Our patient was involved in a road traffic accident and had a suspicion of tibial plateau fracture on the plain radiograph of the knee. Mutiplanar CT imaging helped to diagnose the character of the injury, thus playing a pivotal role in planning the management of the patient.
A 72-year-old lady came off her motorcycle and struck a car sustaining injuries to the right ankle and right knee. She had a fairly complex past medical history and was on long term warfarin following a heart valve replacement. Plain radiographs of the right ankle revealed a Weber B fracture with talar shift of the right ankle and that of the right knee showed a large lipohaemarthrosis with a suspicion of a depressed fracture of the lateral tibial plateau (Fig 1).
The patient subsequently underwent a CT of the right knee, which showed an undisplaced fracture of the proximal medial and lateral tibial plateaus extending to and involving the articular surfaces and the metaphyseal region(Fig 2).
The patient was treated conservatively and made an uneventful recovery.
When imaging knee injuries with bony tenderness, the preferred examination consists of radiographs in multiple obliquities of the knee. Cross-table lateral and AP may be the only views possible in the trauma setting and the cross-table lateral radiograph may be the most important to detect occult fractures. The presence of these subtle fractures may be inferred by the presence of a lipohemarthrosis on the cross-table lateral radiograph, indicating disruption of an articular surface, most often the tibia. Nondepressed tibial plateau fractures occasionally are difficult to appreciate with standard radiographs.
Studies1 have proved that CT is more accurate than conventional tomography in assessing depressed and split fractures when they involved the anterior or posterior border of the plateau and in demonstrating the extent of fracture comminution. Visualisation of split fragments with an oblique plane of fracture is also better by CT. Thus spiral CT with multiplanar imaging has evolved as the preferred investigation while imaging suspected or proven tibial plateau fractures.
The efficacy of MR imaging was compared with CT by some authors2, which revealed MR imaging was equivalent or superior to two-dimensional CT reconstruction for depiction of fracture configuration in most patients. In addition, MR showed significant soft-tissue injuries. However MR imaging in every case would be time consuming and less cost effective.
While planning treatment of patients with tibial plateau fractures, the factors that must be considered include the patient's age and physical condition, the presence and degree of plateau depression, the presence and degree of separation of split fragments, and the severity of fracture comminution.
There are several methods of describing the fractures, including the Schatzker and AO systems. The Schatzker classification3 system, described below
· Type I fractures are split fractures of the lateral tibial plateau, usually in younger patients. No depression is seen at the articular surface.
· Type II fractures are split fractures with depression of the lateral articular surface and typically are seen in older patients with osteoporosis.
· Type III fractures are characterized by depression of the lateral tibial plateau, without splitting through the articular surface.
· Type IV fractures involve the medial tibial plateau and may be split fractures with or without depression.
· Type V fractures are characterized by split fractures through both the medial and lateral tibial plateaus.
· Type VI fractures are the result of severe stress and result in dissociation of the tibial plateau region from the underlying diaphysis.
Undisplaced (Schatzker type V) tibial plateau fracture
Based on the provided anteroposterior and lateral X-ray images of the knee joint, as well as subsequent CT and MRI imaging, the following observations can be made:
Taking into account these imaging findings and the history of trauma, the possible diagnoses and differential diagnoses include:
Based on the patient’s advanced age, history of traffic accident trauma, and the multi-plane CT/MRI findings of irregular articular surface collapse and visible fracture lines, the most likely diagnosis is:
Considering the patient’s older age and the fact that this is an intra-articular fracture, the treatment strategy and rehabilitation goals include:
The rehabilitation plan should adhere to the FITT-VP principles (Frequency, Intensity, Time, Type, Progression, and Individualization), creating a personalized approach for the patient:
Throughout the rehabilitation process, closely monitor knee pain and swelling, and communicate with the physician to ensure safe and effective treatment.
Disclaimer: This report is a reference analysis and does not replace a face-to-face consultation or professional diagnosis. Patients should combine their own medical history, physical examinations, and relevant clinical findings to develop and implement a final treatment and rehabilitation plan under the guidance of qualified healthcare professionals.
Undisplaced (Schatzker type V) tibial plateau fracture
