A bicondylar tibial plateau fracture is an injury to the top surface of the shinbone (tibia), just below the knee. This fracture involves breaks on both the inner (medial) and outer (lateral) sides of the tibial plateau, a primary weight-bearing surface. The damage disrupts the smooth cartilage of the joint and can extend into the metaphysis, the wider part of the bone. This makes the knee joint unstable and unable to support the body’s weight, requiring a structured treatment plan to restore alignment and function.
Anatomy of a Bicondylar Tibial Plateau Fracture
The tibial plateau is the upper surface of the tibia, which is broad and flat to support the rounded ends of the femur (thigh bone), forming the knee joint. This surface is covered with smooth articular cartilage that allows the bones to glide with minimal friction. The plateau is divided into two compartments: the medial condyle on the inside of the knee and the lateral condyle on the outside. A bicondylar fracture means both of these supportive structures are broken.
These fractures result from high-energy trauma that applies a strong force to the knee. Common causes include motor vehicle accidents, falls from a significant height, or sports injuries. In older individuals with weaker bones, a similar fracture can happen from a lower-energy incident.
The immediate aftermath is characterized by intense pain and significant, rapid swelling around the knee. The leg may appear deformed due to the displacement of bone fragments. Attempting to put any weight on the injured leg is impossible and results in severe pain and instability.
Diagnosis and Initial Assessment
Confirming a bicondylar tibial plateau fracture begins with a physical examination to assess for swelling, deformity, and knee stability. The initial diagnostic imaging involves X-rays of the knee. These images provide a clear view of the bone structure and can confirm the presence of a fracture in both the medial and lateral condyles.
To fully understand the fracture’s complexity and plan for surgery, a computed tomography (CT) scan is standard practice. A CT scan generates detailed, cross-sectional images of the bone. This creates a 3D reconstruction that allows surgeons to see the exact location, size, and displacement of each fracture fragment.
In some cases, a magnetic resonance imaging (MRI) scan may also be ordered to evaluate the condition of surrounding soft tissues. It can identify tears in the menisci or ruptures of ligaments like the ACL. Surgeons use this collective information to classify the fracture, often using systems like the Schatzker classification to guide the surgical approach.
Surgical Treatment Options
Due to their instability and the disruption of the joint surface, these fractures almost always require surgical intervention. The goal of surgery is to restore the anatomical alignment of the joint surface and provide stable fixation so the bone can heal correctly. The most common procedure is Open Reduction and Internal Fixation (ORIF), which helps prevent long-term complications like arthritis.
During an ORIF procedure, the surgeon makes one or more incisions to access the fractured bone. The “Open Reduction” phase involves maneuvering the displaced bone fragments back into their proper anatomical position. Once the articular surface is realigned, the surgeon proceeds with “Internal Fixation,” using hardware like metal plates and screws to hold the fragments securely while they heal. Fixation on both sides of the tibia is often required, which may involve two separate plates.
In situations with severe swelling or soft tissue damage, a staged surgical approach may be necessary. Initially, an external fixator is applied, which consists of pins inserted into the bone above and below the knee connected to an external frame. This temporarily stabilizes the limb, allowing the soft tissues to recover before the definitive ORIF surgery is performed.
Rehabilitation and Recovery Timeline
Rehabilitation begins almost immediately after the operation. This initial phase focuses on managing pain and swelling, and gentle motion is encouraged to prevent stiffness. A continuous passive motion (CPM) machine may be used, which slowly moves the knee joint without the patient engaging their muscles.
A primary component of early recovery is the non-weight-bearing period, which allows the bone to heal without being disrupted. Patients are instructed to avoid putting any weight on the injured leg for an extended time, typically 6 to 12 weeks. During this phase, physical therapy is introduced, focusing on range-of-motion exercises and strengthening muscles around the hip and thigh.
As bone healing progresses, confirmed by follow-up X-rays, the surgeon will permit a gradual return to weight-bearing. This starts with partial weight-bearing using crutches or a walker, and slowly increases over several weeks. Physical therapy becomes more intensive, with exercises aimed at restoring full knee motion, building leg strength, and improving balance. Returning to strenuous activities or sports can take from 6 months to over a year.
Associated Complications and Long-Term Outlook
Patients face potential complications in both the short and long term. One acute risk is compartment syndrome, a medical emergency where excessive swelling in the lower leg cuts off blood supply, requiring immediate surgery. Other immediate risks include surgical site infections and blood clots, such as deep vein thrombosis (DVT), which can travel to the lungs.
Over the long term, the most common complication is post-traumatic arthritis. The initial damage to the articular cartilage can lead to its progressive wear over time, causing chronic pain, stiffness, and reduced function. Even with successful surgery, some degree of knee stiffness or a loss of full range of motion can persist.
Other potential long-term issues include malunion, where the fracture heals in an incorrect position, or nonunion, where the bone fails to heal. These may require additional surgery. Despite these risks, the outlook for patients who undergo successful surgical repair and adhere to a rehabilitation program is positive. Most individuals can expect to return to their normal daily activities, though high-impact sports may not always be possible.