Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table. A leg holder was utilized to facilitate varus manipulation for joint distraction, with the knee slightly flexed to allow optimal access to the lateral aspect of the tibia.

Anatomical surgical approach:  A lateral parapatellar approach was employed for the tibial plateau fixation. The incision extended from the lateral aspect of the patella, curving distally along the lateral border of the tibial tuberosity. Subperiosteal dissection was performed to expose the lateral tibial plateau. Joint visualization was enhanced using a medial and lateral dialing distractor system.

Intraoperatively, careful sequencing was critical due to the complex fracture pattern. The tibial plateau was stabilized first using standard fixation techniques, ensuring that implant placement did not obstruct subsequent nailing of the shaft fracture. A blocking screw was inserted to prevent valgus malalignment during intramedullary nail insertion. An intraoperative flat plate X-ray was obtained prior to locking the nail to confirm accurate alignment, as fluoroscopic assessment alone was deemed insufficient.

Postoperative protocol:   Postoperatively, the patient was placed in a hinged knee brace allowing controlled range of motion exercises starting from day one. Toe-touch weight bearing (TTWB) was advised for the first six weeks, progressing to partial weight bearing (PWB) by week seven, and full weight bearing (FWB) by week twelve, contingent on radiographic evidence of healing.

Follow up:   Not specified.

Orthopaedic implants used:   Lateral tibial plateau locking plate, intramedullary nail, blocking screw.