Proximal Tibial Fractures: Clinical Guidelines

List of Abbreviations

EFA – external fixation apparatus

AO – Association for Osteosynthesis

TIB – tibia

VTE – venous thromboembolism

RTA – road traffic accident

Knee – knee joint

CT – computed tomography

HDL – high-density lipoproteins

ABI – ankle-brachial index

LDL – low-density lipoproteins

PT – physical therapy

Ministry of Health of the Russian Federation – Ministry of Health of the Russian Federation

MRI – magnetic resonance imaging

LMWH – low-molecular-weight heparin from group B01AB Heparin group

NSAIDs – nonsteroidal anti-inflammatory drugs from the M01A Non-steroidal anti-inflammatory and antirheumatic products group

PTF – proximal tibial fracture

TP – tibial plateau fracture

PHF – proximal fibular head fracture

TAT – tetanus antitoxin

HTIG – human tetanus immunoglobulin

SWD – surgical wound debridement

SCT – spiral computed tomography

TIA – transient ischemic attack

RF – risk factors

PRM – physical and rehabilitation medicine

FS – functional status

TENS – transcutaneous electrical nerve stimulation

Surgical antibiotic prophylaxis

LCP – locking compression plate

MIPO – minimally invasive plate osteosynthesis

ORIF – open reduction internal fixation

Terms and Definitions

Absolute stability – absence of micromotion at the fracture site, provided there is anatomical reduction and interfragmentary bone compression after fixation with hardware.

Allograft – a bone tissue fragment from another human (donor), typically cadaveric, that has undergone preservation.

External fixation device (EFD) – an orthopedic device containing an implant (a transosseous or extracorporeal element protruding through the skin, reaching the bone or inserted into it) and an external (non-implantable) support connecting bone fragments via transosseous elements in the treatment of fractures, pseudoarthrosis, or gradual lengthening (deformity correction) of a segment.

Autograft – a fragment of the patient's own bone harvested from a donor site for transplantation to fill a bone tissue deficit (bone defect).

Internal fixation device – an orthopedic implant implanted beneath the patient's skin that connects bone fragments in the treatment of fractures, deformities, or nonunions.

Impression – the process of articular surface fracture formation resulting from excessive pressure of the articulating bone exceeding the strength of spongy bone tissue, as well as the resulting impression fracture.

Fracture union – mutual connection of fragments by living bone tissue as a result of the successful completion of reparative regeneration.

Contracture – restriction of the range of motion in a joint.

Bone fragment – a portion of bone separated as a result of trauma, surgery, or a destructive process.

Migration of fixation elements – loss of the optimal position of fixation elements due to bone resorption around them, occurring when allowable cyclic loads or their number are exceeded, or due to errors in the surgical technique of implanting the element into the bone (within the context of this topic).

Load – mechanical force applied to a limb, bone, and fixation system during treatment, typically recurring with constant periodicity (cyclically).

Delayed union / Nonunion – changes in the reparative regeneration of bone tissue leading to a decrease in its rate, cessation, or formation of a callus insufficient to perform mechanical function.

Post-traumatic deformity – fracture consolidation with disruption of spatial relationships between fragments, including axial and rotational alignment.

Fixation stability – resistance of the system to external loads, allowing it to maintain the constancy of the mutual orientation of fragments and the optimal distance between them.

Fixation – a state in which relative or complete immobilization of fragments is achieved.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Proximal tibial fractures (PTFs) encompass extra-articular and intra-articular fractures of the proximal tibial metaepiphysis, localized within a square whose sides equal the widest part of the proximal tibial metaphysis [1, 2].

This group of injuries includes a wide spectrum of osseous lesions: from low-energy lateral condyle fractures in elderly patients (most frequently women with osteoporosis) to high-energy comminuted proximal tibial fractures as part of polytrauma (more typical for young male patients), involving both condyles, the metaepiphyseal zone, and the diaphysis, accompanied by knee dislocation, major vascular and nerve injuries, and complicated by compartment syndrome and a high rate of infectious complications [1, 3-6].

Proximal tibial fractures in children are particularly challenging due to their specific localization, the presence of the growth plate, proximity to the joint, and involvement of the ligamentous apparatus in the pathological process. For this very reason, they present a complex management and rehabilitation challenge.

The proximal tibia has a complex anatomical structure. The proximal tibial metaepiphysis consists of two condyles: medial and lateral. The articular surfaces of the tibial condyles are covered with hyaline articular cartilage and partially by the lateral and medial menisci, which attach to the tibial plateau via specialized coronary ligaments. This anatomical feature influences the arthrotomy technique during osteosynthesis procedures. When performing an intra-articular approach, the joint capsule is incised "submeniscally" beneath the corresponding meniscus. The integrity of the meniscus must be assessed intraoperatively, as partial or complete avulsions, as well as interposition of a meniscal fragment into the fracture line, are possible. Such injuries must be addressed, and the menisci should be preserved whenever possible, as they play a crucial role primarily in preventing post-traumatic osteoarthritis [1, 3-6].

The articular surfaces of the tibial condyles lie at different levels. The lateral condyle is located slightly higher than the medial one, corresponding to a slight physiological varus of the knee joint. Furthermore, the articular surfaces of both condyles slope posteriorly, forming a sagittal "slope" visible on lateral radiographs, averaging about 5 degrees (3 to 10 degrees). The articular surfaces of the condyles also differ somewhat in shape. The lateral condyle is flatter or slightly convex, while the medial condyle is concave and matches the articular surface of the medial femoral condyle more closely. These features are important when assessing the quality of articular surface reconstruction on anteroposterior and lateral radiographs [3, 6].

The articular surfaces of the tibial condyles are separated by the intercondylar eminence with medial and lateral tubercles, to which the anterior and posterior cruciate ligaments attach. Isolated avulsion fractures of the tibial tubercle are considered extra-articular and in most cases can be fixed arthroscopically. In some instances, the avulsion of the intercondylar eminence may also be part of a severe comminuted bicondylar fracture, leading to marked knee instability. Consequently, correct fixation of the avulsed intercondylar eminence can be technically challenging [1, 5, 6].

The tibial condyles differ in bone density. The lateral condyle has a lower bone mineral density; therefore, isolated lateral condyle fractures occur much more frequently compared to isolated medial condyle fractures. They are caused by both low- and high-energy trauma and may present as a pure depression or split, or a combination of both. The medial condyle is stronger and more resistant to axial loading. Therefore, medial condyle fractures more often present as split fractures and require high energy to occur. The medial condyle is more frequently damaged as a component of a high-energy bicondylar fracture [1, 5-13].

Modern concepts of the clinical anatomy of the proximal tibial metaepiphysis describe it in terms of the column theory. According to many authors, the tibial plateau should be divided into medial, lateral, and posterior columns, and treatment planning should involve evaluating the injury to each column individually [14, 15]. Additionally, many authors subdivide the posterior fragment into two quadrants: posteromedial and posterolateral, emphasizing their fundamental features and different approaches for their reconstruction and fixation [16].

Depending on the energy of injury, mechanism of trauma, and limb position at the time of injury, various combinations of damage to one or more columns occur in each specific clinical situation. Furthermore, associated injuries to the capsuloligamentous apparatus of the knee joint are of great clinical significance. The menisci, cruciate ligaments, and collateral ligaments may also be damaged at the time of injury. The fibular head forms the proximal tibiofibular joint with the lateral tibial condyle—a joint possessing its own cartilaginous articular surfaces, joint capsule, and synovial bursa. The proximal fibula is of great importance as a factor in the lateral stability of the knee joint and the lateral tibial plateau. Fractures of the fibular head and neck resulting from trauma or osteotomy reduce lateral knee stability [6, 17, 18].

Thus, when traumatic energy is applied, a complex of proximal tibial injuries most commonly occurs; identifying all its elements is a crucial stage in diagnostics and surgical treatment planning, the goal of which is to restore the congruence of the articular surfaces, restore the length and axial alignment of the lower leg and knee joint, and restore knee stability necessary for high-quality function [1, 3-6].

Knee dislocation is a pathological condition resulting from direct or indirect trauma to the knee joint, characterized by the separation of the articular surfaces of the distal femur and proximal tibia, displacement of the distal segment in any direction or its rotation, and rupture of at least two knee ligaments [168].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Proximal tibial fractures can result from direct or indirect trauma. The primary direction of traumatic energy leading to an intra-articular tibial plateau fracture is an axial load, which causes a split of the articular surface and part or all of a tibial condyle, depression of the articular surface with impaction of the epiphyseal and metaphyseal bone underneath, creating a bone defect [5-13]. Most commonly, axial compression is combined with angular loading (causing varus or valgus deformities) and rotational forces. If the lower limb was in extension at the time of injury and the force acts from the lateral side, a compression fracture of the anterior lateral condyle occurs. If the limb is in extension but the force is applied from the medial side of the knee, the anterior medial condyle will be injured. However, if the lower limb was in a flexed position at the time of injury (e.g., in a driver or front-seat passenger in a head-on collision), the greatest impact and destruction occurs specifically in the posterior column of both condyles [1, 5-13, 19, 20].

Extremely high traumatic energy usually leads to destruction localized in both condyles, extension of the fracture into the tibial diaphysis, and damage to the ligamentous stabilizers of the knee, causing avulsion fractures of the marginal fragment of the tibial condyle or the intercondylar eminence along with its attached ligamentous apparatus, potentially with dislocation or subluxation of the knee [1, 3-6].

A direct blow to the knee joint and proximal lower leg—such as the so-called "bumper fracture" of the leg—leads to extra-articular or intra-articular fractures extending into the tibial diaphysis [1, 3, 4].

Rotational indirect force applied to the proximal lower leg, occurring for instance during sports injuries like skiing, can also lead to extra-articular or simple intra-articular fractures [1, 3-6].

Depending on the mechanism, two main groups of proximal tibial fractures are distinguished. The first group comprises high-energy fractures resulting from motor vehicle accidents or falls from a height. They are characterized by significant destruction of the articular surface and the metadiaphyseal zone of the tibia, can extend to the diaphysis, are often accompanied by extensive soft tissue damage—particularly to the popliteal vascular bundle—can be open, and may lead to compartment syndrome. In the group of high-energy knee fracture-dislocations, the probability of vascular injury, compartment syndrome, and common fibular nerve injury reaches 25% [5].

The second group consists of low-energy fractures, which may result from a fall from standing height or a sports injury. Low-energy tibial plateau fractures often occur due to indirect trauma in the setting of osteoporosis and, much like high-energy fractures, can be comminuted with significant articular surface depression [5].

Knee dislocation is typically the result of high-energy trauma. Up to 50% of all knee dislocation cases occur due to motor vehicle accidents. The second and third leading causes of this injury are sports injuries (33%) and falls from standing height (12%).

