Tibial Plateau Fracture Imaging 

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Although tibial plateau fracture was originally termed a bumper or fender fracture, only 25% of tibial plateau fractures result from impact with automobile bumpers. The most common mechanism of injury involves axial loading, such as results from a fall. Other patterns of injury result from laterally directed forces or from a twisting injury. In all cases, force is directed from the femoral condyles onto the medial and lateral portions of the tibial plateau, resulting in fracture. In younger patients, the most common pattern of fracture is splitting, while in older, more osteoporotic patients, depression fractures typically are sustained.

Examples of tibial plateau fractures are provided in the images below:

Tibial plateau fractures are often associated with soft tissue injuries, with the lateral meniscus and the anterior cruciate ligament (ACL) being the most common structures affected.  ^{[1, 2]}  In a retrospective study of 265 patients with posterolateral tibia plateau fractures, the incidence of anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL), lateral meniscus, and medial meniscus injuries were assessed from MRI. ACL and PCL tears were present in 80% and 36%, respectively; LCL injuries were present in 76% of patients; and 64% had MCL injuries. The incidence of lateral meniscus tears was 48%, and that of medial meniscus tears was 4%. ^[1]

Medial plateau injuries may result in fracture of the fibular head, which may injure the peroneal nerve or may be associated with popliteal artery occlusion. Patients may present with a knee effusion, pain, and joint stiffness. Finally, although severe fractures often are repaired surgically, both operatively and nonoperatively treated fractures are at risk of developing posttraumatic osteoarthritis as a result of ligamentous injuries with resultant instability, as well as articular discongruities, biomechanical alteration of normal compressive forces, and cartilage damage.

The preferred examination consists of radiographs in multiple obliquities of the knee. ^[3] Typically, these include anteroposterior (AP), cross-table lateral, patellar (sunrise), and, possibly, oblique views. Cross-table lateral and AP may be the only views possible in the trauma suite. In this setting, 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. Cross-table lateral radiographs may demonstrate a lipohemarthrosis within the joint, with layering of bone marrow fat upon blood.

If lipohemarthrosis is present, an intra-articular fracture is present and must be located. In this situation, axial CT is an excellent tool for defining fracture anatomy using reconstructed images in the sagittal and coronal planes.The images below demonstrate the radiographic, computed tomography (CT), and magnetic resonance imaging (MRI) appearance of lipohemarthrosis.

CT is used by most orthopedists to further characterize fractures of the tibial plateau and assess the depression of the tibia and the degree of diastasis (splitting) of the fractured parts to plan for surgical intervention. Generally, slice thickness should be minimized (1 mm is ideal), and high milliamperage-second (mAs) technique should be used. ^{[4, 5, 6]}  MRI may be used as well for this determination but often is not readily available. MRI is excellent for depicting ligamentous and meniscal injuries. Arteriography (and possibly MR angiography) may be used if popliteal artery injury is suspected. ^{[7, 8, 9, 10]}

Brunner et al found that CT scanning improved the interobserver and intraobserver reliability of the Schatzker, OTA/AO, and Hohl classification systems for tibial plateau fractures. The 3 systems showed moderate interobserver reliability and good and moderate intraobserver reliability when based only on findings on plain radiographs. Interobserver and intraobserver reliability improved significantly when CT was added. ^[11]

According to Mustonen et al, although postoperative multidetector-row CT (MDCT) scanning of tibial plateau fractures is performed infrequently, it can in most cases reveal clinically significant information. In their study, the main indications for MDCT were assessment and follow-up of the joint articular surface and evaluation of fracture healing. Postoperative MDCT revealed additional clinically important information in 81% of patients, and 39% underwent reoperation. Orthopedic hardware caused no diagnostic problems with MDCT. ^[12]

Nuclear medicine studies are not used in the diagnosis of tibial plateau fractures unless a stress-type fracture is suspected or there is concern that osteomyelitis exists.

Type IV fractures involving the medial tibial plateau raise concern that the popliteal artery has been injured. These arterial injuries can be clinically silent or present with decreased peripheral pulses. If clinical concern exists that a popliteal artery injury has occurred with any fracture type, obtain an arteriogram (or possibly an MR angiogram). Surgical manipulation of the tissues surrounding an injured popliteal artery can result in thrombosis, with dire consequences unless the thrombosis is addressed immediately. However, angiography is not used for the primary detection of tibial plateau fractures.

