What is the recommended management for proximal tibial fractures?

Management of Proximal Tibial Fractures

Surgical management within 24-48 hours of admission is the recommended approach for proximal tibial fractures to reduce mortality and complications, with treatment tailored to the specific fracture pattern. 1

Initial Assessment and Management

• Implement multimodal analgesia immediately:

  • Regular paracetamol/acetaminophen
  • Cautious use of opioids
  • Regional nerve blocks for lower limb fractures
  • Cold therapy (ice) for 20-30 minutes, 3-4 times daily

• Immobilize the affected limb to prevent further injury and promote comfort

• Assess for vascular compromise (blue, purple, or pale extremities) which requires immediate attention

• Cover open fractures with clean dressing to prevent contamination

Fracture Classification and Surgical Approach

Treatment Based on Fracture Type:

• Extraarticular fractures (AO Type A):

  • Stable fixation with locking plates (LISS - Less Invasive Stabilization System) shows good outcomes with low complication rates 2
  • Consider intramedullary nailing for fragments longer than 5-6 cm 3

• Intraarticular fractures (AO Type B and C):

  • Anatomic reduction of articular surface is critical
  • Polyaxial locking-plate systems provide stable fixation with good functional outcomes 4
  • Double-plating may be necessary for complex bicondylar fractures

Surgical Approach Selection:

• The choice of approach is dictated primarily by the fracture pattern, with consideration of:

  • Soft tissue envelope condition
  • Patient factors
  • Associated injuries 5

• For fractures with short proximal fragments and extensive soft-tissue injury, external fixation remains the most versatile method 3

Anesthesia and Perioperative Care

• Both regional and general anesthesia are appropriate options:

  • Regional anesthesia requires blockade of multiple nerves
  • Neuraxial blockade is effective for conscious patients
  • General anesthesia requires additional postoperative analgesia, often via peripheral nerve blockade 1

• Perioperative considerations:

  • Administer prophylactic antibiotics within one hour of skin incision
  • Implement active warming strategies
  • Consider additional monitoring for high-risk patients (invasive BP, cardiac output) 1

Postoperative Care and Rehabilitation

• Continue multimodal analgesia protocol
• Monitor for and treat anemia
• Implement thromboprophylaxis for 4 weeks
• Begin early mobilization and weight-bearing as tolerated in most cases 1

Potential Complications

• Complication rates may reach 50% for complex fractures 1
• Major complications include:
  • Varus malunion (especially with closed management when fibula is intact) 3
  • Compartment syndrome (higher rates with proximal tibial fractures) 3
  • Arterial injury (especially with displaced fractures) 3
  • Infection and fixation failure (particularly with plating techniques) 3

Special Considerations

• Temporary joint-spanning external fixation has a role in initial management of certain fracture patterns with severe soft-tissue injury 3
• For intramedullary nailing, place the entry portal more proximal and lateral, lock in extension, and use blocking screws to improve alignment 3
• In complex articular fractures, additional screws should be used with locking plate systems 2

Follow-up Care

• Long-term follow-up is essential to monitor for complications
• Consider osteoporosis evaluation and treatment when appropriate
• Provide clear instructions on weight-bearing status and warning signs

The management of proximal tibial fractures requires careful consideration of fracture pattern, soft tissue status, and patient factors. While both plating and nailing techniques can be effective, the evidence suggests that modern locking plate systems provide excellent outcomes for most proximal tibial fractures when applied appropriately.