tibial plateau fracture

Monday, October 9, 2017

It’s difficult to understand why bad things happen to good people. It goes without saying that the Texans’ J.J. Watt is beloved in his adopted home of Houston. It is also true that his broken leg, a tibial plateau fracture, will call into question whether he will play again in the NFL.

His response on Twitter to his situation?

“I can’t sugar coat it, I am devastated. All I want to do is be out there on that field for my teammates and this city. I’m sorry.”

This from the man who raised tens of millions of dollars for the Houston hurricane relief efforts and who has played and been recognized as the best defensive player in the league. but the demon of injuries is blind to ability to play and a tibila plateau fracture is a big deal.

Broken bones are not all created equally. It’s all about location. The tibia (shin bone) connects to the femur to form the knee, and to the talus to form the ankle joint. Fractures that involve the joint surface have the potential to not heal appropriately and cause long term problems like arthritis, stiffness and loss of range of motion. This is especially true for the tibial plateau.

The top of the tibia, has two shallow surfaces lined with cartilage that allow space for the femoral condyles to slide and allow the knee joint to flex (bend) and extend (straighten). It takes a lot of force to fracture the tibial plateau and in addition to the trauma, there needs to be some bad luck involved, where the knee is just in the right position, so that the force drives the tibia into the femur and shatters that once smooth surface. Most often, these injuries occur in car wrecks or falls from height where a load is placed on an extended leg and all the force is transmitted into the knee.

Anatomy is important in understanding injury patterns. The top of the tibia is expensive real estate. There is a medial and a lateral tibial plateau, both covered with a meniscus or cartilage, and between the two is the intercondylar notch where the ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament) attach. Because the knee is designed to be held in slight valgus, the medial tibial plateau tends to have thicker bone that that makes is less prone to injury than the lateral tibial plateau.

When the tibial plateau is forced into the femoral condyle the bone collapses and the surface where the cartilage sits, may or may not get crushed. The pain is immediate, the swelling occurs quickly and trying to walk on the injury may or may not be possible, depending on the severity of the break. X-rays can show the general injury, but they are only 2D images and the body is three dimensional. CT may be needed to look at the surface of the plateau and understand the extent of damage…and if there is concern that there are ligaments involved, an MRI might also be needed.

When it comes a decision about surgery, it’s all about making certain that the joint surface lines up properly. If there is any step off, inflammation will occur with each step taken as the femoral condyle rubs against the uneven surface. The long-term complications include pain, knee stiffness and arthritis, but other problems might arise, including malunion (failure of the bone to heal) or collapse of the fracture, so that the knee joint has no bone beneath for support.

The bottom line for Mr. Watt is that a tibia plateau fracture is a bad thing that happened to a good person. Depending upon the extent of the injury, his recovery and return to play might span a spectrum that runs months to never. The goal for all patients is to return them to the level of function that they had enjoyed prior to the injury. Unfortunately, most patients aren’t best in class NFL defensive lineman.

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