Clinical and Instrumental Diagnosis of Fractures of the Proximal Tibial Epimetaphyseal Fractures

Proximal tibial epimetaphyseal fractures account for 8.9 to 11% of all fractures of the tibia and up to 87% of all fractures of the knee joint. In this group, lateral condyle fractures occur in 52–80% of cases, medial condyle fractures – up to 7%, and multifragmentary fractures – in 41% of patients. Such fractures are accompanied by damage to the soft tissue structures of the knee joint: meniscal injuries – in 50–94% of patients, collateral ligaments – in 20–83%, anterior cruciate ligament – in 20–69%, thigh muscle tendons –up to 47%, joint capsule ruptures – up to 75%, and peroneal nerve injuries – in 3% of cases. Diagnosis of the fracture itself, and even more so of soft tissue injuries, based on the results of a physical examination is difficult due to pain, swelling and instability, characteristic of a number of other injuries of this area. The objective: to improve the level of diagnosis of proximal tibial epimetaphyseal fractures by determining the informativeness of instrumental diagnostic methods and developing a clinical diagnostic algorithm. Materials and methods. Literature publications of databases PubMed, UpToDate, Scopus, Web of Science, MedLine, The Cochrane Library, EMBASE, Global Health (by search: “fractures of the proximal epimetaphysis of the tibia”, “clinical and instrumental diagnostics”) and own experience of diagnosis and treatment of 437 patients with proximal tibial epimetaphyseal fractures from 2004 to the present. Results. A statistically significant difference in the frequency of accurate diagnosis according to computed tomography (CT) and X-ray examination was established. In fractures in the knee joint without displacement of fragments, the frequency of accurate diagnoses is higher according to CT results (92.9%) than with X-ray examination (57.1%), p = 0.029. In fractures with displacement of fragments, the difference in the frequency of unerring diagnosis is also statistically significant: with CT – 98.5% and with X-ray examination – 57.1% (p = 0.002). Due to the high accuracy of fracture diagnosis using CT, this method can be considered a reference standard for them. MRI diagnostics is characterized by high accuracy in detecting damage to the ligamentous apparatus (94.9% of cases) and meniscus (92.9%). X-ray examination of such knee joint injuries has low diagnostic efficiency: 3.9% (1.7–8.7%) with damage to the ligamentous apparatus (sensitivity 3.4%, specificity 4.1%) and 5.4% (2.6–10.8%) with damage to the meniscus (sensitivity 2.9%, specificity 7.8%), p < 0.001. Conclusions. Clinical and instrumental diagnosis of proximal tibial epimetaphyseal fractures, which are often accompanied by damage to ligaments and menisci, is a difficult task and requires anatomical and biomechanical knowledge of the functioning of the knee joint. X-ray examination is the basic instrumental method of examination. CT and MRI studies depends on the goal set by the doctor at a certain stage of the diagnostic process. The proposed clinical and instrumental diagnostic algorithm for proximal tibial epimetaphyseal fractures includes the determination of concomitant neurovascular disorders and justifies the feasibility of choosing a particular instrumental method of examination, which will reduce the number of diagnostic errors and ensure timely treatment of patients with this pathology.