Tibial Plateau Fractures

For Medical Students

What It Shows

A tibial plateau fracture involves the articular surface of the proximal tibia, so the question is always about the surface rather than the shaft. 5.2.2 covers the image formation.

The radiograph shows the cortical break, the depression of the surface and how far the fracture extends. 5.3.1 covers the anteroposterior view.

It matters because the surface's displacement decides the operation, and a projection measures displacement poorly. 5.16.2 covers tibial plateau fractures on computed tomography.

How It Is Acquired

Obtain anteroposterior and lateral views, since a depression visible on one may be hidden on the other. 5.3.2 covers the lateral view.

Look at the subchondral line for a step, a break or a discontinuity. 5.3.1 covers the anteroposterior view.

Look for a lipohaemarthrosis on a horizontal beam lateral, which indicates an intra-articular fracture. 5.5.12 covers the bursa.

Assess the fibular head and the proximal tibia for associated fractures. 5.3.15 covers Segond fractures.

Proceed to computed tomography for any fracture involving the surface, because the plain films understate it. 5.16.2 covers tibial plateau fractures on computed tomography.

What Normal Looks Like

A continuous subchondral line across both plateaux on both views.

Smooth metaphyseal cortices without a lucent line or a buckle.

No intra-articular fluid level on a horizontal beam lateral. 5.5.12 covers the bursa.

Trabecular pattern uninterrupted through the metaphysis. 5.2.1 covers the generation of X-rays.

What Abnormal Looks Like

A step or a discontinuity in the subchondral line. 5.3.1 covers the anteroposterior view.

A depressed segment of articular surface, which may be visible on only one view. 5.3.2 covers the lateral view.

A vertical split extending from the surface into the metaphysis.

A fat and blood level in the suprapatellar region, indicating that the fracture reaches the joint. 5.5.12 covers the bursa.

MRCS Level

How It Is Acquired

In a viva the expected answer moves from the plain films to computed tomography and says why.

The expected points are the two views, the subchondral line, the lipohaemarthrosis, the associated fractures, and the computed tomography.

Say that the plain films screen and the computed tomography plans. 5.16.2 covers tibial plateau fractures on computed tomography.

Say that a posterior fragment is the pattern plain films miss most. 5.16.8 covers three dimensional reconstructions.

Say that a soft tissue injury accompanies these fractures more often than is reported. 5.9.3 covers deep medial collateral injuries.

What Abnormal Looks Like

The reasoning expected is that a projection sums everything along the beam, so a depression whose walls are oblique to both standard beams can leave the subchondral line looking continuous. 5.2.2 covers the image formation.

Posterior fragments are the clearest case, because the standard views project them behind the rest of the plateau. 5.16.2 covers tibial plateau fractures on computed tomography.

The articular depression that decides the operation is therefore the measurement the plain film is least able to give. 5.2.5 covers magnification.

These are high energy injuries in younger patients and low energy in older ones, and the associated ligamentous and meniscal injuries follow that split. 5.6.9 covers root tears.

How Good It Is

The plain films detect these fractures reliably and measure them poorly.

Their best contribution is detection and the decision to obtain a computed tomography study. 5.16.1 covers the fracture assessment.

They are limited for depression depth, fragment number and posterior involvement, all of which are the operative parameters. 5.16.2 covers tibial plateau fractures on computed tomography.

No figures appear for accuracy on this page, under decision 028, and no displacement or depression thresholds appear either: the operative thresholds are published quantities and this environment cannot check them.

FRCS Level

How Good It Is

At decision level the plain films establish that there is a fracture and almost nothing else that matters.

Any articular involvement needs a computed tomography study before planning, which makes the plain film's role a triage one. 5.16.2 covers tibial plateau fractures on computed tomography.

A three dimensional reconstruction changes the approach chosen, particularly where a posterior fragment exists. 5.16.8 covers three dimensional reconstructions.

A magnetic resonance study adds the meniscal and ligamentous injuries, which are commoner than the plain films suggest and change the operation. 5.6.9 covers root tears.

A low energy fracture in an older patient raises insufficiency rather than trauma, which changes the whole assessment. 5.13.4 covers insufficiency fractures.

Where It Misleads

The commonest error is accepting plain films as sufficient for planning. 5.16.2 covers tibial plateau fractures on computed tomography.

A posterior fragment is missed because both standard views project through it. 5.16.8 covers three dimensional reconstructions.

Depression is measured on a projection and underestimated. 5.2.5 covers magnification.

A lipohaemarthrosis is not sought, so an occult intra-articular fracture is missed. 5.5.12 covers the bursa.

The associated soft tissue injuries are not looked for at all. 5.9.3 covers deep medial collateral injuries.

Fellowship Level

Where It Misleads

At fellowship level the plain film's role in these fractures has shrunk to triage and the classification systems built on plain films have not.

The widely used classifications were defined on radiographs and group fractures that computed tomography shows to be mechanically different, particularly in the posterior column. 5.16.2 covers tibial plateau fractures on computed tomography.

Column based descriptions derived from computed tomography correspond better to the approach needed, and the two systems coexist in the same conversation. 5.16.8 covers three dimensional reconstructions.

The soft tissue injuries are under-recognised because the fracture dominates the assessment, and a meniscal root or a posterolateral corner injury left unaddressed outlasts the fracture. 5.10.3 covers posterolateral corner injuries.

Weight bearing computed tomography after fixation measures the surface under load, which is the outcome that matters and is not routinely assessed. 5.18.5 covers weight bearing imaging.

The defensible position is that the radiograph detects, computed tomography plans, magnetic resonance imaging completes the injury, and the classification should match the study it was derived from. 5.16.1 covers the fracture assessment.