Treatment of Proximal Tibial Fractures
For high-energy proximal tibial fractures, implement staged management with immediate knee-spanning external fixation followed by delayed definitive internal fixation once soft tissues permit, which achieves union rates of 97% while minimizing wound complications.
Initial Stabilization and Fracture Classification
The treatment approach depends critically on fracture energy and soft tissue status:
- High-energy fractures (typically OTA types 41A, B, C or Schatzker IV-VI) require immediate knee-spanning external fixation on the day of admission to stabilize the skeleton, protect soft tissues, and prevent further articular damage 1
- This staged protocol reduces deep wound infection rates to 5% overall (only 2% in closed fractures) compared to immediate definitive fixation 1
- Low-energy fractures in appropriate candidates may be treated with alternative approaches including locked plating or, in elderly patients with poor bone quality, primary total knee replacement 2
Definitive Surgical Management
Staged Protocol for High-Energy Fractures
Timing of definitive fixation:
- Delay formal internal fixation until soft tissue envelope permits safe surgical approach, typically 7-14 days after initial injury 1
- Convert from spanning external fixator to plates and screw constructs or ring fixator for meta-diaphyseal repair 1
Locked Plating Technique
- The Less Invasive Stabilization System (LISS) provides stable fixation with 97% union rates and only 4% infection rates when proper technique is employed 3
- This approach requires meticulous attention to reduction accuracy, as malalignment (6-15 degrees angular deformity) occurred in 10% of cases, emphasizing the learning curve with minimally invasive techniques 3
- Mean time to full weight bearing is 12.6 weeks (range 6-21 weeks) 3
Primary Total Knee Replacement (Select Elderly Patients)
- Consider primary TKR in elderly patients (mean age 74 years) with low-energy proximal tibial fractures and pre-existing degenerative changes 2
- This enables immediate full weight bearing and rapid mobilization, avoiding prolonged non-weight bearing periods 2
- Achieves mean Knee Society Score of 160 and Oxford Knee Score of 27 at 19-month follow-up, with 82% patient satisfaction 2
- Critical caveat: Revision surgery rate is higher than primary TKR for osteoarthritis but lower than TKR for post-traumatic arthritis 2
Perioperative Management
Pain Control
- Administer regular paracetamol throughout the perioperative period 4
- Use opioids cautiously in patients with renal dysfunction (approximately 40% of elderly fracture patients have GFR <60 mL/min), reducing both dose and frequency 5
- Avoid NSAIDs in patients with renal dysfunction 6
- Consider peripheral nerve blocks (femoral/fascia iliaca) for additional analgesia, though these don't reliably block all three nerves (femoral, obturator, lateral cutaneous) 5
Infection Prevention
- Administer prophylactic antibiotics within one hour of skin incision per hospital protocols 5
- Deep infection rates with staged protocols are 5% overall, with only 1 wound problem expected in closed fractures 1
Thromboprophylaxis
- Prescribe fondaparinux or low molecular weight heparin, administered between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia 5
- Use thromboembolism stockings or intermittent compression devices intraoperatively 5
- Early mobilization is the most effective DVT prevention 4
Temperature Management
- Implement active warming strategies during and after surgery to prevent hypothermia, particularly in elderly patients 4
- Maintain theatre temperature at 20-23°C 5
Rehabilitation Protocol
Weight Bearing Progression
- High-energy fractures with internal fixation: Progress to full weight bearing at mean 12.6 weeks based on radiographic healing 3
- Primary TKR: Immediate full weight bearing postoperatively 2
Range of Motion Goals
- Expected final knee motion: 1-122 degrees with locked plating 3
- Mean flexion of 109 degrees achievable with primary TKR 2
- Pitfall: Knee stiffness (<90 degrees) occurs in 4% of cases with staged protocols; early structured physiotherapy is essential 1, 7
Monitoring
- Perform regular radiographic assessment to ensure proper bone healing 6
- Monitor for signs of infection throughout recovery 4
Critical Pitfalls to Avoid
- Positioning errors: Avoid excessive flexion and internal rotation of the non-operative hip during surgery to prevent complications 4, 6
- Premature definitive fixation: Operating through compromised soft tissues dramatically increases infection risk; wait for soft tissue recovery 1
- Inadequate reduction: The LISS technique has a learning curve; malalignment occurred in 10% of early cases, requiring meticulous attention to reduction principles 3
- Hardware irritation: 5% of patients require hardware removal at mean 13 months due to irritation 3