What is the appropriate management of a medial tibial plateau fracture?

Management of Medial Tibial Plateau Fracture

For medial tibial plateau fractures, obtain CT imaging immediately after radiographs to characterize fracture severity and articular depression, then proceed with surgical open reduction and internal fixation for displaced fractures (>5 mm displacement or >2 mm depression) to restore articular congruity and prevent post-traumatic arthritis. 1, 2

Initial Imaging Protocol

• Start with plain radiographs to identify the fracture, but recognize that radiographs miss 17% of tibial plateau fractures that CT detects 1
• CT is mandatory as the next step after radiographs show any tibial plateau abnormality, providing 100% sensitivity compared to 83% for radiographs alone 1
• CT critically defines articular surface depression—if depression exceeds 11 mm, this predicts higher risk of lateral meniscus tear and ACL avulsion fracture 1, 3

When to Add MRI

Order MRI after CT if any of these criteria are met: 1, 3

• Articular depression >11 mm on CT
• Clinical suspicion of meniscal or ligamentous injury (locking, catching, giving-way)
• Surgical planning requires evaluation of soft tissue injuries
• Need to assess bone marrow contusions or occult fracture extension

MRI has 96% sensitivity and 97% specificity for detecting associated meniscal tears and provides multiplanar assessment of ligamentous injuries that alter surgical planning 3

Treatment Algorithm Based on Fracture Displacement

Type 1: Minimal Displacement (<5 mm displacement, <2 mm depression)

• Non-operative management is appropriate with protected weight-bearing 2
• Expect 100% excellent or good results with conservative treatment 2

Type 2: Moderate Displacement (5-10 mm displacement or depression)

• Surgical reduction by poking technique with bolt or wire fixation 2
• 95.83% achieve excellent or good results with this approach 2

Type 3: Comminuted or Unstable Fractures

• Open reduction with bone grafting and rigid fixation using grooved angle plate 2
• 100% excellent or good results when operated within first week 2

Surgical Approach for Isolated Medial Plateau Fractures

Use an anterior midline incision with medial parapatellar arthrotomy rather than posteromedial approach for isolated medial tibial plateau fractures 4

Benefits of this technique: 4

• Provides superior visualization of the articular surface
• Simplifies fracture reduction
• Creates a functional scar if future procedures (e.g., total knee arthroplasty) become necessary
• More familiar approach for most orthopaedic surgeons

Alternative: Extended Medial Approach

For comminuted medial plateau fractures with central/dorsal fracture lines: 5

• Perform approximately 2 × 2 cm osteotomy of the medial femoral epicondyle
• Allows complete visualization of comminuted articular surface
• Enables anatomical reconstruction without postoperative instability

Critical Timing Considerations

Operate within the first week after trauma whenever possible 2

• Delayed surgery (beyond 1 week) due to soft tissue conditions reduces excellent/good outcomes from 100% to 85.19% 2
• Perfect reduction, rigid fixation, and early joint motion are essential for optimal outcomes 2

Postoperative Protocol

• Full mobilization with 10-20 kg partial weight-bearing on forearm crutches 5
• Continue protected weight-bearing for 6-12 weeks depending on fracture pattern 5
• Early functional rehabilitation prevents knee stiffness 6

Common Complications and Prevention

Knee Stiffness

• Mobilization under anesthesia if duration <3 months 6
• Arthroscopic release for 3-6 months duration 6
• Open release for refractory cases >6 months 6

Infection Risk

• If fracture healed: remove hardware, perform lavage/debridement with antibiotics 6
• If fracture not healed: retain hardware, perform lavage/debridement with antibiotics, maintain fracture stability 6

Post-Traumatic Arthritis Risk Factors

Key predictors include: 7, 6

• Bicondylar and comminuted fractures
• Meniscal removal during surgery
• Residual instability or malalignment
• Articular incongruity >2 mm

At least half of patients return to original physical activity level when anatomy and stability are restored 7

Critical Pitfalls to Avoid

• Do not rely on radiographs alone—17% of fractures are missed without CT 1
• Do not delay surgery beyond 1 week unless soft tissue conditions mandate it 2
• Do not accept articular incongruity >2 mm—this significantly increases post-traumatic arthritis risk 5
• Do not use posteromedial approach for isolated medial fractures—anterior midline provides better visualization 4
• Do not skip MRI when CT shows >11 mm depression—associated soft tissue injuries require identification before surgery 1, 3