Tibial Plateau Fractures Treatment & Management

All high-energy fractures must 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 - This 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 must be addressed in accordance with 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 - Emergency treatment is required because a delay in treatment is directly correlated with further damage; if signs of compartment syndrome are present, four compartment fasciotomies are performed
• Spanning external fixator - Closed fractures undergo external fixator placement on the basis of patient stability and operating room availability, unless the patient has signs of compartment 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

Treatment of these fractures is governed by the vascularity (local tissue and distal), the condition of the 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.

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 for nonoperative treatment are as follows:

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

Advantages of nonoperative treatment are as follows:

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

Disadvantages of nonoperative treatment are as follows:

• Risk of displacement and need for surgery (follow-up with imaging studies every 2 weeks for 6 weeks; activity restriction for 4-6 months)
• 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 ^[13] ; related complications of recumbency can include pulmonary embolism or phlebitis
• Joint stiffness (if immobilization >2-3 weeks)
• Instability and posttraumatic arthritis in the long term

Fracture displacement ranging from 4-10 mm can be treated nonoperatively; however, a depressed fragment greater than 5 mm should be elevated and grafted. ^[14]

The following are absolute indications for surgery:

• Open plateau fractures
• Fractures with an associated compartment syndrome
• Fractures associated with a vascular injury

The following are relative indications for surgery:

• Most displaced bicondylar fractures
• Displaced medial condylar fractures
• Lateral plateau fractures that result in joint instability

Contraindications for surgical treatment include the following:

• Presence of a compromised soft-tissue envelope (for immediate open reduction)
• Fractures that do not result in joint instability or deformity and can therefore be treated with nonoperative modalities

Open or arthroscopic-assisted techniques are considered for fractures with displacement, depression of the condylar surfaces, or both. ^{[15, 16, 17]} Open surgical therapy can be immediate or staged.

Internal fixation can be accomplished by means of the following:

• Biologic fixation - Screw fixation, minimally invasive plate osteosynthesis, least invasive stabilization system ^[18]
• Arthroscopic-assisted fixation
• Conventional double-plating

External fixation can be accomplished with the following:

• Ilizarov fixator ^[19]
• Hybrid fixator

Combination devices may also be employed.

Some promising results have been achieved with balloon tibioplasty for depression fractures of the tibial plateau, but long-term results remain to be determined. ^[20]

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 (see the image below). ^[21] In such a case, painless knee function may be achieved and posttraumatic arthritis 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. ^[22]

Regardless of whether internal or external fixation techniques are used, appropriate management of soft tissues is vital for successful management of severe injuries of the proximal tibia. Yu et al reviewed treatment with high-strength calcium sulphate ^[23] , Lasanianos et al followed up patients treated with freeze-dried cancellous allografts. ^[24] , and Russel et al compared the results of autogenous bone grafts and calcium phosphate cement. ^[25]

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.

Type-specific treatment of tibial plateau fractures

Type I

Preoperative magnetic resonance imaging (MRI) or arthroscopy is necessary to visualize the lateral meniscus and the fracture. When the fracture is displaced, the lateral meniscus commonly is detached peripherally and not infrequently is trapped within the fracture site.

If a peripheral tear is present, with or without incarceration of the meniscus in the fracture site, open reduction with internal fixation (ORIF) 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 (see 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, whereas a buttress plate is advocated for a comminuted fracture in soft osteoporotic bone.

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 one or two cannulated screws or with a plate (see the image below).

Formal open reduction and plate fixation for Schatzker type I-III fractures is an alternative to arthroscopically assisted reduction and fixation. ^[26] 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 one is in doubt, buttressing should be used.

Type IV

Because type IV tibial plateau fractures 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. (See the image below.)

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 poor prognosis associated with these fractures is the result of related neurovascular injury, soft-tissue instability, the increased demands placed on the articular surface of the medial plateau with weightbearing, and the high-energy forces involved in producing these fractures. ^[27]

Types V and VI

Type V and VI tibial plateau fractures (see the images below) 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.

Summary of indications, advantages and disadvantages

Indications, advantages, and disadvantages of percutaneous screw fixation may be summarized as follows:

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

Indications, advantages, and disadvantages of percutaneous elevation and screw fixation may be summarized as follows:

• 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

Indications, advantages, and disadvantages of arthroscopic-assisted elevation and screw fixation may be summarized as follows:

• Indications - Types I, II, III, and IV fractures with ligamentous and meniscal injuries
• Advantages - Minimal soft-tissue injury; helps diagnose and treat intra-articular injuries; aids in reduction of depressed articular fractures; allows joint lavage
• Disadvantages - Not useful in high-energy fractures

Indications, advantages, and disadvantages of ORIF with or without bone grafting may be summarized as follows:

• 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

Indications, advantages, and disadvantages of biologic internal fixation may be summarized as follows:

• 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

Indications, advantages, and disadvantages of external fixators (half-pin fixator, ring fixator, or hybrid fixator) may be summarized as follows:

• 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 such as the following:

• Those who cannot actively participate in rehabilitation
• Those who may have soft-tissue injuries that preclude immediate range of motion
• Those who 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 ^[28]  and Rossi et al. ^[29]

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, whereas late complications are often associated with mechanical problems. ^[30]

Early complications include the following:

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

Late complications include the following:

• Knee stiffness
• Knee instability
• Angular deformities
• Late collapse
• Malunion
• Osteoarthrosis ^[31]

Nonweightbearing precautions generally continue for 12 weeks. Active flexion and passive extension are encouraged for 6 weeks, after which period active knee extension is started. Active knee extension is delayed if ORIF of a tibial tubercle avulsion was required.

A study by Garner et al found that elective removal of implants after ORIF for tibial plateau fracture led to improved clinical outcomes at 12 months. ^[32]