What is the appropriate treatment for a patient with a tibial plateau fracture?

Treatment of Tibial Plateau Fractures

The appropriate treatment for tibial plateau fractures depends on fracture stability and displacement: stable, minimally displaced fractures can be managed conservatively, while displaced, depressed, or unstable fractures require open reduction and internal fixation (ORIF) to restore articular congruity, mechanical alignment, and ligamentous stability. 1, 2, 3

Initial Assessment and Imaging Algorithm

Step 1: Obtain radiographs first to identify the fracture and assess for displacement 4

Step 2: Always proceed to CT imaging after radiographs show any tibial plateau abnormality, as CT demonstrates 100% sensitivity for detecting tibial plateau fractures compared to only 83% for radiographs alone 4

• CT is critical for characterizing fracture severity, measuring articular surface depression, and planning treatment 4
• Radiographs miss 17% of tibial plateau fractures that CT detects, so advanced imaging is mandatory rather than clinical observation alone 4

Step 3: Add MRI when any of the following are present: 4

• Articular depression >11 mm on CT (predicts lateral meniscus tear and ACL avulsion)
• Clinical suspicion of meniscal or ligamentous injury
• Surgical planning is being considered
• Need to evaluate bone marrow contusions or occult fracture extension

Treatment Decision Algorithm

Conservative (Non-operative) Management

Indicated for: 3

• Stable fractures
• Minimally displaced fractures (<2-3 mm articular step-off)
• Non-depressed fractures

Results: 66% satisfactory outcomes with closed treatment in appropriate cases 3

Surgical Management (ORIF)

Indicated for: 5, 2, 3

• All displaced fractures
• Unstable fractures
• Depressed articular surfaces
• Complex knee trauma with multiple structural element involvement

Primary goals of surgery: 1, 5

• Precise reconstruction of articular surfaces
• Stable fragment fixation allowing early motion
• Repair of all concomitant soft tissue lesions
• Restoration of limb alignment and mechanical axis

Results: 87% satisfactory outcomes with operative treatment 3

Surgical Approach Strategy

For Simple Fracture Patterns:

• Minimally-invasive methods with arthroscopic assistance to control reduction and treat intra-articular soft-tissue injuries 2

For Complex Fractures with Severe Soft-Tissue Injury:

Use staged treatment approach: 5, 2

Stage 1 (Primary treatment):

• Closed reduction
• Wound debridement if necessary
• External fixation ("transfixation") to stabilize the limb
• Allow soft tissue recovery

Stage 2 (Definitive treatment):

• ORIF after soft tissue recovery
• Complex bone and soft-tissue reconstructions
• Use specific posterolateral or posteromedial approaches for posterior fragments, as anterolateral and anteromedial approaches do not permit adequate reduction of these fragments 2

Alternative Surgical Options:

• Ring external fixators with minimally-invasive osteosynthesis (EFMO) for complex articular fractures—outcomes equal to or superior to ORIF despite potentially suboptimal articular reduction 2
• Primary total knee arthroplasty may be considered in specific elderly patients with specific fracture patterns 2

Critical Pitfalls to Avoid

Soft-tissue assessment is crucial: 5

• Grade the soft-tissue injury severity (use four-grade classification for closed and open injuries)
• Any type of tibial plateau fracture can present with soft-tissue complications 2
• Timing matters: perform definitive surgery only after soft tissue recovery in complex cases 5

Don't miss associated injuries: 4

• Articular depression >11 mm indicates higher risk of lateral meniscus tear and ACL avulsion fracture
• CT detects bony avulsion fractures with 80% sensitivity and 98% specificity, indicating ligamentous injury requiring different management

Surgical technique matters: 5, 3

• Follow principles and techniques of internal fixation carefully
• Inadequate reduction leads to worse outcomes

Expected Outcomes and Complications

Medium-term functional outcomes are generally excellent when anatomy and stability are restored: 1

• At least half of patients return to their original level of physical activity
• Better outcomes in isolated fractures compared to multiple injured patients and complex knee trauma 5

Common complications include: 1, 6

• Post-traumatic arthritis (higher risk with bicondylar/comminuted fractures, meniscal removal, instability, malalignment, articular incongruity)
• Knee stiffness
• Infection (acute or chronic osteomyelitis)
• Malunion/non-union

Complication management: 6

• Knee stiffness: mobilization under anesthesia if <3 months, arthroscopic release if 3-6 months, open release if >6 months
• Acute infection with healed fracture: hardware removal, lavage, debridement, antibiotics
• Acute infection with unhealed fracture: retain hardware, lavage, debridement, antibiotics (fracture stability crucial for infection resolution)