Tibial Plateau Fractures Treatment & Management

Immediate management

All high-energy fractures need to be immediately checked for soft-tissue integrity and impending compartment syndrome. The overall management can be one of the following.

• Antiedema measures: Joint aspiration, rest, immobilization, compression, elevation, and other antiedema measures are advocated in patients with high-energy fractures surrounded by evidence of compromised soft tissues (eg, skin blisters, edema). Limbs with features suggestive of compartment syndrome should not be treated with antiedema measures.
• Traction: Traction can be used as a temporary or definitive management modality. Calcaneal traction can be continued during the traction mobilization treatment of selected plateau fractures without gross articular incongruity. Traction is contraindicated in patients undergoing vascular repairs.
• Debridement of open injuries: Open fractures need to be addressed based on the universal guidelines. Patients optimally undergo surgical debridement of open traumatic wounds within 8 hours of injury. Aggressive debridement of open fracture wounds is performed, including removal of contaminating debris and any devitalized fascia, muscle, and bone.
• Fasciotomy for impending compartment syndrome: This requires emergency treatment because a delay in treatment is directly correlated with further damage. If signs of compartment syndrome are present, 4 compartment fasciotomies are performed.
• Spanning external fixator: Closed fractures undergo external fixator placement based on patient stability and operating room availability, unless the patient has signs of compartmental syndrome. Patients undergoing debridement for open fractures and fasciotomy for compartment syndrome can be treated with a temporary external fixator until the soft-tissue condition improves.

Definitive management

Treatment of these fractures is governed by the vascularity (local tissue and distal), the condition of soft tissues, and the presence or absence of compartment syndrome. Not all fractures of the tibial plateau require surgery. The first challenge in the management of upper tibial fractures is to decide between nonoperative and surgical treatment.

Nonoperative treatment

In the past, long leg cast and traction mobilization were used for some fractures; however, the Sarmiento program of functional cast bracing is now preferred.

• Indications

  • Nondisplaced stable split fractures
  • Minimally displaced or depressed fractures
  • Submeniscal rim fractures
  • Fractures in elderly, low-demand, or osteoporotic patients
• Advantages

  • Simple technique
  • No surgical trauma or risk for sepsis
  • Shorter hospital stay
  • Early joint mobilization (only if functional cast brace is used) and delayed weightbearing
• Disadvantages

  • Risk of displacement and need for surgery (follow-up with imaging studies every 2 wk for 6 wk; activity restriction for 4-6 mo)
  • Prolonged immobilization and related complications: If traction is used, good motion is obtained at the cost of a lengthy hospital stay and the risk of pin-tract infection.^[14] Related complications of recumbency can include pulmonary embolism or phlebitis.
  • Joint stiffness (if immobilization >2-3 wk)
  • Instability and posttraumatic arthritis in the long term

Open or arthroscopic-assisted techniques are considered for fractures with displacement, depression of the condylar surfaces, or both.^{[15, 16]} Open surgical therapy can be immediate or staged.

Operative treatment

• Internal fixation (can be an immediate or a staged procedure)

  • Biologic fixation - screw fixation, minimally invasive plate osteosynthesis, least invasive stabilization system^[17]
  • Arthroscopic-assisted fixation
  • Conventional double plating
• External fixation

  • Ilizarov fixator^[18]
  • Hybrid fixator
• Combination devices

Surgical principles

The ultimate goals of tibial plateau fracture treatment are to reestablish joint stability, alignment, and articular congruity while preserving full range of motion, as depicted in the image below. In such a case, painless knee function may be achieved and posttraumatic arthritis may be prevented.

If fracture displacement is great enough to produce joint instability, operative management should be selected. Current internal fixation techniques include ligamentotaxis, percutaneous fixation, and antiglide techniques. When extensive comminution and damaged soft tissues prohibit the use of internal fixation, circular external fixators are an excellent fallback option for management.

Unicondylar and bicondylar plateau fractures in young patients with good bone stock and only a few well-defined articular fragments do well with modern reduction and internal fixation techniques. For osteopenic elderly persons with a bicondylar plateau fracture or for patients who are unable to cope with adequate pin care, a functional brace, possibly followed by a total knee arthroplasty, may be preferable.^[19]

Regardless of whether internal or external fixation techniques are used, appropriate management of soft tissues is an important factor in the successful management of severe injuries of the proximal tibia. In recent studies of grafts, Yu et al reviewed treatment with high-strength calcium sulphate^[20] , Lasanianos et al followed up patients treated with freeze-dried cancelous allografts.^[21] , and Russel and Leighton compared the results of autogenous bone grafts and calcium phosphate cement.^[22]

Fixation of tibial plateau fractures must be rigid, and fracture stability should be maintained. If fixation implants are obviously loose or provide inadequate fixation, they should be removed. Intra-articular sepsis combined with fixation instability results in rapid chondrolysis and destruction of the joint.

