What is the recommended treatment for depression in a patient with an acute lateral tibial plateau fracture?

Treatment for Depression in Lateral Tibial Plateau Acute Fracture

For patients with an acute lateral tibial plateau fracture, CT imaging followed by MRI is the recommended diagnostic approach to fully assess the fracture pattern and associated soft tissue injuries before determining appropriate treatment.

Diagnostic Imaging Algorithm

1. Initial Assessment:

   • Radiographs (minimum of two views) should be the initial imaging modality for acute knee trauma 1
   • Look for signs of tibial plateau fracture, including articular depression and fracture lines

2. Secondary Imaging:

   • CT scan: Should be performed after radiographic diagnosis of tibial plateau fracture
     • Provides superior classification and characterization of fracture severity (100% sensitivity vs 83% for radiographs) 1
     • Helps predict associated soft tissue injuries
     • Particularly valuable for assessing articular surface depression (>11mm depression indicates higher risk of lateral meniscus tear and ACL avulsion) 1

3. Tertiary Imaging:

   • MRI: Recommended after CT to evaluate for additional injuries
     • Superior for detecting associated soft tissue injuries including meniscal and ligamentous damage 1
     • Provides detailed evaluation of bone marrow contusions and occult fractures 1
     • Critical for surgical planning

Treatment Algorithm for Lateral Tibial Plateau Fracture

Surgical Management (Primary Approach)

• Indications for surgery:

  • Depression >8-10mm 2
  • Unstable fracture pattern
  • Significant articular incongruity

• Surgical Techniques:

  1. Anterolateral approach with submeniscal arthrotomy 2

     • Provides direct visualization of the articular surface
     • Allows for accurate reduction of depressed fragments

  2. Elevation of depressed fragments with bone graft/cement augmentation 2, 3

     • Fill residual defect with bone graft or bone cement
     • Prevents post-reduction collapse

  3. Internal fixation options:

     • Locking plate fixation with subchondral "raft" screws 3
     • For fragmented articular depression: consider subchondral rafting plate technique 4
     • For posterior tibial plateau involvement: specific posterior approaches may be required 5

Special Considerations

• Posterolateral tibial plateau fractures:
  • Often missed on standard radiographs
  • Require 45° internal oblique views for proper assessment 6
  • If untreated, can lead to significant functional instability when the knee is in flexion 6
  • 94% of surgically treated cases achieve good/excellent outcomes 6

Post-Surgical Management

• Early mobilization with protected weight-bearing
• Regular follow-up imaging to ensure maintenance of reduction
• Monitor for articular subsidence (common complication)

Pitfalls and Caveats

• Failure to obtain proper imaging (CT and MRI) may lead to missed associated injuries
• Inadequate reduction of articular depression can result in post-traumatic arthritis
• Posterolateral fracture patterns are frequently missed on standard radiographs but cause significant disability
• Articular comminution increases risk of subsidence despite adequate fixation 4
• Chronic depressed fractures lead to significant disability and should be addressed acutely 6

Long-term Considerations

• Monitor for post-traumatic arthritis development
• Assess for secondary fracture risk in patients over 50 years, as they may benefit from osteoporosis evaluation and treatment 1
• Follow-up should continue for at least 12-24 months to monitor for late complications

By following this structured approach to diagnosis and treatment of lateral tibial plateau fractures, optimal outcomes can be achieved with reduced risk of long-term disability and complications.