Tibial Plateau Fracture-7months after

[m_reeson]

hello, thanks in advance for answering my questions!
i will try to be brief.
about 7 months ago, had a bike accident resulting in a tibial plateau fracture. it was not badly displaced, and so dr opted to treat non-operativly.
my leg was immobilized for almost 3 months and i didnt weight bear for 3.5 months. have been in physio for almost 5 months and have progressed from 30 degrees flexation to about 90. it is going very slow and has remained very painful and stiff. joint is always hot to the touch.
i had an mri about a month ago. just got the results. they are:
-old avulsion fracture of tibial insertion of anterior cruciate ligament. bone fragment is 1.2 x 0.4 x 2.2 cm anteroposterior, transverse and craniocaudal dimensions respectively. shows no marrow edema. mildly displaced proximally with no osseous union with tibia.
-fracture of tibial spines extending posteriourly to involve insertion of pcl.
-mild thickening of proximal pcl
-mild impaction fracture of posterior aspect of lateral tibial pleateau with 2 mm depression with chondrosis
-patchy bone marrow edema in medial femoral condyle and medial tibial plateau
-patellar retinaculae extensor tendons and collateral ligaments intact
-minisci intact
-root of posterior horn of medial meniscus is attached to fracture portion of tibia and anterior horn of lateral meniscus is attached to anterior cruciate ligament footplate avulsion
-resolving contusion of medial femoral condyle and medial tibial plateau
-lowgrade partial tear of pcl in proximal portoin
-sequelae of old impaction fracture of posterior aspect of klateral tibial plateau
-mild thickening of proximal aspect of pcl
-sequelae of mild impaction fracture of posterior aspect lateral tibial plateau with 2mm depression with chondrosis

im meeting with my ortho guy in june, just curious if anyone can let me know if there is anything here i should be worried about, that may be contributing to the ongoing pain and stiffness in my knee. it is taking so long to get better and im feeling totally in the dark about how it is. thanks so much!!

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[roycar]

hey.

thats a very interesting mri report there!

tibial plateau fractures are not straightforward, as you are experiencing, because the area of fracture can extend into the joint. i imagine at this stage the fracture itself is well healed.

the main thing that jumps out with regard your knee remaining painful and stiff and hot to touch is the avulsion fracture of your distal acl insertion. you basicly have a loose body moving around in your knee. as you try to move and stretch the knee out its more than likely causing the knee to remain inflamed and not letting it settle down. your ortho may decide to scope your knee and see about cleaning it out. this would more than likely help.

the other thing is that because of the avulsion fracture you dont have an intact acl. your anterior cruciate ligament is pretty important with regard stability of the knee so it may be that you are having some degree of instability too which could also be a factor with regard the longstanding inflammation.

either way im sure your ortho was more worried about the fracture to begin with and making sure that it gets healed up well. discuss your options with him in light of the mri results and see where you go from here. id be fairly optimistic of a good outcome if he were to scope it.

keep going with your physio. you need to keep working on range and power/control, balance etc. the better shape your knee is in from that point of view the easier it is to go through another surgery and rehab quicker.

all the best.

[m_reeson]

hi roycar,
thanks so much for answering!
i am looking forward to seeing my ortho dr soon to discuss the mri results.
im curious, does the fact that the joint is consistently warm indicate to you that there is a problem (such as the fragment attached to the acl?) and in a more general sense does being at only 90 degrees of flexation, 7 months post fracture seem alarming? or given the mri results, does that seem understandable? and if my dr agrees that the fragment could be hindering me and should be addressed surgically, do you have an idea of what the recovery would be like?
again i really appreciate your time, its so helpful!
michael

[roycar]

that the joint is consistently warm indicates that there is an ongoing inflammation in the joint. there are a number of things that could cause this but the loose fragment is the most obvious one from what i read.

90 degrees after seven months would worry me a small bit but given the mri results i believe that there are reasons that may explain your deficit in range. what does it feel like when you try to push past 90, is it a solid "bony" end feel or does it feel "springy" and soft tissue like? again it could possibly be that the loose body is positioned in such a way that its limiting further flexion of the joint. if the joint is hot and swollen that would limit flexion also.

IF its the loose body thats causing most of your problems, and its removed, in theory it should immediately make things a lot easier for you.

[m_reeson]

hey roycar,
thanks again for the info!
trying to push the knee feels like stretching leather. thats a quote from my physiotherapist. so its not a case of a bone on bone type blockage.
at any rate i will continue to work the knee with my physio routine.
i guess seeing my ortho doctor will be the best way to determine where i am at and what should be done.
this has just been such a long and drawn out recovery, and the constant discomfort and stiffness in my knee is wearing me down! and i have a sense that everyone i speak with about my knee has a different take on it! for the first 3 months my ortho dr. said he intended to examine the knee for soft tissue damage, and then at my last apt said it was not necessary as that kind of damage was rare with a fracture like mine (as well as contradicting himself, it seems the opposite of all the medical journal articles ive read online re: tibial plateau fractures). my family dr ordered the mri when i saw him and told him about my knee. i had the results faxed to him, and to my physiotherapist. my physiotherapist said she didnt see anything very concerning in the mri report, but felt i should check in with my orth dr as the flexation was so slow to recover, but my family dr said he was very concerned with the bone fragment that was floating in the knee. anyways, its just been confusing to establish what is actually going on in my knee, which is frustrating as i really want to get back to my previous level of activity, ie riding a bike, running, walking with out a cane...etc.
i thank you again for your perspective and insights. i find it very helpful to hear your take!
michael