Tibial plateau fractures: what the surgeon expects from the radiologist Poster No.:
C-2482
Congress:
ECR 2012
Type:
Educational Exhibit
Authors:
M. Jarraya , A. maalej , M. W. Turki , Y. guermazi , F. Akid , S.
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Haddar , H. Abid , K. Ben Mahfoudh , J. Mnif ; Sfax/TN, SFAX/ TN Keywords:
Trauma, Bones, Education, CT, Structured reporting
DOI:
10.1594/ecr2012/C-2482
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Learning objectives Fractures of the tibial plateau is about 25% of tibial fractures, their exploration is essentially based on the CT and their treatment is usually surgical, so radiologist is asked to satisfy surgeon's requirement. Our purpose is to expose what a surgeon expects from the radiologist concerning a CT exam made for a tibial plateau fracture.
Background ANATOMICAL REMINDER (Fig. 1, Fig. 2, Fig. 3, Fig. 4): The Upper Extremity (proximal extremity) of the tibia is large, and expanded into two eminences: the medial and lateral condyles. The superior articular surface presents two smooth articular facets: - The medial facet, oval in shape, is slightly concave from side to side, and from before backward. - - The lateral, nearly circular, is concave from side to side, but slightly convex from before backward, especially at its posterior part, where it is prolonged on to the posterior surface for a short distance. The intercondyloid eminence (spine of tibia), surmounted on either side by a prominent tubercle, on to the sides of which the articular facets are prolonged; in front of and behind the intercondyloid eminence are rough depressions for the attachment of the anterior and posterior cruciate ligaments and the menisci. The anterior surfaces of the condyles are continuous with one another, forming a large somewhat flattened area; this area is triangular, broad above, and perforated by large vascular foramina; narrow below where it ends in a large oblong elevation, the tuberosity of the tibia, which gives attachment to the ligamentum patellæ. Posteriorly, the condyles are separated from each other by a shallow depression, the posterior intercondyloid fossa, which gives attachment to part of the posterior cruciate ligament of the knee-joint. The medial condyle presents posteriorly a deep transverse groove, for the insertion of the tendon of the Semimembranosus. Its medial surface is convex, rough, and prominent; it gives attachment to the tibial collateral ligament.
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The lateral condyle presents posteriorly a flat articular facet, nearly circular in form, directed downward, backward, and lateralward, for articulation with the head of the fibula. Its lateral surface is convex, rough, and prominent in front: on it is an eminence, situated on a level with the upper border of the tuberosity and at the junction of its anterior and lateral surfaces, for the attachment of the iliotibial band. Just below this a part of the Extensor digitorum longus takes origin and a slip from the tendon of the Biceps femoris is inserted. Images for this section:
Fig. 1: PROXIMAL TIBIA : ANTERIOR VIEW
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Fig. 2: PROXIMAL TIBIA POSTERIOR VIEW
Fig. 3: PROXIMAL TIBIA : MEDIAL VIEW
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Fig. 4: PROXIMAL TIBIA : LATERAL VIEW
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Imaging findings OR Procedure details MECHANISM OF THE FRACTURES: Forced valgus ==> lateral compression ==> lateral tibial plateau fracture (fig.5) Forced varus ==> medial compression ==> medial tibial plateau fracture (Fig.6) Fall on the feet ==> axial compression ==> fracture-separation of the two tuberosities (fig.7) Lateral and axial compression ==> lateral fracture of the spinal tuberosity (fig.8) SURGICAL AND RADIOLOGICAL CLASSIFICATION: DUPARC AND FICAT CLASSIFICATION: Type 1: uni-tuberosity fracture (Fig. 9): The fracture line interests only one tuberosity. Two types can be associated, affecting preferentially the lateral tibial plateau: Fracture compaction: depression of the tibial plateau; surgical limit = 4mm Fracture separation: distasis between two fragments; surgical limit = 2 mm Type 2: bi-tuberosity fracture The fracture line reaches both medial and lateral tibial plateau, it can have a T, Y or V shape. Type 3: medial spinal tuberosity fracture The fracture line separates the tuberosity and the spine of tibia Type 4: comminuted fracture PRINCIPALS OF SURGICAL TREATMENT: Uni-tuberosity fractures are treated by percutaneous osteosynthesis under radiological and arthroscopical control. It is there the great contribution of the VR reconstraction which offers by the superior view an arthroscopic view allowing a better planification and reaches an unexplored area during the arthroscopy by the posterior view. For the other types of fractures: surgical osteosynthesis by screw or plate
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Associated fracture of the tibial spines (fig. 19): bone avulsion of the anterior cruciate ligament insertion area è checking the ligament è osteosynthesis by screw or a flexible metallic wire REALIZATION OF THE IMAGE: Equipment: 16 B GE CT Scan; image processing console adw Patient install: - Dorsal decubitus - knee flexed to 15° - foot maintained by a sandbag - contralateral leg folded and held by the patient Acquisition: - 1 cm above the upper border of the patella - 1 cm below the tibial tuberosity - expand if necessary to cover the entire fracture line Reconstructions: - Thin sections: 0,75 mm - soft and bone window 2D and 3D reconstructions (fig.10): CT with 2D (axial(Fig. 11), frontal (fig. 12) and sagittal (fig. 13) ) and 3D reconstructions (anterior view (Fig 14), posterior view (Fig 15), lateral view (Fig 16), medial view, superior view (fig 17)) is certainly very useful in displaced fractures with multiple fragments, as it allows the exact review of injuries and a more precise classification, in addition, it makes easier surgical planning. RADIO-SURGICAL SYNTHESIS: which information is usefull to the surgeon? - Importance of the fragmentary moving (fig 9) - Importance of the tibial plateau depression (fig 18) - Associated fractures - Damage of the tibial spines (fig 19)
