Physician Life Care Planners must understand that patients with tibial plateau fractures are at significant risk for post-traumatic arthritis says Dr. Greg Vigna, MD, JD

Tibial plateau fractures are often related to high-speed motor vehicle accidents and are a result of blunt trauma when the knee and lower legs hit the dashboard. They are often associated with severe soft-tissues injuries, open fractures, nerve injuries, and vascular injuries. The goal of repair is to restore the structure of the joint, allow for full range of motion, and normal weight bearing through the joint. Complications include knee stiffness, infections, non-union, blood clots, and over-time post-traumatic arthritis.

Orthopaedic trauma surgeons have a variety of treatments that may include internal fixation with plates and screws, external fixation devices, and arthroscopic fixation of fractures as well as meniscal repair.

Internal fixation is a procedure where plates and screws are placed under the skin into the bone fragments with a goal of a rigid fixation and ultimate bony union. If rigid internal fixation is attempted but fails to intra-operatively provide stability, external fixation should be used. The most disastrous complication involves postoperative wound infections with ‘failure of the hardware’ which may lead to joint infections and destruction of the cartilage. Early diagnosis of post-operative infections is necessary to allow for timely intervention with broad-spectrum intravenous antibiotics.

External fixation with or without internal fixation is utilized in complex fractures and those with open wounds where skin closure is not possible. Post-operatively patients will need ongoing wound care as well as pin site nursing care. Any symptoms or signs of infection require early intervention with intravenous antibiotics to prevent a pin site infection that extends to the joint.

Arthroscopic internal fixation with or without external fixation may be an option. Studies indicate that this may lead to earlier rehabilitation, improved range of motion, and decreased complications including blood clots than open reduction and fixation. Arthroscopic internal fixation, however, may not be technically possible given the diversity and severity of injuries.

With any tibial plateau fracture that requires operative management there will be four to twelve weeks where the patient will be non-weight bearing. It is critical that these patients are case managed appropriately and referred to a rehabilitation facility with adequate physician supervision to ensure that complications are timely diagnosed. Complications related to infection, blood clots, and pressure ulcers are common especially in those with other injuries such as pelvic fractures and traumatic brain injuries that often coexist with these injuries.

Knee stiffness or contractures are a severe and common complication of a tibial plateau fracture. Early mobilization is required with a goal of achieving 90 degrees of flexion of the knee within 4 weeks following surgery. In patients who fail to meet certain milestones of range of motion, more likely than not there will be a need for early release of adhesions (scar tissue) with arthroscopic surgery. It again absolutely required that physician and physical therapist communicate often to ensure that there is consistent progress in range of motion and if not early surgical release may need to be contemplated.

Infection is an ongoing concern since wound infections in the setting of internal hardware may lead to osteomyelitis (bone infection), a septic joint, or a non-union of the fracture fragments. Early intervention with intravenous antibiotics covering hospital acquired bacteria such as MRSA and pseudomonas is necessary.

A nonunion is a complication of any tibial plateau fracture and represents the situation when the fracture does not heal. In the setting where nonunion is not complicated by a bone infection the patient may need a bone graft, repeat internal or external fixation, and may need a bone stimulator. Nonunion in the setting of infection is a limb threatening medical condition and may need multiple physician specialties including plastic-reconstructive surgery for flap closure of a wound defect, orthopedic trauma surgeons, infectious disease specialist, and wound care specialist trained in hyperbaric oxygen treatment.

Case managers must understand that patients with tibial plateau fractures may need both inpatient rehabilitation and skilled nursing facilities, and ultimately prolonged outpatient rehabilitation. Case managers must understand that there must be physician oversight to ensure range of motion goals are obtained, and complications are timely identified.

Physician Life Care Planners must understand that patients with tibial plateau fractures are at significant risk for post-traumatic arthritis. They must interpret the operative findings and subsequent imaging studies, use the current literature as a foundation for their expert opinion regarding the timing of future interventions including medication management, steroid injections, synvisc injections, physical therapy, and ultimately a total knee replacement.

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