Proximal tibial fractures in adults

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Official reprint from UpToDate

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Proximal tibial fractures in adults

Author
Karl B Fields, MD

Section Editor
Patrice Eiff, MD

Deputy Editor
Jonathan Grayzel, MD, FAAEM

Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2014. | This topic last updated: Nov 14, 2012.
INTRODUCTION Closed tibial fractures are common long-bone fractures. Greater than 70,000 hospitalizations,
800,000 office visits and 500,000 hospital days, have been attributed to tibial shaft fractures alone. While the
elderly suffer many of these fractures from falls, the presence of significant osteoporosis increases the risk for
compound or more complex fractures with higher morbidity [1].
This topic will review issues related to proximal tibial fractures. A general overview of tibial fractures is presented
separately. (See "Overview of tibial fractures in adults".)
PERTINENT ANATOMY The tibia is the major weight-bearing bone of the lower leg (picture 1 and picture 2).
The proximal portion of the bone, the tibial plateau, forms the lower surface of the knee joint (picture 3). The
thicker of the two articular surfaces is the medial tibial condyle, while the lateral tibial condyle is a relatively thinner
and weaker portion of the joint.
Separating the medial from the lateral tibial condyle is the intercondylar eminence, an important bony prominence
that anchors the attachment of the anterior cruciate ligament (ACL).
Another key bony landmark is the tibial tuberosity which is on the anterior surface, several centimeters below the
joint line and the inferior patellar pole, which serves as the attachment site for the patellar tendon [2].
A strong fibrous structure, the interosseous membrane, connects the tibia and fibula along the length of the two
bones. Proximally, this structure, reinforced by strong anterior and posterior ligaments, forms a synovial joint, the
proximal tibiofibular articulation.
Another fibrous structure, the crural fascia, surrounds the bones and muscles of the lower leg. Fascial extensions
and the interosseous membrane separate the muscles, nerves and vessels of the lower leg into four distinct
compartments (figure 1). Three of these, the anterior, posterior and deep posterior compartments all border the
tibia and can be compromised by tibial injury.
Nerves and vessels lie within the anterior and the deep posterior compartments and trauma that causes significant
swelling in these compartments can result in neurovascular compromise. The key blood supply of the tibia arises
from periosteal vessels and the nutrient artery. The nutrient artery originates from the posterior tibial artery and
enters the posterolateral cortex at the middle third of the tibial shaft near the origin of the soleus muscle. Fractures
in this region potentially compromise this blood supply.
The periosteal vessels provide a less vulnerable circulation as they derive an abundant blood supply from the
anterior tibial artery which travels down along the interosseous membrane. Vascular compromise can arise more
proximally from marked effusion of the knee joint or trauma that affects the popliteal artery before it branches into
the anterior and posterior tibial arteries or at the level of the anterior tibial artery as it branches off the popliteal
artery and passes through a gap in the interosseous membrane [2].
The tibial nerve and several branches provide the key innervation to the muscles of the lower leg and foot. Nerve
roots arise from L4 through S3. The posterior tibial nerve parallels the course of the posterior tibial artery and
courses through the deep posterior compartment. In the popliteal space branches of the tibial nerve provide
innervation to the posterior compartment and to the popliteus muscle. The deep peroneal nerve branches and

