am. 2015;97(18):1512-1520. doi:10.2106/JBJS.N.00866
Mellema JJ, Doornberg JN, Molenaars RJ, Ring D, Kloen P; Traumaplatform Study Collaborative & Science of Variation Group. Tibial Plateau Fracture Characteristics: Reliability and Diagnostic Accuracy [published correction appears in J Orthop Trauma. 2016 Nov;30(11):e376]. J Orthop Trauma. 2016;30(5):e144-e151. doi:10.1097/BOT.0000000000000511
Wicky, S., Blaser, P., Blanc, C. et al. Comparison between standard radiography and spiral CT with 3D reconstruction in the evaluation, classification and management of tibial plateau fractures. Eur Radiol 10, 1227–1232 (2000). doi:10.1007/s003300000326
Rafii M, Firooznia H, Golimbu C, Bonamo J. Computed tomography of tibial plateau fractures. AJR Am J Roentgenol. 1984;142(6):1181-1186. doi:10.2214/ajr.142.6.1181
Mthethwa J, Chikate A. A review of the management of tibial plateau fractures. Musculoskelet Surg. 2018;102(2):119-127. doi:10.1007/s12306-017-0514-8
Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968--1975. Clin Orthop Relat Res. Jan-Feb 1979;(138):94-104. https://pubmed.ncbi.nlm.nih.gov/445923/
Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends.
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Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.
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