What is the step by step procedure for managing a fracture of the proximal tibia?

Step-by-Step Procedure for Managing Proximal Tibial Fracture

Proximal tibial fractures require prompt surgical management within 24-48 hours of admission to reduce mortality and complications, with treatment approach determined by fracture type, patient characteristics, and soft tissue status. 1

Initial Management

Emergency Department Assessment and Stabilization

• Implement multimodal analgesia immediately:
  • Regular paracetamol/acetaminophen
  • Cautious use of opioids (especially with renal dysfunction)
  • Consider regional nerve block (femoral/fascia iliaca) 1
• Immobilize the affected limb to prevent further injury 1
• Provide IV fluid therapy and warming strategies as needed 1
• For open fractures: immediate wound care and IV antibiotics 1

Imaging and Diagnosis

• Initial radiographs should include:
  • Anteroposterior and lateral views
  • Patellofemoral view to assess patellar alignment
  • Cross-table lateral view to visualize lipohemarthrosis 1
• Consider advanced imaging:
  • MRI to assess soft tissue injuries and bone contusions
  • CT to better characterize fracture pattern, especially with articular involvement 1
• Assess for vascular compromise requiring immediate attention 1

Pre-operative Planning

Fracture Classification and Treatment Decision

• Determine fracture pattern and stability
• Assess soft tissue status and presence of compartment syndrome
• Consider patient factors (age, activity level, comorbidities)
• Decide between non-operative vs. surgical management based on:
  • Fracture displacement
  • Articular involvement
  • Stability of the fracture
  • Overall patient condition 1

Operating Room Preparation

• Trauma theater should be large enough for imaging equipment and traction table 2
• Maintain theater temperature at 20–23°C and humidity at 50–60% to prevent hypothermia 2
• Ensure availability of appropriate implants and instruments 2
• Minimum theater team: operating department practitioner, two scrub practitioners, and a circulator 2
• Dedicated radiographer to reduce intra-operative delays 2

Surgical Management

Anesthesia Considerations

• Both regional and general anesthesia are appropriate options 1
• Regional anesthesia may require blockade of multiple nerves 1
• General anesthesia requires additional postoperative analgesia 1
• Should be performed by experienced anesthesiologist, ideally a consultant 2
• Administer prophylactic antibiotics within one hour of skin incision 1

Surgical Approach and Fixation

• Surgical approach depends on fracture pattern:
  • For simple fractures: consider less invasive stabilization techniques 3
  • For complex or articular fractures: may require open reduction
• Fixation options based on fracture type:
  • Lateral tibial plateau fractures: lateral locking plates
  • Medial plateau fractures: medial buttress plates
  • Bicondylar fractures: dual plating or external fixation
  • Severely comminuted fractures with soft tissue compromise: consider external fixation 4
• For open fractures or compartment syndrome: perform fasciotomy followed by external fixation 4

Post-operative Care

Immediate Post-operative Management

• Continue analgesia protocol
• Monitor for and treat anemia
• Implement thromboprophylaxis for 4 weeks
• Begin early mobilization as appropriate 1

Rehabilitation Protocol

• Protected weight-bearing with immobilization initially
• Gentle isometric quadriceps exercises
• Elevation and ice to control swelling
• Progress to:
  • Full weight-bearing (typically at 6-12 weeks depending on fracture type)
  • Advanced strengthening exercises
  • Gradual return to activities based on functional progress 1, 3

Follow-up Care

• Regular radiographic assessment to monitor healing
• Assess for complications:
  • Loss of reduction (occurs in approximately 3% of cases) 3
  • Infection (rate approximately 4%) 3
  • Nonunion (rate approximately 3%) 3
  • Malalignment 3

Special Considerations

Compartment Syndrome

• Monitor for signs of compartment syndrome (pain out of proportion, paresthesia, pallor, pulselessness, paralysis)
• If suspected, perform immediate fasciotomy followed by external fixation 4

Elderly Patients

• Implement orthogeriatric comanagement to improve outcomes 1
• Perform comprehensive geriatric assessment including cognitive evaluation 1
• Consider osteoporosis evaluation and treatment 1

Pediatric Patients

• For epiphyseal fractures, consider closed reduction if possible 5
• Open reduction and internal fixation may be necessary for displaced fractures 5
• Below-knee cast immobilization can be effective for distal tibial physeal fractures 6

Common Pitfalls and Caveats

• Delayed surgical intervention beyond 48 hours increases mortality and complications 1
• Aggressive rehabilitation in the early postoperative period can lead to complications 7
• High-impact activities should be discouraged for 9-12 months after fixation 7
• Prolonged immobilization can lead to stiffness and muscle atrophy; balance this with need for fracture healing 4
• Despite proper management, complications like osteomyelitis may occur, requiring additional interventions 4