This type of fractures occurs by forced flexion or hyperextension with internal rotation of the tibia [26]. They are common in pediatric population 8–13 years and related to sports in contrast with the adult population; here these fractures are related to traffic accidents [33–36]. The classification system that is more commonly used is the Mayer and McKeever since 1959 [35] with the following types: I, undisplaced; II, partially displaced fracture; IIIA, completely displaced fragment; and IIIB, completely displaced fragment and rotated; Later Zariczynj [37] included type IV, complete displacement with comminution. In children cartilaginous tibial eminence fracture can occur, which are very often misdiagnosed. Nevertheless, there is a good prognosis even after misdiagnosis and treatment of the nonunion, which may be due to the low-energy mechanism of injury and low rate of associated lesion. In this sense, the surgical treatment plays a crucial role because when the patient is exposed to the conservative treatment, the nonunion might expose to ACL involution [38] (Fig. 18.3).

Knee pain and hemarthrosis are present, and drainage of the hemarthrosis can be performed in order to relieve symptoms. Entrapment of soft tissue (such as the anterior horn of the lateral meniscus) can also occur [39].

The initial study is made by anteroposterior and true lateral radiographs. CT scans are obtained to obtain a better characterization of the degree of communication. MRI can be obtained for more information about the soft tissue structures [40, 41].

Type I is treated with a long leg cast immobilization for 4–6 weeks with follow-up radiographs every 2 weeks [42].

In type II the treatment is controversial and can be conservative or surgical depending on the surgeon opinion [26, 42].

Type III/IV is managed surgically with arthroscopy. The more common methods of fixation are by a cannulated screw or by tensioning the fragment with a wire and then passing it through two tibial tunnels drilled to that purpose [26, 42]. Weight bearing is allowed with a pair of elbow crutches with early range of motion [43–45].

The prognosis for surgical treatment is considered very good [42]. Several complications such as residual laxity, growth deformity, and arthrofibrosis are described [39, 42].

This type of fractures is rarely associated with noncontact sports and can be considered an uncommon knee injury; they are usually related with high-impact incidents such as car accidents [23, 46]; however, there are some reports in amateur football that report this type of fracture as one of the most common in the inferior limb [14]. The fracture usually occurs with a varus or valgus force coupled with axial loading [23]. The classification of these fractures is mainly by the Schatzker classification (six types) that is pathoanatomic and suggests treatment strategies [24, 47, 48] (Fig. 18.4).

The inability to continue to play immediately after this injury is mentioned in a case report of a tibial plateau fracture [46]. In hemarthrosis, a painful knee and inability to bear weight are typical findings [23].

Neurovascular examination and assessment for meniscal or ligament injury remain a key aspect in the evaluation of these fractures [23].

Compartment syndrome can occur but is more common in high energy fractures [23, 24].

Several associated lesions can occur to the meniscus and cruciate or collateral ligaments [23, 24].

The initial study is made by anteroposterior (10–15 degree caudal view) and lateral radiographs. CT scans are obtained to obtain a better characterization of the fracture pattern and for preoperative planning. MRI can be obtained for more information about the soft tissue structures (meniscus and ligaments) [23, 24].

The conservative treatment can be performed in nondisplaced or minimal displaced fractures; other situations that are also managed by nonoperative treatment but that aren’t related to this book are elderly patients or patients with severe medical problems. The patient is kept in a cast brace with non-weight bearing for 4–8 weeks and progressive weight bearing until 12 weeks [3, 7].

Obvious concerns exist to this kind of treatment due to the problem of the long period of immobilization in athletes.

Operative treatment is indicated with vascular injury, compartment syndrome, fractures, open fractures, displaced unstable fractures, and with a variable degree of articular depression <2 mm to 1 cm [23–25].