Many methods have been developed to classify tibial plateau fractures, but all available classification systems for tibial plateau fractures are limited by their reliability and reproducibility.  The Schatzker system has been found to have fair to substantial interobserver reliability. More sophisticated imaging modalities such as 2D and 3D CT typically improve reliability estimates. ^{[13, 14, 15]}  Most fractures of the tibial plateau are diagnosed readily by conventional radiography. A false-negative radiograph may be encountered on the rare occasions in which a fracture is present but only a lipohemarthrosis is visualized. In these patients, CT or MRI is required to visualize the fracture.

The Schatzker system is depicted in the images below. ^[3]

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Type I fractures (demonstrated in image below) are split fractures of the lateral tibial plateau, usually in younger patients. No depression is seen at the articular surface.

Type II fractures (shown in images below) are split fractures with depression of the lateral articular surface and typically are seen in older patients with osteoporosis.

Type III fractures (shown in image below) 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 (demonstrated in the images below) are the result of severe stress and result in dissociation of the tibial plateau region from the underlying diaphysis.

In most patients, CT scanning mimics the findings of conventional radiography. With reconstruction of the axial images into coronal and sagittal planes, precise localization of surgical landmarks, as well all fracture fragments, is obtained. CT is critical in formulating a surgical plan for Schatzker type IV, V, and VI fractures. ^[16]

Although, as previously mentioned, most fractures of the tibial plateau are diagnosed readily by conventional radiography, CT often is used to confirm the anatomic relationship of fracture fragments with more complex fractures. This is especially true at the articular surface of the tibia, where precise 3-dimensional anatomy is critical to the success of surgical repair. Less comminuted and depressed fractures may not require imaging by CT.

The value of CT is in the speed and availability of the technique. In addition, most patients with extensive injuries also undergo CT of other portions of the body in the trauma setting. With current scanners, image thickness of 1 mm or less is possible, which generally yields unequivocal depiction of fracture patterns. However, for a full depiction of soft tissue injury, such as ligaments and menisci, MRI is superior. ^{[8, 10]}

False-negative errors with CT  can occur when only axial imaging is used. If a fracture predominates in the axial plane, it may be overlooked by CT. However, in most instances, sagittal and coronal reconstructions of axial data, as shown in the images below, are used to avoid this problem. By reconstructing the initial data set into different planes, additional information such as articular depression and diastasis may be obtained easily. False positives are not common with CT.

MRI is very sensitive to the presence of osseous injury. Injuries to osseous structures manifest as areas of edema within bone marrow. However, fractures through the cortex are less well depicted, as cortical bone appears as an area of low signal (generally black) on MRI sequences. Thus, fractures through cortical bone can be difficult to depict with MRI. Complex and comminuted fractures with multiple cortical fragments are exceedingly difficult to analyze with MRI.

False negatives with MRI are uncommon. MRI is used routinely for the detection of occult fracture because of its superior depiction of bone marrow edema, a direct indicator of osseous injury. False-negative information may result when MRI data are analyzed for the presence of cortical fractures. False-negative and false-positive errors may occur if the incorrect MRI sequences are chosen. In general, a fluid-sensitive sequence, such as short tau inversion recovery, rather than a simple T2-weighted sequence, is best to detect bone marrow edema.

In a study by Kode et al investigating the usefulness of CT and MRI in visualizing fracture patterns, ^[17] MRI was often found to be superior to CT unless the fracture was extremely comminuted. Meniscal injuries, as well as injuries to the collateral and cruciate ligaments, may be depicted better with MRI than with CT. ^{[9, 10, 18]}

(See the image below.)

Wang Y, Cao F, Liu M, Wang J, Jia S. Incidence of Soft-Tissue Injuries in Patients with Posterolateral Tibial Plateau Fractures: A Retrospective Review from 2009 to 2014. J Knee Surg. 2016 Aug. 29 (6):451-7. [Medline].

Tang HC, Chen IJ, Yeh YC, Weng CJ, Chang SS, Chen AC, et al. Correlation of parameters on preoperative CT images with intra-articular soft-tissue injuries in acute tibial plateau fractures: A review of 132 patients receiving ARIF. Injury. 2017 Mar. 48 (3):745-750. [Medline].

Mattiassich G, Foltin E, Scheurecker G, Schneiderbauer A, Kröpfl A, Fischmeister M. Radiographic and clinical results after surgically treated tibial plateau fractures at three and twenty two years postsurgery. Int Orthop. 2014 Mar. 38 (3):587-94. [Medline].

Zhu Y, Yang G, Luo CF, Smith WR, Hu CF, Gao H, et al. Computed tomography-based Three-Column Classification in tibial plateau fractures: introduction of its utility and assessment of its reproducibility. J Trauma Acute Care Surg. 2012 Sep. 73(3):731-7. [Medline].

