Initial Management and Treatment of Tibial Plateau Fractures
For tibial plateau fractures, initial management should include radiographic assessment followed by CT imaging for fracture classification, with temporary external fixation for unstable patients and definitive surgical fixation for displaced fractures (>2mm) once the patient is stabilized. 1
Initial Assessment and Imaging
- First-line imaging: Plain radiographs of the knee (AP and lateral views) to identify tibial plateau fracture 1
- Second-line imaging: CT scan is essential for:
Treatment Algorithm Based on Patient Status
For Hemodynamically Stable Patients:
- Minimally displaced fractures (<2-4mm): Nonoperative treatment is preferred 2
- Better outcomes in terms of pain, sports function, and quality of life
- Significantly fewer complications (0% vs 4%) and reoperations (6% vs 39%)
- Immobilization and protected weight-bearing
For Hemodynamically Unstable Patients:
- Damage Control Orthopedics (DCO): 1
- Temporary stabilization with external fixator
- Delay definitive fixation until patient is medically stable
- This approach reduces systemic complications, operative blood loss, and coagulopathy
Definitive Treatment Options
Surgical Indications:
- Intra-articular displacement >2mm
- Articular depression >3mm
- Varus/valgus instability >10°
- Open fractures
- Associated compartment syndrome
- Associated vascular injury requiring repair
Surgical Techniques:
Open Reduction and Internal Fixation (ORIF): Gold standard for displaced fractures 3
- Restores articular congruity and mechanical alignment
- Permits early mobilization
Combined External Fixation with Intramedullary Fixation: 4
- 84% primary union rate
- 5.62 months mean union time
- 22.3% refracture rate
- Recommended for complex fractures with soft tissue compromise
External Fixation Alone:
- For severe soft tissue injury
- When definitive ORIF must be delayed
- Can be used as definitive treatment in select cases
Complications and Prevention
Common complications: 3
- Knee stiffness (treat with mobilization under anesthesia if <3 months, arthroscopic release if 3-6 months)
- Infection (acute: 4% with surgery, chronic: requires staged treatment)
- Malunion (may require osteotomy in young patients)
- Post-traumatic osteoarthritis
Prevention strategies:
- Anatomic reduction of articular surface
- Stable fixation allowing early motion
- Repair of associated soft tissue injuries
- Early mobilization to prevent stiffness
Thromboprophylaxis
- LMWH prophylaxis is advised for arthroscopically assisted repair of tibial plateau fractures due to longer operation time and more extensive surgery 1
- Continue prophylaxis throughout the period of reduced mobility
Follow-up Protocol
- Regular clinical and radiographic assessment
- Early range of motion exercises when fixation is stable
- Progressive weight-bearing based on fracture healing
- Long-term follow-up is crucial as complications can occur years after initial treatment 4
Pitfalls to Avoid
- Underestimating soft tissue injury can lead to wound complications
- Inadequate reduction of articular surface increases risk of post-traumatic arthritis
- Overly aggressive early weight-bearing can lead to fixation failure
- Delayed mobilization increases risk of knee stiffness
- Missing associated ligamentous or meniscal injuries leads to poor outcomes
By following this structured approach to tibial plateau fracture management, focusing on accurate diagnosis, appropriate timing of intervention, and meticulous surgical technique, optimal functional outcomes can be achieved while minimizing complications.