Postoperative Management

For postoperative management, elevation of the limb is required at 20⁰–60⁰ of flexion for up to 5 days on a frame or on a CPM machine set. The other option is the placement of the leg in a knee immobilizer. Active assisted range of motion can be started on the third day after surgery. The knee immobilizer can be discontinued if the quadriceps control is regained by the patient. Generally, a minimum 90⁰ of flexion is achieved by 7-10 days. A cephalosporin antibiotic is given for 24–48 hours after surgery. Suction drainage can be maintained for a minimum 24 hours if required. Physical therapy can be delayed if there is considerable swelling or tension on the suture line. On the basis of conformity, patients with type B and C fractures can be maintained with a partial weight bearing of 10–15 kg or non-weight bearing for about 6–8 weeks. The goal of starting active movement is to attain 120⁰   flexion of the knee by 1 month after surgery. Weight bearing can be increased up to 50%of body weight at 6–8 weeks on the basis of x-ray evidence of consolidation of fracture. In case of fracture patterns of higher-energy for e.g. in B3 and C3 injuries, full weight bearing can be delayed to 12–16 weeks. But in case of low-energy injuries, full weight bearing is attained by 8–12 weeks, and simple routine activities can be resumed at 4–6 months. In higher-grade injuries, patients may take 12–18 months for resuming daily routine activities. Usually, union at the metaphyseal-diaphyseal junction is slow. If there is no progress, bone grafting of that area can be carried out. 

Pitfalls and complications

During the treatment of high-energy tibial plateau fractures, the wound complications are the primary one. But a careful evaluation can be useful in minimizing it. The soft-tissue envelope, the right timing of surgery, minimizing soft-tissue stripping at the fracture region, development of full-thickness flaps, extraperiosteal dissection of fracture fragments are some issues that should be taken care of. Immediate surgical intervention is advisable in case of superficial wound breakdown. Repetition of irrigation and debridement together with secondary closure, rotational flap or vascularized free flap can be suggested.

In case of late joint collapse or deformation at the metaphyseal shaft junction, mal-union can take place. In case of mechanical axis disturbance, an osteotomy is suggested for the restoration of the normal mechanical axis. If in the starting period after surgery, there is displacement of major articular fragments, this must be revised immediately. After the unison of the large articular fragment in the displaced position, its anatomical reduction will not be possible.

In case of severe fractures, arthrofibrosis may also occur or if early range of motion is not introduced immediately. For the patients who fail to attain 90° of flexion within the first 4 weeks post-operatively, arthroscopic lysis of adhesion in combination with gentle manipulation under anesthesia is advised. 

Surgical treatment has shown excellent results in case of low-energy tibial plateau fractures i.e. 41-B1.1, 41-B2, and 41-C1.11. Satisfactory results have been revealed in case of patients with low-energy fractures treated with internal fixation techniques in comparison of non-operative management. Generally, the patients have an excellent prognosis who were treated with internal fixation technique for low energy type fractures with minimal comminution and sufficient soft tissues to resume complete and restricted activities only with least limitations. Studies conducted on patients with comminuted high energy fractures revealed that extensile approaches with single or double buttress plates had considerable complications like deep infection, wound slough, and mal-union or non-union. In studies conducted on patients with articular comminution or metadiaphyseal extension with limited articular fixation in together with hybrid external fixation have revealed least complications with 70–80% rate of good to excellent results for these fracture patterns. In case of a high energy type plateau fracture treated with limited internal fixation using anti-glide plates and bridge plates, and limited posteromedial extra-periosteal plate, have minimized complications to a great extent and the clinical results were also better.

Sometimes the elastic nail is important for achieving stabilization of the fragment. It is also suggested for fractures in the shaft of tibia and also for the metaphyseal fractures. External fixators are used externally to keep the fractured bone in alignment and stabilized.