Synopsis
Separate articular plateau injury from shaft injury, identify open fracture, arterial damage and evolving compartment syndrome early, obtain pattern-defining imaging, and coordinate soft-tissue-safe fixation, rehabilitation and surveillance.
- Begin with trauma ABCDE and haemorrhage control; inspect from thigh to toes and examine skin, wounds, compartments, pulses, capillary refill and tibial and fibular nerve function before and after every manipulation.
- For an open fracture, photograph once if policy permits, cover with saline-soaked gauze and an occlusive layer, give intravenous antibiotics as soon as possible and ideally within one hour, realign and splint, and avoid repeated wound inspection or emergency-department irrigation.
- Do not rule out compartment syndrome because pulses are present. Escalating pain, pain on passive stretch, tense swelling and evolving sensory or motor change require immediate senior review and repeated documented examination.
- Obtain AP and lateral radiographs spanning the knee and ankle for shaft injury; obtain AP and lateral knee films for plateau injury, then CT for articular mapping and operative planning.
- Use CT angiography after immediate realignment when vascular injury is suspected but the limb remains perfused; hard signs or a persistently ischaemic limb need direct vascular and orthopaedic action without imaging delay.
- Stable minimally displaced plateau or shaft patterns may follow protected non-operative care with close radiographic review; displaced articular, unstable, open or malaligned injuries need specialist fixation planning.
- High-energy plateau fractures often require spanning external fixation until swelling and skin recover before definitive fixation; many adult displaced shaft fractures receive an intramedullary nail when soft tissues allow.
- Every discharge or transfer plan must specify weight bearing, knee and ankle movement, wound and cast checks, VTE assessment, follow-up imaging and urgent return symptoms.
Key red flags
An open wound, gross contamination, exposed bone, threatened skin, major deformity or uncontrolled bleeding needs immediate cover, antibiotics, alignment, splintage and orthopaedic trauma escalation.
Absent or asymmetric pulses, a cold pale foot, expanding haematoma, active haemorrhage, bruit or distal ischaemia after a plateau or shaft injury requires an emergency vascular pathway; a palpable pulse does not exclude intimal injury.
Pain out of proportion, escalating analgesic requirement, pain on passive toe movement, tense compartments or new paraesthesia or weakness suggests acute compartment syndrome; do not await paralysis or pulse loss.
A high-energy plateau fracture with knee dislocation features, marked swelling or peroneal deficit may conceal popliteal arterial, ligament and common fibular nerve injury even after spontaneous reduction.
Investigation priorities
Define plateau or shaft pattern, alignment and joint extension.
Management branches
A tibial injury is open, grossly deformed, ischaemic or associated with possible compartment syndrome.
- Complete trauma ABCDE, control external haemorrhage and expose the entire injured limb while preventing hypothermia.
- Cover open wounds, give intravenous network prophylaxis immediately, verify tetanus requirements, align and splint without repeated wound handling.
- Document and repeat pulses, perfusion, named nerve function and compartment findings after every intervention and during transfer.
- Activate orthopaedic, plastic and vascular pathways according to contamination, tissue loss, perfusion and compartment findings; do not delay indicated surgery for cross-sectional imaging.
CT confirms a tibial-plateau fracture after urgent limb threats have been controlled.
- Assess displacement, condylar widening, alignment, stability, soft tissues and patient function rather than treating a classification number alone.
- Use a brace and protected loading with early specialist review for an acceptably aligned stable pattern and arrange interval radiographs.
- Temporise severe swollen high-energy injury with spanning fixation when needed and wait for skin recovery before definitive articular reconstruction.