n Feature Article
Population-Based Epidemiology of Tibial
Plateau Fractures
Rasmus Elsoe, MD; Peter Larsen, MR; Nina Pil Hostrup Nielsen, MD; Johanna Swenne, BM;
Sten Rasmussen, MD; Svend Erik Ostgaard, PhD, MD
abstract
Although epidemiologic studies of tibial plateau fractures have been conducted,
none have included geographically defined populations or a validated fracture classification based on computed tomography (CT). The goals of this study were to
provide up-to-date information on the incidence and basic epidemiology of tibial
plateau fractures in a large unselected patient population and to report the mechanisms of injury involved and the distribution of fractures according to a validated
CT-based fracture classification. The authors conducted a population-based epidemiologic study of all patients treated for tibial plateau fracture over a 6-year period
from 2005 to 2010. The study was based on an average background population of
576,364 citizens. A retrospective review of hospital records was performed. During
this time, a total of 355 patients were treated for tibial plateau fracture. This group
included 166 men and 189 women, and mean age was 52.6 years (SD, 18.3). The
most common fracture type was AO type 41-B3, representing 35% of all tibial
plateau fractures. The second most common fracture type was AO type 41-C3, representing 17% of all tibial plateau fractures. The incidence of tibial plateau fractures was 10.3 per 100,000 annually. Compared with women, men younger than
50 years had a higher incidence of fractures. The incidence of fractures increased
markedly in women older than 50 years but decreased in men older than 50 years.
In both sexes, the highest frequency was between the ages of 40 and 60 years. [Orthopedics. 2015; 38(9):e780-e786.]
The authors are from the Department of Orthopaedic Surgery (RE, NPHN, JS, SR, SEO), the Department of Occupational Therapy and Physiotherapy (PL), and the Department of Clinical Medicine (SR),
Aalborg University Hospital, Aalborg University, Aalborg, Denmark.
The authors have no relevant financial relationships to disclose.
This study was supported by unrestricted grants from the Department of Orthopaedic Surgery and
the Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg
University, Aalborg, Denmark.
Correspondence should be addressed to: Rasmus Elsoe, MD, Department of Orthopaedic Surgery,
Aalborg University Hospital, Aalborg University, 18-22 Hobrovej, DK-9000 Aalborg, Denmark (rae@
rn.dk).
Received: September 26, 2014; Accepted: December 29, 2014.
doi: 10.3928/01477447-20150902-55
e780
Copyright © SLACK Incorporated
n Feature Article
T
he incidence of fractures of the
lower limb is reported with variation over time and between coun1-3
tries. Fractures of the proximal articular
surface of the tibia are uncommon injuries. Tibial plateau fractures constitute
approximately 1% of all bone fractures.1,4
Epidemiologic studies of tibial plateau
fractures have been reported, but not in a
geographically defined and unselected patient population. In addition, earlier studies did not use a computed tomography
(CT)-based validated fracture classification or provide complete information on
the mechanism of injury.
The current study reported up-to-date
information on the incidence and basic
epidemiology of tibial plateau fractures
in a large and unselected population, including the mechanism of injury and the
distribution of fractures according to a
validated fracture classification based on
CT scans.
Materials and Methods
The authors performed a populationbased epidemiology study of all patients
treated for tibial plateau fracture over a
6-year period from 2005 to 2010.
The study was conducted at Aalborg
University Hospital, Denmark, in the
North Denmark Region, and was based
on an average background population of
576,364 citizens (Figure 1). The region
is served by Aalborg University Hospital,
which is a Level I trauma center, as well
as by 6 smaller hospitals. The study included all patients in the region who were
treated for tibial plateau fracture between
2005 and 2010.
Denmark provides a unique opportunity to conduct population-based studies.
Danish law requires all patient contacts
with a hospital or clinic in Denmark to be
recorded in the Danish National Patient
Registry.5 A Civil Registration Number
is given to all residents of Denmark and
recorded in the Civil Registration System.
For each hospital or clinic visit, specific
information is recorded, including hospi-
SEPTEMBER 2015 | Volume 38 • Number 9
Figure 1: Average population between 2005 and 2010 by sex and age.
tal identification, date and time of activity,
and patient’s municipality.6 This system
provides researchers with complete records on all health-related issues on both
individual and population levels.
A retrospective review of clinical and
radiologic records obtained from this system was performed in April 2014.
Clinical information about patient
age, sex, mechanism of injury, and highor low-energy trauma was obtained.
High-energy trauma was defined as a fall
from more than 3 m or a fracture as a result of a traffic or road accident at more
than 30 km/h. Information recorded included length of hospital stay, time to
surgery after admission, use of conservative or operative treatment, additional
bone injury, and the presence of multiple
injuries.
