What is the step-by-step procedure for treating a fracture of the proximal tibia with plating?

Step-by-Step Procedure for Proximal Tibia Fracture Plating

The optimal surgical approach for proximal tibia fractures involves percutaneous locked plating (PLP) which provides minimal soft tissue damage while ensuring rigid fixation, resulting in better outcomes and fewer complications.

Preoperative Planning

• Obtain appropriate imaging:

  • Standard radiographs (AP and lateral views)
  • CT scan for better visualization of fracture pattern and preoperative planning
  • MRI if soft tissue injury is suspected

• Assess fracture pattern to determine:

  • Fracture classification
  • Presence of articular involvement
  • Degree of comminution
  • Bone quality

Anesthetic Considerations

• Regional anesthesia (spinal) is preferred unless contraindicated 1

  • Lower doses of intrathecal bupivacaine (<10 mg) to reduce hypotension
  • Consider lateral positioning with fractured limb inferior when using hyperbaric bupivacaine
  • Fentanyl is preferred over morphine or diamorphine for intrathecal opioids

• If general anesthesia is required:

  • Use reduced doses of induction agents
  • Consider inhalational induction to maintain spontaneous ventilation
  • Provide higher inspired oxygen concentrations to prevent hypoxemia 1

• Peripheral nerve blockade (femoral nerve/fascia iliaca block) should be considered as an adjunct for postoperative analgesia 1

Surgical Procedure

Step 1: Patient Positioning and Preparation

• Position patient supine on a radiolucent table
• Apply a tourniquet to the proximal thigh
• Prepare and drape the entire limb from mid-thigh to foot
• Ensure C-arm positioning allows for AP and lateral views

Step 2: Approach and Exposure

• For percutaneous plating technique:
  • Make a 3-5 cm longitudinal incision at the level of the joint line on the lateral aspect of the proximal tibia 2
  • Develop the plane between the iliotibial band and the anterior compartment
  • Create a submuscular tunnel along the lateral aspect of the tibia

Step 3: Fracture Reduction

• Achieve provisional reduction using:
  • Longitudinal traction
  • Manual manipulation
  • Percutaneous reduction clamps
  • Temporary K-wires to maintain reduction
• Confirm reduction with fluoroscopy in both AP and lateral views

Step 4: Plate Insertion and Positioning

• Select an appropriately sized precontoured proximal tibial locking plate
• Use the suture-assisted technique for plate insertion:
  • Attach a suture to the proximal pole of the plate
  • Guide the plate through the submuscular tunnel using the suture 3
  • Manipulate both poles of the plate to achieve accurate positioning
• Position the plate on the lateral aspect of the proximal tibia
• Confirm plate position with fluoroscopy

Step 5: Plate Fixation

• Insert a guide wire through the most proximal hole of the plate
• Confirm proper position with fluoroscopy
• Insert proximal locking screws first to secure the plate to the proximal fragment
• Insert distal screws through small stab incisions
• Use locking screws in the metaphyseal region and combination of locking and cortical screws in the diaphyseal region
• Ensure adequate screw length and position with fluoroscopy

Step 6: Final Assessment and Closure

• Perform final fluoroscopic assessment in multiple planes to confirm:
  • Fracture reduction
  • Plate and screw position
  • Overall alignment
• Irrigate all wounds thoroughly
• Close subcutaneous tissue and skin
• Apply sterile dressing and splint if necessary

Special Considerations

• For complex proximal tibial fractures with posterolateral fragments:

  • Consider modified anterolateral approach for better visualization 4
  • Double plating may be necessary for unstable fractures 5

• For open fractures:

  • Consider staged treatment with initial external fixation followed by definitive internal fixation 6
  • More aggressive antibiotic prophylaxis is required

Postoperative Management

• Early mobilization to improve respiratory function 7
• Immediate full weight-bearing to tolerance after surgery for most comminuted fractures 7
• Venous thromboembolism prophylaxis 7
• Regular imaging to assess healing progression:
  • Follow-up radiographs at 2,6, and 12 weeks 7

Expected Outcomes and Complications

• Average time for union: 20 weeks for closed fractures, 25 weeks for open fractures 2
• Potential complications:
  • Infection (higher risk in open fractures)
  • Malunion (approximately 20% of cases) 2
  • Nonunion (may require bone grafting)
  • Hardware failure
  • Neurovascular injury

By following this step-by-step procedure, surgeons can achieve favorable outcomes with minimal complications in the treatment of proximal tibia fractures using plating techniques.