Meniscus and ligament injuries associated with tibial plateau fractures cannot be predicted from CT scans, even with high surgical experience

Tibial plateau fractures are associated with a range of meniscal and ligamentous injuries that are relevant to the outcome. Standard diagnostics include radiographs and computed tomography (CT). Magnetic resonance imaging (MRI) is not routinely recommended, although it visualizes meniscal and ligamentous injuries with high sensitivity and specificity. The aim of the study was to analyze tibial plateau fractures for meniscal and ligamentous injuries and to determine whether predictability could be achieved using CT. The study also examined whether the detection of meniscal and ligamentous injuries depended on the experience of the trauma surgeon. Initially, 30 CT scans and subsequently 30 MRIs were evaluated by three residents and three consultants. To prevent rater recall of MRI–CT findings for a given patient, findings were presented in a randomized order with a two-week interval between CT and MRI assessments. A standardized questionnaire was used to evaluate soft-tissue injuries, fracture classification, surgical strategy, and the treatment of associated meniscal and ligamentous injuries for each CT and MRI. The radiologists’ MRI report was defined as the reference standard. The incidence of meniscal and ligamentous injuries associated with tibial plateau fractures was 93% (n=30). The regions most affected by soft-tissue injuries were the posterolateral corner, the anterior cruciate ligament, and both collateral ligaments. Sixty additional soft-tissue injuries were identified upon evaluation of MRI scans. The greatest improvement in diagnostic accuracy for meniscal and ligamentous injuries due to MRI was observed in cases of posterior cruciate ligament tears. Differences between consultants and residents were particularly evident in the detection of soft-tissue injuries in the lateral meniscus (63% vs. 48%, n=30, p=0.036) and the collateral ligament (70% vs. 56%, n=30, p=0.045). Predicting meniscal and ligamentous injuries in tibial plateau fractures based solely on CT scans is insufficient, irrespective of the surgeon’s experience. The benefit and indication for MRI should be assessed on an individualized basis. The fracture extent, suspicion of soft-tissue injury, the treatment goal, and patient factors all influence this decision.