1.3 Epidemiology of the Disease or Condition

According to modern authors, the incidence of proximal tibial fractures accounts for 2–5% of all skeletal fractures [21, 22]. Among all intra-articular fractures of major limb joints, the proportion of tibial condyle (tibial plateau) fractures reaches 60% [23]. Furthermore, isolated fractures of the lateral tibial condyle account for 55–70% of all fractures in this localization, whereas injuries to the medial or both tibial condyles are observed in only 10–30% [23]. From 15% to 35% of these are localized predominantly in the posterior regions of the tibial plateau [19, 20, 24]. According to Moore et al., in the group of severe high-energy fractures accompanied by ligamentous apparatus injury, knee dislocations, and subluxations, 62% of victims are relatively young men with a mean age of 44 years [6, 25]. In the low-energy fracture group, many authors note a high proportion of female patients, with an increasing probability of proximal tibial fracture after the age of 60, and especially after 70 years [6].

In children, fractures around the proximal tibial growth plate are relatively rare injuries, the majority of which result in anterior, anterolateral, and anteromedial displacement of the epiphysis relative to the metaphysis [7]. The tibial tuberosity in childhood acts as an effective block, making posterior displacement of fragments less common. Therefore, in proximal tibial fractures, the fracture line usually extends below the tibial tuberosity, resulting in the proximal epiphysis and tibial tuberosity displacing as a single unit [8]. This type of tibial fracture is generally more common in children aged 3–6 years and can be complete or greenstick [9-12].

Knee dislocation is a rare pathological condition that occurs in less than 0.2% of musculoskeletal injuries. It is more common in young men, with a male-to-female ratio of 2.5:1 [169, 170]. In 14–44% of cases, knee dislocation occurs as part of polytrauma, and in 5% of patients, it is bilateral [169].

1.4 Features of Coding the Disease or Condition

S82.1 – Fracture of proximal section of tibia;

S82.10 – Closed fracture of proximal section of tibia;

S82.11 – Open fracture of proximal section of tibia.

S83.1 – Dislocation of knee

1.5 Classification of the disease or condition

Proximal tibial fractures belong to the group of periarticular and intra-articular fractures of the knee joint.

From the standpoint of selecting surgical treatment tactics, the AO/ASIF (Association for Osteosynthesis) classification is currently the most widely used. According to the universal AO fracture classification, proximal tibial fractures correspond to code 41 [2]. Fractures of this localization are subdivided into three types based on the degree of involvement of the tibial articular surface:

41-A – Extra-articular fracture

41-A1 – Extra-articular fracture, avulsion

41-A2 – Extra-articular fracture, simple metaphyseal

41-A3 – Extra-articular fracture, wedge or comminuted metaphyseal

41-B – Partial intra-articular fracture

41-B1 – Partial intra-articular fracture, pure split

41-B2 – Partial intra-articular fracture, pure depression

41-B3 – Partial intra-articular fracture, split and depression

41-C – Complete intra-articular fracture

41-C1 – Complete intra-articular fracture, simple articular, simple metaphyseal

41-C2 – Complete intra-articular fracture, simple articular, wedge or comminuted metaphyseal

41-C3 – Complete intra-articular fracture, comminuted articular, comminuted or multi-fragmentary metaphyseal

Comments: Alongside the AO classification, the J. Schatzker classification, proposed in 1974, is widely used [26]. Although this classification is based on the analysis of two-dimensional radiographs of the injured knee joint, it takes into account the energy and mechanism of trauma (Types I–III are low-energy, IV–VI are high-energy fractures), patient age and bone quality, the nature of articular surface damage (split or depression), the degree of fracture comminution, and its extension to the diaphysis.

Schatzker fracture:

Type I – Occurs due to axial and valgus force on the lateral column, causing a split fracture of the lateral condyle in a young patient with good bone quality.

Type II - The same mechanism of injury, but in older patients with poorer bone quality and predictable articular surface depression.

Type III – Pure depression without disruption of the articular ring integrity.

Type IV – High-energy trauma in the form of varus deformity, causing injury to the stronger medial column and frequently accompanied by joint dislocation or subluxation and potential injury to the popliteal vessels.

Type V – High-energy comminuted bicondylar fractures.

Type VI – Type V, but extending into the metadiaphyseal zone and diaphysis.

Modern perspectives on the surgical treatment of proximal tibial fractures entail mandatory CT imaging to clarify the fracture angioarchitecture and select surgical treatment tactics [1, 5, 6, 24, 27].

Multislice CT data analysis allows for assessing fracture extension into the lateral, medial, and posterior columns according to C.F. Luo et al. [14] or the anteromedial, anterolateral, posteromedial, and posterolateral quadrants according to S.M. Chang et al. [16].

To more precisely localize the damaged portion of the articular surface, Krause et al. proposed distinguishing 10 plateau segments – 5 anterior and 5 posterior. According to the authors, in low-energy type B fractures according to the AO classification, the most frequently affected fragments are posterolateral-lateral (65.2%), anterolateral-lateral (64.6%), and anterolateral-central (60.9%); in high-energy type C fractures, the medial condyle fractures via a split mechanism, while compression of the lateral condyle occurs most frequently in the posterolateral-central (85.9%), posterocentral (84.7%), and anterolateral-central segments (78.8%). The authors proved the high frequency of involvement of the posterior plateau segments in both low-energy and high-energy fractures and confirmed the necessity for broader and more frequent use of posterior approaches for the reconstruction of these regions [28].

M. Kfuri and J. Schatzker (2018) supplemented the classic Schatzker classification (1974) with CT data. For more precise fracture localization, the authors added letter designations A (anterior), P (posterior), M (medial), and L (lateral) to the numerical codes, accurately localizing the injury in the sagittal and frontal planes. Additionally, in this modified classification, specific letters denote the localization of the condylar split "apex" in the metaepiphyseal zone and the "articular ring" disruption points, providing an individualized description of the specific fracture architecture and facilitating the planning of necessary surgical approaches and implants [13].

Thus, regardless of the fracture classification system used for the proximal tibia, surgical planning requires evaluating the precise localization of all fracture components: fracture lines, planes, and articular surface depression areas. Mapping these injuries by columns and quadrants (anteromedial, anterolateral, posteromedial, posterolateral) provides a clear understanding of the required surgical approaches and allows for an operative plan—namely, the sequential steps of reduction and fixation aimed at the most complete restoration of the tibial plateau anatomy.

For open fractures of the proximal tibia, the classification by R.B. Gustilo and J.T. Anderson (1976) [29], as modified by R.B. Gustilo, R.M. Mendoza, and D.N. Williams (1984) [30], is used:

Type I – open fracture, the wound is minimally contaminated, wound size is less than 1 cm;

Type II – open fracture, the wound is greater than 1 cm and less than 10 cm in length without significant soft tissue damage, flaps, or skin detachment;

Type IIIA – open fracture, soft tissues cover the fragments, no periosteal stripping in the presence of extensive soft tissue damage or flaps, or in high-energy trauma regardless of wound size;

Type IIIB – open fracture with an extensive soft tissue defect, periosteal stripping, and a comminuted fracture pattern, often with significant microbial contamination of the wound;

Type IIIC: open fracture complicated by major vascular injury requiring surgical reconstruction, regardless of the extent of soft tissue damage.

The scientific literature on proximal tibial fractures in pediatric patients features a wide variety of classifications and modifications also used in adult traumatology. However, a typical characteristic of pediatric trauma is the potential for traumatic cartilage injury at the junction of the tubular bone metaphysis and epiphysis. This feature is reflected in the classifications for proximal tibial fractures as well. Proximal tibial fractures in children are often described using the Salter–Harris classification, taking into account the direction of the fracture line relative to the growth plate (valgus, varus, flexion, extension).

Watson-Jones [31] described three types of tibial tubercle avulsion fractures; this classification was subsequently modified by Ogden [8, 32], who noted that the degree of displacement depends on the severity of adjacent soft tissue injury. Pretell-Mazzini et al. [33] conducted a systematic review of the literature on tibial tubercle fractures and modified the Ogden classification into five groups, where within each group the fracture may be comminuted, displaced, or non-displaced:

- Type I fractures involve the tibial tubercle apophysis, where the patellar tendon attaches,

- Type II fractures involve both the apophysis and epiphysis, but do not extend into the articular surface,

- Type III fractures are similar to Type II fractures but extend into the articular surface of the tibia,

- Type IV fractures result in displacement of the entire tibial epiphysis (either anteriorly or posteriorly) with the potential formation of a Thurston-Holland fragment.

- Type V fractures are not true fractures, but rather avulsion injuries of the tibial tubercle or the patellar ligament at its insertion into the tubercle.

The classification of knee dislocations described by Kennedy (1963) is based on the direction of displacement of the distal segment [171]. According to this classification, the following types are distinguished:

• Anterior dislocation

• Posterior dislocation

• Medial dislocation

• Lateral dislocation

• Rotatory dislocation

A more modern classification is the modified R.C. Schenck classification (2004) [172, 173]:

• KD-I - dislocation without injury to both cruciate ligaments;

• KD-II - dislocation with injury to both cruciate ligaments only;

• KD-III - dislocation with injury to both cruciate ligaments + posteromedial or posterolateral corner tear;

• KD-IV - dislocation with injury to both cruciate ligaments + posteromedial and posterolateral corner tears;

• KD-V - fracture-dislocation:

o KD-V1 - fracture-dislocation without injury to both cruciate ligaments;

o KD-V2 - fracture-dislocation with injury to both cruciate ligaments only;

o KD-V3M - fracture-dislocation with injury to both cruciate ligaments + posteromedial tear;

o KD-V3L - fracture-dislocation with injury to both cruciate ligaments + posterolateral tear;

o KD-V4 - fracture-dislocation with injury to both cruciate ligaments + posteromedial and posterolateral tears;

1.6 Clinical presentation of the disease or condition

The clinical presentation of a proximal tibial fracture is characterized by severe pain in the proximal leg and knee joint, impaired joint function, smoothed contours and swelling, tenderness upon palpation and axial loading. When fragment displacement is present, shortening of the leg segment and knee deformity are observed; the type of deformity (valgus, varus, ante- or retrocurvation) is determined by the direction of the traumatizing force and the position of the limb at the time of injury. Pathological mobility in the proximal leg and knee joint is noted; in fractures with displacement and/or ligamentous stabilizer injury, knee instability is detected upon attempts at passive varus or valgus deviation, as well as in the anteroposterior direction. Of note, knee instability with excessive valgus deviation does not necessarily indicate knee ligament injury, but also occurs in fractures of the lateral condyle with displacement and shortening of the lateral column of the proximal tibial metaephysis. When the fracture extends to the tibial diaphysis, bone crepitus of the fragments is elicited [1, 3, 5, 6].