All patients with suspected or confirmed tibial plateau fracture underwent
CT scans to classify the fracture and plan
operative or conservative treatment. All
fractures were categorized according to
the AO classification.7
This study was conducted in accordance with the ethical standards of the responsible committee and within the ethical
principles of the 1975 Declaration of Helsinki. The study was approved by the Danish Data Protection Agency (J. nr. 2010-414354).
Statistics
Mean values and SDs are given for
continuous variables. Frequencies and
percentages are used for categorical
data. Normal distribution was checked
visually by QQ plots. Statistical analysis was performed with SPSS software
(PAWStatistic, version 21.0; IBM Corporation, Armonk, New York).
Results
A total of 355 patients were treated for
tibial plateau fracture between 2005 and
2010. Mean age was 52.6 years (SD, 18.3
years). Mean age was 57.7 years (SD,
18.3 years) for women and 46.8 years
(SD, 16.4 years) for men. The study included 166 men (46.8%) and 189 women
(53.2%). Of these patients, 57% had a
left-sided fracture and 43% had a rightsided fracture.
Conservative treatment with a cast was
used in 28 patients (7.9%), and 327 patients (92.1%) were treated surgically.
e781
n Feature Article
Table 1
Table 2
Additional Bone Injuries
AO Fracture Type
Classification
Fracture
No.
Clavicle
4
AO Type
Colles’/ulna
9
41-A1
4 (1.1)
Columna lumbalis
5
41-A2
22 (6.2)
Femur
9
41-A3
4 (1.1)
Costa
1
41-B1
30 (8.5)
Patella
3
41-B2
59 (16.6)
Humerus
5
41-B3
123 (34.6)
Maxilla
1
41-C1
28 (7.9)
Metacarpal
2
41-C2
23 (6.5)
Calcaneus
3
41-C3
62 (17.5)
Lower leg
1
Total
Acetabulum
2
Malleolus
3
Metatarsal
3
Total
51
Figure 2: Incidence of tibial plateau fractures between 2005 and 2010.
Patients treated conservatively were primarily patients with small articular depression or small nondisplaced pure split fractures (AO type 41-B1 and AO type 41-B2,
N=18). The remaining patients were treated conservatively because of late recognition of the fracture or comorbidity. Of the
patients treated conservatively, 20 (71%)
were women and 8 (29%) were men. Mean
age of the conservatively treated patients
was 66.5 years (SD, 16.2) vs 51.4 years
(SD, 18.0) for patients treated operatively.
Of the 355 patients, 310 (87.3%) had
a single traumatic injury, and 42 patients
e782
No. (%)
355 (100.0)
(11.8%) were admitted to the hospital
with multiple traumatic injuries. Additional bone injuries were present in 51
patients (Table 1).
Average length of hospital stay was
10.6 days (SD, 11.0 days) for patients
treated surgically. Average time from hospital admission to surgery was 2.5 days
(SD, 2.0 days).
The AO classification of fractures is
shown in Table 2. The most common
fracture type was AO type 41-B3, representing 35% of all tibial plateau fractures.
The second most common fracture type
was AO type 41-C3, representing 17% of
all tibial plateau fractures.
The incidence of tibial plateau fractures was 10.3 per 100,000 annually. The
incidence was 9.6 per 100,000 annually
in men and 11.0 per 100,000 annually in
women. Figure 2 shows the yearly incidence between 2005 and 2010. A large
variation over the years is evident, ranging from 7 to 13 per 100,000 annually.
This study showed no decrease in incidence from 2005 to 2010. Analysis of seasonal variation showed equal distribution
among seasons.
Compared with women, men younger
than 50 years had a higher incidence of
fractures. The incidence of fractures in
women older than 50 years increased
markedly, whereas a major decrease in
incidence was noted in men older than 50
years (Figure 3A).
Figure 3B shows the age and sex distribution of high-energy trauma. This type
of fracture was more common in men
than in women. In both men and women,
the highest frequency of fractures was
between the ages of 40 and 60 years. In
men, 64% of fractures were the result of
high-energy trauma compared with 35%
in women. Figure 3C shows the percentage of high-energy trauma by age and sex.
Both younger men and younger women
had a high proportion of high-energy fractures. After the age of 40 years, the incidence of high-energy fractures in women
declined, whereas the incidence in men
remained relatively high.
Figure 3D shows the age and sex distribution of low-energy trauma. Men and
women had a similar low frequency of lowenergy trauma until the age of 40 years. In
older age groups, an increase in frequency
was seen in women but not in men.
Figure 3E shows the relationship between age group and AO classification.
Both AO type A and AO type C fractures
were evenly distributed among the age
groups. The incidence of AO type B fractures showed a peak between the ages of 40
and 70 years, representing more than 50%
of total fractures. The distribution of AO
classification between age and sex is shown
in Figure 3F for women and Figure 3G for
men. A similar pattern was seen with regard
to AO classification in men and women.
