A 27-year-old man presents to the emergency department after he developed pain in his right leg after landing off a ski jump. The patient is otherwise healthy and does not take any medications. He states his pain is 10/10. He is requesting medications and is crying out in pain. His temperature is 98.7°F (37.1°C), blood pressure is 149/85 mmHg, pulse is 103/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals swelling over his right leg and knee. The patient cries out in pain with passive motion of the foot at the ankle. A radiograph is performed as seen in Figure A. Which of the following is the most likely diagnosis?
Patellar fracture
Apophysitis of the tibial tubercle
Posterior dislocation of the knee
Tibial plateau fracture
Tibial plateau fracture
This patient is presenting after an axial load on his lower extremity (landing off a ski jump) with severe pain, a fracture on radiography, and severe pain with passive range of motion. This suggests compartment syndrome in the setting of a tibial plateau fracture.

Tibial plateau fractures occur as a result of an axial load, where the femur forcefully impacts the tibia, leading to intense pain in the proximal tibia region. One potential complication of this type of fracture is compartment syndrome, which presents with exquisite pain out of proportion to exam with passive motion of the lower extremity. While radiography can aid in diagnosing tibial plateau fractures, a negative radiograph should prompt further investigation with a CT scan in patients with a high suspicion of this type of fracture. Treatment involves performing a fasciotomy if compartment syndrome is present. Surgical repair is warranted if there is evidence of neurovascular compromise or a significantly displaced fracture. Otherwise, immobilizing the knee and providing outpatient orthopedic follow-up care is deemed appropriate for certain less severe fractures.

Schneiderman et al. studied compartment syndrome in high-energy tibial plateau fractures. The authors found that younger patients aged 12-29 years old are more likely to develop compartment syndrome, likely due to increased muscle mass and thicker fascial tissue. The risk of deep surgical site infection remains high at 20-25% of cases. The authors recommend that clinicians should be aware of factors associated with increased risk for compartment syndrome, including young age, male gender, and a high-energy mechanism of injury.

Figure/Illustration A is a radiograph demonstrating a tibial plateau fracture with the red arrows demonstrating a fracture of the tibial plateau.

Incorrect Answers:
Answer A: Anterior cruciate ligament tear would present with a sudden popping sensation of the knee with swelling, knee instability, and laxity to anterior traction when force is applied to the tibia causing anterior displacement of the tibia relative to the femur. Management involves assessment with MRI and surgical repair in complete tears or immobilization in partial tears.

Answer B: Apophysitis of the tibial tubercle (Osgood-Schlatter disease) is common in pediatric patients and presents after exertion (such as basketball or jumping) with pain and tenderness over the tibial tubercle. It is caused by repeated microtrauma or microavulsion, separation of the proximal patellar tendon from the tibial tubercle, and subsequent callous deposition at the tibial tubercle. Management involves rest, ice, and nonsteroidal anti-inflammatory drugs.

Answer C: Patellar fracture would present with tenderness over the patella with a fracture line on the patella. Treatment of non-displaced fractures includes rest and immobilization in a straight-leg knee immobilizer.

Answer D: Posterior dislocation of the knee presents with sudden trauma to the knee with pain, swelling, and a loss of pulses in the extremity when the popliteal artery is compromised. Radiography is diagnostic and will show a knee dislocation. Treatment involves immediate reduction to avoid permanent injury to the popliteal artery.

Bullet Summary:
Tibial plateau fractures present after trauma with severe lower extremity pain and are highly associated with compartment syndrome.