Tibial Plateau Fracture, ABOS Oral Boards Preparation

This is a 45-year-old female attorney who was struck by a car as a pedestrian at low speed. She had immediate right knee pain and could not bear weight. No significant medical history and no medications.

On exam, the right knee was swollen with a tense effusion. She was tender over the lateral tibial plateau. Valgus stress was painful with increased laxity compared to the other side. I checked the peroneal nerve, normal dorsiflexion, eversion, and sensation in the first web space. Distal pulses were symmetric.

AP, lateral, and oblique radiographs showed a split-depression fracture of the lateral tibial plateau with approximately 8mm of articular depression and lateral condylar widening. I obtained a CT with coronal, sagittal, and axial reconstructions, this confirmed a Schatzker II pattern with a 10mm depressed articular fragment and an intact posteromedial column. I also obtained an MRI, which showed an intact ACL and PCL, an MCL sprain without complete disruption, and a lateral meniscus tear with entrapment in the fracture cleft.

Given the degree of articular depression, well beyond the generally accepted 3 to 5mm threshold, the condylar widening, the valgus instability on exam, and the meniscal entrapment requiring repair, this was a clear operative indication. We discussed the surgical plan and she agreed to proceed.

I performed ORIF through an anterolateral approach with a submeniscal arthrotomy, using a lateral periarticular locking plate with calcium phosphate bone substitute for the metaphyseal void. The entrapped lateral meniscus was reduced and repaired. I confirmed articular reduction and joint stability with fluoroscopy and valgus stress.

Post-operatively, she was placed in a hinged knee brace and started immediate range of motion from 0 to 90 degrees. She was non-weight-bearing for eight weeks to protect the meniscal repair and the articular surface. At six weeks, X-rays showed early healing with maintained articular reduction, but her range of motion had plateaued at 0 to 85 degrees despite compliant therapy. At ten weeks, she was still stuck at 0 to 90. Given the persistent stiffness, I performed a manipulation under anesthesia at twelve weeks. Under general anesthesia I was able to achieve 0 to 130 degrees of flexion. She was started on an aggressive therapy protocol immediately after the manipulation. At four months, she had regained 0 to 120 degrees of motion and was progressing to full weight-bearing. At six months, she was walking without a significant limp, back to most of her normal activities, and had no instability on exam.

She was satisfied with the result and returning to her active lifestyle. In retrospect, I would consider using arthroscopic assistance for the articular reduction rather than relying solely on direct visualization through the submeniscal arthrotomy. I also think starting continuous passive motion in the immediate post-operative period might have prevented the stiffness that required manipulation. I monitored her closely for post-traumatic arthritis given the articular involvement, and at six months her joint space was well-maintained.