Review Question - QID 215806

The patient is presenting with a bicondylar tibial plateau fracture and increased soft tissue swelling. Temporizing the soft tissues and close monitoring for compartment syndrome by applying a knee spanning external fixator followed by delayed internal fixation with dual incision dual plating is the preferred treatment option.

Bicondylar tibial plateau fractures are associated with high-energy mechanisms, especially in younger patient populations. Often, soft-tissue swelling and fracture blisters can form as a result of the energy transfer. This can complicate definitive management by predisposing the patient to wound complications and infections. In these instances, external fixation of the fracture to allow for soft tissue stabilization is preferred. Definitive fixation with dual-incision dual-plating is ideal for bicondylar tibial plateau fractures.

Higgins et al. performed a retrospective study of 111 patients presenting with bicondylar tibial plateau fractures. They reported 59% of patients presented with a posteromedial shear fracture fragment that is vertically unstable and accounts for 25% of the involved articular surface. They concluded treating surgeons should be cognizant of this fracture pattern and should direct surgical treatment to address this unstable injury.

Barei et al. retrospectively studied 57 bicondylar tibial plateau fractures for fracture morphology. They reported 74% of patients presented with a posteromedial fragment that comprised 58% of the medial tibial plateau with a mean sagittal fracture angle of 81°. They concluded the treating surgeon should be aware of this fracture pattern and have preparations to address this injury appropriately.

Barei et al. performed a retrospective study of 83 patients with bicondylar tibial plateau fractures that were treated with dual incisions. They reported a 62% satisfactory articular reduction and removal of symptomatic hardware being the most common cause of secondary reoperation. They concluded bicondylar tibial plateau fractures can be successfully treated with medial and lateral plating through dual incision approaches.

Figure A is an AP radiograph of the left knee with bicondylar tibial plateau fracture.

Incorrect answers
Answer 1: Lateral locked plating would not be sufficient definitive fixation for a highly comminuted Schatzker V tibial plateau fracture.
Answer 3: Definitive fixation for this fracture would ideally buttress both condyles, which cannot be achieved through a single incision.
Answer 4 and 5: Temporizing this injury with a splint would not allow for soft tissue surveillance and provisional reduction through ligamentotaxis.