What is the recommended management for a patient with a non-displaced tibial plateau fracture?

Management of Non-Displaced Tibial Plateau Fractures

Non-displaced tibial plateau fractures should be managed conservatively with initial immobilization in a long leg cast or splint, followed by early protected mobilization in a hinged knee brace. 1

Initial Immobilization

• Immobilize immediately in a long leg cast or splint to provide optimal pain relief and prevent fracture displacement 1
• This initial rigid immobilization is critical during the first phase of healing when the fracture is most vulnerable to displacement 2

Pain Management Protocol

• Start scheduled acetaminophen (paracetamol) as first-line analgesia unless contraindicated 1
• Add opioids cautiously, particularly since approximately 40% of fracture patients present with at least moderate renal dysfunction 1
• Avoid NSAIDs if renal dysfunction is suspected or confirmed, as these are relatively contraindicated in patients with impaired kidney function 1
• Consider regional nerve blocks (femoral or fascia iliaca) for additional pain control, which can be administered by appropriately trained emergency or orthopedic staff 1

Imaging Confirmation

• Obtain CT imaging to fully characterize the fracture and confirm non-displacement, as CT demonstrates 100% sensitivity compared to 83% for radiographs alone in detecting tibial plateau fractures 3
• CT is superior for characterizing fracture severity and can predict associated meniscal and ligamentous injuries 3
• Consider MRI if there is concern for soft-tissue injuries (meniscal tears, ligament injuries), as articular surface depression >11 mm on CT predicts higher risk of lateral meniscus tear and ACL avulsion 3

Transition to Protected Mobilization

• Apply a hinged knee brace as soon as the acute pain subsides (typically within 1-2 weeks), allowing early range of motion while maintaining protected weight-bearing for 8 weeks 4, 5
• Cast-bracing allows early restoration of limb function while maintaining fracture stability 5
• Permit early range of motion exercises to prevent knee stiffness and optimize functional outcomes 4

Weight-Bearing Protocol

• Allow protected weight-bearing immediately after hinged brace application, as this promotes fracture healing without compromising stability 4, 5
• Progress to full weight-bearing at 8 weeks if radiographic follow-up confirms maintained fracture position 4

Rehabilitation Strategy

• Begin early physical training and muscle strengthening once immobilization is discontinued, followed by long-term balance training to prevent future falls and maintain function 1
• Quadriceps-strengthening exercises are particularly important to restore knee stability and function 2

Follow-Up Monitoring

• Obtain repeat radiographs at 10-14 days to ensure fracture position is maintained 6
• Continue radiographic monitoring at 4-6 week intervals until union is confirmed 4
• If displacement occurs despite adequate immobilization, operative fixation becomes necessary 6

Critical Pitfalls to Avoid

• Do not rely solely on initial radiographs to rule out displacement, as CT is significantly more sensitive 3
• Do not delay transition to hinged bracing once acute pain subsides, as prolonged rigid immobilization leads to unnecessary stiffness 4, 5
• Ensure patient compliance with the hinged brace, as removable devices have a median 3-month longer healing time when not worn consistently 6
• Monitor for skin breakdown in patients wearing braces, particularly those with sensory neuropathy or diabetes 6

Expected Outcomes

• All non-displaced fractures treated conservatively should achieve union 4
• 87% of patients achieve successful outcomes using standardized criteria when appropriate conservative management is followed 4
• At least half of patients return to their original level of physical activity with proper treatment 7

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