How should a 1‑week‑old subchondral fracture of the medial tibial plateau presenting with knee pain be managed?

Management of 1-Week-Old Subchondral Fracture of Medial Tibial Plateau

For a 1-week-old subchondral fracture of the medial tibial plateau causing pain, conservative management with protected weight-bearing and immobilization is the recommended treatment approach, as these fractures are typically minimally displaced and stable injuries that heal well without surgery. 1, 2

Initial Management Strategy

Conservative Treatment Protocol

• Immobilization with a cast brace for 6-12 weeks is the standard treatment for subchondral tibial plateau fractures without significant displacement. 2
• Protected mobilization should be initiated early to prevent knee stiffness while maintaining fracture stability. 1
• Weight-bearing status should be restricted initially, with gradual progression as pain and fracture healing allow. 2

Key Clinical Considerations

Subchondral fractures of the tibial plateau are often insufficiency fractures, particularly in elderly patients with osteopenia or osteoporosis, and may not be visible on initial radiographs. 2 At 1 week post-injury, the fracture line may now be visible on plain films, but if clinical suspicion remains high with negative radiographs, advanced imaging is warranted.

Imaging Recommendations

Advanced Imaging When Needed

• MRI is the most sensitive modality for detecting subchondral fractures and bone marrow edema in the tibial plateau, even when plain radiographs are negative. 3, 2
• CT scanning provides excellent characterization of fracture severity and can detect fractures missed on plain radiographs, with 100% sensitivity compared to 83% for radiographs alone. 3
• MRI also evaluates for associated meniscal and ligamentous injuries that commonly accompany tibial plateau fractures. 3

Surgical Indications (When Conservative Treatment Fails)

Surgery is reserved for displaced fractures with articular incongruity, not for minimally displaced subchondral fractures at 1 week. 1 However, you should be aware of these criteria:

When to Consider Surgical Intervention

• Significant articular surface depression or displacement requiring anatomic reduction. 1
• Fractures with associated ligamentous instability or meniscal pathology requiring repair. 3
• Progressive collapse despite conservative treatment. 2

The goal of tibial plateau fracture management is achieving a stable, well-aligned, congruent joint with painless range of motion. 1

Common Pitfalls to Avoid

Critical Management Errors

• Delayed diagnosis can cause prolonged pain, disability, and structural collapse of the knee joint, particularly in osteoporotic bone. 2
• Immobilization beyond 12 weeks increases risk of knee stiffness requiring mobilization under anesthesia (if <3 months duration) or arthroscopic release (if 3-6 months duration). 4
• Failure to assess for underlying osteoporosis in elderly patients—DEXA scanning and bisphosphonate therapy should be considered. 2

Monitoring for Complications

• Knee stiffness is the most common complication and can be prevented by early protected mobilization within the constraints of fracture stability. 4
• Post-traumatic osteoarthritis may develop, particularly if articular congruity is not maintained. 4
• Monitor for progressive collapse on serial radiographs at 2-4 week intervals during the healing phase. 2

Expected Outcomes

Conservative treatment with cast bracing for 6-12 weeks produces good results in subchondral tibial plateau fractures, with most patients returning to previous activity levels. 2 All patients in the insufficiency fracture series achieved good outcomes without operative intervention. 2