Treatment of different types of tibial plateau fractures

• Type I: Preoperative MRI or arthroscopy is necessary to visualize the lateral meniscus and the fracture. When the fracture is displaced, the lateral meniscus is commonly detached peripherally and, not infrequently, trapped within the fracture site. If a peripheral tear is present, with or without incarceration of the meniscus in the fracture site, open reduction and internal fixation is recommended with meniscal repair. If the meniscus is intact, closed reduction and percutaneous cannulated cancellous screw fixation is preferred. The quality of the reduction is assessed arthroscopically or with an image intensifier. If satisfactory reduction is not possible by closed means, open reduction is used.
• Type II: With joint instability, surgery should be used to address the impacted articular fragments, as in the images below. In these fractures, the depressed fragment must be elevated and supplemented with a bone graft. This can be performed either intra-articularly, elevating the anterior horn of the lateral meniscus, or by making a window in the lateral condyle and elevating the fragment with support from graft material and fixation with a buttress plate.

  • If depression is anterior or central, a straight lateral parapatellar skin incision with transverse submeniscal joint exposure is better. Preservation and repair of the lateral meniscus is the goal. With the use of an impactor from below, the fracture fragments are disimpacted, elevated, and supported with a bone graft. In the case of minimal comminution of the lateral condyle, cancellous screws with washers suffice, while a buttress plate is advocated for a comminuted fracture in soft osteoporotic bone. Type II tibial plateau fracture in a young active adult with good bone stock treated with percutaneous elevation and cannulated cancellous screw fixation without bone grafting. Type II tibial condyle fracture involving the tibial spine and more than 50% of the medial condyle fixed with biological buttress plating of the lateral plateau.
• Type III: If the depression is small and the joint remains stable, nonoperative treatment is preferred in elderly persons. However, if the joint is unstable in a physiologically younger patient, surgery is usually indicated. The depressed fracture can be visualized with arthroscopy or under a C-arm. A window is made in the metaphyseal region, the depressed articular surface is elevated, and the subarticular portion is supported with a graft and then supported with 1-2 cannulated screws or with a plate, as in the image below. Type III tibial plateau fracture with central depression in an elderly person treated surgically using percutaneous elevation, bone grafting, and cancellous screw fixation.

  • (Formal open reduction and plate fixation for Schatzker type I-III fractures is an alternative to arthroscopically assisted reduction and fixation.^[23] Direct visualization of the reduction of the joint surface can be obtained via a submeniscal arthrotomy or by detaching the anterior horn of the lateral meniscus using a lateral approach. In cases with wide displacement, associated fibular head fracture, and osteoporotic bone, buttressing with a plate provides better fixation than screws alone and may decrease the risk of collapse of the elevated fragments. If in doubt, buttressing should be used.)
• Type IV: Because these are high-energy injuries, they may be associated with soft-tissue injuries and sometimes neurovascular injuries and knee dislocation, thereby adding to the knee instability. Nonoperative treatment is indicated only for nondisplaced fractures. Patients with good bone stock who have sustained low-energy trauma are better treated by closed reduction and percutaneous cannulated cancellous screw fixation. In those with high-energy fractures with tearing of the lateral collateral ligament or fracture of the fibular head, a midline or medial parapatellar approach and extraperiosteal approach is preferred.

  • The fracture must be elevated, reduced, and supported by a buttress plate, and the soft tissues should be repaired. If the intercondylar eminence with the cruciate is avulsed, it should be reduced and fixed with a lag screw or loop of wire. In patients with a predominant posterior fragment, an additional posteromedial incision may be necessary. The images below reflect the poor prognosis associated with these fractures is the result of related neurovascular injury, soft-tissue instability, increased demands placed on the articular surface of the medial plateau with weight bearing, and the high-energy forces involved in producing these fractures.^[24] See image below. Type IV medial tibial condyle fracture treated with arthroscopy-assisted elevation and percutaneous cancellous screw fixation along with percutaneous screw fixation of the tibial spine fracture.
• Types V and VI: These complex plateau fractures are usually due to high-energy forces and are often associated with compromise of the surrounding soft tissues. In these cases, extensible exposure of the upper tibia with subperiosteal placement of large implants should be avoided. This approach has been associated with an increased risk of wound dehiscence and infection. Fractures involving both condyles routinely require repair. The plateau with the most severely involved articular surface should be plated first. The less involved side should be treated with minimal, biologic fixation using percutaneous implants, limited posteromedial incisions, or a small external fixator to minimize exposure and bone stripping. They are frequently comminuted, and the shaft may be dissociated with the metaphysis. Many of these fractures, portrayed in the images below, are better treated with external fixation. Shown is a Schatzker type V fracture, with a displaced and depressed medial tibial plateau. Type VI tibial plateau fracture undergoing biological fixation of the lateral condyle and external fixation of the medial plateau, resulting in an acceptable clinical and radiological result. Type VI tibial plateau fracture with severe soft tissue injury successfully treated with Ilizarov external ring fixator. High-energy type VI tibial plateau fracture treated with bone grafting and double plating after the soft tissue condition improved.

