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What is the diagnosis?

Lateral tibial plateau fracture in a generally osteopenic knee.

Image 2. 3 view plain films of the right knee with annotations. Author’s own images.

What is the mechanism of injury?

Typically direct traumatic load (often valgus load for lateral tibial plateau fractures), often a product of MVC collisions, contact sports, hyper extending the knee.

What physical exam findings are expected?

Bony tenderness to the affected region, soft tissue swelling (sometimes visualized effusion on POCUS), varus/valgus laxity > 10 degrees can indicate ligamentous injury.

Which imaging modalities can be used?

X-rays are typically the first imaging modalities followed by CT scans if you continue to have a high index of suspicion or if you identify a fracture on X-ray and require CT scan for further surgical planning [1].

•  Pearl: Studies have shown that CT scans can provide further information which can dictate surgical management and long term outcomes demonstrating the degree of bony depression/displacement, and involvement of the medial plateau with increasing severity describing higher impact injuries. Some studies have even suggested that MRI may assist in surgical planning given concern for concomitant meniscal injuries [2,3,4].

Image 3. Demonstration of the fracture coronal/sagittal view on the CT non-contrast study. Author’s own images.

What is the management of the in the ED/when should you consult orthopedics?

In the ED, if it’s not an open fracture or majorly displaced/shortened/depressed, patients can be placed in a knee immobilizer, made non weight bearing, and sent for outpatient orthopedic surgery follow up.  Many are referred for expedited follow up. Orthopedic surgery should be emergently consulted for surgery when you have an open fracture, significant depression, or there is concern for neurovascular compromise (compartment syndrome). Some studies have shown that ORIF often leads to decreases in long term functional outcome [5].

• Pearl: Maintain high suspicion for fractures in osteopenic patients who have continued pain. This often will require CT imaging as treatment varies widely based on findings.