The surgical goals are to restore articular surface, tibial alignment, and associated menisco-ligament injuries. In this sense, preserving the menisci is fundamental. There are several fixation methods such as plates, screws, and external fixators, and their application depends on the fracture pattern. There are also several surgical approaches such anterolateral, posteromedial, anteromedial, posterolateral, and combined anterior and posteromedial that are used accordingly with the fracture pattern. Arthroscopy has several applications such as soft tissue lesion visualization, joint lavage, osteochondral fragment removal, reduction assistance, or other lesion repair. Weight bearing starts at 8–12 weeks after surgery [24, 25].

Excellent results have been reported with conservative treatment [24, 46].

The results with surgical treatment are largely dependent on the fracture pattern.

Several complications can occur such as infection, arthrofibrosis, malunion, or nonunion [23–25].

It is important to mention that most of the results are referent to non-athletes, and in the literature, the results for this type of population are not favorable like it was demonstrated in a paper where the majority of athletes did not return to the previous level with the authors referring that for competitive sports this can be a career-ending lesion [15] (Figs. 18.5, 18.6, and 18.7).

This injury occurs mainly in the adolescent population just before the skeletal maturations occurs. It comprises 3% of tibial fractures and results from a vigorous contracture of the quadriceps, and it is typically an injury that occurs in males [16, 49, 50].

Initial classification was proposed by Watson-Jones [51] in three types and later revised by Ogden (subtypes A and B) in order to account the degree of displacement and comminution [52].

Type I consists of a fracture through the tubercle, type II in fracture at the level of the tibial physis, and type III in a fracture that extends into the joint.

More recently a rare type IV fracture was described, and it consists of a fracture that extends posteriorly through the physis [53] and a type V that consists of a type IV and IIIB, creating a Y configuration [50].

An audible pop at the time of the injury may be heard. Acute pain, swelling, and tenderness characterize the presentation. The ability to extend the knee against gravity is variable but weakness is a constant finding. It is important to perform a meticulous knee examination to exclude other injuries such as meniscal or ligament tears [20, 49, 54].

Lateral, anteroposterior, and oblique radiographs are required. MRI is rarely necessary, only if associated injuries are suspected [54].

Conservative treatment is proposed for the type I fractures and for IB or IIA that can be reduced anatomically with a long leg or cylinder cast.

Surgical treatment, open reduction and internal fixation with fluoroscopy, is reserved for types IB and IIA that can’t be reduced, and for types IIB, III, IV, and V, the use of screws with or without washers, tension band wiring, and repair of periosteum are described in the literature. Arthroscopic-assisted techniques are important particularly in type III fractures to assess and repair any intra-articular pathology such as meniscal tear or osteochondral injury. In type V the epiphyseal and metaphyseal fractures should be treated independently. Immobilization is required after surgical treatment for 4–6 weeks [54, 55].

The prognosis is excellent and the main concerns should be addressed to the eventuality of a compartment syndrome. Loss of motion and patellar malposition have also been reported. Return to sports can be expected from 8–22 weeks depending if the treatment is conservative or surgical and the type of fracture [54, 55].

Segond fracture avulsion was described in 1879 by Dr. Paul Segond; it is located at the lateral aspect of proximal tibia immediately distal to the plateau [56, 57]. The mechanism of injury is tibial internal rotation and varus stress [19, 57].

It is associated with ACL tears (75%–100%), meniscal tears (66%–75%), avulsion fracture of the intercondylar eminence, and other injuries [19, 57–59]. Association between ACL injury and Segond fracture may be different in skeletally immature patients [60].

In the acute setting, pain, edema, hemarthrosis, and muscle spasm are usually present, and special tests for ACL tear can be present and positive [19, 61, 62]. Pain on the proximal-lateral tibial plateau has been also described [61].

Initial studies consist of knee radiographs; anteroposterior is the best view for the lesion [63].

Since this pathology is associated almost always with other lesions, MRI should be performed [61].

Since there are several associated lesions to Segond fracture, a personalized treatment should be performed [59] (described in other chapters).

Has stated before a broad spectrum of associated lesions exist with a variety of treatments performed according with each type making the prognosis associated with the concomitant injuries.