Tibial plateau fractures result from high energy, blunt force trauma and are associated with severe bone and soft-tissue injury. Surgery requires putting the bones back together with what are known in the medical trade as “Fixation techniques.” These require considerable surgical skill and experience. The available surgical options do not always guarantee a favourable outcome. There are many options for surgical treatment including, internal and external fixation, hybrid fixation and arthroscopically assisted fixation. I had arthroscopically assisted fixation. What type of treatment you receive will be governed partly by the country in which your accident occurred, where your surgeon trained, whether he/she is is an emergency trauma surgeon or a specialist orthopaedic surgeon and the degree of violence attending the injury ie is it a minor type 1 or a major type 6.
Post operative management of high-energy fractures is difficult and may be associated with serious complications, such as:
*Deep Vein Thrombosis,
*Long term arthritis,
*Metal allergy. In severe cases of metal allergy your body will reject the plate and screws.
*Other Minor issues can be things like Varicose eczema, shoulder injuries relating to wheelchairs and crutches or strains to soft tissue such as the Achilles tendon in the injured leg due to compromised muscle structures.
The surgeon’s skill, the degree of injury, the age of the patient, the patient’s approach to post-surgical care, the patient’s weight and whether he/she is a smoker or heavy drinker can all impact the outcomes. Whether the patient was physically fit and followed a regular exercise regime before the accident will have a dramatic impact on recovery outcomes in my opinion.
I will examine in detail some of those complications and what to look for.
Deep vein thrombosis (DVT) Deep vein thrombosis, is the formation of a blood clot (thrombus) within a deep vein, usually in the legs. Symptoms include pain, swelling, redness, warmness, and engorged superficial veins. It can be a fatal complication if it leads to the formation of a Pulmonary embolism. This potentially life-threatening complication, is caused by the detachment of a clot, that travels though the deep veins in the leg, such as the Popliteal Vein, and lodges in the lungs. Along with Compartment Syndrome, DVT is the most serious complication arising from Tibial Plateau Surgery. Compartment Syndrome wont kill you, but a DVT might. Prevention options include walking as soon as possible after surgery, calf exercises, anticoagulants such as Warfarin, Clexane, Xarelto and aspirin, and the wearing of graduated compression stockings.
Compartment syndrome is a biggie. If you attract this you are in the shit! There is no nicer way of putting it! You are unlikely to suffer Compartment Syndrome from a type I or type II tibial plateau fracture of the sort usually associated with snow skiing. Compartment syndrome usually presents in patients suffering really severe types of plateau fractures where the muscle in the centre of the calf sustains significant injury. This is known in medical lingo as the proximal posterior calf muscle. Damage that and you could be in a world of trouble. In simple terms the injury you suffered which broke your leg has also damaged the blood vessels. These blood vessels swell and leak, causing inflammation. Fluid builds up in the area contained by the fascia. You are bleeding internally in your leg and the fluid has no place to go. It gets so tight in there that the normal arterial and venous flows in your leg are obstructed and the muscle structure grinds to a halt. If left untreated the tissue in your leg will start to die.
Luckily if you are going to suffer compartment syndrome you will know about it within several hours of incurring the injury. You will notice severe, unremitting pain out of all proportion to the bone injury. Your calf will swell and become firm, and passive movement of your calf muscles will result in further pain.
Some of the symptoms of compartment syndrome e.g. a swollen calf are similar to a DVT. Like a DVT it can go undetected if the surgeon is not focused on complications from tibial plateau injury/ surgery. If you are in the slightest doubt you should insist that your orthopaedic surgeon refers you to a vascular surgeon for a clinical diagnosis which may require a CAT scan of your leg.
If you are diagnosed with compartment syndrome you will be treated via a surgical procedure known as a fasciotomy of the affected calf. This involves cutting away the fascia to relieve the pressure in your leg. The fascia is thin connective tissue covering, and separating, the muscles and internal organs of your calf. It varies in thickness, density, elasticity, and composition, and is different from ligaments and tendons.
Be aware that compartment syndrome may appear after you injure yourself but before surgery. It may require treatment before the operation to stabilise your fractured leg. A further complication is that the pain from compartment syndrome may be masked by the heavy painkilling drugs which you are taking to alleviate the pain of the fracture. Postoperative nerve blocks, although well-intentioned, will also mask an impending compartment syndrome.
In addition to documenting the vascular status of the extremity, the surgeon should perform a detailed examination of the neurologic status of the affected limb. The varus force generating medial tibial plateau fractures is sufficient to produce a stretch injury to the peroneal nerve. Patients with tibial plateau fractures are often in significant pain and may be reluctant to enthusiastically participate in a neurologic examination. Documenting a patient’s traumatic “foot drop” before surgery, however, is much better than waiting until several days later.
Fortunately, patients who have peroneal nerve palsies usually recover without any additional surgical intervention. Patients with a foot drop should be maintained in an ankle-foot orthosis (AFO) until active ankle dorsiflexion returns to avoid an Achilles contracture. Using an AFO on all patients who have tibial plateau fractures will help avoid equinus contractures. The AFO is used until the patient is allowed to bear weight on the affected extremity.
Knee stiffness is perhaps the most common complication seen after tibial plateau fractures. Although immobilizing the knee is acceptable while bridging a tibial plateau fracture with an external fixator or while waiting for soft-tissue flaps to heal, in most cases, the knee should be moved as soon as possible. Physical therapy should be initiated to obtain full extension and as much flexion as possible.
Knee pain after tibial plateau fractures is often due to arthrofibrosis, and the patient needs to be counseled that the time to achieve knee motion is now—not later when the patient thinks that it will feel better! Unless the surgeon intervenes and encourages early motion, most patients will be content to keep their knee immobilized in 30 degrees of flexion.
Malalignment of the knee is a possibility after open reduction and fixation of tibial plateau fractures. If your surgeon does not sufficiently elevate the deformity to your lateral plateau you may end up knock-kneed. Doctors call this conditon genu valgum (they would!) but you and I know it as knock-kneed.
How surgeons avoid malalignment is too complicated for this post. Suffice to say that despite the availability of surgical techniques which allow exposure and fixation of the plateau fragments, the surgeon still may not get right the exact mechanical axis of the tibia. Placement of the screws and the plate in the correct axis and ensuring that the surface of the plateau is smooth with no bumps or dips is critical if you are to walk normally again.
Ligament and meniscal tears
Knee ligament and meniscal tears are commonly seen in conjunction with tibial plateau fractures. Tears of the anterior cruciate ligament (ACL) occur in 10 percent and meniscal tears occur in 20 percent of tibial plateau fractures. These associated injuries may be very difficult to diagnose prior to surgery, and some surgeons recommend preoperative magnetic resonance imaging to more thoroughly evaluate the injured knee. The surgeon may be able to repair some meniscal tears while stabilizing the plateau fracture. ACL tears, however, should not be reconstructed until after the fracture has completely healed and the hardware is removed. At that point, knee stiffness may reduce the need for ACL reconstruction.
Douglas W. Lundy, MD, FACS, a member of the AAOS Medical Liability Committee, and Mary Jo Albert, MD, practice at Resurgens Orthoapedics in Atlanta. Additional readings on this topic can be found online at www.aaos.org/now.
September 2007 AAOS Now