Complaints: pain in the proximal leg and knee joint; impaired mobility and severe pain during knee flexion and extension; pathological mobility; leg and knee deformity; knee instability; swelling and edema of the leg and knee region; wound pain (in open fractures); potential protrusion of bone fragments through the wound; presence of subepidermal fluid-filled blisters (phlyctenulae) and areas of skin de-epithelialization in the proximal leg in cases of rapidly increasing soft tissue swelling. With the development of compartment syndrome, the patient complains of severe tight swelling of the leg, intense pain disproportionate to the bone injury whose intensity increases with passive dorsiflexion of the hallux, and impaired movement of the foot and toes. As compartment syndrome progresses, cutaneous sensory deficits of the foot develop. With associated common fibular nerve injury, patients report inability to actively dorsiflex the foot and toes, and sensory loss over the dorsal aspect of the foot. In popliteal vessel injury, patients complain of intense pain distal to the site of trauma, along with loss of movement and sensation in the distal lower extremity [1, 3, 5, 6].

History: history of trauma; the patient describes a characteristic mechanism of injury.

The classic injury mechanism is an axial load combined with angular deformation, most commonly valgus, in which the femur impacts the proximal articular surface of the tibia, resulting in a comminuted fracture and articular surface depression. This mechanism typically occurs in motor vehicle accidents. In recent years, such injuries have become more frequent among riders of low-power two-wheeled transport, mopeds, scooters, as well as electric scooters and bicycles [1, 5, 6, 34, 35].

In some cases, a tibial plateau fracture may result from a direct blow to the proximal leg, such as a pedestrian being struck by a car bumper.

Low-energy periarticular and simple intra-articular tibial plateau fractures can result from sports injuries, such as downhill skiing. Additionally, such fractures can occur from a fall from standing height, particularly in patients with osteoporosis and an elevated body mass index [1, 5, 6, 34, 35].

Objective findings: swelling in the leg and knee joint, limitation of active and passive range of motion due to severe pain, visually apparent deformity of the knee and proximal leg, tenderness upon palpation of the proximal leg and knee, bone fragment crepitus, and pathological mobility in the proximal leg and knee joint [1, 5, 6].

In the presence of pronounced swelling in the knee and proximal leg, serous or hemorrhagic subepidermal phlyctenulae frequently form, which subsequently progress to areas of skin de-epithelialization, dry eschar formation, and skin necrosis [5, 6]. Wounds are present in open fractures.

In high-energy fractures accompanied by severe swelling, impairment of peripheral blood circulation and innervation of the foot may occur, along with the development of compartment syndrome, presenting with characteristic clinical features such as intense pain, tense edema, skin pallor, exquisite tenderness on passive toe movement, sensory disturbances in the leg and foot, and absent peripheral arterial pulses [1, 5, 6].

If a proximal tibial fracture is suspected, all patients must be evacuated to a medical facility for diagnosis verification.

In pediatric patients, there is no specific clinical presentation for proximal tibial fractures. However, given the generally less developed subcutaneous adipose tissue in this area, one may tentatively assume the fracture pattern based on the deformation of the injury zone and classify it with relative reliability.

The clinical presentation of a knee dislocation is caused by damage to the capsular-ligamentous apparatus of the knee joint, and may also be determined by the presence or absence of concomitant vascular injury resulting from tibial displacement.

Complaints: pain in the knee joint area, inability to perform active movements in the knee joint caused by both pain syndrome and mechanical restrictions, inability to bear axial weight on the injured limb, visually determined deformation of the knee joint area, sensory disturbances in the distal lower extremity, paresthesias, muscle weakness. In open knee dislocations, the patient may present with complaints of bleeding, sensory disturbances, general weakness, dizziness [3, 4, 5, 6].

History: history of trauma; the patient describes a characteristic mechanism of injury.

Objectively: edema in the leg and knee joint area, limitation of active and passive movements due to pronounced pain syndrome, visually determined knee joint deformation, tenderness upon palpation in the proximal leg and knee joint area, pathological mobility in the knee joint area. Pronounced soft tissue edema, as in the case of proximal tibial fractures, can lead to the development of subepidermal blisters with serous or hemorrhagic contents [1, 5, 6].

It must be taken into account that a knee dislocation is the result of high-energy trauma and may be combined with a proximal tibial fracture, which can lead to the development of compartment syndrome. This clinical condition is characterized by intense pain, tense edema, skin pallor, sharp pain upon passive movements of the toes, impaired skin sensitivity of the leg and foot, and the absence of peripheral arterial pulsation [1, 5, 6].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

• anamnestic data: indication of a characteristic mechanism of lower limb injury (fall, blow to the knee joint and proximal leg area, motor vehicle accident, high-fall trauma, etc.);

• physical examination data: impaired function of the injured segment, deformation, local edema and tenderness of the injury area (tenderness increases with axial load), presence of pathological mobility and/or bone fragment crepitus;

• instrumental examination data: radiographic signs of fracture based on X-ray imaging of the tibia and fibula in 2 projections. For fractures of the proximal tibia with suspected intra-articular involvement, an additional CT scan of the lower limb is recommended as prescribed by the on-duty or attending orthopedic trauma surgeon to clarify the fracture pattern and determine the degree of fragment displacement.

2.1 Complaints and Anamnesis

In most cases, patients present with the complaints described in section 1.6 "Clinical Presentation".

• In patients with suspected proximal tibial fractures, it is recommended to take a thorough history of complaints and anamnesis for diagnostic purposes [1, 3-6, 150].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• In patients with suspected knee dislocation, it is recommended to take a thorough history of complaints and anamnesis for diagnostic purposes [3-6, 168].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

2.2 Physical Examination

Physical examination findings are described in section 1.6 "Clinical Presentation".

• In patients με με suspected proximal tibial fractures, evaluation of the following parameters (initial examination, consultation by an orthopedic trauma surgeon) for diagnostic purposes is recommended to be performed no later than 1 hour after hospital admission, with mandatory documentation of the results in the medical chart:

- assessment of somatic status;

- visual and palpation assessment of local status [1, 3-6, 150];

- blood pressure measurement (measuring blood pressure on peripheral arteries);

- body temperature measurement (general thermometry) [4];

- assessment of the risk of venous thromboembolic complications (Appendix H1) [36].

Level of Evidence 5Grade of Recommendation C (Level of Evidence – 5).

• In patients with suspected proximal tibial fractures, it is recommended to assess the state of innervation and blood circulation in the peripheral parts of the lower extremity to rule out neurovascular bundle injury at the fracture level or compartment syndrome [1, 3-6, 27, 150].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• In patients with suspected proximal tibial fractures, it is recommended to assess the condition of soft tissues and the severity of edema to rule out hematomas and open fractures [1, 3-6, 150].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• When deciding on surgical treatment for a proximal tibial fracture in adult patients, it is recommended to collect an anamnesis and perform a physical examination to identify risk factors and cardiovascular diseases [37, 38].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: Risk factors for cardiovascular disease include: arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women) [37]. Established cardiovascular disease is defined as: coronary artery disease, cerebrovascular disease, peripheral artery disease, heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies [38, 39].

• All adult patients scheduled for elective surgical treatment of a proximal tibial fracture are recommended to undergo perioperative cardiovascular risk assessment taking into account the type of planned surgical treatment for the proximal tibial fracture, regardless of the presence of comorbid pathology [37, 40].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: When surgical treatment is performed for emergency (<6 hours) and urgent (6–24 hours) indications, preoperative risk assessment is not performed.

Minor orthopedic surgeries are associated with a low risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is less than 1%). Major orthopedic surgeries are associated with an intermediate (moderate) risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is 1-5%) [41].

• To assess the risk of perioperative cardiovascular complications in adult patients, it is recommended to use a special algorithm [Appendix B2] [40, 42].

LoR CLE 3Level of recommendation C (level of evidence 3).

• Elective surgical treatment of a proximal tibial fracture is recommended without additional testing in adult patients whose cardiovascular risk is assessed as low. In patients with intermediate or high perioperative risk of cardiovascular complications, assessment of the patient's functional status is recommended [41, 43].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• In patients with suspected knee dislocation, evaluation of the following parameters (initial examination, consultation by an orthopedic trauma surgeon) for diagnostic purposes is recommended to be performed no later than 1 hour after hospital admission, with mandatory documentation of the results in the medical chart:

- somatic status assessment;

- visual and palpation assessment of local status [3-6, 168, 170];

- blood pressure measurement (measuring blood pressure on peripheral arteries);

- body temperature measurement (general thermometry) [4];

- assessment of the risk of venous thromboembolic complications (Appendix H1) [36].

Level of Evidence 5Grade of Recommendation C (Level of Evidence – 5).

• In patients with suspected knee dislocation, it is recommended to assess the state of innervation and blood circulation in the peripheral parts of the lower extremity to rule out neurovascular bundle injury at the injury level or compartment syndrome [3-6, 168, 169, 170, 173].

• In patients with a knee dislocation, it is recommended to assess the ankle-brachial index to determine indications for surgical intervention regarding major vascular injury at the knee joint level [168, 169, 170, 173].

Level of Evidence 5Grade of Recommendation C (Level of Evidence – 5).

Comments: The ankle-brachial index (ABI) is calculated by determining the ratio of the systolic blood pressure (BP) in the lower extremities (just above the ankle joint) to the pressure level in the upper extremities (in the brachial area). The mathematical ratio of these two values is the ABI: lower extremity BP / upper extremity BP.

An ABI value of less than 0.9 indicates, with high sensitivity and specificity, the presence of major vascular injury in the traumatized lower extremity requiring surgical intervention [168, 169, 170, 173].

2.3 Laboratory Diagnostics

All patients diagnosed with a proximal tibial fracture or knee dislocation who are scheduled for surgical treatment are recommended to undergo the following laboratory tests for diagnostic purposes:

- complete blood count (CBC);

- urinalysis;

- general general-medical blood chemistry panel: total bilirubin, ALT, AST, urea, creatinine, total protein, glucose [3, 44, 45, 46];

- determination of the main blood groups by the AB0 system and determination of the D antigen of the Rh system (Rh factor);

- determination of antibodies to hepatitis A virus (Hepatitis A virus) in the blood;

- determination of hepatitis B virus surface antigen (HbsAg) in the blood;

- determination of class G antibodies (anti-HCV IgG) to hepatitis C virus in the blood;

- testing for human immunodeficiency virus HIV 1/2 antibodies (IgM, IgG) and p24 antigen (Human immunodeficiency virus HIV 1/2 + Agp24) in the blood;

- Determination of antibodies to Treponema pallidum in the blood;

- coagulogram (screening test of the hemostatic system) with determination of the international normalized ratio (INR) [45].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

• When deciding on surgical treatment for proximal tibial fracture in adult patients, it is recommended to test the blood level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in cases of intermediate or high risk of cardiovascular complications and low functional status (see Appendix B2) [37, 41, 47, 48].

LeE 2Grade of Recommendations B (Level of Evidence – 2).