Yang G, Zhu Y, Luo C, Putnis S. Morphological characteristics of Schatzker type IV tibial plateau fractures: a computer tomography based study. Int Orthop. 2012 Nov. 36(11):2355-60. [Medline]. [Full Text].

Yang G, Zhai Q, Zhu Y, Sun H, Putnis S, Luo C. The incidence of posterior tibial plateau fracture: an investigation of 525 fractures by using a CT-based classification system. Arch Orthop Trauma Surg. 2013 Jul. 133(7):929-34. [Medline].

Zhai Q, Luo C, Zhu Y, Yao L, Hu C, Zeng B, et al. Morphological characteristics of split-depression fractures of the lateral tibial plateau (Schatzker type II): a computer-tomography-based study. Int Orthop. 2013 May. 37(5):911-7. [Medline]. [Full Text].

Piątkowski K, Kwiatkowski K, Piekarczyk P, Zegadło A, Rojkowski R. Comparative Analysis of Clinical Outcomes of Tibial Plateau Fractures and Computed Tomography Examinations. Ortop Traumatol Rehabil. 2015 Mar-Apr. 17 (2):135-45. [Medline].

Lee SY, Jee WH, Jung JY, Koh IJ, In Y, Kim JM. Lateral meniscocapsular separation in patients with tibial plateau fractures: detection with magnetic resonance imaging. J Comput Assist Tomogr. 2015 Mar-Apr. 39 (2):257-62. [Medline].

Xu Y, Li Q, Su P, Shen T, Zhu Y. MDCT and MRI for the diagnosis of complex fractures of the tibial plateau: A case control study. Exp Ther Med. 2014 Jan. 7 (1):199-203. [Medline].

Brunner A, Horisberger M, Ulmar B, Hoffmann A, Babst R. Classification systems for tibial plateau fractures; Does computed tomography scanning improve their reliability?. Injury. 2009 Sep 8. [Medline].

Mustonen AO, Koivikko MP, Kiuru MJ, Salo J, Koskinen SK. Postoperative MDCT of tibial plateau fractures. AJR Am J Roentgenol. 2009 Nov. 193(5):1354-60. [Medline].

Taşkesen A, Demirkale İ, Okkaoğlu MC, Özdemir M, Bilgili MG, Altay M. Intraobserver and interobserver reliability assessment of tibial plateau fracture classification systems. Eklem Hastalik Cerrahisi. 2017 Dec. 28 (3):177-81. [Medline]. [Full Text].

Mellema JJ, Doornberg JN, Molenaars RJ, Ring D, Kloen P, Traumaplatform Study Collaborative & Science of Variation Group. Interobserver reliability of the Schatzker and Luo classification systems for tibial plateau fractures. Injury. 2016 Apr. 47 (4):944-9. [Medline].

Millar SC, Arnold JB, Thewlis D, Fraysse F, Solomon LB. A systematic literature review of tibial plateau fractures: What classifications are used and how reliable and useful are they?. Injury. 2018 Mar. 49 (3):473-490. [Medline].

Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA. Detecting Vascular Injury in Lower-Extremity Orthopedic Trauma: The Role of CT Angiography. Orthopedics. 2008 Aug. 31(8):[Medline].

Kode L, Lieberman JM, Motta AO. Evaluation of tibial plateau fractures: efficacy of MR imaging compared with CT. AJR Am J Roentgenol. 1994 Jul. 163(1):141-7. [Medline].

Mustonen AO, Koivikko MP, Lindahl J, Koskinen SK. MRI of acute meniscal injury associated with tibial plateau fractures: prevalence, type, and location. AJR Am J Roentgenol. 2008 Oct. 191(4):1002-9. [Medline].

Amilcare Gentili, MD Professor of Clinical Radiology, University of California, San Diego, School of Medicine; Consulting Staff, Department of Radiology, Thornton Hospital; Chief of Radiology, San Diego Veterans Affairs Healthcare System

Amilcare Gentili, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Sulabha Masih, MD Associate Professor of Diagnostic Radiology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Staff, Department of Radiology, Section of Musculoskeletal Radiology, West Los Angeles Veterans Affairs Medical Center

Sulabha Masih, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

William R Reinus, MD, MBA, FACR Professor of Radiology, Temple University School of Medicine; Chief of Musculoskeletal and Trauma Radiology, Vice Chair, Department of Radiology, Temple University Hospital

William R Reinus, MD, MBA, FACR is a member of the following medical societies: Alpha Omega Alpha, Sigma Xi, American College of Radiology, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Steven Sorenson, MD, is gratefully acknowledged for this extensive contributions made to this topic.

Tibial Plateau Fracture Imaging 

Research & References of Tibial Plateau Fracture Imaging |A&C Accounting And Tax Services
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