What is the management of an impacted, depressed, non-displaced fracture of the medial tibial plateau?

From the Guidelines

Management of an impacted, depressed, non-displaced fracture of the medial tibial plateau typically involves a combination of non-operative treatment and careful monitoring. Initial management includes protected weight-bearing with crutches or a walker for 6-8 weeks, with weight-bearing restrictions based on fracture severity (typically toe-touch or partial weight-bearing) 1. A hinged knee brace should be used for 4-6 weeks to provide stability while allowing controlled motion. Pain management consists of NSAIDs like ibuprofen (400-600mg every 6-8 hours) or naproxen (500mg twice daily), with short-term opioids such as hydrocodone/acetaminophen 5/325mg every 4-6 hours as needed for breakthrough pain in the first 1-2 weeks. Physical therapy should begin early with gentle range of motion exercises, progressing to strengthening as healing permits. Regular follow-up with orthopedics at 2,6, and 12 weeks with serial radiographs is essential to monitor healing and ensure the depression doesn't worsen. Surgical intervention may become necessary if the fracture displaces during healing, if depression exceeds 2-3mm, or if knee instability develops. This conservative approach is appropriate because these fractures typically maintain good alignment and stability when non-displaced, and the intact periarticular structures help maintain the joint's integrity during healing 1. Some key points to consider in the management of these fractures include:

• The use of CT scans to further characterize the fracture severity and predict potential ligamentous or meniscal injuries 1
• The potential for MRI or CT scans to evaluate for additional bone or soft-tissue injury after a fall or acute twisting trauma to the knee 1
• The importance of careful monitoring and regular follow-up to ensure proper healing and prevent potential complications. In terms of specific imaging studies, CT knee without IV contrast or MRI knee without IV contrast is usually appropriate as the next imaging study after radiographic diagnosis of tibial plateau fracture 1. Overall, the goal of management is to promote proper healing, prevent complications, and optimize outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Management of Impacted, Depressed, Non-Displaced Fracture of Medial Tibial Plateau

The management of an impacted, depressed, non-displaced fracture of the medial tibial plateau can be approached through various methods, considering the fracture's characteristics and the patient's overall condition.

• The decision for treatment is often based on the degree of displacement and the stability of the fracture, as well as the patient's ability to tolerate surgical intervention 2, 3.
• For non-displaced or minimally displaced fractures with less than 10 mm of depression, conservative management with plaster immobilization or traction may be sufficient, as these fractures are usually tolerated well and can result in successful outcomes without surgical intervention 2.
• However, in cases where there is significant joint depression or instability, surgical intervention may be necessary to achieve adequate reduction and fixation, thereby preventing further complications such as post-traumatic osteoarthritis 3, 4.
• Surgical techniques can include limited internal fixation using percutaneous cannulated screws, open reduction with internal fixation (ORIF) using buttress plates, or the use of external fixators for more complex fractures 3, 4.
• The use of bone grafting may also be considered to support depressed fractures and promote healing 3, 4.
• Postoperative management often involves early range of motion exercises and protected weightbearing for a period of time to facilitate recovery and prevent stiffness 3, 4.
• In specific cases, such as those related to unicompartmental knee arthroplasty, the management of tibial plateau fractures may require careful consideration of the implant's stability and the degree of fracture displacement, with treatment options ranging from conservative management to surgical intervention with plate and screw fixation 5, 6.