Symptoms, Signs, and Classification
Fractures of the proximal tibia usually result from a lateral bending force (eg, as when a car strikes a pedestrian from the side). As the leg bends, the femoral condyle drives the tibial articular surface down into the underlying metaphyseal bone, which gives way easily in the elderly because of osteoporotic weakness. Patients present with knee pain and effusion, proximal tibial tenderness, and an inability to bear weight. Although standard anteroposterior and lateral x-rays typically show displaced fractures, oblique views may be needed to see occult fractures. Fat globules in blood aspirated from the knee joint are also diagnostic of an occult fracture.
Treatment and Prognosis
Because soft tissue swelling can cause neurovascular complications, patients are usually hospitalized so the leg can be elevated and observed. Following initial traction or continuous passive motion to help mold the fragments, patients are placed on a regimen of restricted weight bearing in a long leg brace or cast for 8 to 12 wk. Patients need physical therapy to learn to walk using ambulatory aids (eg, crutches or walkers). In the elderly, articular surface displacement of <= 1 cm is usually acceptable, but severe displacement requires operative reduction of the articular surface with a bone graft to fill the void left by the impacted trabecular bone. Unfortunately, weight bearing must be prohibited for 2 to 3 mo postoperatively, until healing occurs.
Elderly patients have a lower risk than young, active patients of developing osteoarthritis from joint surface disruption. When it does develop, total joint replacement is a good option.
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