The distribution according to AO
classification and mechanism of injury
showed a weak tendency toward AO
type 41-B and AO type 41-C fractures
in the high-energy trauma group and toward AO type 41-B fractures in the lowenergy trauma group. Men had an increased frequency of injuries as a result
of motorcycle or other motorized vehicle
accidents and also as a result of falls from
a height, both of which show a tendency
toward an increase in the frequency of
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n Feature Article
AO type B3 and AO type C3 fractures.
Women had an increase in injuries as a result of bicycling, walking, indoor activity,
and falls from a height, with a tendency
toward AO type B2 and AO type B3 fractures (Tables 3-5).
Discussion
This was the first study to show the
incidence of tibial plateau fractures and
fracture distribution according to AO classification based on CT scans and mecha-
SEPTEMBER 2015 | Volume 38 • Number 9
A
B
C
D
E
F
Figure 3: Incidence of
tibial plateau fracture by
age and sex (number per
100,000 annually) (A).
Frequency of high-energy
trauma by age and sex
(B). Percentage of highenergy trauma by age and
sex (C). Frequency of lowenergy trauma by age and
sex (D). AO classification
by age (E). AO classification for women by age
(F). AO classification for
men by age (G).
G
e783
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Table 3
Mechanism of Injury and Fracture Classification
No.
AO Typea
High
Energyb
Low
Energyb
Multiple
Traumatic
Injuries
Car
Motorcycle
Other
Motorized
Vehicle
Bicycle
Walking
Indoor
Fall
From
Height
41-A1
2
1
0
0
0
1
0
1
0
1
41-A2
8
14
3
1
0
5
0
3
11
2
41-A3
4
0
1
1
0
0
0
0
0
2
41-B1
14
14
3
3
1
2
4
9
8
3
41-B2
19
39
2
3
0
6
3
20
10
16
41-B3
49
74
16
8
7
9
20
29
15
34
41-C1
15
13
6
2
1
4
5
8
7
1
41-C2
15
8
7
0
3
7
2
6
5
0
41-C3
41
20
4
3
3
14
8
10
11
12
Total
167
183
42
21
15
48
42
86
67
71
Total women
64 (38%)
123 (67%)
10 (24%)
7 (33%)
2 (13%)
7 (15%)
30 (71%)
56 (65%)
54 (81%)
32 (45%)
Total men
103 (62%)
60 (33%)
32 (76%)
14 (67%)
13 (87%)
41 (85%)
12 (29%)
30 (35%)
13 (19%)
39 (55%)
a
Information on 5 patients not included because of missing data in the medical charts.
b
Information on 3 patients not included because of missing data in the medical charts.
nism of injury in a large unselected and
well-defined cohort.
Reports on the incidence of fractures
of the lower limb showed variation over
time and in different countries.1-3 In 2000,
Court-Brown and Caesar1 concluded that
the incidence of fractures is changing
quickly as a result of changes in mechanism of injury and aging of the population.
The incidence of patients with tibial
plateau fractures in the North Denmark
Region was 10.3 per 100,000 annually
between 2005 and 2010. This finding
was lower than the incidence of 13.3 per
100,000 annually in 2000 reported by
Court-Brown and Caesar1 in the United
Kingdom. The reason for this difference
may be inaccuracy in estimating population size, exclusion of children younger
than 12 years, the use of different time
periods, and regional differences. Further,
the current authors used a 6-year study
period and showed considerable year-toyear variation in incidence. In contrast, in
1990, Donaldson et al2 reported an average
e784
incidence of 26 per 100,000 annually for
the 3 years surrounding the 1981 census.
The variation in incidence in their report
vs the current results may be the result
of inclusion of all fractures of the upper
end of the tibia and fibula. In contrast, the
current study included only tibial plateau
fractures. Furthermore, Donaldson et al2
used an approximated population size to
calculate incidence. Most studies of tibial
plateau fractures lack accurate information
on population size.1,2,8 In the current study,
incidence was calculated based on an unselected and well-defined population.
Distribution of fractures according to
sex and age groups in this study showed a
bimodal distribution among women and a
unimodal distribution among men. Men had
an increasing incidence of fractures until 50
to 60 years of age, followed by a decline
in incidence. Women showed a peak incidence between 20 and 30 years of age. After the age of 40 years, they had an increase
in incidence throughout life compared with
men. This is in contrast to the findings of
Court-Brown and Caesar,1 who reported a
bimodal distribution for both sexes.
