Proximal tibial fractures constitute approximately 7% of lower limb fractures. A vast majority includes fractures involving the articular surface, the so-called tibial plateau. The degree of damage of the articular cartilage surface and the bone tissue is crucial for prognosis. In the case of severe damages, the most frequently in the case of severe damages (ie. split-depression fractures), the injury may lead to rapid development of the degenerative disease of the knee joint – gonarthrosis (1, 2). Obviously, the treatment outcome is affected by the knee condition before the accident, previous problems with the menisci, degree of use of the articular cartilage, existing limitation of movement range, and perhaps past surgeries, which are factors worsening the prognosis.

In elderly people, a fracture (fig. 1) is frequently caused by a fall as a result of a stumble or injury resulted from a fall from a small height, e.g. from a chair, windowsill, table, etc. Small forces are necessary to create a fracture in weak osteoporotic bone.

Basic components of the fracture include edema of the knee joint, severe pain at pressure and during movement attempt, and frequently valgus deformation of an axis. Puncture of the knee joint reveals the presence of hematoma and frequently, fat droplets. Basic evaluation consists of X-rays in two projections (fig. 2).

Evaluation includes fracture type, degree of depression and displacement of the bone fragments as well as the bone quality. However, very often an X-ray image is not sufficient in fracture evaluation and it is not able to support a decision on the treatment method. The most useful evaluation method is computed tomography (CT-scan) and magnetic resonance imaging (MRI) (fig. 3). While computed tomography image, especially 3D, perfectly visualizes the degree of bone fragments depression and displacement, the MRI evaluation is irreplaceable in the evaluation of soft tissue damage, mainly the menisci and the ligaments, which may accompany the fracture (fig. 4).

One should remember that just as in the case of the spine, elderly people with advanced osteoporosis may suffer from invisible fractures. The patient reports to the doctor pain in the knee joint lasting for some time, and frequently associated with progressing deformity of the limb axis, but the patient does not remember any injury.

Intra-articular fractures of the proximal tibia occur as a result of not only indirect, but also direct injuries. In elderly patients, there are mainly indirect injuries resulted from a fall on the knee in a slightly valgus position. In general, direct injuries accompany car accidents or result from direct impact on the tibial epiphysis. The important role in the mechanism of fractures is played by the anatomical structure of the femoral and tibial condyles as well as the physiological valgus position of the knee joint. If the force during the injury acts on the lateral surface of the knee joint, the strong and hard femoral condyle crushes and splits the more fragile lateral condyle of the tibia (fig. 5). Damage of the tibial lateral collateral ligament may also occur in such case. If the force comes from the medial direction, the medial femoral condyle, which is also stronger, crushes or splits the more fragile medial condyle of the tibia (fig. 6), and in addition, lateral ligament structures may be damaged. In the case of a fall from a height on an extended limb, the femoral condyles, acting as a ram, may crush and split the tibial condyles (fig. 7). Fracture lines, which are occurring in this case, resemble reversed letters “V”, “T” and “Y”.

Pathomechanism of fracture of the lateral tibial condyle according to Trickey, who was one of the pioneers noticing possible coexistence of injuries of the menisci and ligaments (fig. 8):

a) tears of the tibial collateral ligament and frequent tears of the anterior cruciate ligament usually occur in both types of fractures,