Terminology

• Proximal tibial fractures (PTFs) include both intra-articular and extra-articular fractures of the upper portion of the tibia.
• Tibial plateau fractures are intra-articular fractures of the weight-bearing articular surface and can be classified with the Schatzker classification.
• A more recent, three-dimensional three-column model (medial, lateral, posterior) is especially useful in complex PTFs with posterior involvement, helping surgeons see where fragments are, how they got there, and how they should be repositioned and fixated.

Trauma mechanism

Proximal tibia fractures are often caused by road traffic accidents. Other mechanisms include falls from height, industrial accidents, and assaults.

The mechanism often involves axial loading combined with valgus or varus stress on the knee. A valgus force primarily affects the lateral tibial condyle, while a varus force tends to collapse the medial condyle. A flexed knee is more likely to injure the posterior column. In extension, the anterior column tends to be involved.

Due to the tibia’s subcutaneous position and limited soft tissue coverage, these injuries are highly prone to extensive soft tissue damage, with an increased risk of infection.

Specific management in the ER

General initial management principles apply, as described in:

Initial evaluation and management in open fractures in the ER

Specific points for open proximal tibia fractures are: 

• Vascular status – Palpate the dorsalis pedis and posterior tibial pulses. If absent, realign immediately. If still absent, proceed to urgent surgery.
• Neurological assessment – Evaluate active movement and sensation to light touch.
• Compartment syndrome – Consider and manage accordingly if pain persists despite adequate analgesia on the reversed WHO pain ladder.

Early complications in open fractures

Temporary stabilisation in the ER can be achieved with an upper leg cast or skeletal traction with a pin through the calcaneus.

AP and lateral imaging of the knee and lower leg is essential to initial management. A CT, if available, is useful for planning definitive fixation and is often obtained after temporary spanning with an external frame.

Fracture management options

How to make an integrated open fracture treatment plan

Once the patient has been stabilized, a definitive fracture management plan should be made, weighing: non-operative treatment, immediate definitive fixation, and a staged approach – depending on fracture type, stability, soft tissue status, and available resources. The primary goal is stable fixation that maintains alignment, restores the articular surface, and preserves a functional limb.

Both intra,- and extra-articular proximal tibia fractures can present as unstable. Stability is assessed by grading displacement, articular involvement and cortical continuity.

The AO/OTA classification defines three main types of proximal tibial fractures:

• Type A: Extra-articular – e.g. avulsion of the intercondylar eminence.
• Type B: Partial articular – e.g. split or depression fractures of a single condyle.
• Type C: Complete articular – e.g. bicondylar or comminuted tibial head fractures.

Non-operative management

In general in open fractures of the proximal tibia there is no place for definitive non-operative treatment. Only undisplaced fractures with preserved joint stability and minimal soft tissue damage (Gustilo-Anderson grade 1) could be considered to manage non-operatively. Although in very limited resource settings where internal and/or external fixation is unavailable, it might be your only option.

Non-operative management consists of immobilization with a posterior long leg splint (above knee splint), followed by conversion to a circular above-knee cast once swelling has reduced. Non-operative fracture stabilisation will only be possible if the soft-tissues allow a cast. Sometimes a window in the plaster can be used for wound care. Confirm unchanged good alignment during follow-up. Conversion to a walking cast can be considered after about 6-8 weeks, with good follow-up during mobilization. Alternatively, calcaneal pin traction can be used to stabilize open fractures when there is significant soft tissue injury.

Non-operative management of open fractures

Operative management

Unstable or displaced proximal tibia fractures require reduction and definitive stabilisation, preferably with internal fixation using screws and plating. If soft tissues cannot be directly closed after debridement, or if the expected risk of infection is high, temporary knee-bridging external fixation is advised untill soft tissues are fully healed. With severe prolonged soft tissue compromise or a need for gradual deformity correction in case of older/non-united fractures, definitive fixation using external ring fixation is the preferred treatment modality of choice.

^{External ring fixator}

Absence of local expertise or resources for these procedures should prompt referral, if possible with temporary stabilisation. If referral is not possible, definitive treatment with external fixation can be considered, but should be recognized as suboptimal, carrying higher risk of non/mal-union, joint stiffness, or post-traumatic arthritis.

Definitive fixation with an external fixator

Acute tibia and fibula shortening belong to the treatment options that can be considered in case of bone loss or extensive soft-tissue damage in limited resourced settings. Be aware of the risk of acute vascular compromise due to arterial kinking when shortening larger segments.