2.4 Instrumental Diagnostics

For patients with suspected proximal tibial fracture, it is recommended to perform knee radiography capturing the lower third of the femur and the leg (entire lower extremity radiography) in two projections for diagnostic purposes [3-6, 27, 150].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Radiographs allow assessing limb axis alignment and drawing initial conclusions regarding the direction of traumatic forces and primary traumatic deformation. For a correct evaluation of initial radiographs, it is recommended to determine deviations of standard reference lines (anatomic and mechanical axis of the tibia) and angles [49]. Normally, the joint line of the knee joint runs at an angle of 87º (85-90) to the anatomical axis of the tibia, creating a slight physiological varus. In the sagittal plane, the joint line and the anatomical axis of the tibia form an angle of 81º (77-84), or in other words, the posterior slope of the articular surface in the sagittal projection is normally about 10º from the horizontal line. Another important parameter is the width of the tibial plateau articular surface in the frontal plane. Normally, it is 1 mm wider than the articular surface of the distal femur along both the medial and lateral margins. The widths of the most prominent points of the tibial condyles and the epicondyles of the distal femur are also approximately comparable. Thus, on follow-up radiographs, one can monitor the correct restoration of the tibial plateau width in the frontal plane relative to the width of the distal femur [50].

In proximal tibial fractures, reference axes and angles are altered under the influence of deforming forces acting on the segment during trauma. Valgus or varus deformity occurs, along with changes in the physiological angles of the joint line inclination due to impression and displacement of articular fragments in both the frontal and sagittal planes, and widening of the tibial plateau articular surface relative to the distal femoral condyles.

These data are taken into account both when planning surgical treatment and when analyzing surgical results on postoperative radiographs.

• For patients with proximal tibial fractures, it is recommended to perform MSCT of the proximal leg and knee joint (lower extremity computed tomography, joint computed tomography) when an intra-articular fracture is suspected, in order to clarify the diagnosis [1, 3-16, 27, 50, 150].

Adults - Recommendation grade C (Level of evidence – 4).

Children - Recommendation grade C (Level of evidence – 5).

Comments: MSCT provides additional information on the fracture pattern, the degree of fragment displacement, and the presence and localization of tibial plateau articular surface impression [13, 18, 27]. It is recommended to perform a thorough evaluation of 3D reconstructions, frontal, sagittal, and axial CT slices [51, 52].

In two-stage surgical treatment of tibial plateau fractures, it is advisable to perform MSCT after applying the primary external fixation device under moderate distraction, since distraction provides primary reduction of major fracture fragments through ligamentotaxis, which significantly facilitates preoperative planning [13, 18, 27, 53].

• For patients with proximal tibial fractures, it is recommended to perform duplex ultrasound of the lower extremity vessels (arteries and veins) when impaired blood supply to the distal parts of the injured limb is suspected, in order to rule out major vascular injury [6, 150].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: After confirming the diagnosis of proximal tibial fracture using diagnostic imaging, the issue of hospital admission is addressed. The patient should be hospitalized if surgical treatment is planned. If conservative treatment is chosen, lower extremity immobilization may be performed. The method of primary immobilization will be described below in the section dedicated to conservative treatment.

• For patients with suspected knee dislocation, it is recommended to perform knee radiography capturing the lower third of the femur and the leg (entire lower extremity radiography, knee radiography) in two projections for diagnostic purposes [3-6, 168, 169, 170].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• For patients with knee dislocations, it is recommended to perform MSCT of the proximal leg and knee joint (lower extremity computed tomography, joint computed tomography) when a concomitant intra-articular fracture is suspected, in order to clarify the diagnosis [3-6, 168, 169, 170].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• For patients with knee dislocations, it is recommended to perform MRI of the proximal leg and knee joint (lower extremity magnetic resonance imaging, joint magnetic resonance imaging) to identify injuries to the capsule-ligamentous apparatus components of the knee joint in order to clarify the diagnosis [168, 169, 170].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• For patients with knee dislocations, it is recommended to perform duplex ultrasound of the lower extremity vessels (arteries and veins) when impaired blood supply to the distal parts of the injured limb is suspected, in order to rule out major vascular injury [168, 169, 170].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• For patients with knee dislocations, it is recommended to perform computed tomography angiography of the lower extremity vessels or magnetic resonance angiography (one region) when there are signs of impaired blood supply in the distal parts of the injured lower extremity, in order to rule out or confirm major vascular injury and identify the level of this injury [169, 174].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• ECG recording for all patients with proximal tibial fractures older than 65 years, as well as for all adult patients with risk factors or established cardiovascular disease, regardless of age, if surgical treatment of the proximal tibial fracture is planned with an intermediate risk of cardiovascular complications [41, 54].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

• Echocardiography may be considered before planned surgical treatment of a proximal tibial fracture in adult patients with low functional status, elevated NT-proBNP levels, left ventricular systolic dysfunction, cardiomyopathies, valvular heart disease, newly detected heart murmurs, and suspected cardiovascular disease [41, 57, 58].

Level of Evidence: 5Grade of Recommendation: C (Level of Evidence: 5).

2.5 Other Procedures

• When treating patients with proximal tibial fractures or knee dislocations, it is recommended to take into account the following indications for consultations with related specialists in clinical practice in order to rule out conditions threatening the patient's life or health:

- neurosurgeon consultation: in case of nerve injury or suspected nerve injury and concomitant traumatic brain injury;

- general surgeon consultation: in case of suspected or objectively diagnosed concomitant abdominal and/or chest trauma;

- neurologist consultation: in case of nerve injury or suspected nerve injury and concomitant traumatic brain injury;

- cardiovascular surgeon consultation: in case of concomitant vascular injury or suspected vascular injury;

- general physician consultation: in the presence of concomitant medical conditions (according to medical history) [59].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• In case of acute or unstable clinical conditions, it is recommended to postpone elective surgical treatment of a proximal tibial fracture or knee dislocation until the cardiac status improves and the patient's condition stabilizes; transfer of the patient to a regional vascular center or a specialized cardiology department is indicated [41].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

• For patients with proximal tibial fractures or knee dislocations upon admission to the hospital, the following minimum scope of care in the emergency department is recommended to stabilize the general condition and prevent complications:

- ensuring thermal comfort for the patient;

- adequate pain management;

- immobilization of the injured lower extremity;

- correction of fluid and electrolyte imbalances [3, 4, 168, 178, 179, 180].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Correction of fluid and electrolyte imbalances is carried out taking into account the patient's general condition, changes in homeostasis, acid-base balance, etc., upon admission to the hospital. Solutions affecting the water-electrolyte balance are used. Protecting the patient from body cooling by infusing warm solutions, warming blankets, and electric heaters reduces the risks of complications and helps decrease the volume of blood transfusion [60, 61].

• For patients with proximal tibial fractures, application of a plaster cast for bone fractures or an immobilization bandage for bone fractures as part of conservative treatment is recommended to achieve bone union in the following cases:

- isolated fracture of the proximal tibia without fragment displacement;

- proximal tibial fracture in elderly patients with severe comorbidities and low quality-of-life expectations;

- presence of comorbidities that serve as a contraindication to surgery;

- upon the patient's voluntary refusal of surgery [1, 3-6, 27].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Conservative treatment consists of closed reduction of fragments under adequate anesthesia and immobilization. When performing the reduction, it is necessary to take into account the existing primary traumatic deformation and perform manipulations to restore the axis of the leg [3, 4]. The quality of the performed reduction must be monitored by radiographs in anteroposterior and lateral projections. The criteria for the adequacy of closed reduction are the elimination of gross fragment displacement and the restoration of knee joint congruence. In case of unsuccessful closed reduction of fragments, as well as significant soft tissue edema and contraindications to surgical treatment, temporary skeletal traction using calcaneal traction (in case of a periarticular fracture and/or extension of the fracture into the tibial diaphysis) or a fixing bandage that prevents soft tissue compression as edema increases is recommended.

Immobilization of the damaged lower extremity (application of an immobilization bandage for bone fractures) is performed using various types of fixing bandages. In the case of closed manual reduction, it is recommended to use two lateral plaster splints supplemented by a posterior plaster splint or a primarily incised circular plaster cast from the upper third of the thigh to the toes. Plaster immobilization (application of a plaster cast for bone fractures) is applied with the lower extremity extended at the knee joint to an angle of 175°. In case of pronounced hemarthrosis of the knee joint, knee arthrocentesis with evacuation of the hemarthrosis is recommended. An important condition for conservative treatment with prolonged plaster immobilization is monitoring the state of soft tissue edema and maintaining blood supply to the distal extremities. A patient undergoing conservative treatment needs regular contact with the attending trauma surgeon of the outpatient service to monitor the condition of the cast and perform staged radiographs. Control radiographs must be taken on the 7th (5th–10th) day after the injury to rule out secondary fragment displacement and every 4–6 weeks until signs of fracture union appear on radiographs in two standard projections. The duration of immobilization and axial load restriction is determined by the dynamics of fracture consolidation and averages 3–4 months [3, 4].

Quite often, proximal tibial fractures with minimal displacement in children are treated conservatively (undisplaced fractures or fractures after reduction). There are no significant differences in treatment tactics compared to adults, except for recommendations to apply a plaster cast with full extension in the knee joint (180°) and the possibility in some cases (absence of significant edema and hemarthrosis) to use a circular plaster cast, which is more convenient for immobilizing children [62]. When using a circular plaster cast, it is imperative to use padding under the cast in the popliteal region and over the bony prominences of the knee joint to prevent skin damage. To monitor the development of compartment syndrome, even in fractures with minimal displacement, it is better to hospitalize the patient. The timing of control radiographs and cast removal does not differ between children and adults.

• For patients with knee dislocations, closed manual reduction (reduction of joint dislocation) is recommended as soon as possible to eliminate the dislocation of the lower leg bones and relieve potential compression of major blood vessels [169, 175].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• For patients with knee dislocations, a reassessment of blood circulation in the distal parts of the injured lower extremity after dislocation reduction is recommended in order to decide on further management tactics for the patient [170].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

3.2 Surgical Treatment

The choice of surgical tactics for a tibial plateau fracture is determined by the fracture type, soft tissue condition, presence of associated injuries, and individual patient characteristics. When performing osteosynthesis, the priority is to restore the axis, length, and rotation of the leg, achieve anatomical reconstruction of the tibial articular surface, and restore knee joint stability.

- presence of a proximal tibial fracture with fragment displacement;

- presence of an intra-articular proximal tibial fracture accompanied by disruption of the congruence of the articular surfaces forming the knee joint;

- open proximal tibial fractures;

- proximal tibial fracture as part of polytrauma;

- unsatisfactory results of conservative treatment [1, 3-13, 27].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

• For patients with knee dislocations, surgical repair of knee ligaments (arthroscopic repair of collateral knee ligaments) or their reconstruction (joint ligament reconstruction, arthroscopic reconstruction of the anterior cruciate ligament) is recommended to restore knee joint stability [168, 169, 170].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Repair of knee ligaments can be performed within up to 3 weeks from the injury (acute reconstruction) or after 3 weeks from the injury (delayed reconstruction). In the first case, the surgery is performed open, as capsule damage precludes arthroscopic intervention [168, 169, 170]. If a knee dislocation is combined with vascular injury, reconstructive surgery on the ligamentous apparatus is performed 6–12 months after the injury. This is necessary for edema regression, as well as for the engraftment of the transplanted vessel segment or vascular graft [169].

