01Approach to the Critical Patient/attcp29

Immediate threats

›Immediate threats and triggers

›If hemodynamic instability, trauma resuscitation pathway

›If uncontrolled hemorrhage concern, activate massive transfusion protocol

›If open fracture, immediate antibiotics and orthopedic consultation

›If gross contamination, broaden coverage per open fracture protocol

›If neurovascular compromise, emergent orthopedic consultation

›If absent distal pulses after reduction attempt, emergent vascular consultation

›If compartment syndrome concern, emergent fasciotomy pathway

›If escalating pain despite analgesia, admit for serial exams and pressure measurement

Immobilization and protection

›Limb protection

›Knee immobilizer in extension

›If significant swelling or instability, long leg posterior splint plus stirrup

›Non weight bearing

›Crutches or walker based on balance and age

›Elevation above heart level

›Ice in short intervals if skin intact

Neurovascular safety checks

›Neurovascular priority checks

›Distal pulses and symmetry

›Dorsalis pedis pulse quality

›Posterior tibial pulse quality

›Perfusion

›Capillary refill

›Skin temperature and color

›Motor function

›Ankle dorsiflexion and plantarflexion

02History/hx24

Mechanism and risk stratification

›Mechanism and risk stratification

›High energy mechanism

›Motor vehicle collision

›Fall from height with axial load

›Low energy mechanism

›Ground level fall with osteoporosis risk

›Twisting injury with immediate inability to bear weight

›Time from injury

›Progressive swelling timeline

›Functional status

›Immediate inability to bear weight

›Ambulatory status at baseline

Symptoms and associated injuries

›Symptoms and associated injuries

›Knee pain severity and progression

›Pain out of proportion concern for compartment syndrome

›Swelling and tightness

›Rapidly expanding swelling concern for hemarthrosis or vascular injury

›Instability or giving way

›Concern for ligamentous injury or fracture dislocation pattern

›Neurovascular symptoms

›Numbness or tingling in foot

›Cold foot or color change

›Wound history

›Skin breach near knee concern for open fracture

03Physical Exam/exam28

Knee and limb exam

›Knee and limb exam

›Inspection

›Deformity or malalignment

›Skin tenting or threatened skin

›Soft tissue status

›Blisters

›Ecchymosis pattern

›Effusion

›Tense hemarthrosis

›Palpation

›Tibial plateau tenderness

›Proximal fibula tenderness

›Range of motion limits

›Pain limited active motion

›Mechanical block concern for displaced fragment

Neurovascular and compartment exam

›Neurovascular and compartment exam

›Pulses and perfusion

›Pulse asymmetry

›Cool or pale foot

›Peripheral nerve function

›Common peroneal nerve distribution symptoms

›Tibial nerve distribution symptoms

›Compartment syndrome features

›Pain with passive toe or ankle stretch

›Tense compartments

›Red flags

04Differential Diagnosis/ddx22

Knee trauma differentials

›Knee trauma differentials

›Tibial plateau fracture

›ICD-10 S82.1 category fracture of upper end of tibia

›Knee dislocation with spontaneous reduction

›Popliteal artery injury risk

›Distal femur fracture

›Supracondylar fracture

›Patellar fracture

›Extensor mechanism disruption

›Proximal fibula fracture

›Posterolateral corner injury association

Mimics and associated injuries

›Mimics and associated injuries

›Meniscal tear

›Locked knee symptoms

›ACL or PCL injury

›Instability and hemarthrosis

›Quadriceps or patellar tendon rupture

›Inability to straight leg raise

›Septic arthritis

›Fever and atraumatic onset history

›Deep vein thrombosis

›Calf swelling after immobilization

05Laboratory Tests/lt16

Preoperative and bleeding assessment

›Preoperative and bleeding assessment

›Complete blood count for anemia or hemorrhage concern

›Hemoglobin trend if significant swelling or trauma

›Basic metabolic panel for perioperative planning

›Creatinine for contrast and medication dosing

›Coagulation studies if anticoagulant use or surgical planning

›INR for warfarin exposure

›Type and screen for high energy fracture patterns

›Crossmatch if hemodynamic concern

Complications and special testing

›Complications and special testing

›Creatine kinase if compartment syndrome concern

›Rising value supporting muscle injury

›Venous blood gas if shock physiology concern

›Lactate for perfusion assessment

›Pregnancy test when applicable

›Imaging and medication planning

06Diagnostic Tests/dt36

Scoring Systems

›Classification and decision tools

›Schatzker classification for tibial plateau fractures

›Type I lateral split fracture

›Type II lateral split depressed fracture

›Type III lateral pure depression fracture

›Type IV medial plateau fracture

›Type V bicondylar fracture

›Type VI metaphyseal diaphyseal dissociation

›Ottawa Knee Rule for radiography after acute knee injury

›Age 55 years or older

›Isolated patellar tenderness

›Fibular head tenderness

›Inability to flex knee to 90 degrees

›Inability to bear weight for 4 steps immediately and in ED

MRI

›MRI considerations

›Indications

›Suspected meniscal injury requiring characterization

›Suspected ligament injury affecting stability plan

›Utility

›Meniscus and ligament evaluation

›Occult fracture assessment when CT nondiagnostic

CT

›CT considerations

›Indications

›High suspicion with negative or equivocal radiographs

›Surgical planning for depression and comminution

07Disposition/dispo20

Consultation and level of care

