What is the current management and treatment of tibia plateau fractures?

Management and Treatment of Tibial Plateau Fractures

Initial Diagnostic Approach

Radiographs (anteroposterior and lateral views) should be the initial imaging modality for suspected tibial plateau fractures, followed by CT scanning for fracture characterization and surgical planning. 1

Imaging Algorithm

• Obtain plain radiographs first with minimum two views (AP and lateral) when tibial plateau fracture is suspected based on mechanism of injury and clinical examination 1

• CT is mandatory after radiographic diagnosis as it demonstrates 100% sensitivity for detecting tibial plateau fractures compared to only 83% for radiographs alone, and is superior for characterizing fracture severity 1, 2

• CT provides critical surgical planning information including:

  • Precise fracture pattern classification 1
  • Articular surface depression measurement (depression >11 mm predicts higher risk of lateral meniscus tear and ACL avulsion) 1, 2
  • Detection of bony avulsion fractures (80% sensitivity, 98% specificity) 1
  • Morphological subclassification, particularly for medial plateau fractures (Schatzker type IV) 1

• Add MRI when any of the following are present: 2

  • Articular depression >11 mm on CT
  • Clinical suspicion of meniscal or ligamentous injury
  • Surgical planning requires soft tissue assessment
  • Need to evaluate bone marrow contusions or occult fracture extension

• MRI has superb accuracy for evaluating bone marrow contusions, occult fractures, meniscal injuries, and ligamentous injuries due to its multiplanar capability and contrast resolution 1

Imaging Modalities to Avoid

• Do not order MR arthrography, MRA, bone scan with SPECT/CT, or ultrasound as the next imaging study after radiographs show tibial plateau fracture 1, 2

Surgical Treatment Strategy

Open reduction and internal fixation (ORIF) is the gold standard treatment for displaced and unstable tibial plateau fractures, with the primary goals being restoration of articular congruity, mechanical alignment, and ligamentous stability to permit early mobilization. 3, 4

Treatment Decision Framework

• Displaced and unstable fractures require ORIF to achieve precise articular surface reconstruction and stable fixation allowing early motion 4

• Complex fractures with severe soft tissue injury require staged treatment:

  • Primary: External fixation ("transfixation") and wound debridement if necessary 4
  • Secondary: ORIF and complex bone/soft-tissue reconstruction after soft tissue recovery 4

• Minimally-invasive approaches can be used for partially articular fractures 3

Surgical Technique Considerations

• Arthroscopic-assisted fixation for lateral plateau fractures (Schatzker I-III) demonstrates excellent/very good outcomes in >90% of patients, with advantages over traditional ORIF including: 5

  • Better range of motion (mean difference 5.21°)
  • Lower blood loss (66.19 mL less)
  • Shorter hospital stay (1.41 days shorter)
  • Better Hospital Special Surgery scores
  • Higher Rasmussen radiographic scores

• Posterolateral and posteromedial fragments require specific approaches as anterolateral and anteromedial approaches do not permit adequate reduction and fixation of these fragments 3

• Optimal plate/screw placement requires direct visualization through appropriate posterior approaches 3

Fixation Method Options

The evidence comparing different fixation methods is very uncertain, but available data suggests: 6

• Hybrid fixation (circular fixation with percutaneous screws) versus standard ORIF may have little or no difference in outcomes at 24 months, though evidence is very uncertain 6

• Single-plating versus double-plating ORIF shows no clear difference in patient-reported function at 24 months, but evidence quality is very low 6

• External fixation with minimally-invasive osteosynthesis (EFMO) can achieve outcomes equal to or superior to ORIF, though may be related to suboptimal articular reduction 3

Bone Defect Management

• Bone substitute versus autologous bone graft: Insufficient evidence exists to determine the best method for addressing bone defects during surgery 6

• Current practice includes use of bone defect fillers by orthopaedic surgeons, though no consensus exists on necessity or optimal type 6

Critical Pitfalls to Avoid

• Radiographs miss 17% of tibial plateau fractures that CT detects, so "subtle features" warrant CT rather than clinical observation alone 2

• Soft tissue injury assessment is crucial for treatment planning, as any tibial plateau fracture type can present with soft-tissue complications requiring staged treatment 3, 4

• Concomitant lesions are common in specific fracture types and must be identified and repaired for optimal outcomes 4

• Inadequate posterior fragment fixation occurs when only anterior approaches are used for fractures with posterior involvement 3

Expected Outcomes and Complications

• Medium-term functional outcomes are generally excellent when anatomy and stability is restored, with at least half of patients returning to original physical activity level 7

• Good results are achievable even in extensive fractures with tolerable complication rates when proper surgical technique is employed 4

• Risk factors for poor outcomes include: 7

  • Postoperative arthritis
  • Bicondylar and comminuted fractures
  • Meniscal removal
  • Instability
  • Malalignment
  • Articular incongruity

• Functional recovery is relatively impaired in multiple injured patients and complex knee trauma cases 4