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Complications
Introduction
Tibial plateau fractures occur when a varus or valgus stress is applied to the knee in conjunction with axial loading. Younger individuals sustain this fracture through high-energy mechanisms such as motor vehicle accidents, pedestrian strikes, or falls from heights. In older individuals, it typically occurs due to their poor bone quality and a low-energy fall. , This section will focus on the sequelae and complications involved in the treatment of these fractures. Complications/sequelae include but are not limited to wound healing problems, deep infection, compartment syndrome, neurovascular injury, posttraumatic osteoarthritis (PTOA) of the ipsilateral knee and ankle, knee instability, arthrofibrosis, loss of muscle function/strength around the knee, ankle, and foot, malunion, nonunion, and loss of limb. For the sake of clarity, we will focus here on four of the most common and devastating problems: compartment syndrome, wound healing issues, arthrofibrosis, and PTOA. Complications can be minimized through proper history and physical examination (bearing in mind the mechanism of injury and overall amount of energy imparted to cause fracture), consideration of the soft-tissue health and whether staged treatment is necessary, and excellent surgical technique with a focus on anatomic reduction using limited incisions and meticulous soft-tissue handling. ,
Compartment Syndrome
Acute compartment syndrome (ACS) most often occurs following a fracture or crush injury to a limb. Following an injury, accumulation of blood and other tissue fluids results in significant swelling within the myofascial compartment. This accumulation of fluid results in venous hypertension and transudation of further fluid into the compartment. The progressive increase in compartment fluid causes an increase in pressure, which may result in tissue ischemia and necrosis without prompt intervention. Treatment for ACS involves urgent fasciotomy with the release of skin and muscle fascia to allow a reduction in compartment pressure.
Diagnosis
Fractures about the tibia and specifically bicondylar tibial plateau fractures have an increased incidence of severe soft-tissue injury and are associated with ACS. , Patients who are male and younger have been found to be at increased risk of ACS following tibial plateau fracture. Clinical signs of compartment syndrome that are generally well accepted are pain that is out of proportion to what should be expected, pain with passive stretch of the involved muscle, and paresthesias in the distribution of sensory nerves within the compartment. However, when used as a screening test, these clinical signs and symptoms have been shown to have low sensitivity when diagnosing ACS. If the clinical signs are at all in question regarding a diagnosis of ACS, then intramuscular pressures should be obtained. Numerous studies advocate for the use of routine intramuscular pressures in the general diagnosis of compartment syndrome. , Others advocate for the use of serial intramuscular pressures that provide more information regarding absolute changes in compartment pressures and changes in perfusion pressures. McQueen et al. found a sensitivity of 94% and a specificity of 98% when using continuous anterior compartment measurements, and a diagnosis of ACS was made when patients’ differential pressure remained less than 30 mmHg for more than 2 hours. At the author’s institution, clinical signs and symptoms are typically used for diagnosis of ACS. If physical examination and patient symptoms are in question, then intramuscular pressures are taken at the anterior and posterior compartments with fasciotomies performed when a 30-mmHg threshold for absolute compartment pressures and a perfusion pressure of less than 30 mmHg result.
Treatment
Our bias is to have more false positives and err on the side of surgical release rather than watchful waiting. A delayed diagnosis/treatment of ACS can result in significant morbidity for the patient, not to mention legal repercussions for the treating team. A two-incision technique to release all four compartments is utilized to allow for evaluation of muscle viability and adequate debridement as necessary in all four compartments of the lower leg ( Fig. 8.1 ). A knee spanning external fixator is routinely placed at the time of fasciotomies to allow for fracture stabilization and allows the patient to mobilize if other injuries are not present. Vessel loops, rubber bands, or prolene sutures can be utilized at the fasciotomy sites in a “roman sandal” configuration to allow for skin tension but also permit swelling and expansion of wound as needed ( Fig. 8.2 ). Multiple second look evaluations may be required, and definitive closure with fracture fixation must not occur until the soft-tissue envelope permits, with all necrotic tissue removed and wounds able to undergo either delayed closure or split-thickness skin grafting.
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