What is the management of a tibial plateau fracture?

Management of Tibial Plateau Fracture

The management of tibial plateau fractures requires surgical intervention with open reduction and internal fixation (ORIF) for all displaced and unstable fractures to restore articular congruity, mechanical alignment, and permit early mobilization. 1

Diagnostic Evaluation

Initial Assessment

• Standard radiographs (AP and lateral views) should be obtained first to identify fracture pattern
• CT scan is essential for:
  • Precise fracture classification and characterization (100% sensitivity in detecting tibial plateau fractures)
  • Surgical planning
  • Assessment of fracture severity
  • Predicting associated soft tissue injuries 1, 2
• MRI is the preferred next imaging modality to evaluate:
  • Additional radiographically occult fractures
  • Internal derangements (meniscal and ligamentous injuries)
  • Particularly important when lateral tibial plateau depression is >11mm (higher risk of lateral meniscus tear and ACL avulsion) 1, 2

Classification

• Schatzker classification is commonly used to guide treatment:
  • Types I-III: Lateral plateau fractures
  • Type IV: Medial plateau fracture
  • Type V: Bicondylar fracture
  • Type VI: Plateau fracture with metaphyseal-diaphyseal dissociation 3
• Three-column concept (anterior, medial, posterior) provides additional understanding of fracture morphology 4

Treatment Algorithm

Non-Operative Management

• Reserved for minimally displaced stable fractures (<2-3mm depression, <5° varus/valgus instability)
• Protected weight-bearing with hinged knee brace
• Early range of motion exercises 3, 5

Surgical Management

1. Preoperative Planning

   • Assess soft tissue status (crucial for timing of surgery)
   • Grade soft tissue injury using a four-grade classification system 6
   • Consider staged treatment for complex fractures or compromised soft tissues

2. Timing of Surgery

   • Immediate: Open fractures requiring debridement
   • Delayed (5-14 days): Complex fractures with soft tissue compromise
   • Sequential (staged) treatment for complex patterns:
     • Initial external fixation
     • Definitive ORIF after soft tissue recovery 4

3. Surgical Approach

   • Simple lateral fractures: Anterolateral approach
   • Medial fractures: Anteromedial approach
   • Posterior fragments: Specific posterolateral or posteromedial approaches
   • Consider arthroscopy-assisted reduction for partial articular fractures 4, 7

4. Fixation Methods

   • ORIF is the gold standard for displaced fractures
   • Techniques include:
     • Buttress plating
     • Lag screws
     • Periarticular rafting constructs
   • Bone grafting indicated when:
     • Severe depression (>11mm)
     • Significant metaphyseal comminution
     • Poor bone quality/osteoporosis
     • Posterolateral depression difficult to support with standard fixation 1
   • External fixation with minimally invasive osteosynthesis (EFMO) for complex fractures or compromised soft tissues 4

Postoperative Care

• Stable fixation allowing early mobilization
• Hinged knee braces to facilitate protected motion
• Progressive weight-bearing based on fracture pattern and fixation stability
• Early range of motion exercises 1

Complications and Outcomes

• Medium-term functional outcomes are generally excellent when anatomy and stability are restored
• At least half of patients return to their original level of physical activity
• Potential complications:
  • Postoperative arthritis
  • Infection (higher risk with severe injuries)
  • Malalignment
  • Articular incongruity
  • Instability
  • Need for knee arthroplasty in severe cases 3

Special Considerations

• Complex knee trauma may require a stepwise approach:
  1. Primary treatment: Closed reduction, wound debridement, external fixation
  2. Secondary treatment: ORIF and complex bone/soft tissue reconstruction after soft tissue recovery 6
• Primary total knee arthroplasty may be considered in specific elderly patients with complex fracture patterns 4

The key to successful management is precise reconstruction of articular surfaces, stable fixation allowing early motion, and repair of all concomitant soft tissue injuries to optimize functional outcomes.