35 year old M presents after spending the weekend doing parkour. The patient is able to bear weight. There is a moderate knee effusion and diffuse pain.
What is your diagnosis?
What do you have to rule out?
What causes this diagnosis?
What is your management?
What is your disposition?
When would you consult orthopedics?
See below for answers!
What is your diagnosis?
This is a tibial plateau fracture with displacement of a small bone fragment in the central posterior region of the tibial plateau with joint effusion.
PEARL: Tibial plateau fractures are classified in the Schatzker system which divides the fractures into six types based upon fracture fragment anatomy and fracture pattern. The AO/OTA classification for proximal tibia fracture groups them into: extra-articular, partial articular fracture and complete articular fracture.
What do you have to rule out?
Additional damage to neurovascular structures, menisci, ligaments, and compartment syndrome.
PEARL: Tibial fractures are the most common cause of acute compartment syndrome. Compartment syndrome occurs in 2-9% of all tibial fractures.
What causes this diagnosis?
Direct blows to the knee with forces directed medially, laterally, or axially including knee hyperextension injuries. In many cases, the medial or lateral femoral condyle acts as an anvil imparting a combination of both shearing and compressive force to the underlying tibial plateau.
What is your management?
Strict non-weight-bearing, splinting knee in near-full extension, analgesia, and RICE.
What is your disposition?
If fracture is stable in extension and minimally displaced, place in brace, and follow up with sports medicine in 2 weeks.
When would you consult orthopedics?
If there is an open fracture, neurovascular compromise, extensive intra-articular, or multi-fragmentary metaphyseal fracture (i.e. Schatzker >4).
References:
Armstrong, A., & Hubbard, M. (2016). Essentials of Musculoskeletal Care 5. American Academy of Orthopaedic Surgeons.
Khodaee, M., Waterbrook, A., & Gammons, M. (2020). Sports-related Fractures, Dislocations and Trauma. Springer.
Xie X, Zhan Y, Wang Y, Lucas JF, Zhang Y, Luo C. Comparative Analysis of Mechanism-Associated 3-Dimensional Tibial Plateau Fracture Patterns. J Bone Joint Surg Am. 2020 Mar 4;102(5):410-418. doi: 10.2106/JBJS.19.00485. PMID: 31855868.
Stella M, Santolini E, Sanguineti F, et al. Aetiology of trauma-related acute compartment syndrome of the leg: A systematic review. Injury. 2019;50 Suppl 2:S57-S64. doi:10.1016/j.injury.2019.01.047
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