Computed tomography of tibial plateau fractures

Subdivision of injured area for Schatzker IV tibial plateau fracture repair: A report of 12 cases

BACKGROUND

Treatment of Schatzker IV tibial plateau fractures is challenging due to the wide variety of potential fracture morphologies and injury to multiple ligaments. Subdivision of the injured area into three zones may simplify the preoperative plan. In this study, we reported 12 cases of Schatzker IV tibial plateau fracture that were treated with pre-operative plans based on a new subdivision of the injured area.

METHODS

From January 2012 to April 2016, 12 patients with a Schatzker IV tibial plateau fracture were treated in our hospital with preoperative plans guided by the new sub-division method. Clinical and radiological results were evaluated during follow-up.

RESULTS

In all cases, the incisions healed without skin necrosis, and the average Lysholm knee score was 73 points (range, 53-90) at the final follow-up.

CONCLUSION

Sub-division of the injured area represented a useful strategy for preoperative surgical planning in the treatment of Schatzker IV tibial plateau fractures.

Two column classification of tibial plateau fractures; description, clinical application and reliability

PURPOSE

In this era of life highly comminuted and multi planar tibial plateau fractures involving the posterior corners are more commonly seen and addressed in the literature than before. Among these several types have not been described in the currently used classification systems. In fact simple classification systems ignore several fracture types and leniently grouped the fractures with different mechanism, morphology, treatment modalities and prognosis in same category. On the other hand, more extensive nature classifications with detailed subdivisions are difficult to remember for clinicians. The clinical reliability of these classifications is another problem. All these issues demand the potential need of a new classification. The aim of this study was to describe a quadrant specific two column classification of tibial plateau fractures and to analyse its inter-observer and intra-observer reliability, clinical assessment and application.

MATERIALS AND METHODS

From January 2009 to December 2015, 44 patients with tibial plateau fractures were studied retrospectively. The antero-posterior (AP), lateral X-rays and computed tomography (CT) with axial transverse, sagittal, coronal and three dimensional (3D) reconstruction images were performed for all the patients. All of the fractures were categorized according to quadrant specific two column classification and the traditional Schatzker's classification. The comparative analysis for inter-observer and intra-observer reliability of the new classification and the Schatzker's classification was conducted by four observers.

RESULTS

Three cases didn't match any type in the Schatzker's classification. While on the other hand, all cases were classified by two column classification. The mean kappa values for inter-observer reliability by using the Schatzker's classification was 0.723 (range, 0.674-0.823), representing substantial agreement, whereas the mean kappa value was 0.939 (range: 0.897-0.974), representing almost perfect agreement according to two column classification. The mean kappa values for intra-observer reliability using the Schatzker's classification and two column classification were 0.789 (range: 0.590-0.864) and 0.955 (range:0.923-0.948) showing substantial agreement and almost perfect agreement.

CONCLUSION

The quadrant specific two column classification is anatomically oriented, CT based and clinically valid. The different fracture types according to anatomic location are represented alphanumerically so that treatment matched to specific fracture type (quadrant specific anatomic fixation) for optimal outcomes. Furthermore, it demonstrates higher inter-observer and intra-observer reliability. This classification can be adopted to strengthen the traditional Schatzker's classification, particularly in the multi planar and posteriorly extended plateau fractures. It can be used as a reliable research tool. The database can be used to distinguish different fracture types, individual type incidences, specific treatment and also prognosis. Authors suggest a large multi-centre study.

Lateral tibial plateau fracture depression as a predictor of lateral meniscus pathology

The goal of this study was to determine if the degree of lateral tibial plateau fracture depression on computed tomography (CT) images predicted the presence of lateral meniscus tears. The study group comprised 85 patients who sustained a lateral tibial plateau fracture and underwent open reduction and internal fixation by the same surgeon. Degree of plateau depression was measured in millimeters by CT. Operative reports were retrospectively reviewed to determine if the lateral meniscus tear was intact or torn at the time of surgery. Twenty-eight patients had a lateral meniscus tear noted at the time of surgery. No significant differences existed in gender, mechanism or energy level of injury, Schatzker classification, or type of fracture among patients with a lateral meniscal tear as compared to those without a tear. Patients with > or =10 mm of plateau depression had an eight-fold increase in risk of having a lateral meniscus tear compared to those with <10 mm of depression. Patients younger than 48 years had a four-fold increase in risk of having a lateral meniscus tear than older patients.This study demonstrated an association between the amount of tibial plateau depression and the likelihood of a lateral meniscus tear. These findings may be used to predict those who have sustained a tear of the lateral meniscus and to advise the surgeon to prepare for a repair. Further prospective studies using magnetic resonance imaging as a tool to evaluate the extent of soft tissue injuries in plateau fractures is needed.

New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

Emergency MR imaging of orthopedic trauma. Current and future directions

Fast MR imaging protocols pave the way for more widespread use of MR imaging to evaluate emergency room trauma patients. This article reviews technical developments and protocols facilitating rapid imaging, conventional applications of MR imaging to evaluate soft tissue injuries, and newer applications in which MR imaging is used to image both axial and appendicular fractures.

Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures

OBJECTIVE

To evaluate the interobserver and intraobserver agreement for both treatment plan and fracture classification of tibial plateau fractures using plain films alone and with computed tomography (CT) scans.

