Characteristics

• Increasingly seen in the elderly (approx 10% of fractures seen in the elderly).

• Intra-articular injury and thus result in loss of joint congruity.

• Lateral tibial-plateau fractures are most common.

• Beware avulsion fracture of the lateral tibial plateau (Segond fracture) as this is often associated with anterior cruciate injury – see soft tissue knee.

• Medial plateau fractures are uncommon and may be associated with lateral ligament ruptures and common peroneal nerve palsy.

• Classified according to Schatzker – types I–VI (see table).

• 50% have a meniscal injury and 30% have an associated ligamentous injury.

Clinical features

• Suspect in a non-weight-bearing patient with history of fall or RTA.

• Bruising, joint effusion, deformity (usually valgus) of the knee.

• The clinical effusion is due to a lipohaemarthrosis and is often tense.

• Always examine and document the neurovascular status as the relatively immobile popliteal vasculature and peroneal nerve can be damaged, especially in bicondylar and medial plateau fractures respectively.

• Further examination under GA (after bony ORIF) to assess ligament damage.

Radiological features

• AP and horizontal lateral are usually enough, although a subtle fracture may be revealed on an oblique film.

• Look for a lipo haemarthrosis on the horizontal-beam lateral X-ray.

• Look closely for bony avulsion fragments and widening of the joint space in the unaffected compartment as these are suggestive of associated ligamentous injury.

• CT is useful in planning surgery.

• MRI is useful for soft-tissue information – menisci and ligaments particularly.

Management

• ABCs, assess soft tissues, neurovascular status and immobilise with backslab.

• Non-operative treatment includes immobilisation in plaster followed by hinged cast and rehabilitation – suitable for minimal articular damage particularly in the elderly patient.

• For the majority of displaced fractures, open reduction and internal fixation possibly with arthroscopic assistance is required.

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