3.2.1 External Fixation and Two-Stage Treatment Protocol

• For patients with proximal tibial fractures, the use of external fixation devices is recommended to create conditions for fracture consolidation or temporary fragment fixation according to the following indications:

- open proximal tibial fracture type Gustilo-Anderson II, IIIA-C;

- proximal tibial fracture with fragment displacement as part of multiple and associated trauma, as a method of temporary fracture fixation;

- in complex comminuted proximal tibial fractures as a method of primary reduction and temporary fixation in the presence or expected significant soft tissue edema, as a preparation method for definitive internal osteosynthesis;

- in proximal tibial fractures of any complexity for definitive stabilization according to the surgeon's individual preference [5, 6, 16, 27, 53, 63].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

Comments: The use of an external fixation frame (EFF) as a method for temporary stabilization of a proximal tibial fracture, followed by conversion to definitive internal plate osteosynthesis after the patient's general condition and soft tissue status have normalized, is a standard approach referred to in modern literature as a "two-stage protocol." The goal of the initial stage is to restore the axis and length of the leg segment, correct rotational displacement of fragments, and eliminate major displacement of the articular surface fragments through ligamentotaxis. For initial surgical stabilization, basic transarticular configurations of the military field rod fixation kit are used as a temporary stabilizer. The duration of EFF fixation ranges from 7 to 21 days. The timing of conversion to internal osteosynthesis is determined by the subsidence of edema, the appearance of skin wrinkles on the leg and knee joint, epithelialization of blisters, or wound healing in open fractures [5, 6, 16, 27, 53, 63].

Circular or hybrid external fixation devices are preferred as the method for definitive fracture stabilization. To increase their stability and to achieve reduction of intra-articular fragments, it is recommended to use olive wires (orthopedic bone wire***) [64]. In certain clinical cases, in the presence of poor soft tissue condition and skin defects, or according to the surgeon's preference, a combination of limited open reduction of intra-articular fracture fragments with their fixation using individual cortical, cancellous, or cannulated screws (non-absorbable, non-sterile orthopedic bone screw***, non-absorbable, sterile orthopedic bone screw***) placed parallel to the articular surface of the tibia, followed by external fixation, is possible. The duration of EFF fixation in this case is determined by the healing time of the tibial fracture [6].

Regardless of the type of EFF used, the fixation pins in the femur and tibia must be inserted taking into account the anatomical features of the segment, "safe zones," the topography of vessels, nerves, muscles, and tendons, as well as the anticipated locations of surgical approaches for internal osteosynthesis in the two-stage treatment protocol [5, 6, 63, 64].

• Patients with knee dislocations are recommended to undergo external fixation after closed manual reduction in order to immobilize the limb [168].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

3.2.2. Plate Osteosynthesis

• Patients with proximal tibial fractures are recommended to undergo plate osteosynthesis during surgical treatment to create conditions for fracture healing [1, 5, 6].

Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).

Comments: When performing plate osteosynthesis for proximal tibial fractures, the following implants are used: non-absorbable, sterile bone-plate for fracture fixation with screws***, non-absorbable, non-sterile bone-plate for fracture fixation with screws***, non-absorbable, sterile orthopedic bone screw***, non-absorbable, non-sterile orthopedic bone screw***.

To ensure high-quality preoperative planning, the following stages of internal plate osteosynthesis of a proximal tibial fracture should be distinguished:

- reconstruction of the articular surface;

- fixation of the diaphyseal fragment;

- closure of surgical wounds.

Reconstruction of the articular component of the fracture requires an adequate surgical approach or a combination of approaches, often performed using a distractor. Fragment reduction is carried out in a specific sequence depending on the individual fracture architectonics, combining direct and indirect reduction methods using joysticks, bone holding clamps, K-wires (orthopedic bone wire***), lag screws, and plate-assisted reduction. Reduction is performed under visual and fluoroscopic control. Restoring the anatomy of the articular surface frequently requires bone grafting to fill subchondral bone defects. Provisional fixation can be performed using K-wires (orthopedic bone wire***). Definitive fixation of the articular component must follow the principle of absolute stability, achieving anatomic reduction and interfragmentary compression of the fragments containing the joint surface. In osteosynthesis of the metaphyseal component of the fracture, it is sufficient to restore only the axis, segment length, and eliminate rotational displacement. Anatomic reduction of the metaphyseal component is possible in simple fracture patterns, but requires broader surgical approaches, is more invasive, and is associated with a higher rate of postoperative complications [1, 5, 6].

• Patients with proximal tibial fractures who require osteosynthesis for these fractures are recommended to undergo the following surgical approaches depending on the fracture architectonics, soft tissue condition, and the surgeon's individual preferences:

- anterolateral approach is the classical approach for most lateral condyle fractures, allowing visualization of the anterolateral quadrant of the latter after performing a submeniscal arthrotomy. It is used for Schatzker type I, II, and III fractures, and in combination with a posteromedial approach for Schatzker type V and IV fractures;

- posteromedial approach is used for osteosynthesis of the medial tibial condyle in Schatzker type IV, V, and VI fractures;

- anteromedial approach is used for osteosynthesis of an isolated medial tibial condyle [1, 5, 6, 65-68].

GCR ALoE 2Grade of Recommendation A (Level of Evidence – 2).

Comments: To improve the quality of reduction and fixation of complex tibial plateau fractures, alternative surgical approaches to the posterior aspects of the lateral and medial condyles have been developed: the posterolateral approach with and without fibular head osteotomy, the direct posterior approach, the reverse L-shaped, and the direct posteromedial approaches. These are performed with the patient in the prone, lateral, or so-called "floating" position. These approaches have not only advantages but also certain topographical and anatomical limitations, and should be used under strict indications by experienced surgeons [69, 70, 71, 72, 73, 74].

If open reduction and internal fixation of a tibial plateau fracture using two approaches was initially planned, but during the first stage of the operation through the first approach significant intraoperative blood loss is noted, the duration of surgery exceeds the planned time, and significant soft tissue edema develops, the execution of the second surgical approach may be postponed for 5–10 days until the edema subsides. Fracture immobilization between stages can be achieved by one of the standard methods (EFF, plaster splint, skeletal traction) [1, 6].

• Patients with intra-articular tibial plateau fractures are recommended to undergo the most accurate anatomical reconstruction of the articular surface to create optimal conditions for bone healing [1, 6, 13].

Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).

Comments: To this end, for type 41-B1, Schatzker I lateral tibial condyle fractures, the application of interfragmentary compression is recommended. Reduction of a split-type fracture can be performed under visual control of the contact line of the articular surface of the bone fragments, as well as in the area of bone contact at the "apex" of the fractured piece. Fixation of such a fragment is carried out using the lag screw principle perpendicular to the fracture plane, or by using a buttress plate applied as an anti-glide plate [1, 6, 13].

A similar fragment reduction principle is used for isolated split fractures of the medial condyle, or medial condyle fractures combined with an impression fracture of the lateral condyle [1, 6, 13].

In fractures with articular surface depression of the 41-B3, Schatzker II, and III types, it is necessary to provide an approach to the articular surface displacement zone, elevate it using undamaged articular fragments as a guide, and provide subchondral support with bone defect reconstruction and implant placement to prevent secondary displacements. In relatively simple fractures, such as Schatzker II, it is possible to use the "open book" technique of retracting the fractured lateral wall fragment with direct reduction and fracture fixation via an anterolateral approach. If the cortex of the articular ring is intact, as in Schatzker III fractures with pure depression, only re-impaction of the central fragment under fluoroscopic or arthroscopic control is required, along with defect filling using auto-, allograft, or a synthetic bone substitute through a "window" in the metaepiphyseal zone [1, 6, 13].

In cases of more complex comminuted Schatzker IV, V, and VI fractures, a combination of the described reduction and bone fragment fixation techniques is indicated for accurate reconstruction of the articular surface [1, 6, 13, 19].

• In patients with proximal tibial fractures, it is recommended to use special buttock/support plates for the fixation of intra-articular tibial plateau fractures [6, 16, 27, 71, 84].

Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).

Comments: In cases of multi-fragmentary intra-articular fractures, it is recommended to use a combination of plates with fixation of all damaged columns of the distal tibial metaepiphysis [6, 16, 27, 71, 84].

• In patients with proximal tibial fractures, it is recommended to use bone autografts, allografts, and synthetic bone substitutes to reconstruct bone defects of the distal tibial metaepiphysis [1, 5, 6, 13].

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: Bone defect reconstruction should be performed during internal osteosynthesis in multi-fragmentary tibial fractures with articular surface depression, following its re-impaction [1, 5, 6, 13].

• In patients with proximal tibial fractures, to minimize additional surgical trauma, it is recommended to use minimally invasive plate osteosynthesis techniques by placing plates through surgical approaches to the articular component of the fracture and distally fixing them through separate mini-approaches in extra-articular and simple intra-articular fractures of the proximal tibia, where the articular component of the fracture is absent or anatomical reduction of the articular surface can be achieved without fragment exposure [1, 5, 6, 85].

Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).

Comments: In simple intra-articular fractures (type 41-C1, C2) it is recommended to first perform closed reduction of the articular fragment using bone-holding forceps and fix them with lag screws, followed by minimally invasive placement of a buttress plate. In complex intra-articular fractures (type 43C3), a combination of limited open reduction of the articular component of the fracture and minimally invasive fixation of the diaphyseal fracture fragment is recommended to reduce operative wound length, lower surgical trauma, and optimize healing processes [1, 5, 6, 27].

• In patients with proximal tibial fractures, it is recommended to use intraoperative fluoroscopy during plate osteosynthesis of tibial plateau fractures to monitor fragment reduction and implant position [1, 3, 4, 59].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

Comments: In Schatzker III fractures with articular surface depression, the use of arthroscopic control for articular surface restoration is recommended.

In multi-fragmentary tibial plateau fractures, the use of arthroscopic control is not recommended as it increases the risk of postoperative compartment syndrome [1, 3, 4, 59].

• In patients with proximal tibial fractures, it is recommended to use a technique ensuring adequate wound edge adaptation with minimal trauma during the closure of postoperative wounds in the proximal leg area (cosmetic epidermal suture, Donati suture, Allgöwer suture) [1, 6].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

Comments: In some cases, when wound closure without skin flap tension is impossible and there is an increased risk of postoperative skin necrosis, delayed suturing or plastic wound coverage methods are indicated [1, 6].

3.2.3. Intramedullary osteosynthesis.

• For patients with proximal tibia fractures, it is recommended to use intramedullary osteosynthesis to create conditions for fracture healing according to the following restricted indications:

· extra-articular tibial fractures

· proximal tibial fracture extending into or combined with a tibial shaft fracture

· simple intra-articular tibial fracture provided preliminary osteosynthesis of the proximal metaepiphysis is performed with lag screws

· individual surgeon preference

· specific clinical cases [5, 6].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

Comments: The following implants are used when performing intramedullary osteosynthesis of the proximal tibia: tibial intramedullary nail, sterile***; tibial intramedullary nail, non-sterile***; orthopedic bone screw, non-absorbable, sterile***; orthopedic bone screw, non-absorbable, non-sterile***.

