Is unilateral open reduction of the femur (thigh bone)/tibia (shin bone) with internal fixation and bone graft indicated for lateral tibial plateau fractures with vertical fracture lines and mild cortical depression?

Treatment of Lateral Tibial Plateau Fractures with Vertical Fracture Lines and Mild Cortical Depression

Unilateral open reduction with internal fixation (ORIF) and bone grafting is indicated for lateral tibial plateau fractures with vertical fracture lines and mild cortical depression to restore articular congruity and prevent post-traumatic osteoarthritis. 1

Imaging Assessment

• Initial evaluation should include standard AP and lateral radiographs
• CT scan is essential for:
  • Precise fracture classification and characterization (100% sensitivity vs 83% for radiographs) 2
  • Surgical planning and assessment of fracture severity 2
  • Predicting associated soft tissue injuries 2, 1
• MRI is recommended to evaluate:
  • Associated meniscal tears (present in 36.58% of lateral plateau fractures) 3
  • Ligamentous injuries, particularly when depression exceeds 11mm 1
  • Occult fractures not visible on radiographs 2

Surgical Indications

Surgical management with ORIF and bone grafting is indicated when:

• Articular depression is present (particularly >2-3mm)
• Vertical fracture lines create instability
• Metaphyseal comminution exists
• Poor bone quality is present
• Posterolateral depression that is difficult to support with standard fixation 1

Surgical Technique

1. Approach: Anterolateral approach with submeniscal arthrotomy for direct visualization of the articular surface 4
2. Reduction:
   • Elevation of depressed articular fragments to restore joint congruity
   • Temporary fixation with K-wires
3. Bone Grafting:
   • Fill metaphyseal void created after elevation of depressed fragment
   • Options include autologous iliac crest bone graft or bone substitutes 5
4. Internal Fixation:
   • Subchondral support with 2.7mm locking screws in "raft" configuration 4
   • Lateral buttress plate fixation with locking screws
   • Consider periarticular or anti-glide plate for additional stability 6

Outcomes and Complications

• When properly treated, outcomes are generally favorable with 82.9% excellent to good results 3
• Complications to monitor:
  • Post-traumatic osteoarthritis (29.68% of cases) 3
  • Infection (12.19%) 3
  • Deep vein thrombosis (7.3%) 3
  • Loss of reduction if inadequate fixation or early weight-bearing

Post-operative Protocol

• Early range of motion exercises to prevent stiffness
• Protected weight-bearing (10-15kg) for 8 weeks 4
• Follow-up imaging at 3 months to assess healing and maintenance of reduction 4

Prognostic Factors

Poor outcomes are associated with:

• Associated soft tissue injuries (particularly lateral meniscus tears) 3
• Degree of initial displacement and depression 3
• Comminution of the fracture 3
• Quality of articular reduction (steps >2mm associated with worse outcomes)

The key to successful management is anatomic reduction of the articular surface, stable fixation that allows early mobilization, and appropriate bone grafting to support the elevated fragments and prevent secondary subsidence.