Conservative Management of a Complex Schatzker Type V Bicondylar Tibial Plateau Fracture: A Case Report with 2-Year Follow-Up

Introduction

Tibial plateau fractures are a common peri-articular fractures of the proximal tibia [1]. They may result from either high- or low-energy trauma. High-energy injuries occur predominantly in adults following motor vehicle collisions or pedestrian accidents, whereas low-energy injuries are more commonly observed in patients with osteoporotic bone [2].

According to the Schatzker and Arbeitsgemeinschaft für Osteosynthese/Orthopaedic Trauma Association classification, tibial plateau fractures could be classified into complete and partial articular fractures. Complete fractures are bicondylar fractures usually caused by high-energy trauma, while partial fractures are usually caused by low-energy trauma [1,2,3].

The management of complex tibial plateau fractures is challenging and aims to restore the articular surface and limb alignment, achieve stable fixation that permits early knee mobilization, and address associated soft-tissue injuries [4]. Treatment options include open reduction and internal fixation with plates and screws or, in selected cases, external fixation [5,6,7]. Regardless of its classification, surgery remains the gold standard for its management, which consists of open reduction and internal fixation (ORIF) with plates and screws [5].

In this case, we describe a patient with a complete tibial plateau articular fracture that was treated conservatively with satisfactory clinical and functional outcomes.

Case Report

Discussion

Tibial plateau fractures account for approximately 1–2% of all fractures and represent a heterogeneous group of injuries, ranging from low-energy split-depression fractures in osteoporotic bone to high-energy bicondylar fractures associated with severe comminution and soft-tissue injury [2].

The widely used Schatzker classification divides these fractures into six types according to fracture morphology, including fracture-line orientation and articular depression. Schatzker type V and VI fractures represent complex bicondylar injuries and are generally managed surgically. ORIF with plates and screws remains the standard treatment, while external fixation, including hybrid and circular constructs, may be used in selected cases, particularly when significant soft-tissue compromise is present [4,5,6].

Lee et al. [5] reported 65 patients with high-energy Schatzker Type V and VI fractures treated surgically. Partial weight-bearing was initiated 2–3 months postoperatively after radiographic evidence of callus formation. At follow-up, mean knee motion ranged from a 3.9° extension deficit to 136.3° of flexion. According to the Oxford Knee Score, outcomes were excellent in 33% of patients and good in the remaining patients.

External fixation has also demonstrated satisfactory outcomes. Babis et al. [6] reported 33 Schatzker Type V and VI fractures treated with hybrid external fixation. The frame was removed after a mean of 3.4 months, and 26 patients achieved satisfactory knee function and alignment without pain or instability. At 1 year, mean flexion was 115°, with a mean extension deficit of 5° and a mean Knee Society Score of 81.6. Pin-tract and deep infections occurred in 9.1% and 3% of patients, respectively.

Similarly, Ferreira and Marais [7] reported 54 high-energy bicondylar fractures managed with circular external fixation. Mean knee flexion was 100.5°, and the mean Knee Society Score was 81.6. Pin-site infection was the most frequent complication, occurring in 23.9% of patients.

Although satisfactory outcomes have been reported, surgical treatment carries potential risks and complications, including infection, prolonged hospital stay, knee stiffness, non-union, and the need for additional surgical procedures [8].

In contrast to these surgical approaches, our patient was managed entirely non-operatively, without incisions, percutaneous wires, screws, or external fixation. Treatment consisted of a knee motion brace and progressive weight-bearing, with discontinuation of the brace after 4 months. At the 2-year follow-up, the patient achieved 137° of knee flexion with only a 2° extension deficit, an Oxford Knee Score of 47, and a Knee Society Score of 89, indicating an excellent functional outcome.

The favorable mid-term outcome observed in this case raises the possibility that, in carefully selected patients with complex tibial plateau fractures in whom surgery is declined or contraindicated because of local or systemic factors, non-operative management may occasionally represent a viable option.

Early mechanical loading may also have contributed to fracture healing; mechanical loading is sensed by osteocytes and modulates cellular signaling pathways involved in bone formation [9,10].

Williamson et al. [11] evaluated 90 patients with tibial plateau fractures managed with restricted or minimal weight-bearing versus immediate weight-bearing as tolerated. No fixation failures occurred in either group, and although no significant difference in healing rate was demonstrated, the authors supported immediate weight-bearing in appropriately selected patients. These findings suggest that early loading may be safe under certain circumstances [12,13]. However, evidence derived from surgically stabilized fractures cannot be directly extrapolated to non-operatively managed Schatzker Type V or VI fractures.

To the best of our knowledge, reports of successful non-operative management of complex bicondylar tibial plateau fractures using a knee motion brace with early weight-bearing are extremely limited [3,4,8,11]. Non-operative management is rarely indicated due to concerns regarding fracture displacement, delayed union, joint instability, and post-traumatic osteoarthritis. Nevertheless, avoiding surgery eliminates procedure-related complications, including wound complications, deep infection, and pin-tract infection [9]. However, the favorable outcome observed in this patient should not be interpreted as evidence that conservative management is equivalent or superior to established surgical treatment.

One of the major long-term complications following tibial plateau fractures is the development of post-traumatic osteoarthritis, which is particularly relevant in younger patients because of their longer life expectancy and greater cumulative joint loading [14,15]. The development of post-traumatic osteoarthritis is influenced by several factors, including residual joint instability, malalignment, and articular incongruity [15,16]. In the present case, some degree of articular incongruity persisted despite the satisfactory mid-term clinical and functional outcome, emphasizing the importance of continued long-term clinical and radiographic surveillance.

This report has several limitations. As a single case, its findings cannot be generalized to the broader population of patients with complex bicondylar tibial plateau fractures. The absence of a control group prevents direct comparison with surgical management, and the favorable outcome may have been influenced by patient- and fracture-specific factors. Furthermore, this case cannot establish the safety or effectiveness of early weight-bearing in unstable or displaced tibial plateau fractures. Longer-term follow-up is also required to assess the durability of the clinical and radiographic outcomes.

Conclusion

Complex Schatzker Type V bicondylar tibial plateau fractures are generally managed surgically because of their complex fracture pattern and the risk of displacement, joint instability, malalignment, and post-traumatic osteoarthritis. Nevertheless, the satisfactory mid-term clinical, functional, and radiographic outcome observed in this case suggests that carefully monitored non-operative management may occasionally represent a reasonable alternative in highly selected patients who decline surgery or have local or systemic contraindications to surgical treatment. Close clinical and radiographic follow-up is essential to monitor fracture healing, alignment, joint stability, and functional recovery. However, the favorable outcome of a single case should not be interpreted as evidence of equivalence to established surgical treatment, and longer-term follow-up is required to assess the durability of the outcome, particularly with regard to the development of post-traumatic osteoarthritis.

Clinical Message

Complex Schatzker Type V bicondylar tibial plateau fractures generally require surgical management. However, when surgery is declined or contraindicated, carefully selected patients may be considered for non-operative treatment with close clinical and radiographic monitoring, recognizing that evidence supporting this approach remains limited.

References

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About the Authors

• 

  Bassel El-Osta

• 

  Alaa Hamdan

• 

  Mariam Al Ali

• 

  Fabio Valerio Sciarretta

• 

  Hassan Zmerly