The use of intramedullary osteosynthesis has limited indications in the surgical treatment of proximal tibial fractures. In such cases, special designs of intramedullary nails with multi-plane proximal locking capabilities should be used, and the length, diameter, and specific nail model should be carefully selected to achieve sufficient stability of fracture fixation [5, 6].

3.2.4. Specifics of surgical treatment of proximal tibial fractures in children.

Unstable fractures in children that can be closed reduced may be stabilized using percutaneous Kirschner wire fixation (orthopedic bone wire***) or by inserting screws in the same manner (orthopedic bone screw, non-absorbable, sterile***, orthopedic bone screw, non-absorbable, non-sterile***). Fractures that cannot be closed reduced are a direct indication for surgical correction [75, 76]. Another relative indication for open reduction and subsequent osteosynthesis Open reduction is also indicated for all displaced Ogden type III injuries with intra-articular involvement [8, 77-83]. Although Kirschner wires do not provide stable osteosynthesis, this treatment method is considered relevant for pediatric patients because it minimizes the risk of iatrogenic physeal injury. The choice of wire diameter depends on the size of the tibia and, consequently, on the patient's age. It typically ranges from 0.062 to 2.5 mm in older children. Kirschner wires are recommended to be inserted extra-articularly to reduce the risk of inflammatory intra-articular complications. When large Thurston-Holland free fragments result from trauma, a percutaneous compression screw can be used.

If intra-articular fractures are suspected, additional CT imaging must be performed. The presence of intra-articular injury may be considered an indication for open reduction or arthroscopic visualization of the articular surface. Cannulated screws (4.0 to 6.5 mm) are used for the osteosynthesis of such fractures.

3.3 Other Treatment

3.3.1. Postoperative analgesia

• For adequate analgesia, patients with proximal tibia fractures or knee dislocations are recommended to receive multimodal analgesia, which may include NSAIDs from the M01A group (Antiinflammatory and antirheumatic products, non-steroids), paracetamol**, gabapentinoids, and immediate-release opioids, taking into account age restrictions in the instructions for medical use, or monomodal analgesia if multimodal analgesia cannot be prescribed [86-88, 89, 155, 156, 180]. Recommended analgesic medications are listed in Appendices A3.1-A3.3.

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments:

Adequate pain relief must be provided to a patient with a fracture prior to any manipulations and throughout the entire fracture treatment period, the duration of which varies significantly depending on the chosen management strategy. When managing pain in an inpatient setting, it is necessary to take into account the prescriptions administered at the emergency medical care stage. In the acute phase of trauma, to achieve pain control, proper immobilization of the bone fragments must be provided using a vacuum splint, vacuum mattress, or external fixation device.

Among pharmacological strategies, the current consensus is to use multimodal analgesia (MMA), which involves the combination of several analgesic agents (opioid and non-opioid) from the N02 Analgesics group with different mechanisms of action, along with non-pharmacological interventions targeting the peripheral and/or central parts of the nervous system [89]. This combination provides more effective pain relief by potentiating the effects of various drugs, which in most cases leads to a reduced frequency of prescriptions and/or lower doses of opioid analgesics. Thus, MMA improves the risk profile of each drug while providing synergistic pain control through various drug classes. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, gabapentinoids, regional anesthesia (single-shot or continuous peripheral nerve catheter placement), local injections, and opioids [87].

In modern literature, authors emphasize using the lowest effective doses of opioids for the shortest possible duration, avoiding extended-release opioids. As an adjuvant during MMA in adult patients, a single intravenous dose of #dexamethasone** 1.25–20 mg can be administered before surgery (60 minutes prior to the incision), which significantly reduces pain [86].

It must be remembered that the duration of parenteral administration of most NSAIDs (ketorolac**, ketoprofen**, diclofenac**) is limited to two days, which requires timely switching of the patient to oral administration, changing the drug, or coordinating further use with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization.

When prescribing analgesic therapy for children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal administration routes, avoiding intramuscular injections.

• In children with proximal tibial fractures, the use of paracetamol** and ibuprofen** is recommended for analgesia [155]. Recommended dosing regimens and age restrictions according to the instructions for medical use are given in Appendices A3.3.

GCR BLOE 2Grade of Recommendation B (Level of Evidence – 2).

• In cases of severe pain and ineffectiveness of paracetamol** and ibuprofen** in children, it is recommended to use other non-steroidal anti-inflammatory and antirheumatic drugs (M01A) and narcotic analgesics from the opioid group (N02A) if there are corresponding indications and no contraindications [155].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

• Patients with proximal tibial fractures are recommended to undergo local blockade or regional anesthesia as part of a postoperative multimodal regimen for pain relief [87, 159].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

3.3.2. Surgical antibiotic prophylaxis

• In the surgical treatment of patients with closed proximal tibial fractures, it is recommended to perform surgical antibiotic prophylaxis (SAP) of surgical site infections by a single preoperative administration of an antibacterial drug to reduce the risk of infectious complications [90–92].

GRC ALOE 1Grade of Recommendation A (Level of Evidence – 1).

Comments: In accordance with international clinical guidelines for the prevention of surgical site infections [93, 91], the objective of SAP is to establish bactericidal concentrations of the antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The need for SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not associated with the placement of orthopedic implants and metal structures. SAP should be performed: for clean-contaminated and contaminated surgical wounds; for "clean" surgical wounds involving the placement of orthopedic implants and metal structures. For infected ("dirty") wounds, SAP is not indicated; instead, antibiotic therapy is administered.

• In patients with proximal tibial fractures, it is recommended to use first- and second-generation cephalosporins (cefazolin**, cefuroxime**) as the primary drugs for surgical antibiotic prophylaxis during surgical interventions in traumatology and orthopedics; glycopeptide antibiotics (vancomycin**), lincosamides (#clindamycin**) serve as alternatives in case of beta-lactam allergy [91].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: For patients with an unremarkable allergic history and without significant risk factors for methicillin-resistant staphylococci carriage, first- and second-generation cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes before skin incision. In case of beta-lactam intolerance, a combination of vancomycin** with one of the fluoroquinolones (ciprofloxacin**, #levofloxacin**) administered over at least 60 minutes starting 2 hours prior to the incision, or #clindamycin** should be prescribed. When significant risk factors for methicillin-resistant staphylococci (MRS) carriage are present, the SAP regimen must include an antibiotic with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of the antibiotic is sufficient for effective prophylaxis. For prolonged procedures or massive blood loss, an additional intraoperative dose of the antibiotic should be administered (the estimated timing for intraoperative administration is two half-lives after the preoperative dose). Administering an antibiotic after wound closure in the operating room is impractical even if indwelling drains are present.

Single doses of main antibacterial drugs for SAP in traumatology and orthopedic surgery in adults: cefazolin** 2 g (for patients weighing ≥120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg [91].

Single doses for children should be calculated based on actual weight in accordance with the attached product leaflet: cefazolin** 30–50 mg/kg, cefuroxime** 50 mg/kg, #clindamycin 10 mg/kg, vancomycin 15 mg/kg; the use of fluoroquinolones during the period of bone and joint system formation in the presence of open growth plates is contraindicated due to the risk of arthropathy [151, 152].

Comments: In the case of open fractures, prophylactic antibiotic administration is effective in preventing early infection. Antibiotics should be administered as soon as possible after trauma; cefazolin** is the antibiotic of choice, but in patients with open high-energy fractures with displacement and segmental loss, major vascular injury, or heavily contaminated wounds, broadening the spectrum of prescribed antibiotics to cover Gram-negative pathogens is advisable. In such cases, adult patients may be considered for the addition of #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** [95, 96]. An alternative to this combination may be #ampicillin+sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [97], the latter being particularly relevant in cases of clostridial infection risk. According to most researchers, in Gustilo-Anderson type III open fractures, antibiotics should not be continued for more than 72 hours after soft tissue wound closure [98].

• In the surgical treatment of patients with proximal tibial fractures, it is recommended to administer antibiotic prophylaxis for surgical site infections for a duration of no more than 24 hours [99].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: In accordance with the regulatory documents in force in the Russian Federation (SanPiN 3.3686-21) and clinical guidelines [99], to achieve an effective concentration of the antibacterial drug in tissues and blood serum at the time of the skin incision, antibiotics for the prevention of surgical site infection should be administered intravenously 30 to 60 minutes before the skin incision, or within 2 hours before the incision in the case of vancomycin**. The maximum duration of prophylactic antibiotic administration should not exceed 24 hours after the end of surgery. In most cases, a single dose of antibiotic is sufficient for effective prophylaxis. Additional doses should be administered during prolonged surgeries when the time elapsed since preoperative antibiotic administration exceeds the half-life of the administered drug, creating a risk of concentration dropping below the bactericidal level and increasing the risk of surgical site infection.

3.3.3. Prevention of venous thromboembolic events

• In all patients with fractures followed by tibial plateau osteosynthesis, in the absence of active bleeding, it is recommended to implement VTE prophylaxis measures until the patient's normal or expected physical activity is restored [102, 103].

Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).

Comments: Patients with proximal tibial fractures may belong to a moderate or high risk group for VTE development, depending on patient characteristics, the nature of the sustained trauma (multiple and polytrauma carry a higher risk of DVT), and the planned duration of surgery.

To assess the risk of VTE before surgery, it is advisable to use the Caprini risk assessment scale for VTE (Appendix G1).

Non-pharmacological means of VTE prophylaxis include:

- elastic and/or intermittent sequential pneumatic compression of the lower extremities;

- early mobilization and activation of the patient;

- medical gymnastics (physical therapy).

All patients with limited motor activity (mobility), regardless of the degree of VTE risk, are recommended to undergo mechanical VTE prophylaxis [101]. All patients at moderate or high risk of VTE are recommended to undergo medical (pharmacological) VTE prophylaxis, typically until normal or expected physical activity is restored.

Preoperative pharmacological prophylaxis of venous thromboembolism (VTE) is carried out with unfractionated heparin (UFH) from group B01AB or, preferably, low-molecular-weight heparins (LMWHs) from group B01AB [Appendices A3.3, A3.4]. Patients receiving chronic antithrombotic therapy from group B01 who present with a tibial plateau fracture are recommended to receive VTE prophylaxis and anesthesia based on specialized clinical guidelines [100, 106].

GGR BLOC 3Grade of recommendation B (Level of evidence 3).

• In patients with tibial plateau fractures undergoing conservative treatment and limb immobilization, it is recommended to initiate pharmacological VTE prophylaxis immediately after ruling out ongoing hemorrhage to prevent complications [100].

GGR BLOC 3Grade of recommendation B (Level of evidence 3).

