Open reduction and interal fixation of the tibial plateau fracture

Open reduction and interal fixation of the tibial plateau fracture

Anesthesia type	General
Airway	standard ETT, or specific to situation (if trauma)
Lines and access	standard PIV, more if indicated based on trauma or comorbidities
Monitors	Standard ASA Monitors, more if indicated based on trauma or comorbidities
Primary anesthetic considerations
Preoperative	unlikely to be candidate for nerve block/catheter (although literature equivocal about risks); if trauma watch for fat embolism, myoglobinuria, hyperkalemia
Intraoperative	if trauma, likely will need RSI; standard maintenance, fluid management; X-rays, may need NMB to facilitate surgical manipulation
Postoperative	PACU, possibly ICU if trauma patient; pain control may be more difficult; compartment syndrome
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Tibial plateau fracture account for about 1% of all fractures, often associated with high energy mechanisms. Associated with injury to nearby soft tissue and ligaments (Cunningham). With age, increased incidence of osteoporotic fracture. Fracture pattern described by Schatzker types 1-6 (with 1-3 being on the simpler side) (Wang).

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic
Cardiovascular
Pulmonary	Bone fractures may lead to fat embolism, assess oxygenation
Gastrointestinal
Hematologic	Assess bleeding and hypovolemia
Renal	Myoglobinemia and hyperkalemia from crush injuries
Endocrine
Other	Likely trauma as cause, need to assess other organs that may be involved (eg neck, thorax)

Labs and studies

• CBC, BMP, consider checking CPK, urine drug screen
• ECG and/or ECHO as indicated

Operating room setup

• Standard setup
• If trauma, may need additional equipment for airway and infusion of blood products
• Arterial line and CVC setup as indicated

Patient preparation and premedication

• For elective cases, consider PO acetaminophen and/or PONV prophylaxis

Regional and neuraxial techniques

• Usually not offered due to concern for post-op missed compartment syndrome (Hyder, Dwyer; although there are case reports of missed compartment syndrome with regional anesthesia, there are also case reports of diagnosing compartment syndrome with regional anesthesia onboard)
• Study examining single shot RA in patients with tibial plateau fracture without evidence of compartment syndrome (Cunningham n = 60)
• Ask surgical team about consideration

Intraoperative management

Monitoring and access

• 1-2x 14-16G PIV
• Consider arterial line, or CVC (large blood loss, continued need for mechanical ventilation post-op)

Induction and airway management

• Elective cases, standard induction
• If trauma, RSI to prevent aspiration; may need specific airway equipment if patient with limited neck mobility (eg in C-collar)

Positioning

• Supine, or slightly lateral

Maintenance and surgical considerations

• Standard anesthesia maintenance
• Maintain euvolemia -> goal directed fluid management with crystalloids and blood products as needed
• Active warming especially for trauma patients, including convection blanket, active humidifier, warm fluids
• If use of tourniquet, MAP may drop with release of tourniquet
• TXA IV or topical may decrease blood loss with overall minimal side effects (Wang)

Emergence

• PONV prophylaxis
• Especially for trauma patients, wait until full return of protective airway reflexes before extubation

Postoperative management

Disposition

• PACU, or ICU if trauma patient

Pain management

• Multimodal PO and IV medications

Potential complications

• Compartment syndrome (usually clinical diagnosis), may lead to hyperkalemia and myoglobinuria/emia
• Fat embolism (symptoms of hypoxemia, increased heart rate, tachypnea, respiratory alkalosis, mental status changes, petechiae)
• Wound infection
• DVT
• Peripheral nerve damage

ERAS

• For elective cases, standard guidelines; consider PO acetaminophen for pain control and PO aprepitant for PONV prophylaxis

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Cunningham DJ, LaRose M, Zhang G, Patel P, Paniagua A, Gadsden J, Gage MJ. Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery. Anesth Analg. 2022 May 1;134(5):1072-1081. doi: 10.1213/ANE.0000000000005980. PMID: 35313323.

Dwyer T, Burns D, Nauth A, Kawam K, Brull R. Regional anesthesia and acute compartment syndrome: principles for practice. Reg Anesth Pain Med. 2021 Dec;46(12):1091-1099. doi: 10.1136/rapm-2021-102735. Epub 2021 Jun 29. PMID: 34187911.

Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg Br. 1996 May;78(3):499-500. PMID: 8636198.

Anesthesiologist's manual of surgical procedures ISBN978-1-4963-0594-7OCLC888551588

Wang Z, Lu Y, Wang Q, Song L, Ma T, Ren C, Li Z, Yang J, Zhang K, Zhang B. Comparison of the effectiveness and safety of intravenous and topical regimens of tranexamic acid in complex tibial plateau fracture: a retrospective study. BMC Musculoskelet Disord. 2020 Nov 12;21(1):739. doi: 10.1186/s12891-020-03772-7. PMID: 33183258; PMCID: PMC7659088.