Amputation

Above/through-knee amputation should ultimately be considered and discussed with the patient in cases of severe intra-articular fractures with vascular injury, or extensive soft-tissue damage such as crush necrosis. In both high- and low-resource settings, limb salvage in these circumstances often means prolonged, complication-prone treatment, whereas amputation with appropriate prosthetic fitting can offer a shorter, more predictable recovery and, for some patients, a better ultimate quality of life.

External fixator for a proximal tibial fracture

General principles of external fixation apply:

Applying an external fixator

When applying an external fixator for a proximal tibial fracture, follow some specific considerations: 

• Safe zones - Insert pins within the recognized femoral safe zones to avoid injury to surrounding structures including the common peroneal nerve, deep peroneal nerve, and popliteal artery, and to prevent intrasynovial pin placement.

• Construct choice - If possible, keep the fixator below the knee to reduce the risk of irreversible stiffness. In most cases this is not possible, as the proximal fragment is too small to allow safe pin placement, making a knee-bridging external fixator the only viable option. When the proximal fragment is sufficiently large, a reversed delta frame can be used instead. 
• Knee-bridging construct - For a knee-bridging construct, place femoral pins (antero)laterally into the midshaft and tibial pins in the midsagittal plane, ≥15 mm distal to the joint line. 

Adding stability 

For the proximal tibia, the standard bar-to-bar construct is not always stable enough. Depending on the fracture pattern, consider to:

1 Add a neutralisation bar (from the distal femoral pin to the proximal tibial pin, for knee-bridging constructs) or an AP pin in the proximal segment (for a reversed delta frame, avoiding the patellar tendon and posterior neurovascular bundle);

2 Maximise pin spread within each bone segment;

3 Use the thickest pins (6 mm) and bars the system allows;

4 If needed, add a medial accessory frame to resist varus forces, through an open approach with great attention to the popliteal neurovascular structures.

Technical considerations

• Reduction - Closed reduction via ligamentotaxis is usually adequate; control with fluoroscopy if available.
• Knee position - If open reduction is performed, keep the knee neutral or slightly flexed (~10°), never hyperextended.
• Drill guide - Use a tissue protector for drilling.
• Duration - A knee-bridging frame immobilises the joint; minimise the time it stays in place to limit stiffness.

How to manage the soft tissue

The reconstructive ladder is helpful in deciding your strategy. Start with the simplest effective option, but do not oversimplify.

Soft tissue management in open fractures

For small to medium-sized defects with exposed bone, local transposition or rotation flaps may provide reliable coverage. For larger defects of the distal femur some locoregional options include:

The reconstructive ladder is helpful in deciding your strategy.  Start with the simplest effective option and escalate to flaps if necessary.

Soft tissue management in open fractures

For proximal tibia soft tissue defects, a localregional flaps are a reliable choice, options include:

• Medial fasciocutaneous flap
• Medial gastrocnemius flap 

Open Proximal Tibia Fracture Gustilo-Anderson Grade II - Managed with gastrocnemius flap

In the case of a bone defect or a combined chronic defect, a local pedicled fibula graft, used for combined osseous reconstruction and soft tissue coverage, can offer a valuable solution. These are advanced reconstruction options.

Grade 3B Open Tibia Fracture With Segmental Bone Loss - Uganda

Aftercare after treatment with external fixator

1  Pin-site care – Because of the soft metaphyseal bone, pins loosen more easily in the proximal tibia, and their proximity to the knee raises the risk of septic arthritis if infected – good pin-site care and monitoring are essential.

2  Early mobilization – Restart knee movement as soon as possible to avoid severe stiffness; keep the leg elevated and monitor closely for compartment syndrome during the first 48 hours – patients with open fractures remain at risk despite the open wound.

3  Weight-bearing – Restricted after fixation of intra-articular fractures and resumed gradually. Extra-articular, simple fractures may allow early weight bearing in the frame, with conversion to a long leg cast once healed. Intra-articular or multifragmentary fractures are generally delayed until 6–8 weeks; the frame may stay 3–6 months or be exchanged at 6–12 weeks for a cast or hinged knee brace. Significant knee stiffness is to be expected.

4 Follow-up - Close clinical follow-up is essential; functional recovery can continue for up to a year, particularly in complex cases, with physiotherapy focused on knee and ankle range of motion to prevent long-term stiffness. Complications of fracture management in open fractures