Comments: LMWHs are the drugs of choice, or UFH if LMWHs are unavailable; subsequently, starting from days 3–4 depending on the patient's condition, switching to VKAs (warfarin) is possible provided that the dose is adequately titrated and the INR is monitored regularly [100].

Features of thromboprophylaxis in pediatric patients

• Hospitalized patients older than 6 months are recommended to undergo bleeding and VTE risk assessment within 24 hours of admission [107] and periodically during their hospital stay [108–110].

GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3).

Comment: There are no validated VTE risk assessment scales or bleeding risk assessment scales for anticoagulant therapy in pediatric patients; therefore, when deciding on VTE prophylaxis, individual bleeding risk factors (Appendix A3.6), VTE risk factors (Appendix A3.7), and the risk-benefit ratio should be considered [111, 113].

For the prevention of VTE in children, both mechanical and pharmacological methods are used. Specific prophylactic measures against thromboembolic complications in children with traumatic injuries are absent due to their low incidence.

3.3.4. Blood-conserving technologies

Comments: Tranexamic acid** effectively reduces blood loss and leads to a smaller decrease in postoperative hemoglobin levels. Randomized clinical trials demonstrate the efficacy of local subfascial administration of #tranexamic acid** into the postoperative wound in adult patients, comparable to intravenous administration of an equivalent dose [162].

Comments: Systematic reviews and meta-analyses demonstrate that perioperative use of intravenous iron preparations, specifically iron(III) derisomaltose / ferric carboxymaltose**, in adult trauma and orthopedic patients—especially in the postoperative period—is an effective alternative to blood transfusion, as it reduces the proportion of patients receiving blood transfusions, lowers the volume of transfused red blood cell mass, and decreases the incidence of infectious complications, although it does not affect mortality rates [122, 123].

Evidence in the pediatric population has demonstrated the efficacy of intravenous iron preparations for correcting preoperative iron deficiency anemia in elective orthopedic procedures [153, 154]. Data on the use of these drugs in children during the postoperative period following trauma surgery are lacking.

3.3.5. Tetanus prophylaxis

Comments: In accordance with clauses 4156–4157 of the Sanitary Rules and Norms on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is performed for any injuries involving a breach of integrity of the skin and mucous membranes. Emergency tetanus prophylaxis is carried out up to the 20th calendar day from the moment of injury [124, 165]. The administration of emergency tetanus immunoprophylaxis drugs is carried out differentially, depending on whether there is documentary confirmation of a preventive vaccination or immunological monitoring data on anti-tetanus immunity titers, as well as the nature of the injury.

Emergency tetanus immunoprophylaxis is carried out in the form of taking into account age restrictions:

- passive immunization or seroprophylaxis with human tetanus immunoglobulin** (HTIG), or, in its absence, tetanus antitoxin** (TAT), taking into account age restrictions;

- active-passive prophylaxis, consisting of the simultaneous administration of human tetanus immunoglobulin (or TAT in its absence) and tetanus toxoid** (TT) into different anatomical sites;

- emergency revaccination with tetanus toxoid** (or reduced-antigen diphtheria-tetanus toxoid** — Td-m) to stimulate immunity in previously vaccinated individuals [124, 125, 165].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: At this stage of treatment, rehabilitation objectives include improving blood circulation in the immobilized limb, preventing muscle hypotrophy and joint stiffness, and training in walking with assistive devices.

The program consists of isometric exercises for the thigh and lower leg muscles, ideomotor exercises for the ankle and knee joints, dynamic exercises for the hip joint on the fractured side and for the joints of healthy limbs, alternated with breathing exercises.

Walking with assistive devices without weight-bearing on the injured leg is permitted from the first days [127, 133-135]. The duration of the immobilization period is determined by the trauma surgeon based on follow-up X-ray findings.

Comments: Rehabilitation modalities are aimed at restoring joint mobility, muscle tone and strength, elasticity of the capsular-ligamentous structures, and limb weight-bearing capacity. Currently, there are no clear recommendations regarding rehabilitation protocols (programs), but the following are used to achieve the goals: motorized continuous passive motion (CPM) therapy, therapeutic exercise (kinesiotherapy) for bone fractures (free dynamic exercises, assisted exercises, with resistance, soft tissue stretching, positioning), apparatus- and equipment-based therapeutic exercises for bone fractures, robotic mechanotherapy for joint diseases and injuries, hydrokinetotherapy, biofeedback-based weight-bearing training for joint diseases and injuries, balance therapy, lower limb massage for bone fractures, barotherapy – limb pressure therapy, pneumatic compression, ultrasound therapy for joint diseases, transcutaneous electrical nerve stimulation (TENS), and, as indicated, thigh muscle electromyostimulation. The choice of modalities and application methods is tailored individually depending on the functional impairments. The main principle of rehabilitation: early movements in the knee joint under assisted conditions and graded axial load on the limb [128, 131, 132, 136-138]. Full axial weight-bearing is possible after 3–4 months.

Comments: The principles of postoperative rehabilitation are general: improving blood circulation in the limb, preventing joint stiffness and stepwise restoration of their function, strengthening muscles, training in ambulation with assistive devices, followed by restoration of the weight-bearing function of the limb [141, 142]. To reduce tissue edema, cryotherapy, hardware lymph drainage, and electrostatic field massage are used [128, 139, 143].

There is no single protocol, but it has been proven that rehabilitation improves functional outcomes of surgical treatment and accelerates the recovery of the patient's quality of life [128-130, 139, 140, 143].

Following stable osteosynthesis, additional immobilization is not required; breathing exercises, active exercises for the joints of the unaffected limb, isometric exercises for the muscles of the operated limb, passive movements in the joints of the operated limb with increasing range of motion, positioning therapy, and passive mechanotherapy are prescribed [128, 129]. In some cases, a plaster cast or brace is applied for 2–4 weeks after surgery [136, 140].

At the final stages of rehabilitation, strength exercises with additional weight and movement resistance, active mechanotherapy, manual leg massage, and physical therapy (ultrasound therapy for joint diseases, muscle electrical stimulation) are prescribed [126, 128, 140, 141, 143].

The issue of allowing axial loading on the lower extremity and gait training is decided based on the dynamics of bone healing under pain control. It has been proven that early graded weight-bearing on the limb is safe and effective, and full-scale rehabilitation improves clinical outcomes [129, 130, 132, 136, 140, 142].

• Postoperative mobilization of the patient and restoration of the range of motion in the knee joint should be initiated as early as possible. Patient activation is recommended within 24 hours after surgery [144].

GCR CLOCE 3Level of recommendation validity C (Level of evidence – 3).

Comments: The objectives of the early postoperative period are the prevention of general postoperative complications involving the cardiovascular system, respiratory system, gastrointestinal tract, and the prevention of trophic disorders. Prevention of local complications includes reducing soft tissue edema and creating optimal anatomical and physiological conditions for the healing of tissues traumatized during surgery [1, 5, 6, 27, 35, 53].

Physical therapy methods aim to reduce pain and edema, relieve inflammation, and improve tissue nutrition and metabolism in the surgical area. Physical therapy procedures are indicated in the absence of contraindications, as prescribed by a physical medicine and rehabilitation doctor.

5. Prevention and Dispensary Observation

Prevention of proximal lower leg fractures consists of citizens observing social safety rules when performing household chores, being in traffic areas, walking on poor-quality surfaces, and during icy conditions.

A significant share of responsibility in fracture prevention also belongs to state structures, which are obliged to ensure safety to prevent road traffic injuries, as well as ensure compliance with safety regulations in industries with increased risk of trauma.

Comments: Upon discharge from the hospital, the patient must be referred to a trauma center or outpatient traumatology department, indicating the treatment provided and detailed recommendations for the continuation of treatment and rehabilitation. This will ensure continuity between the inpatient and outpatient stages of treatment.

Follow-up examinations with radiographs (lower limb radiography) and assessment of functional recovery dynamics are performed at 6 weeks post-surgery (assessment of fracture consolidation degree and possibility of full weight-bearing on the limb), 12 weeks post-surgery (assessment of fracture consolidation degree and possibility of weight-bearing on the limb), 24 weeks post-surgery (assessment of consolidation degree, assessment of functional recovery dynamics), and 1 year post-surgery (assessment of functional treatment outcome and decision on the need and timing for implant removal).

6. Organization of Medical Care

Clinical application of recommendations: Traumatology and Orthopedics, Anesthesiology and Intensive Care, Medical Rehabilitation, Health Organization and Public Health.

The aim of the clinical guidelines: The clinical guidelines have been developed to improve the quality of medical care, standardize diagnostic algorithms, and treatment of patients with malleolar fractures.

Indications for planned hospitalization:

- presence of a displaced proximal lower leg fracture identified during outpatient trauma follow-up examinations;

- unsatisfactory result of conservative treatment: secondary displacement of fragments, lack of signs of fracture consolidation after conservative treatment; secondary displacement, or implant migration after osteosynthesis surgery [1, 3-6].

Indications for emergency hospitalization:

Patients with suspected or confirmed proximal lower leg fractures must be referred to a hospital to determine the need for emergency hospitalization. Indications for emergency hospitalization include:

- proximal lower leg fracture with fragment displacement;

- open proximal lower leg fracture;

- gunshot fracture of the proximal lower leg region;

- proximal lower leg fracture accompanied by major vascular and nerve injuries;

- proximal lower leg fracture as part of polytrauma [1, 3-6].

Indications for emergency hospitalization for a proximal lower leg fracture are determined based on:

1) presence of symptoms typical of a proximal lower leg fracture;

2) presence of characteristic clinical signs of a proximal lower leg fracture;

3) presence of radiological signs of a proximal lower leg fracture in the patient.

Indications for patient discharge from the hospital:

1. Internal fixation of the fracture with hardware, stabilization with an external fixation device, or adequate plaster immobilization during conservative treatment has been performed.

2. The first stage of rehabilitation has been completed.

3. There is no acute infectious process.

4. Refusal of the patient or their legal guardians (in case of legally established incapacity of the patient) to continue inpatient treatment (the reason for refusal must be documented in the medical chart with the personal signature of the patient or their guardians).

7. Additional Information

No additional information is required.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Belenky I.G., MD, DSc, Associate Professor, Saint Petersburg I.I. Janelidze Research Institute of Emergency Medicine, Saint Petersburg, member of ATOR

2. Bozhkova S.A., D.Sc. in Medicine, Vreden National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of Russia, St. Petersburg, member of ATOR

3. Geroyeva I.B., MD, Professor, Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Russian Ministry of Health, Moscow.

4. Kleymenova E.B., MD, Professor, Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Russian Ministry of Health, Moscow.

5. Mayorov B.A., Ph.D. in Medicine, Janelidze St. Petersburg Research Institute of Emergency Medicine, Pavlov First St. Petersburg State Medical University, St. Petersburg, member of ATOR

6. Nazarenko A.G., MD, DSc, Professor of the RAS, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow, Vice President of ATOR.

7. Novikov V.A., Ph.D. in Medicine, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Ministry of Health of Russia, St. Petersburg.