Summary of indications, advantages, and disadvantages of various treatment modalities used for tibial plateau fractures

• Percutaneous screw fixation

  • Indications - Nondisplaced type I fractures
  • Advantages - Simple technique with minimal soft-tissue injury
  • Disadvantages - Not applicable for other patterns of fracture
• Percutaneous elevation and screw fixation

  • Indications - Type II and III fractures; bone grafting if severe depression (>10 mm) in osteoporotic bone
  • Advantages - Simple technique with minimal soft-tissue injury
  • Disadvantages - Not useful for high-energy fractures with ligamentous and meniscal injuries
• Arthroscopic-assisted elevation and screw fixation

  • Indications - Types I, II, III, and IV fractures with ligamentous and meniscal injuries
  • Advantages - Minimal soft-tissue injury; helps to diagnose and treat intra-articular injuries; aids in reduction of depressed articular fractures; allows for joint lavage
  • Disadvantages - Not useful in high-energy fractures
• Open reduction and internal fixation with or without bone grafting

  • Indications - Types III, IV, V, and VI fractures without soft-tissue injury
  • Advantages - Allows anatomic reduction with rigid internal fixation and bone grafting; facilitates joint exploration and treatment of intra-articular injuries
  • Disadvantages - Should not be performed in the acute setting in the presence of soft-tissue injury; unnecessary for type I fractures
• Biologic internal fixation

  • Indications - Types IV, V, and VI fractures with minimal displacement and comminution; polytrauma patients
  • Advantages - Simple technique with minimal soft-tissue injury; retention of fracture hematoma
  • Disadvantages - Not useful in severely comminuted and depressed fractures
• External fixators - Half-pin fixator, ring fixator, hybrid fixator

  • Indications - Open injuries and high-energy (types IV, V, and VI) fractures with soft-tissue injury; fractures with vascular injury with or without compartment syndrome; polytrauma patients
  • Advantages - Minimal soft-tissue injury
  • Disadvantages - Nonrigid fixation; difficult to achieve anatomic fracture reduction; joint stiffness; pin-tract infections; septic arthritis

Recovering range of motion is a challenge for patients who (1) cannot actively participate in rehabilitation, (2) may have soft-tissue injuries that preclude immediate range of motion, and (3) have had external-fixation pins inserted near their quadriceps. Because of the potential disability associated with chronic flexion contracture, after surgery, these patients should be placed in a hinged knee brace that is locked in extension. A padded bump under the heel is used both in the hospital bed and at home after discharge to maximize knee extension. Motion is restricted until surgical and traumatic wounds are dry. Continuous passive motion begins when wounds are dry; the goal is full extension and 90° of flexion within 5-7 days. If other injuries allow, the patient is mobilized with a hinged brace locked in extension for 6 weeks. For follow-up studies, see Chan et al^[25] and Rossi et al.^[26]

Non – weight-bearing precautions generally continue for 12 weeks. Active flexion and passive extension are encouraged for 6 weeks, after which active knee extension is started. Active knee extension is delayed if open reduction and internal fixation of a tibial tubercle avulsion was required.

Complications can be divided into early (eg, loss of reduction, deep vein thrombosis, infection) or late (eg, nonunion, implant breakage, posttraumatic arthritis). Most early complications can be viewed as biologic failures, while late complications are often associated with mechanical problems.^[27]

Early complications

• Compartment syndrome
• Vascular injuries
• Swelling and wound-healing problems
• Infections
• Deep vein thrombosis
• Nerve injuries

Late complications

• Knee stiffness
• Knee instability
• Angular deformities
• Late collapse
• Malunion
• Osteoarthrosis^[28]