What is the treatment for a tibial plateau fracture?

Treatment for Tibial Plateau Fracture

The optimal treatment for tibial plateau fractures requires initial radiographic evaluation followed by CT imaging for fracture classification, with surgical management indicated for fractures with displacement greater than 2-4 mm to restore articular congruity and mechanical alignment. 1, 2

Initial Assessment and Imaging

• Begin with plain radiographs (anteroposterior and lateral views) of the knee to identify tibial plateau fractures 1
• CT is superior to radiographs with 100% vs 83% sensitivity in detecting tibial plateau fractures 1
• CT is essential for:
  • Classification of fracture pattern (Schatzker classification)
  • Characterization of fracture severity
  • Assessment of articular surface depression
  • Evaluation of posterolateral and posteromedial fragments 1, 3
• MRI may be indicated to evaluate for associated soft tissue injuries (meniscal and ligamentous) 1

Treatment Algorithm Based on Fracture Displacement

Minimally Displaced Fractures (≤2-4 mm displacement)

• Nonoperative treatment is recommended for fractures with:
  • Displacement ≤2 mm (traditional threshold) 3
  • Recent evidence suggests nonoperative treatment may be appropriate for displacements up to 4 mm 4
• Nonoperative management includes:
  • Protected weight-bearing
  • Early range of motion exercises
  • Progressive rehabilitation

Displaced Fractures (>2-4 mm displacement)

• Surgical management is indicated for:
  • Articular step-off >2-4 mm
  • Joint instability
  • Significant malalignment 2, 3
• Surgical options include:
  • Open Reduction and Internal Fixation (ORIF) - gold standard 3
  • Minimally invasive techniques with arthroscopic assistance for partial articular fractures 3
  • External fixation followed by definitive osteosynthesis for complex fractures with soft tissue compromise 3

Surgical Approach Considerations

• Standard anterolateral and anteromedial approaches for simple fracture patterns
• Specific posterolateral or posteromedial approaches for posterior fragment fixation 3
• Three-column concept approach for complex fracture patterns 3

Complications and Outcomes

• Nonoperative treatment of minimally displaced fractures has fewer complications (0% vs 4%) and fewer reoperations (6% vs 39%) compared to operative treatment 4
• Surgical management risks include:
  • Infection
  • Hardware complications requiring removal
  • Post-traumatic arthritis 2, 4
• Medium-term functional outcomes are generally excellent when anatomy and stability are restored 2
• Approximately half of patients return to their original level of physical activity 2

Important Caveats

• Soft tissue injury often accompanies tibial plateau fractures and may influence treatment decisions 2, 3
• Sequential (staged) treatment may be necessary for complex fractures with significant soft tissue damage 3
• The three-column concept and detailed evaluation of posterior fragment morphology has changed treatment strategy in recent years 3
• Low-intensity pulsed ultrasound (LIPUS) is not recommended as an adjunct therapy for tibial plateau fractures as it shows no benefit for bone healing 1

Remember that the primary goals of treatment are to restore articular congruity, mechanical alignment, and ligamentous stability while permitting early knee motion to optimize functional outcomes 3.