What is the recommended treatment for a patient with a nondisplaced proximal tibial fracture?

Treatment of Nondisplaced Proximal Tibial Fractures

Nondisplaced proximal tibial fractures should be treated with closed management including immobilization, as these fractures can be effectively managed conservatively when displacement is minimal and soft-tissue injury is limited. 1

Initial Assessment and Imaging

• Obtain standard radiographs in multiple views to confirm the fracture is truly nondisplaced, as these injuries can be subtle and displacement may be underestimated on initial films. 1
• Consider advanced imaging (CT or MRI) if there is any uncertainty about displacement, articular involvement, or associated soft-tissue injuries, particularly in younger patients where growth plate injuries may be missed on routine radiographs. 2
• Assess immediately for vascular compromise by checking distal pulses, capillary refill, and foot perfusion, as proximal tibial fractures carry higher risk of arterial injury and compartment syndrome compared to more distal tibial fractures. 1
• Monitor closely for compartment syndrome, which occurs more frequently with proximal tibial injuries—check for pain out of proportion, pain with passive stretch, tense compartments, and neurovascular deficits. 1, 3

Conservative Management Protocol

• Immobilize in a long leg cast or splint initially, as this provides the most effective pain relief and prevents displacement. 4, 1
• Reserve closed treatment specifically for nondisplaced or minimally displaced fractures with minimal soft-tissue injury, as displaced fractures or those with intact fibula are at high risk for varus malunion with conservative management. 1
• Maintain non-weight-bearing status initially, with gradual progression based on radiographic healing and clinical stability. 1

Pain Management Strategy

• Initiate scheduled paracetamol (acetaminophen) as first-line analgesia unless contraindicated. 4
• Add opioids cautiously, particularly if renal function is unknown, as approximately 40% of fracture patients present with at least moderate renal dysfunction. 4
• Avoid NSAIDs if renal dysfunction is suspected or confirmed, as these are relatively contraindicated in patients with impaired kidney function. 4
• Consider regional nerve blocks (femoral or fascia iliaca) for additional pain control, which can be administered by appropriately trained emergency department or orthopedic staff. 4

Monitoring and Follow-up

• Obtain serial radiographs at regular intervals (typically 1-2 weeks initially, then monthly) to ensure maintenance of alignment and assess healing progression. 1
• Watch specifically for late displacement or varus angulation, which is the most common complication of closed treatment, especially when the fibula remains intact. 1
• If any displacement occurs during the immobilization period, surgical intervention becomes necessary as the risk of malunion is unacceptably high. 1

Rehabilitation Protocol

• Begin early physical training and muscle strengthening once immobilization is discontinued, followed by long-term balance training to prevent future falls and maintain function. 4, 5
• Initiate aggressive range-of-motion exercises when fracture stability permits to prevent stiffness and muscle atrophy from prolonged immobilization. 4, 5
• Avoid overly aggressive therapy that could compromise fracture healing or cause displacement. 5

Critical Pitfalls to Avoid

• Do not attempt closed treatment if there is any significant displacement, comminution, or soft-tissue injury, as these factors dramatically increase the risk of malunion and poor outcomes. 1
• Do not miss compartment syndrome—maintain high clinical suspicion and low threshold for measuring compartment pressures, as this complication is more common in proximal tibial fractures. 1, 3
• Do not underestimate the risk of varus malunion with conservative treatment, particularly when the fibula is intact—this occurs in a substantial percentage of cases and may require corrective osteotomy. 1
• Do not delay conversion to surgical management if displacement occurs during the immobilization period. 1

When Surgical Intervention Becomes Necessary

If the fracture displaces during conservative treatment, or if initial assessment reveals the fracture is not truly nondisplaced, surgical options include external fixation (most versatile for short proximal fragments or extensive soft-tissue injury) or intramedullary nailing (for proximal fragments longer than 5-6 cm). 1