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Swelling and right knee pain following a fall from a ladder

SMITH, JAMI S. MPA, PA-C; NOLLER, DIANA MSPT, MMS, PA-C

Journal of the American Academy of PAs: April 2013 - Volume 26 - Issue 4 - p 57–58
Diagnostic Imaging Review
Free
SDC

Julie Edmiston, PA-C, RT, department editor

Jami Smith is an assistant professor and academic coordinator of the Physician Assistant Program of Arcadia University, Glenside, Pennsylvania. Diana Noller is an assistant professor and academic coordinator of the Physician Assistant Program of Arcadia University, Newark, Delaware.

No relationships to disclose.

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CASE

A 42-year-old male presented to the emergency department with an acute injury to the right knee after falling from a ladder that measured approximately 15 feet. On physical examination, the patient was alert and cooperative. However, he was in obvious pain and unable to bear weight on his right leg, which demonstrated moderate swelling and ecchymosis from the knee to the midcalf. In addition, he was unable to actively move his knee through any range of motion (ROM). No deformities were obvious. The skin was intact. His sensation to light touch was also intact. He had active movement of his toes on the right, and his dorsalis pedis pulses were 2+ and symmetric bilaterally. Strength testing revealed 5/5 extensor hallicus longus strength bilaterally. Passive dorsiflexion and plantar flexion of the right foot did not elicit pain. Radiographs were obtained (Figure 1A and B). What do the images show?

FIGURE 1.

FIGURE 1.

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DISCUSSION

The radiographs revealed a transverse fracture of the right proximal tibia involving bilateral condyles and a fracture of the fibular head. The patient was placed in a long-leg splint in a position of comfort and underwent frequent neurovascular monitoring. He was scheduled for open reduction and internal fixation.

Most lateral tibial plateau fractures occur when an abduction force is applied to the leg with an axial load.1 In younger patients, the usual cause of these fractures is high-energy motor vehicle trauma, fall, or contact sport injury. Fractures of the tibial plateau occur with minor trauma in the elderly population due to underlying osteoporosis.

Diagnosis Determining the mechanism of injury is an important component of the patient assessment and should be elicited during historytaking. Physical examination must evaluate the integrity of the neurovascular system. The patient typically will present with pain, knee effusion, and an inability to bear weight. The neurovascular evaluation should include palpation of the popliteal, posterior tibial, and dorsalis pedis pulses; demonstration of intact sensation over the dorsum of the foot; and strength testing of foot dorsiflexion, eversion, or toe extension. The assessment for vascular injury is particularly important in the setting of medial tibial plateau and bicondylar fractures, as the risk of associated vascular compromise is significant. This is best done by determining the arterial pressure index, as research has shown that physical examination alone is unreliable in detecting vascular injury.2

The clinician should check for bony alignment, palpate for tenderness, and attempt passive ROM. The joints above and below the injury should always be assessed for injury. If there is concomitant ligamentous injury, the knee may have instability on varus or valgus stress testing or Lachman maneuver, depending on which ligament is injured. In addition, the level of soft-tissue injury that frequently accompanies these fractures increases the risk of compartment syndrome, which must be considered. This is particularly true when the fracture involves the tibial diaphysis.

Imaging When evaluating tibial plateau fractures, the initial radiographs should include anteroposterior, oblique, and lateral views of the knee joint. Osseous structures should be evaluated for fractures, and evidence of soft-tissue swelling, such as joint effusions, should be noted. CT and MRI may be utilized to obtain a more detailed view of the fracture and extent of ligamentous injury, which will aid in planning the surgical repair and management of the injury.

Classification The Schatzker classification system for tibial plateau fractures is a commonly accepted means for describing the extent of injury. The Schatzker classification divides tibial plateau fractures into six types. Type I consists of a lateral plateau fracture without depression, and type II comprises a lateral plateau fracture with depression. Type III consists of a compression fracture of the lateral (type IIIA) or central (type IIIB) plateau. The medial plateau is fractured in a type IV fracture, and a bicondylar plateau fracture is a type V. Fractures of the plateau with diaphyseal discontinuity are classified as type VI.3

“Early mobilization is essential to decrease risk of knee arthrofibrosis and maximize the patient’s functional outcome after treatment.”

Treatment Management of type I, II, and III fractures focuses on repairing the articular cartilage. The fracturedislocation mechanism of type IV fractures increases the likelihood of injury to neurovascular structures, such as the peroneal nerve or popliteal vessels. In type V and VI fractures, the location of soft-tissue injury determines the type of surgical repair. The timing of reparative surgery and the need for initial stabilization with an external fixator is determined by the degree of soft-tissue swelling of the knee joint.3

Initial treatment of tibial plateau fractures includes stabilization of the extremity in a long-leg splint in a position of comfort. Goals of definitive management include return of proper axial alignment, joint stability, restoration of the articular surface, and preservation of functional ROM.4 Surgical treatment is generally recommended for open fractures, significant ligamentous injury or instability, articular displacement, and/or fractures associated with compartment syndrome.4 The patient presented here had a Schatzker type VI fracture with a transverse bicondylar fracture of the proximal tibia. The diaphyseal discontinuity of this fracture required open reduction and internal fixation with buttress plates and cancellous screws. After 1 week in a knee immobilizer, a hinged knee brace was applied in order to allow early ROM with varus and valgus support for the healing of the ligamentous structures. The patient remained non-weight-bearing for 6 weeks, after which time, weight bearing was slowly increased based on the level of comfort. Full weight bearing was achieved at 12 weeks postoperatively.

The most common complication of surgical repair of tibial plateau fractures is osteoarthritis, with a higher Schatzker classification generally resulting in less positive outcomes.3 Other, less common complications following surgical repair of tibial plateau fractures include infection, nerve injuries, myositis ossificans, and limited ROM of the knee. Early mobilization is essential to decrease the risk of knee arthrofibrosis and maximize the patient’s functional outcome.

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CONCLUSION

Tibial plateau fractures are most commonly seen in young adulthood and in the elderly population. In the younger patient, fractures typically have a high-energy mechanism of injury; however in the older, osteoporotic patient, fractures may result from low-energy mechanisms. This patient required open reduction and internal fixation, given the severity of his fracture. A comprehensive diagnostic workup of these injuries includes not only assessing the severity of the fracture, but also evaluating for neurovascular compromise and concomitant soft-tissue injury. CT or MRI is useful for surgical planning purposes and to evaluate the extent of associated soft-tissue injury. In repairing these fractures, reconstruction of the normal articular alignment of the joint surfaces is imperative to ensure normal contact pressures, which are important for regaining maximal knee function.2 Monitoring for compartment syndrome both prior to and after surgical fixation is necessary. Extensive physical therapy to include early mobilization once the fracture is fixated will allow for maximal functional recovery. JAAPA

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REFERENCES

1. Newton E, Love J. Emergency department management of selected orthopedic injuries. Emerg Med Clin North Am. 2007;25(3):763-793.
2. Cole P, Levy B, Watson JT, Schatzker J. Tibial plateau fractures. In: Browner BD, Levine AM, Jupiter JB, et al. Skeletal Trauma: Basic Science, Management and Reconstruction. 4th ed. Philadelphia, PA: Saunders Elsevier; 2009:2201-2205.
3. Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics. 2009;29(2):585-597.
4. Rudloff M. Fractures of the lower extremity. In: Canale ST, Beaty JH. Campbell’s Operative Orthopaedics. 11th ed. Philadelphia, PA: Mosby Elsevier; 2008;2668-2681.
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