What is the step-by-step procedure for treating a fracture of the proximal tibia with plating?

From the Guidelines

The treatment of a proximal tibia fracture with plating should be performed as early as possible, ideally within the first 24 hours, in the absence of severe visceral injury, circulatory shock, or respiratory failure, to reduce morbidity and mortality. This approach is supported by recent guidelines for the acute care of severe limb trauma patients 1.

Preoperative Planning

The procedure begins with appropriate preoperative planning and imaging to assess the fracture pattern and plan the surgical approach. The patient's overall clinical status, including any associated injuries or comorbidities, should be evaluated to determine the optimal timing for surgery.

Surgical Approach

The patient undergoes general or regional anesthesia, followed by positioning on a radiolucent table with a tourniquet applied to the thigh. An anteromedial or anterolateral incision is made, depending on the fracture pattern, and extends from just above the fracture to below it, typically 10-15 cm in length. Soft tissue dissection proceeds carefully to protect the saphenous vein and nerve medially or the peroneal nerve laterally.

Fracture Reduction and Fixation

The fracture is then exposed and anatomically reduced using pointed reduction clamps, K-wires, and possibly a femoral distractor. Temporary fixation is achieved with K-wires before definitive fixation. A precontoured proximal tibial locking plate is selected and positioned, typically on the anterolateral or anteromedial surface of the tibia. Locking screws are placed proximally in the metaphyseal region, while cortical or locking screws are used distally. Articular fragments may require additional lag screws for compression.

Postoperative Care

Intraoperative fluoroscopy confirms proper reduction and implant placement. After irrigation, the wound is closed in layers with a drain often placed. Postoperatively, patients receive prophylactic antibiotics and thromboprophylaxis. Early range of motion exercises begin within days, but weight-bearing is typically restricted to touch-down or partial for 6-12 weeks depending on fracture complexity. This procedure aims to restore articular congruity, mechanical alignment, and stability while minimizing soft tissue damage to promote healing and reduce complications like malunion, nonunion, and post-traumatic arthritis.

Key Considerations

In the presence of severe visceral injuries, circulatory shock, or respiratory failure, a delayed definitive osteosynthesis may be recommended within the first 24 hours to reduce the incidence of systemic complications related to surgical hit, perioperative blood loss, coagulopathy, or fat embolism syndrome 1. Initial haemodynamic instability is an aggravating factor for this morbi-mortality risk, prompting an initial stabilisation by aggressive resuscitation and management of other emergent injuries. A sequential surgical approach (damage control orthopaedic surgery – DCO) may be proposed in this context to perform a simplified temporary stabilisation at the initial phase, followed by a delayed osteosynthesis surgery.

From the Research

Step-by-Step Procedure for Treating a Fracture of the Proximal Tibia with Plating

• Preoperative planning:
  • Evaluate the fracture pattern and decide on the appropriate surgical approach 2
  • Consider the use of imaging studies such as X-rays and CT scans to assess the fracture and plan the surgical approach
• Surgical approach:
  • The anterolateral approach is commonly used for proximal tibia fractures, but other approaches such as the posterolateral or posteromedial approach may be necessary for certain fracture patterns 2, 3
  • Consider the use of a limited open technique for bridge plating 4
• Reduction and fixation:
  • Use a combination of manual reduction and instrumentation to achieve anatomical reduction of the fracture 3
  • Apply a plate to the proximal tibia, using a locking compression plate (LCP) or a bridge plate, depending on the fracture pattern and the surgeon's preference 5, 4
  • Ensure that the plate is properly contoured and secured to the bone using screws or other fixation devices
• Postoperative care:
  • Monitor the patient for complications such as infection, nerve damage, or hardware failure 6
  • Encourage early mobilization and weight-bearing as tolerated, to promote healing and prevent stiffness 6, 3
  • Follow up with regular X-rays and clinical evaluations to assess the progress of healing and the stability of the fixation

Considerations for Specific Fracture Patterns

• Extra-articular fractures:
  • May be treated with percutaneous locked plating (PLP) or bridge plating by limited open technique 6, 4
  • Consider the use of intramedullary nailing for select fracture patterns 4
• Intra-articular fractures:
  • Require anatomical reduction and stable fixation to restore the articular surface and prevent post-traumatic arthritis 3
  • May be treated with open reduction and internal fixation (ORIF) or minimally invasive osteosynthesis (EFMO) 3
• Complex fractures:
  • May require staged treatment, with initial external fixation followed by definitive osteosynthesis 5
  • Consider the use of ring external fixators or other specialized fixation devices for complex fracture patterns 3