8. Otdelenov V.A., PhD, Priorov National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, Moscow.

9. Sergeev G.D., PhD, Saint Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, member of ATOR

Conflict of interest.

The working group for drafting clinical guidelines for the treatment of proximal lower leg fractures declares no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Orthopedic trauma surgeons

2. Surgeons

3. General practitioners (family physicians)

4. Medical rehabilitation physicians

5. Healthcare organization and public health specialists.

Stages of evaluating the levels of evidence and grades of recommendation:

1. Definition of search criteria and selection of publications on clinical trials (CTs) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously established criteria.

Systematic search and selection of clinical trial publications:

The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.

Table 1.Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2.Levels of Evidence (LoE) grading scale for prevention, treatment and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic updating at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of well-founded additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1 Pain management recommendations for major musculoskeletal trauma (surgical fixation of long bone fractures or complex joint fractures, extensive soft tissue trauma, extensive surgery, etc.) in adults

The table presents analgesic drugs and their dosing regimens in accordance with the Clinical Practice Guideline for Acute Musculoskeletal Pain Management [89].

Appendix A3.2 Pain management recommendations for non-surgical musculoskeletal trauma (closed fractures, superficial wounds, etc.) in adults

Appendix A3.3. Recommendations for Postoperative Analgesia in Children

* In children under 12 years of age, morphine is the preferred choice when opioid analgesics are required, as tramadol use is associated with a higher risk of adverse reactions [156, 157].

** Not recommended for use in children, as its metabolite accumulates in the body and provokes seizures upon repeated administration [158].

Appendix A3.4 Recommended intervals between prophylactic anticoagulant use and neuraxial interventions in adults [146]

It should be noted that spinal or epidural anesthesia can be performed only 12 hours after the administration of a low-molecular-weight heparin dose (B01AB group) and no earlier than 4–6 hours after the administration of unfractionated heparin (B01AB group), provided that aPTT or ACT values are within the normal range [106].

Appendix A3.5 Recommended dosing regimen of low-molecular-weight heparins for the prophylaxis of high-risk VTE in conservative treatment and orthopedic surgery in adult patients at high risk for VTE

It should be noted that spinal or epidural anesthesia can be performed only 12 hours after the administration of a low-molecular-weight heparin dose and no earlier than 4–6 hours after the administration of unfractionated heparin, provided that aPTT or ACT values are within the normal range [176, 177].

Appendix A3.6 Bleeding risk factors in children aged 6 months to 18 years [109, 110, 113]

Notes:

1. If the patient meets at least one of the "NOT recommended" criteria, avoid pharmacological prophylaxis, as the risks outweigh the benefits.

2. If the patient has at least one relative contraindication criterion, consider omitting pharmacological prophylaxis.

3. Consider consulting a hematologist if the patient is at high VTE risk with a high bleeding risk [109].

4. Uncontrolled hypertension is defined as systolic or diastolic blood pressure above the 95th percentile for age, height, and sex [110].

5. Coagulopathy is defined as INR > 1.5, aPTT > 44 s, fibrinogen < 100 mg/dL, or platelets < 50,000/µL.

Appendix A3.7 VTE risk factors in children aged 6 months to 18 years [113, 164]

Notes:

− Reduced mobility is defined as a decrease in mobility compared to baseline level or inability to participate in physical therapy.

− Central venous access device is defined as a non-tunneled catheter, tunneled catheter, or central venous catheter.

− Extensive burn is defined as a burn involving more than 50% of the body surface area.

− Major surgery refers to procedures lasting longer than 45 minutes.

− Critically ill patients are defined as those admitted to the intensive care unit or critical care unit (receiving inotropic support, mechanically ventilated).

− Thrombophilic states include antithrombin defects, protein C or S deficiency, Factor V Leiden, or prothrombin gene mutation.

− Active malignancy is defined as receiving chemotherapy/radiation therapy within the preceding 6 months.

− Active inflammatory disease includes Kawasaki disease, inflammatory bowel disease, systemic lupus erythematosus, or nephrotic syndrome.

− Estrogen therapy includes oral contraceptives or estrogen replacement therapy within the last 2 weeks.

− Obesity is defined as a BMI above the 95th percentile for age.

Key:

Low VTE risk:

• No altered mobility and 0-1 risk factor

Moderate VTE risk:

• No mobility impairment and 2-3 risk factors

• Altered mobility and 0-1 other risk factors

High VTE risk:

• No mobility impairment and ≥4 risk factors

• Altered mobility and ≥2 other risk factors

Thromboprophylaxis recommendation

Appendix B. Physician Action Algorithms

Appendix B1. Physician action algorithm for suspected proximal tibia fracture

Appendix B2. Assessment of Cardiovascular Surgical Risk

Notes and abbreviations:

CVRF – cardiovascular risk factors (arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women);

CVD – cardiovascular disease (coronary artery disease, cerebrovascular disease, peripheral artery disease, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies);

rRCRI - reconstructed RCRI index (See Appendix G2);

FS – functional status (the patient's ability to climb 2 flights of stairs independently without stopping before the injury).

*- regional vascular center or specialized cardiological department.

Appendix C. Patient Information

Proximal tibia fractures are severe injuries requiring specialized treatment in a trauma department. Conservative treatment for such injuries is possible only for non-displaced fractures. This type of treatment involves prolonged immobilization with a plaster cast or equivalent devices. Its main disadvantage is the extended treatment duration and the need for prolonged rehabilitation, as immobilization results in contracture of the hip, knee, and ankle joints. Surgical treatment is indicated for all displaced fractures. Various configuration plates, intramedullary nails, and external fixation devices in various assemblies can be used to treat proximal tibia fractures. Treatment can be single-stage (for isolated closed fractures with satisfactory soft tissue condition) or two-stage, where the fracture is temporarily fixed with an external fixator followed by conversion to internal fixation (for multiple and polytrauma injuries, severe open fractures, and significant soft tissue trauma). For juxta-articular proximal tibia fractures, complete anatomical restoration of the injured bone is not required; restoring the axis, limb length, and eliminating rotational displacement is sufficient. In most cases, minimally invasive osteosynthesis techniques that do not involve opening the fracture site are used for this purpose. Unlike extra-articular fractures, intra-articular fractures require complete restoration of the articular surface anatomy. To achieve this, it is usually necessary to open the fracture site and reduce the fragments under direct visualization. In all cases, the goal should be stable osteosynthesis that does not require additional external immobilization postoperatively. This allows early rehabilitation treatment to be initiated.

Rehabilitation treatment should begin immediately after surgery. It consists of passive and active movements in the lower extremity joints, physiotherapeutic procedures, and exercises aimed at normalizing trophic processes in the damaged soft tissues and bone. The timing for allowing weight-bearing on the limb may vary depending on the fracture pattern and fixation method. Following osteosynthesis of proximal tibia fractures with plates, weight-bearing is permitted no earlier than 6–8 weeks postoperatively. If the fracture was intra-articular, weight-bearing is delayed further and permitted no earlier than 3 months from the time of surgery.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Caprini Risk Assessment Scale for Venous Thromboembolism (Caprini J.)

Name in Russian: Caprini Risk Assessment Model for Individual Risk of Venous Thromboembolic Complications

Original title: Caprini Score for Venous Thromboembolism

Source: Lobastov K.V., Barinov V.E., Schastlivtsev I.V., Laberko L.A. Caprini scale as a tool for individual stratification of the risk of postoperative venous thromboembolism in a high-risk group. Khirurgiya. Zhurnal im. N.I. Pirogova. 2014; (12):16-23.

Type: scale

Purpose: assessment of venous thromboembolism risk

Content (template):

1 point

Age 41–60 years

Lower extremity edema

Varicose veins

Body mass index over 25 kg/m2

Minor surgery

Sepsis (within 1 month)

Serious pulmonary disease (including pneumonia within 1 month)

Oral contraceptive use, hormone replacement therapy

Pregnancy and postpartum period (up to 1 month)

History of unexplained stillbirths, spontaneous abortions (≥3),

Premature birth with preeclampsia or intrauterine growth restriction

Acute myocardial infarction

Chronic heart failure (within 1 month)

Bed rest in a non-surgical patient

History of inflammatory bowel disease

Major surgery within the past 1 month

Chronic obstructive pulmonary disease

2 points

Age 61–74 years

Arthroscopic surgery

Malignant neoplasm105

Laparoscopic surgery (duration > 45 min)

Bed rest > 72 h

Limb immobilization (within 1 month)

Central venous catheterization

Major surgery (duration > 45 min)

3 points

Age > 75 years

Personal history of VTE

Family history of VTE

Factor V Leiden mutation

Prothrombin G20210A mutation

Hyperhomocysteinemia

Heparin-induced thrombocytopenia

Elevated anticardiolipin antibodies

Lupus anticoagulant

5 points

Stroke (< 1 month)

Multiple trauma (< 1 month)

Major joint arthroplasty

Femur and lower leg fractures (< 1 month)

Spinal cord injury/paralysis (< 1 month)

Key: Depending on the score obtained from history taking and patient examination, the patient is assigned to a specific risk group:

• low risk: 0–1 points;

• moderate risk: 2 points;

• high risk: 3–4 points;

• very high risk: 5 points or more

Appendix G2. Revised Cardiac Risk Index (rRCRI)

Russian title: Reconstructed Revised Cardiac Risk Index for noncardiac surgical procedures

Original title: Reconstructed Revised Cardiac Risk Index (rRCRI)

Source: Davis C., Tait G., Carroll J. et al. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can. J. Anaesth. 2013; 60(9): 855-863.

Type: scale

Purpose: prediction of the risk of perioperative cardiac complications in noncardiac surgery: myocardial infarction, pulmonary edema, ventricular fibrillation or cardiac arrest, complete AV block.

Content:

1. High-risk surgery (intrathoracic, intra-abdominal, or vascular surgery above the groin) - 1 point.

2. Coronary artery disease (myocardial infarction, positive stress test, angina, use of nitroglycerin, pathological Q wave on ECG) - 1 point.

3. Heart failure (history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, bilateral rales, gallop rhythm, pulmonary congestion on chest X-ray) – 1 point.

4. TIA/Stroke - 1 point.

5. Creatinine clearance <30 mL/min – 1 point

Scoring:

• total score of 0 – low risk of cardiovascular complications;

• a total score of 1 – moderate risk of cardiovascular complications;

• a total score of 2 or more – high risk of cardiovascular complications.

Notes:

The RCRI score was developed in 1977 [147] to predict the risk of perioperative cardiac complications in non-cardiac surgery. It was validated in the Lee study [148], and in 2013 [149] it was revised and re-validated based on clinical risk factors (the criterion "creatinine level >176.8 µmol/L" was replaced by "creatinine clearance <30 mL/min", and the clinical criterion "insulin-dependent diabetes mellitus" was removed); therefore, it is referred to as the revised index. It includes 5 parameters, each assigned 1 point. This specific version of the index is recommended by the Russian Society of Cardiology [41].