Tibial Plateau Fracture Treated with ORIF and Tibia Strut in a 37-year-old Male: A Case Report

Tibial plateau fractures (TPFs) are orthopedic challenges that have multiple injury modalities and clinical presentations. These fractures can be caused by high energy or low energy trauma. Epidemiological studies estimate peak incidence in the third and sixth decade of life for males and between the fourth and fifth decade for females. TPFs are often classified using the Schatzker classification system which can dictate management.

Case presentation: this is a 37-year-old male who complained of right knee pain after sustaining a fall from a truck ramp. The patient heard a pop and had severe, sharp pain in his right knee. In the emergency room, CT imaging demonstrated a comminuted tibial plateau fracture involving the medial and lateral tibial plateau as well as the metaphysis. The lateral tibial plateau was depressed by 5 mm. The patient was placed in a knee immobilizer, made non-weight bearing, and scheduled for surgical planning in 2 weeks. Unfortunately, the patient never followed up and opted for non-operative management. 6 months later, he came to our clinic because of significant pain and instability in the knee. X-rays demonstrated a chronic, incompletely healed fracture of the medial tibial metaphysis extending to the tibial eminence. Chronic fracture deformities of the medial femoral condyle and lateral tibial plateau were also observed. The patient agreed to surgery at our clinic.

The surgical technique was a proximal tibial osteotomy. An incision was made centered over the medial aspect of the gastrocnemius. The medial soft tissue sleeve was elevated off the proximal tibia in subperiosteal fashion while maintaining the MCL insertions. Next, a sagittal saw was used to make an osteotomy. The proximal tibia was elevated to correct for varus deformity. Afterwards, a fibula strut was placed followed by plate and screws. After biplanar x-ray verified adequate reduction and hardware replacement, bone filler was used to fill the void. Post operatively, the patient was made non-weight bearing for 3 months. Range of the motion was encouraged as tolerated.

At the first month follow up, the patient’s pain was well controlled and range of motion exercises were done regularly. No paresthesia, numbness, or wound dehiscence were noted. Repeat x-rays demonstrated intact hardware with evidence of healing fracture lines compared to immediate post-operative images. Fragments and the knee were appropriately aligned. No significant soft tissue or joint effusion were appreciated on imaging.

Conclusion: after failing nonoperative treatment, this patient with comminuted bicondylar tibial plateau fracture has received definitive treatment with open reduction and internal fixation. Higher rates of unacceptable results from nonoperative treatment is inline with Schatzker’s series in which operative treatment resulted in more acceptable outcomes. Because the fracture in this patient is more consistent with a Schatzker IV or V classification with intra-articular displacement more than 2 mm, the patient’s choice for nonoperative treatment was not appropriate. This led to a malunion and non-union that necessitated surgery. Perhaps greater warning should have been given to the patient about the risks of nonoperative treatment at their initial encounter.