›Consultation and level of care

›Orthopedic consultation in ED

›All displaced fractures

›Any suspected fracture dislocation pattern

›Admission indications

›Schatzker IV to VI patterns

›Significant soft tissue swelling requiring staged fixation

›ICU or monitored bed indications

›Vascular injury

›Compartment syndrome concern requiring frequent exams

Discharge criteria and follow up

›Discharge criteria and follow up

›Discharge criteria

›Nondisplaced or minimally displaced pattern with stable alignment

›Normal neurovascular exam

›Outpatient orthopedic follow up

›Urgent follow up within 1 week

›Earlier follow up if CT shows depression or split displacement

›Mobility plan

›Non weight bearing with assist device

›Home safety and stairs assessment

08Treatment/t64

Analgesia and symptom control

›Analgesia and symptom control

›Nonopioid analgesia

›Acetaminophen

›1000 mg PO every 6 hours as needed

›Maximum 3000 mg per day with liver risk factors

›Ibuprofen

›400 mg PO every 6 hours as needed

›Avoid in renal injury or high bleeding risk

›Opioid analgesia for severe pain

›Hydromorphone

›0.5 mg IV

›Repeat every 10 to 15 minutes as needed to effect

›Morphine

›0.05 mg per kg IV

›Repeat every 10 to 15 minutes as needed to effect

›Antiemetic adjunct

›Ondansetron

›4 mg IV or PO

›Repeat every 8 hours as needed

Immobilization and soft tissue protection

›Immobilization and soft tissue protection

›Knee immobilizer locked in extension

›Remove only for skin checks when safe

›Long leg splint when swelling or instability significant

›Well padded posterior slab plus stirrup

›Cryotherapy and elevation

›Avoid prolonged direct ice to skin

09Special Populations/sp23

Pregnancy

›Pregnancy considerations

›Radiation minimization

›Shielding when feasible for radiographs and CT

›Analgesia selection

›Avoid NSAIDs in later pregnancy

›Thromboembolism risk

›Lower threshold for prophylaxis if admitted per obstetric guidance

Geriatric

›Geriatric considerations

›Low energy fractures with osteoporosis

›Higher risk of depression pattern with subtle radiographs

›Mobility safety

›Walker preference over crutches

›Disposition support

›Home safety assessment

›Short term rehab placement consideration

Pediatrics

›Pediatric considerations

›Physeal injury risk

›Proximal tibial physis involvement assessment

›Weight based analgesia

›Acetaminophen 15 mg per kg PO every 6 hours as needed

›Ibuprofen 10 mg per kg PO every 6 hours as needed

›Non accidental trauma consideration

›Mechanism congruence check in younger children

10Background/b29

Epidemiology

›Epidemiology

›Frequency

›Approximately 1 percent of all fractures

›Incidence about 10.3 per 100,000 people per year

›Age distribution

›Mean age about 52.6 years

›Bimodal pattern with younger high energy and older low energy mechanisms

Pathophysiology

›Pathophysiology

›Injury mechanism

›Axial load driving femoral condyle into tibial plateau

›Varus or valgus forces creating split and depression patterns

›Associated injuries

›Meniscal injury association

›Cruciate or collateral ligament injury association

›Complications

›Acute compartment syndrome from swelling and bleeding

›Vascular injury risk with fracture dislocation patterns

Therapeutic Considerations

›Therapeutic considerations

›Imaging limitations

›Plain radiograph sensitivity around 85 percent

›CT indicated when suspicion persists despite negative radiographs

›Nonoperative principles

›Alignment and stability preservation

›Soft tissue protection and staged decisions

›Operative indications overview

11Patient Discharge Instructions/pdi19

copy discharge instructions

›copy discharge instructions

›Non weight bearing on the injured leg until cleared by orthopedics

›Use crutches or walker at all times when standing

›Keep knee immobilizer or splint on continuously

›Keep clean and dry

›Elevation and ice

›Elevate leg above heart level as much as possible for 48 to 72 hours

›Pain control plan

›Use acetaminophen and ibuprofen if safe for you

›Return to ED immediately for danger signs

›Increasing pain not controlled with medication

›New numbness or tingling in foot

›Foot becoming cold, pale, or blue

›Increasing swelling or tightness in calf or leg

›New weakness moving ankle or toes

›Wound drainage, fever, or spreading redness

›Follow up

›Orthopedic appointment within 7 days or sooner if instructed

›Bring imaging reports to the appointment

12References/r15

Key sources

›Key sources

›Tibial plateau fractures overview and imaging sensitivity and CT and MRI indications

›StatPearls Tibial Plateau Fractures NCBI Bookshelf

›Initial ED management pathway by Schatzker patterns and open fracture antibiotics and admission triggers

›University of Virginia Tibial Plateau Fractures Initial Management Guidelines

›Operative and nonoperative indications and staged external fixation principles

›Orthopaedic Trauma Association tibial plateau fracture lecture materials

›Ottawa Knee Rule criteria for imaging after acute knee trauma

›RACGP Ottawa knee rules review

›ABI screening protocol for Schatzker IV to VI fractures with symmetric pulses and CTA threshold

›JBJS 2025 ABI screening study in Schatzker IV to VI tibial plateau fractures

›Coding and terminology references

›ICD-10 S82.1 category fracture of upper end of tibia

›SNOMED CT closed fracture of tibial plateau disorder examples in NLM VSAC

›Management system instruction file

Evidence & Review

Evidence & Review