What is the diagnosis?

Tibial plateau fracture 

• Pearl: If you have high clinical suspicion for a tibial plateau fracture and the plain films are negative, as in this patient, consider a CT scan or MRI (for better demonstration of concurrent ligamentous injury).

• Pearl: Tibial Plateau fractures can be characterized using the Schatzker Classification

1. Schatzker I Split

2. Schatzker II Split with depression

3. Schatzker III Central depression

4. Schatzker IV Split fracture, medial plateau

5. Schatzker V Bicondylar fracture

6. Schatzker VI Split extends to metadiaphysis [1]

What is the mechanism of injury?

Occurs via varus or valgus load through direct blow to the knee or other sources of direct trauma [2].

• Pearl: In younger patients this typically occurs through a high energy mechanism of injury vs in older patients they can occur with low energy mechanisms (fall from standing). 

What physical exam findings are expected?

May present with knee effusion, swelling, or local tenderness. 

• Pearl: Ligament tears or meniscal injury are common with proximal tibial fractures and local anesthetic injection can help aid in examination, if limited by pain [3,4].

• Pearl: Acute Compartment syndrome (ACS) is a known short-term complication of a tibial plateau fracture with reported rates ranging from 3-17% [5].}

Which imaging modalities can be used?

Typically start with standard radiographs including AP, lateral, oblique views (internal for lateral plateau, external for medial plateau). As in this patient, if initial radiographs are equivocal, consider CT or MRI, which is useful in detecting meniscal and ligament injury. [3,4].

 Figure 2. CT L  Knee, Case courtesy of Bruno Di Muzio, radiopaedia.com, rID: 47659

What is the management in the ED?

Initially, provide pain management, evaluate for neurovascular integrity. If there are no indications for orthopedic consult as discussed below, you can splint the knee in near-full extension and provide strict non-weight-bearing precautions with urgent outpatient orthopedic follow-up. If you are concerned about an open fracture, be sure to start antibiotics. 

When do you consult Orthopedics?

As with most fracture management, orthopedics should be consulted for open fractures, signs of neurovascular compromise or concern for ACS. For tibial-plateau fracture specifically, consulting orthopedics if there is an intra-articular displacement of >2mm, metaphyseal-diaphyseal translation of >1cm, or evidence of ligamentous injury requiring repair as these are indications for surgical intervention [6].