Tibial plateau fracture overview

# Overview
Tibial plateau fracture is the most common fracture around the knee. The incidence of tibial plateau fracture is approximately 13.3 per 100,000 individuals worldwide. Tibial plateau fracture showed bimodal distribution among women and a unimodal distribution among men. Men had an increasing incidence of fractures until 50 to 60 years of age, followed by a decline in incidence. Women showed a peak incidence between 20 and 30 years of age. The most common classification systems for tibial plateau fracture include Schatzker, Hohl and Moore, Luo's three column concept and AO/OTA classification. The most common cause of tibial plateau fracture is trauma in form of motor vehicle accident and sports injury. Computed tomography (CT) is the gold standard test for the diagnosis of tibial plateau fracture. The non operative management is in the form of above knee cast or hinge knee brace for nondisplaced stable split fractures, fractures in elderly or patients with osteoporosis and minimally displaced or depressed fractures. Surgery is the mainstay of treatment for tibial plateau fractures.

# Historical Perspective
In 1825, Sir Astley Cooper first described fractures of the proximal tibia and recommended treatment by re-alignment, splintage and early passive motion. In 1939, the first classification system was proposed by Marchant. In 1973, Rasmussen introduced open reduction and internal fixation (ORIF) of tibial condylar fractures. In 1979, Schatzker described his classification which is still commonly used today. In 1987, AO/OTA came up with its own classification for tibial plateau fracture.

# Classification
There are multiple classifications available for tibial plateau fracture. The most common classification systems for tibial plateau fracture include Schatzker, Hohl and Moore, Luo's three column concept and AO/OTA classification.

# Pathophysiology
The pattern of fracture and degree of comminution are the resultant of several factors or variables such as the nature of injury, the bone quality, the age and weight of the patient, the energy involved, and the position of the knee and leg at the time of impact. Various combinations of these variables lead to a variety of different fracture patterns.

# Causes
The most common cause of tibial plateau fracture is trauma in form of motor vehicle accident and sports injury.

# Differentiating Tibial plateau fracture from Other Diseases
Tibial plateau fracture must be differentiated from other causes of acute knee pain, restriction of movements, and deformity such as patella fracture, patella dislocation, knee dislocation, ligamentous injury such as anterior cruciate ligament, posterior cruciate ligament, collateral ligaments and meniscal injury

# Epidemiology and Demographics
The incidence of tibial plateau fracture is approximately 13.3 per 100,000 individuals worldwide. Tibial plateau fracture showed bimodal distribution among women and a unimodal distribution among men. Men had an increasing incidence of fractures until 50 to 60 years of age, followed by a decline in incidence. Women showed a peak incidence between 20 and 30 years of age. The median age at diagnosis is 57.7 years for women and 46.8 years for men. There is no racial predilection to tibial plateau fracture. Men are more commonly affected by tibial plateau fracture than women. Surgical management for tibial plateau fracture is done 92% of the cases.

# Risk Factors
Common risk factors in the development of tibial plateau fracture include age, female gender, and health conditions.

# Screening
The risk of tibial plateau fracture due to osteoporosis is threatening, affecting one out of two postmenopausal women and one out of five men older than 50 years. The 10-year risk for osteoporosis-related tibial plateau fracture in a 65-year-old white woman with no other risk factor is 9.3%. According to the guidelines of USPSTF, all women  65 years old along with women < 65 years old with a high risk of fracture are the target of screening for osteoporosis, but there is not any recommendation to screen men for the disease. Dual energy x-ray absorptiometry (DXA) of both hip and lumbar spine bones and quantitative ultrasonography of the calcaneus are two major methods suggested for screening osteoporosis.

# Natural History, Complications, and Prognosis
If left untreated, majority of patients with tibial plateau fracture may progress to develop malunion and loss of range of motion of the knee. Common complications of tibial plateau fracture include knee stiffness, malunion, nerve injuries, and post traumatic arthritis. Prognosis is generally good, with most patients can resume their previous level of activity, including competitive sports.

# Diagnosis

## Diagnostic Study of Choice
Computed tomography (CT) is the gold standard test for the diagnosis of tibial plateau fracture. Computed tomography (CT) with two-dimensional reconstruction in the sagittal and coronal planes provides more detailed information than radiographs. CT is important to identify articular depression and comminution. CT also helps in fracture fragment orientation and surgical planning.

## History and Symptoms
A positive history of pain, deformity, and restricted knee movements is suggestive of tibial plateau fracture.

## Physical Examination
Patients with tibial plateau fracture usually appears well. Physical examination of patients with tibial plateau fracture is usually remarkable for swelling, tenderness, bruises, ecchymosis, deformity  and restricted range of motion of the leg.

## Laboratory Findings
There is a limited role for laboratory tests in the diagnosis of tibial plateau fracture; however, elderly women may have some abnormal laboratory findings suggestive of osteoporosis.

## Electrocardiogram
There are no ECG findings associated with tibial plateau fracture.

## X-ray
Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of tibial plateau fracture. The routine minimal evaluation for tibial plateau fracture must include a antero-posterior (AP) view, oblique and lateral view. The radiological findings include abnormal joint alignment, depressed articular fragments and coronal split fractures.

## Echocardiography and Ultrasound
There are no echocardiography/ultrasound findings associated with tibial plateau fracture.

## CT scan
Computed tomography (CT) with two-dimensional reconstruction in the sagittal and coronal planes provides more detailed information than radiographs. CT is important to identify articular depression and comminution. CT also helps in fracture fragment orientation and surgical planning.

## MRI
Magnetic resonance imaging (MRI) helps in identifying associated meniscal, collateral, and cruciate ligamentous injury.

## Other Imaging Findings
There are no other imaging findings associated with tibial plateau fracture.

## Other Diagnostic Studies
There are no other diagnostic studies associated with tibial plateau fracture.

# Treatment

## Medical Therapy
The non operative management is in the form of above knee cast or hinge knee brace for nondisplaced stable split fractures, fractures in elderly or patients with osteoporosis and minimally displaced or depressed fractures.

## Interventions
There are no recommended therapeutic interventions for the management of tibial plateau fracture.

## Surgery
Surgery is the mainstay of treatment for tibial plateau fractures. Fractures presenting with vascular injury as well as fracture dislocations should be managed emergently. The principles of definitive fixation for tibial plateau fractures include restoration of articular surface and mechanical axis alignment. The fracture fixation depends on fracture pattern. Approach for the fracture depends on fracture pattern and type of implant preferred by the surgeon. The implants commonly used include percutaneous cancellous and raft screws, locking plate, anti-glide plate, and external fixators including Ilizarov ring fixator.

## Primary Prevention
There are no established measures for the primary prevention of tibial plateau fracture. Healthy diet and regular exercises like running and weight lifting help decrease the chances of fracture.

## Secondary Prevention
Effective measures for the secondary prevention of tibial plateau fracture include early detection and management of osteoporosis.