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follows the course of the anterior tibial artery providing innervation to muscles in the anterior lower leg.
MECHANISM OF INJURY Significant direct trauma, knee hyperextension injuries, and twisting motions in
elderly, osteoporotic individuals are among the most common ways that proximal tibial fractures occur. In adults,
vehicle-pedestrian collisions, motor vehicle crashes in which the knee is jammed against the dashboard, and
hyperextension in contact sports are specific scenarios that lead to injuries to this region [3].
SYMPTOMS AND EXAMINATION FINDINGS Injury to the proximal tibia may present as a knee effusion or as
localized swelling and tenderness over the bone. Pain may limit the examination and obscure important findings.
Careful skin inspection is performed to look for puncture/missile wounds, lacerations, and other evidence of an
open fracture.
Knee effusion A knee effusion in a patient with a proximal tibial fracture suggests an osteochondral fracture or
an internal derangement (eg, meniscal or ligamentous damage). Aspiration often reveals hemarthrosis and the
presence of lipid droplets or cellular bone marrow elements is indicative of an intraarticular fracture. (See
"Hemarthrosis".)
Ligamentous and meniscal integrity Ligamentous and meniscal injuries frequently occur in conjunction with
proximal tibial fractures [4,5]. Pain may interfere with accurate assessment of ligamentous and meniscal integrity.
Instillation of local anesthetic into the knee joint may facilitate evaluation of these structures, including the anterior
drawer and/or Lachman test of the ACL, the McMurray test for meniscal damage, and varus and valgus stress
testing to evaluate the lateral and medial collateral ligaments, respectively. A detailed description of the use of
these and other tests in the evaluation of a patient with knee pain is presented elsewhere. (See "General
evaluation of the adult with knee pain", section on 'Examination'.)
More than 10 degrees of opening during varus or valgus stress testing is abnormal. Laxity at the joint line suggests
a tear of one of the collateral ligaments, while laxity inferior to the joint line suggests a displaced fracture.
Acute compartment syndrome Acute compartment syndrome refers to a constellation of symptoms and
findings that result from compromised perfusion of one or more of the muscular compartments of the lower leg.
Blood or edema within an encircling fascia impairs circulation and results in unrelenting pain, muscle weakness, and
hypesthesia or anesthesia in the skin supplied by nerves that course through the fascially enclosed compartment.
Of the four compartments of the lower leg, the anterior, superficial posterior, and deep posterior compartments all
border the tibia and can be compromised by tibial injury.
Tense swelling of the affected muscles, decreased distal pulses, muscle weakness, increased pain elicited by
passive stretch of involved muscles, and impaired sensation due to nerve compression or ischemia may be noted
on examination. This may progress to pulselessness, paralysis, and anesthesia. Permanent neuromuscular
damage may ensue if the compartment pressure is not decreased promptly by fasciotomy. (See "Acute
compartment syndrome of the extremities".)
RADIOGRAPHIC FINDINGS Standard radiographs for suspected proximal tibial fracture include anteriorposterior (AP), lateral, and intercondylar notch views. When clinical suspicion of fracture is high but plain
radiographs are equivocal, computed tomography (CT scan) better defines the fracture. Magnetic resonance
imaging (MRI) may demonstrate bone bruising and associated meniscus or ligamentous injury [4,5]. For this reason
many clinicians prefer to follow standard radiographs with MRI to define the extent of injury when initial imaging is
unremarkable.
FRACTURE LOCATIONS Proximal tibial fractures are classified for management purposes into those that
affect the medial or lateral tibial plateau and fractures of the intercondylar notch.
Tibial plateau fractures Tibial plateau fractures most commonly involve the lateral plateau after a direct blow
that produces a strong force to the lateral knee. Radiographs include lateral, anterior-posterior (AP - (image 1)),
and oblique views (image 2) and typically reveal a depression of the lateral tibial plateau in moderate to severe
fractures. In more subtle injuries, radiographs may appear normal or show only a slight increase in the density of
the bone on an AP view.
When clinical suspicion of fracture is high and plain radiographs are equivocal, many clinicians prefer to proceed to
MRI because of the ability to visualize bone bruising and associated meniscal or ligamentous injury. CT scanning is

