What is the management for a comminuted displaced proximal tibial fracture?

From the Guidelines

Surgical intervention with open reduction and internal fixation (ORIF) is the recommended management for a comminuted displaced proximal tibial fracture, with the goal of restoring articular congruity, limb alignment, and knee stability while allowing for early mobilization. The primary objective is to achieve anatomic reduction and stable fixation, which can be accomplished using a locking plate system specifically designed for proximal tibial fractures 1. In cases with significant comminution, additional techniques such as bone grafting or use of bone substitutes may be necessary to address bone defects.

Preoperatively, the limb should be temporarily stabilized with a long leg splint or external fixator if there is significant soft tissue injury, as recommended by the guidelines for the acute care of severe limb trauma patients 1. Postoperatively, patients typically remain non-weight bearing for 6-12 weeks depending on fracture complexity and fixation stability, with progressive weight bearing as healing progresses.

Physical therapy is essential and should begin early with range of motion exercises to prevent stiffness. Thromboprophylaxis with low molecular weight heparin (e.g., enoxaparin 40mg subcutaneously daily) is recommended for 2-4 weeks. Pain management typically includes multimodal analgesia with scheduled acetaminophen (1g every 6 hours), NSAIDs if not contraindicated, and opioids as needed.

It is worth noting that the study on congenital pseudarthrosis of the tibia in children 1 provides some insights into the use of different fixation devices and techniques, but its relevance to the management of comminuted displaced proximal tibial fractures in adults is limited. Therefore, the recommendation is based on the most recent and highest quality study available, which is the guidelines for the acute care of severe limb trauma patients 1.

Some key points to consider in the management of comminuted displaced proximal tibial fractures include:

• Early definitive osteosynthesis within the first 24 hours to reduce the incidence of local and systemic complications, if the patient is hemodynamically stable 1
• Temporary stabilization with an external fixator or osseous traction if the patient is hemodynamically unstable, followed by definitive osteosynthesis once the patient's condition is stabilized 1
• The use of locking plate systems and bone grafting or bone substitutes as needed to achieve stable fixation and promote healing
• Early mobilization and physical therapy to prevent stiffness and promote functional recovery
• Thromboprophylaxis and pain management as needed to reduce the risk of complications and improve patient outcomes.

From the Research

Management of Comminuted Displaced Proximal Tibial Fracture

The management of comminuted displaced proximal tibial fractures involves several surgical options, including:

• Operative treatment with intramedullary nail, plates, or external fixator 2
• Treatment with the Less Invasive Skeletal Stabilization (LISS) internal fixator system 3
• External fixation followed by planned conversion to internal fixation 4

Surgical Options

The choice of surgical option depends on the severity of the fracture, the patient's overall health, and the surgeon's experience. Some studies suggest that:

• Intramedullary nailing is a viable option for extra-articular proximal tibial fractures 2
• The LISS system can be used successfully to treat complex proximal tibia fractures without the need for additional medial stabilization 3
• External fixation followed by planned conversion to internal fixation is a safe option for high-energy periarticular knee fractures 4

Complications and Outcomes

The complications and outcomes of these surgical options vary, but some studies report:

• Low rates of infection and nonunion with the use of the LISS system 3
• High rates of healing and satisfactory fracture alignment with external fixation followed by internal fixation 4
• Equivalent outcomes with primary internal fixation compared to staged protocol for pilon fractures 5

Treatment Protocol

The treatment protocol for comminuted displaced proximal tibial fractures may involve:

• Preoperative planning and assessment of imaging and soft tissues 5
• Application of a thigh tourniquet and placement of the patient in the supine position 5
• Intraoperative use of a spanning external fixator 5
• Careful exposure of the distal end of the tibia and fracture reduction and fixation 5