TIBIAL PLATEAU FRACTURE: ROLE AND CONTRIBUTION OF MULTIDETECTOR CT SAIDANE, A. DAGHFOUS, A. BEN OTHMEN, S. FELAH, L. REZGUI MARHOUL Radiology service: Trauma center, 1007 Tunis, Tunisia MK11

INTRODUCTION Tibial plateau fracture occurs mainly in a young population It’s consecutive to direct trauma of the knee, generally secondary to traffic accident. Only explored by the past by plain radiographs, it benefits nowadays of an increasing number of CT exploration. Our aim is to clarify the role of multidetector scanner in its pretherapeutic assessment.

MATERIAL & METHODS Retrospective study of 23 patients with fracture of the tibial plateau. All were explored by plain radiographs of the knee and 16 bars CT. The volume of acquisition ranged from 1 cm above the patella to 1 cm below the tibial tuberosity. No injection of contrast in the all cases.

MATERIAL & METHODS Bone and soft tissue filters. Reconstruction in the coronal and sagittal plans 3D reconstruction using GE Volume Rendring (VR) Ten patients were operated 13 were followed in externe consultation.

RESULTS Average age = 35 years Sex ratio (M/W) = 5 Trauma circumstances: traffic accident (n=9), domestic accident (n=6) and accident at work (n=5) The tibial plateau fractures were classified according to Duparc et Ficat method

RESULTS We found: 9 fractures of the lateral tibial plateau 5 spino-condylar fractures 4 medial tibial fractures 5 bituberosity fractures More than a third of patients has associated injuries primarily affecting the fibula 1 case was involved in a polytraumatism                             

RESULTS (B) (A) Coronal (A) et sagittal (B) reconstructions: Fracture of the lateral plateau with an enfoncement measured at 3.7 mm ( ) and an associated fracture of the lateral femoral condyle ( )

RESULTS 3D reconstructions showing the enfoncement ( ) and the fracture of the femoral condyle ( )

RESULTS (A) (C) (B) Coronal (A), sagittal (B) and 3D (C) reconstructions:comminutive medial spino-condylar fracture

RESULTS (B) Axial (B) and coronal (C) reconstructions: (A) Comminutive fracture of the medial plateau with enfoncement. (A) Coronal reconstruction: Fracture of the medial plateau Separation measured at 5mm (C)

RESULTS Comminutive form of bituberosity fractures

RESULTS

RESULTS V form of bituberosity fracture T form of bituberosity fracture Y form of bituberosity fracture

DISCUSSION Tibial plateau fractures are secondary to direct trauma on the knee, the more often of a high velocity Minor trauma may cause similar lesions in case of osteoporosis Functionnal impotence, pain and knee swelling are the main clinical findings      2 classifications are used in both plain radiographs and CT            

DISCUSSION The first one, used in France and countries following the french school, was edicted by Duparc and Ficat in 1960 [3,4] and distinguish: Fractures affecting only one plateau (60%), generally the lateral one, consequently to a direct trauma in valgus (for the lateral plateau) or varus (for the medial) Squamous tuberosity fracture (10%) Bituberosity fracture (30%) in V, Y or T. There are also complex and comminutive forms            

DISCUSSION The second classification, anounced by Schatzker [1], divides tibial plateau fractures into 6 types: Lateral tibial plateau fracture without depression (I) Lateral tibial plateau fracture with depression (II) Compression fracture of the lateral (IIIA) or central (IIIB) tibial plateau Medial tibial plateau fracture (IV) Bicondylar tibial plateau fracture (V) Tibial plateau fracture with diaphyseal discontinuity (VI)            

DISCUSSION Classification of Schatzker [2]

DISCUSSION Conflicting data exists regarding the benefit of a pretherapeutic CT scan in these classifications. Stroet et al[2], Chan et al[5]. et many others did show there were no increase in agreement between different observers for classification of tibial plateau fractures with the addition of a CT scan comparing to radiographies performed solely. A possible explanation is that CT provides an overdose of information, which makes classification more difficult.

DISCUSSION However, practically, CT has many advantages: Easier classification of fractures, especially between Schatzker I and II [2] Modification of surgical plans based on plain radiographic findings after CT in 6 to 60% of cases by more precisely demonstrating the fracture depression and displacement which are the most important factors affecting surgical management of standard tibial plateau fractures (NB: 4 mm depression and 2 mm displacement  surgical levels) [1,4]

DISCUSSION Diagnosis of associated soft-tissue injuries [1]: According to Gardner et al [6], only 1% of patients with tibial plateau fractures has complete absence of soft-tissue injuries and 77% have cruciate or collateral ligaments lesions that may be suspected in CT Moreover, popliteal vessels lesions (associated with Schatzker IV) are well illustrated by angiographic reconstruction after injection of contrast.

CONCLUSION Several studies are questioning the superiority of CT in the classification of tibial plateau fractures However, the scanner offers real practical advantages in the choice of treatment modalities Besides, the fact that classification methods predate the era of the scanner should promote new methods more  more adapted to the scanner

REFERENCES B. Keegan Markhardt, Jonathan M. Gross, Johnny U. V. Monu, Schatzker Classification of Tibial Plateau Fractures: Use of CT and MR Imaging Improves Assessment. RadioGraphics 2009; 29:585–597 2) M. Stroet, M. Holla, J. Biert, A. van Kampen. The value of a CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures. Emerg Radiol 2011; 18:279–283 D. Blin, C. Cyteval, C. Kamba, M. Blondel, FM. Lopez.Imagerie des traumatismes du genou. J Radiol 2007; 88: 775-88 C. Dubois, JN. Ravey, C. Bittighoffer, M. Garelli, T. Delchambre, B. Rubens Duval, N. Mercier, L. Pittet Barbier. TDM et traumatisme des membres inférieurs. JFR 2010 Chan PSH, Klimkiewicz JJ, Luchetti WT et al (1997) Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma 11(7):484–489 Gardner MJ, Geller D, Suk M, et al. The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma 2005;19(2):79–84