(Kiosk 2) Slipping on the Ice: A Right Knee Hyperextension Injury

Case Diagnosis: Right lateral tibial plateau fracture

Case Description or Program Description: 63-year-old female with history of right knee patellar chondromalacia and medial meniscal tear presents for evaluation of acute lateral right knee pain after falling and hyperextending her knee while climbing icy stairs. She denies swelling. Pain is worse with position changes, stairs, and full weight bearing. Her exam revealed tenderness to palpation at the lateral greater than medial joint lines. Range of motion from 0 to 100 with pain at end range. Pain with hyperflexion and extension bounce test. Positive McMurray’s and meniscal grind tests. Knee ligamentous testing was normal. MRI demonstrated new intra-articular lateral tibial plateau fracture with minimal depression. Case was discussed with orthopedic surgery and consensus was to proceed with non-operative management. She was non-weight bearing for two weeks using hinged knee brace and crutches with plan for progression to partial weight bearing as tolerated. Serum vitamin D and calcium levels and a DEXA scan were obtained.

Setting: Tertiary care center

Assessment/Results: DEXA scan revealed osteopenia, and she was encouraged to continue vitamin D and calcium supplementation and follow-up with her primary care provider. At 4-week follow-up, she was pain free with use of the hinged knee brace and participating in physical therapy. At 8-week follow-up, she remained pain free with weight bearing with plan for weaning the brace.

Discussion (relevance): The mechanism of tibial plateau fractures is often a varus or valgus load sometimes accompanied by an axial load. In the setting of low energy mechanisms of injury, workup should include evaluation for osteoporotic disease. Non-operative management is warranted for minimally displaced fractures and non-ambulatory patients. Indications for surgery include significant articular step-off, condylar widening, and ligamentous instability.

Conclusions: Tibial plateau fractures should be on the differential with hyperextension mechanisms of injury. Additional evaluation for osteoporotic disease in the setting of low energy trauma is warranted.