Internal Fixation

Internal Fixation of Tibial Plateau Fractures

Fixation constructs depend largely on fracture patterns and on patient factors such as associated injuries and functional status. Classification systems discussed in Chapter 2 can aid in the determination of definitive treatment for tibial plateau fractures. Many commercially available plating systems specific to the tibial plateau are available, with innovations constantly being brought to market. These provide treatment options with precontoured plates that can help secure stable fixation of difficult fracture patterns. Successful operative treatment in tibial plateau fractures begins with gaining the exposure needed to perform reduction and apply fixation (as detailed in Chapter 1 ). Visualization of the plateau may be obtained with fluoroscopy or arthroscopy, with minimal incisions, or with large and/or multiple incisions. It is imperative that the surgeon determines what approach can be used to reduce and adequately stabilize the fracture pattern while exposing the patient to the minimum amount of risk needed to reach those objectives. While it is recommended to perform biologically friendly fixation to the greatest degree possible, it is equally important to recognize when greater exposure is needed in order to achieve reduction and fixation goals.

Indications

Indications for the surgical treatment of tibial plateau fractures are determined primarily by fracture characteristics, such as fracture displacement and instability. These fractures involve the articular surface in the knee joint and such articular displacement leads to alterations in force transmission across the joint and accelerated degenerative changes. Articular displacement/step-off of 3 mm or more is generally cited as an indication for operative treatment. In highly active and younger patients, however, consideration may be given to reduction and fixation with any articular step-off of 1 mm or more.

Additionally, fractures that cause varus or valgus instability meet indications for operative treatment due to the risk of fracture healing with mechanical axis deformity of the tibia. Instability may be detectable by plain radiographs showing displacement on static films or alternatively determined by stress views. Examination under anesthesia in the operating room with fluoroscopy assistance can be performed if questions remain regarding fracture stability. Varus or valgus deformity of greater than 5 to 10 degrees with stress indicates instability. Metaphyseal comminution, bicondylar tibial plateau involvement, and medial tibial plateau fractures are all fracture characteristics that are often indicative of instability.

Articular surface gapping of 3 to 5 mm or more is another common indication for surgical management. This is often determined by tibial condylar widening, which can be measured by comparing contralateral tibia x-rays and/or by comparing tibial condylar width with femoral condylar width. The tibial plateau lateral margin should normally line up with the lateral margin of the femoral epicondyle. The articular width of the proximal tibia should be slightly larger than the distal femoral articular width, while the total tibial condylar width should be slightly less than the overall femoral condylar width.

Other potential indications for operative treatment of tibial plateau fractures may exist as well. Difficulty/inability to comply with non–weight bearing either due to cognitive deficits or injuries to multiple limbs may be a reason to proceed with surgical management in order to prevent displacement and allow early mobilization. The decision to proceed with surgical management must be individualized to the patient being treated, with consideration of both the risks and the benefits of surgery. Open fractures and compartment syndrome are indications for surgical treatment, although these do not always necessitate internal or external fixation in cases of nondisplaced and stable fractures. Indications for operative treatment of tibial plateau fractures are listed in Box 5.1 .