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- Fibular fracture (fig 14-17) STANDARD REPORT: Uni-tuberosity fracture External Internal Compaction Separation Mixed Bi-tuberosity fracture Medial spinal tuberosity fracture Comminuted fracture Displaced fragment: Yes No 2mm Compaction: Yes No 4mm Fracture of the tibial spine: Yes No Intra articular foreign body: Yes No Underlying bone: Demineralization osteoarthritis Associated fracture: Patella Fibular head Tibial diaphysis Lateral femoral condyle Medial femoral condyle EXAMPLE: a 16-year-old young man, knee trauma in a road accident 2D and 3D reconstryctions (fig.20) report:
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Fig. 21: typical report for plateau tibial fracture References: M. W. Turki; RADIOLOGY, Sfax, TUNISIA Images for this section:
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Fig. 5: MECHANISM OF FRACTURE : Forced valgus ==> lateral compression ==> lateral tibial plateau fracture
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Fig. 6: MECHANISM OF FRACTURE : Forced varus ==> medial compression ==> medial tibial plateau fracture
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Fig. 7: MECHANISM OF FRACTURE : Fall on the feet ==> axial compression ==> fracture-separation of the two tuberosities
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Fig. 8: MECHANISM OF FRACTURE : Lateral and axial compression ==> lateral fracture of the spinal tuberosity
Fig. 9: 22 years old, consulting after a trauma in a road accident. Frontal reconstructuions showing a unituberosal fracture. fracture of internal tubersoity
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Fig. 10: FILMS TO GIVE TO SURGEON
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Fig. 11: Plan for axial reconstructions, batch 19 images with 1 mm thikeness. The total is 20 images for the axial 2D film
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Fig. 12: Plan for frontal reconstructions, batch 19 images with 1 mm thikeness. The total is 20 images for the frontal 2D film
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Fig. 13: Plan for sagittal reconstructions, batch 19 images with 1 mm thikeness. The total is 20 images for the sagittal film
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Fig. 14: Anterior view with 3D recontruction of the proximal tibia showing an assiciated fracture of proximal fibula
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Fig. 15: Posterior view with 3D recontruction of the proximal tibia showing a fracture of lateral tuberosity assiciated with a fracture of proximal fibula : the posterior view can show the areas inaccessible during surgery.
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Fig. 16: lateral view with 3D recontruction of the proximal tibia showing a fracture of lateral tuberosity assiciated with a fracture of proximal fibula
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Fig. 17: Superior view with 3D recontruction of the proximal tibia showing a fracture of lateral tuberosity assiciated with a fracture of proximal fibula : the superior view show the same thing than in arthroscopy and may be helpful to surgeon to planify the surgery.
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Fig. 18: fracture of external tuberosity responsible of 6mm depression of fragment.
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Fig. 19: Fracture of tibial spine associated to a fracture of lateral tuberosity in 26 years old after a fall of 6 feet in an accident at work with unipodal reception
Fig. 20: a 16-year-old young man, knee trauma in a road accident
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Fig. 21: typical report for plateau tibial fracture
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Conclusion Now when CT exam exceeds the 1000 images, the radiologist is required to optimize its performance by providing the surgeon in a clear, concise and explicit way, what he needs to treat the fractures of the tibial plateau.
Personal Information References 1/ J. Schatzker, R. McBroom, D.Bruce; The tibial plateau fracture: the Toronto experience, 1968-1975; Clin Orthop Relat Res 1979; 138:94-104. 2/ Ch. Trojani, L. Jacquot, T. Ait Si Selmi, et al.; Les fractures récentes des plateaux tibiaux de l'adulte: Physiopathologie, diagnostic, classifications et traitement; Maitrise orthopédique. Hôpital de l'Archet Nice - Centre Livet Lyon 3/ JC. Le Huec; Fractures articulaires récentes de l'extrémité supérieure du tibia. Conférence d'Enseignement. Cah. Ens. S.O.F.C.O.T. n°55 1996; 97-117. 4/ D. Blin, C. Cyteval, C. Kamba, et al.; Imagerie des traumatismes du genou; J Radiol 2007; 88:775-88 5/ J. Duparc, P. Ficat; Fractures articulaires de l'extrémité supérieure du tibia; Rev. Chir. Orthop. 1960; 46:399-486 6/ B. Keegan Markhardt et al.; Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment; RadioGraphics 2009; 29:585597 7/ A. Brent, Barrow et al; Tibia plateau fractures : Evaluation with MR imaging. RadioGraphics 1994; 14:553-559.
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8/ S. Wicky et al.; Comparison between standard radiography and spiral CT with 3D reconstruction in the evaluation, classification and management of tibial plateau fractures; Eur.Radiol. 2000; 10:1227-1232
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