DESIGN

Prospective study to assess the impact of an advanced radiologic study on the agreement of treatment plan and fracture classification of tibial plateau fractures.

SETTING/PARTICIPANTS

Two orthopaedic traumatologists, two orthopaedic residents, and two skeletal radiologists were presented with twenty-one cases of tibial plateau fractures imaged with plain films and with CT scans.

MAIN OUTCOME MEASURES

Agreement was measured using kappa coefficients.

RESULTS

Using plain films alone, the mean interobserver kappa coefficient for classification was 0.62, which decreased to 0.61 after addition of CT scans. Using plain films alone for formulating a treatment plan, the mean interobserver kappa coefficient was 0.58, which increased to 0.71 after addition of CT scans. The mean intraobserver kappa coefficient for fracture classification using plain films was 0.70, which increased to 0.80 with addition of CT scans. The mean intraobserver kappa coefficient for treatment plan based on plain films alone was 0.62, which increased to 0.82 after addition of CT scans. Class was changed in an average of 12 percent of cases after addition of CT scans. Treatment plan was changed an average of 26 percent of the time after addition of CT scans.

CONCLUSION

Addition of CT scans to plain roentgenograms increases the interobserver and intraobserver agreement on treatment plan.

Imaging of the knee. Current status

This article reviews the variety of imaging modalities that are currently being used to evaluate the knee. Nuclear scintigraphy is discussed with emphasis on prosthesis abnormalities. Sonography is discussed with regard to the evaluation of popliteal masses. The uses of computed tomography, especially in the evaluation of the tibial plateau fracture, are discussed, and the role of fluoroscopy, computed tomography, and sonography in image-guided needle procedures are reviewed. Emphasis is placed on the role of MR imaging in knee imaging, with attention to internal derangements, bursal and capsular pathology, and other assorted intra- and extra-articular disorders. The focus of this article is to review the wealth of information that may be obtained by using these imaging modalities.

Radiographic evaluation of osseous displacement following intra-articular fractures of the distal radius: reliability of plain radiography versus computed tomography

This study evaluated the reliability of plain radiography versus computed tomography (CT) for the measurement of small (< 5 mm) intra-articular displacements of distal radius fracture fragments. The plain radiographs and CT scans of 19 acute intra-articular distal radius fractures were used by 5 independent observers, using 2 standardized techniques, to quantify incongruity of the articular surface in a blinded and randomized fashion. Repeat measurements were performed by the same observers 2-4 weeks later, allowing determination of intraclass correlation coefficients (ICC) as a measure of intraobserver and interobserver agreement. The average maximum gap displacement on plain radiographs was 2.1 mm (range, 0.0-15.0 mm, lateral view) and on CT images was 4.9 mm (range, 0.7-17.3 mm, axial view). The average maximum step displacement on plain radiographs was 0.9 mm (range, 0.0-6.4 mm, lateral view) and on CT images was 1.2 mm (range, 0.0-6.0 mm, sagittal view). More reproducible values determining step and gap displacement were obtained when the arc method of measurement was used on CT scans (ICC values, .69-.97) as compared to the longitudinal axis method for plain radiographs (ICC values, .30-.50). For measured displacements of 2 mm or more, our data demonstrated poor correlation between measurements made on CT images and those made on plain radiographs (gap or step displacement > 2 mm, K = 0.21; step displacement > 2 mm, K = 0.21). Thirty percent of measurements from plain radiographs significantly underestimated or overestimated displacement compared to CT scan measurements. From these data, we conclude that CT scanning data, using the arc method of measurement, are more reliable for quantifying articular surface incongruities of the distal radius than are plain radiography measurements.

MR imaging of tibial plateau fractures

Magnetic resonance (MR) images of five patients with acute tibial plateau fractures are presented and correlated with both clinical examination and findings at surgical intervention. The role of MR imaging in the evaluation of both osseous and soft tissue deformity in acute trauma, specifically in patients with tibial plateau fractures is discussed. The value of MR imaging as an alternative to computed tomography and arthroscopic evaluation of these patients is emphasized.

Bone bruises: their patterns and significance

MR imaging is sensitive in the detection of occult stress and posttraumatic fractures in and around the knee joint. In some patients, the pain from these bony injuries can mimic that of meniscal tears. The abnormality of the bone may explain completely the patient's symptoms and obviate the need for any further work-up. The types of injuries detected by MRI include bone bruises, stress or insufficiency fractures, and osteochondral fractures. Bone bruises or contusions are characterized by a diffuse or localized pattern of low signal intensity on T1-weighted images without a defined fracture. Blood, edema, hyperemia, and perhaps microfracture of the trabeculae may all contribute to the marrow signal alterations. Anterior cruciate ligament injuries often are accompanied by a characteristic bone contusion pattern, such as hemorrhage or edema in the posterior aspect of the lateral tibial plateau, as well as the anterior aspect of the lateral femoral condyle.

Fractures of the talus and calcaneus: evaluation by computed tomography

Fractures of the talus and calcaneus may be difficult to evaluate using conventional imaging modalities. Failure to recognize these fractures or to appreciate their extent may result in severe deformity or disability. Patients with talar and calcaneal fractures had computed tomography to assess its role in the management of these fractures. Computed tomography is superior to other imaging modalities in showing the position of the fracture fragments, the number of fragments, the relation of the fracture to the articular surfaces, residual articular changes, and evidence of healing.