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another alternative if MRI is contraindicated or not available. CT will better define a fracture but does not allow
meniscal or ligamentous injuries to be assessed.
Medial tibial plateau fractures require a higher force since this side of the joint has more strength. A strong medial
force or an axial load such as landing on one's feet after falling from a height are potential mechanisms. When
standard radiographs suggest a medial injury, additional imaging may demonstrate simultaneous fractures of both
plateaus.
Indications for orthopedic referral Fractures with significant displacement, depression, or those with
suspected or documented meniscal or ligamentous damage merit orthopedic consultation within 48 hours.
Emergent referral is necessary for fractures that cause vascular injury or compartment syndrome.
Initial treatment Compression, icing, knee splinting in full extension, elevation, and strict non-weight bearing
are the initial phase of treatment of a tibial plateau fracture. At the first follow-up visit the patient is placed in a
hinged brace that is locked in full extension and advised to continue non-weight bearing crutch walking, icing, and
intermittent elevation of the leg.
Follow-up care After brace fitting, the patient returns weekly for the first three weeks. If there is no
displacement at two weeks, the patient begins working on knee flexion in the brace with a goal of 90 degrees by
four weeks. Plain radiographs are repeated weekly for three weeks and then on a two to three week basis
depending on radiographic appearance.
Strict non-weight bearing is the norm for six weeks with adjustment by clinical progress. Partial weight bearing in
the brace can begin once there is adequate radiographic healing.
Bracing continues until radiographic healing appears complete this typically requires 8 to 12 weeks. Quadriceps
strengthening follows brace removal. Patients rarely regain full function in less than 12 weeks and more often
require 16 to 20 weeks.
Return to sport or work Once the individual has regained approximately 80 to 90 percent of the strength of
the uninvolved extremity, less stressful job or sport specific functional rehabilitation can begin. This particularly
applies to non-weight bearing activities. For more stressful activity or prolonged weight bearing, healing should be
nearly complete.
Anterior tibial spine and intercondylar notch fractures Avulsion of the anterior tibial spine is particularly
common in skeletally immature adolescents. In contrast, adults with the same mechanism of injury more commonly
have anterior cruciate ligament (ACL) tears. With avulsion, the affected knee often has a significant effusion and
aspiration may show blood and or fat indicative of an intraarticular fracture. The treatment of avulsion of the
anterior tibial spine is discussed in greater detail separately. (See "Proximal tibial fractures in children", section on
'Tibial spine avulsion'.)
Tibial tubercle avulsions Tubercle avulsions occur at the apophysis of the anterior tibia where the patellar
tendon attaches. Plain radiographs demonstrate displacement of a reasonable sized fragment. In adolescents, an
unfused growth plate may cause confusion with an avulsion fracture. The treatment of avulsion of the anterior tibial
tubercle is discussed in greater detail separately. (See "Proximal tibial fractures in children", section on 'Tibial
tubercle avulsion'.)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and
Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable
with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)

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Basics topic (see "Patient information: Shinbone fracture (The Basics)")

SUMMARY AND RECOMMENDATIONS
Proximal tibial fractures usually result from a fall, motor vehicle crash, vehicle pedestrian collision, or an
injury during participation in a contact sport. (See 'Mechanism of injury' above.)
Concomitant injury to the stabilizing ligaments and/or the medial or lateral meniscus often occurs with
proximal tibial fractures. These additional injuries should be suspected, assessed by physical examination,
and further evaluated by MRI when clinically indicated. (See 'Symptoms and examination findings' above.)
Displaced fractures, depressed tibial plateau fractures, intraarticular fractures, associated ligamentous
tears, and/or meniscal damage warrant orthopedic referral within 48 hours. (See 'Indications for orthopedic
referral' above.)
Fractures with vascular injury or suspected compartment syndrome require emergent orthopedic referral.
(See 'Acute compartment syndrome' above.)
Splinting for tibial plateau fractures is in full extension, while splinting for intercondylar fractures is in 5 to 10
degrees of flexion. (See 'Initial treatment' above and 'Anterior tibial spine and intercondylar notch fractures'
above.)
Initial management includes splinting, analgesia, and non-weight bearing with crutches.

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REFERENCES
1. Schmidt AH, Finkemeier CG, Tornetta P 3rd. Treatment of closed tibial fractures. Instr Course Lect 2003;
52:607.
2. Duke Orthopaedics. Wheeless' Textbook of Orthopedics. www.wheelessonline.com (Accessed 3/7/05).
3. Patellar, Tibial, and Fibular Fractures. In: Fracture Management for Primary Care, Eiff MP, Hatch RL,
Calmbach WL. (Eds), Saunders, Philadelphia 2003. p.263.
4. 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; 191:1002.
5. Colletti P, Greenberg H, Terk MR. MR findings in patients with acute tibial plateau fractures. Comput Med
Imaging Graph 1996; 20:389.
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