Tibial plateau fractures are most common between the ages of 30 and 60 years,
a finding reported in a number of studies.8,9 Albuquerque et al8 reported a male
predominance (70%) in tibial plateau
fractures, in contrast to the findings of
the current study, which showed a female
predominance of 53%. This difference
may be related to variations in geography, demography, mechanism of injury,
and exclusion of nonsurgically managed
fractures.
The current study was the first to show
classification of fractures based on CT
scans and the distribution of tibial plateau fractures according to AO classification and mechanism of injury in a large
unselected cohort. The most common
fracture type was AO type 41-B3, representing 35% of all tibial plateau fractures.
The next most common type was AO type
41-C3, representing 17% of all tibial plateau fractures. These findings were simi-
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n Feature Article
Table 4
Mechanism of Injury and Fracture Classification in Men
No.
High
Energy
Low
Energy
Multiple
Traumatic
Injuries
Car
41-A1
1
1
0
41-A2
5
2
2
41-A3
4
0
41-B1
9
6
41-B2
11
41-B3
28
41-C1
11
41-C2
10
41-C3
Total
AO Type
Motorcycle
Other
Motorized
Vehicle
Bicycle
Walking
Indoor
Fall From
Height
0
0
0
0
1
0
1
0
0
4
0
0
1
2
1
1
0
0
0
0
0
2
3
3
1
2
1
5
2
2
7
2
2
0
6
1
3
0
6
25
9
4
5
7
5
8
2
21
5
6
2
1
4
2
4
3
0
3
5
0
3
6
0
2
2
0
24
11
4
2
3
12
3
7
3
5
103
60
32
14
13
41
12
30
13
39
Table 5
Mechanism of Injury and Fracture Classification in Women
No.
High
Energy
Low
Energy
Multiple
Traumatic
Injuries
41-A1
1
0
0
41-A2
3
12
41-A3
0
0
41-B1
5
41-B2
41-B3
41-C1
41-C2
41-C3
17
Total
64
AO Type
Motorcycle
Other
Motorized
Vehicle
Bicycle
Walking
Indoor
Fall From
Height
0
0
1
0
0
0
0
1
1
0
1
0
3
10
0
0
0
0
0
0
0
0
0
8
0
0
0
0
3
4
6
1
8
32
0
1
0
0
2
17
10
10
21
49
7
4
2
2
15
21
13
13
4
8
0
0
0
0
3
4
4
1
5
5
2
0
0
1
2
4
3
0
9
0
1
0
2
5
3
8
7
123
10
7
2
7
30
56
54
32
lar to those of Albuquerque et al8 from a
comparable time, although they included
only surgically treated fractures at a single
trauma center. Further, CT scans were not
used in the classification of fractures.
The current findings showed that AO
type 41-B fractures were primarily present in women and that AO type 41-C
fractures were primarily present in men.
SEPTEMBER 2015 | Volume 38 • Number 9
Car
Albuquerque et al8 did not discuss the sexspecific distribution of fractures in their
study, but calculation based on their tables
showed that AO type 41-B and AO type
41-C fractures were both more common
in men (AO type 41-B, 69%; AO type
41-C, 73%).
No clear association was seen between
type of AO fracture and high- or low-
energy trauma. However, the results
showed a weak tendency toward highenergy trauma resulting in AO type 41-B3
and AO type 41-C3 fractures. More research on this association is needed.
In general, younger and middle-aged
men tend to have fractures as a result of
high-energy trauma, whereas older women have low-energy fractures. The dis-
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n Feature Article
tribution of high-energy trauma between
men and women was equal in younger
age groups. After the age of 30 years,
however, high-energy fractures were still
common in men, whereas in women, the
incidence of these fractures decreased
throughout life. This finding may be related to the mechanism of injury, which
showed that women are primarily injured
during bicycling, walking, indoor activities, and falls from a height. In contrast,
men are injured primarily as a result of
accidents involving motorcycles and
other motorized vehicles and as a result
of falls from a height. Further, men had
a higher frequency of multiple traumatic
injuries compared with women (76%).
The reason for the increase in the frequency of low-energy trauma with older
age and female sex may be related to the
increasing prevalence of osteoporotic
bone.1,10
Conclusion
This study showed an incidence of
10.3 per 100,000 annually for tibial plateau fractures. The most common type of
e786
fracture was AO type 41-B3, representing
35% of all tibial plateau fractures, followed by AO type 41-C3, representing
17% of all tibial plateau fractures. In both
men and women, the highest frequency of
fractures was between the ages of 40 and
60 years. Men younger than 50 years had
a higher incidence of fractures, but after
the age of 50 years, the incidence of fractures increased markedly in women and
decreased in men. Men were predominantly injured as a result of falls from a
height or because of accidents involving
cars, motorcycles, or other motorized
vehicles. Women were injured primarily
while bicycling, while walking, and during indoor activity.
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