Overview
Tibial plateau fractures account for about 18.6% of tibial fractures (AO). Split-depression fractures of the lateral plateau are the most common pattern (Rockwood). In a typical lateral condylar fracture, the lateral rim bursts outward and a fracture line runs longitudinally into the metaphysis, producing a large, usually triangular lateral fragment with its base proximal; the intact fibula usually holds this fragment at joint level (Campbell).
The aims of surgery are elevation of the depressed articular surface, support of the elevated segment, and buttressing of the lateral condyle (Campbell). The main goal in lateral-sided injuries is to prevent valgus deformity (Rockwood).
Relevant Anatomy
The lateral plateau is smaller, convex and slightly higher than the medial; the medial plateau is larger, concave and stronger. Lateral fractures are more common and tend to depress and comminute; medial fractures usually occur as a block and are associated with severe injuries and fracture-dislocations (AO; Rockwood).
The fibular head supports the proximal lateral plateau; an associated fibular head fracture increases knee instability and may worsen prognosis (AO; Rockwood).
Landmarks for incisions: tibial tubercle, Gerdy's tubercle, fibular head and lateral femoral epicondyle (AO).
At risk: peroneal nerve, popliteal artery and its trifurcation; the anterior tibial artery bifurcation lies 27–62 mm below the lateral plateau (AO).
Evaluation
Assess the energy of the injury, soft tissues (blisters, abrasions, deep contusion), and open wounds; high-energy injuries contraindicate immediate extensile surgery (AO).
Compartment syndrome: Repeated neurovascular assessment; pain on passive stretch is the most sensitive sign; paresthesia and paralysis are late (AO).
Absent pulses mean vascular injury until proven otherwise; consider Doppler, CT angiography or angiography without delaying revascularization (AO).
Imaging: AP and lateral radiographs (plus 45° obliques); CT with coronal, sagittal and 3D reconstructions is now standard and improves classification reliability; obtain it after reduction and splinting or spanning external fixation if possible (AO). Rockwood's authors regard CT as indispensable and review 3D images in difficult patterns.
MRI is more sensitive for meniscal and ligament injuries (meniscal tears in about 80%, ligament ruptures in about 40%) but is not routinely recommended acutely (AO); Rockwood's authors usually do not obtain it.
Examine ligament stability after fixation, not before (AO).
Classification
System | Use |
|---|---|
Schatzker | I split; II split-depression; III pure depression; IV medial plateau; V bicondylar; VI with metaphyseal–diaphyseal dissociation (AO; Rockwood) |
AO/OTA 41 | 41A extraarticular; 41B partial articular (B1 split, B2 depression, B3 split-depression); 41C complete articular (AO) |
Three-column (CT-based) | Lateral, medial and posterior columns; guides approach selection and placement of a buttress plate for each involved column (AO) |
Indications
AO: Open fractures; fractures with vascular injury or compartment syndrome; fracture-dislocations; displaced intraarticular fractures; articular depression causing knee instability; malalignment, particularly varus; polytrauma.
Rockwood: Displaced unstable fractures in which near-normal alignment cannot be expected with closed treatment. For lateral patterns, strong indications are a split fragment, depression involving more than half of the lateral articular surface, a fibular head fracture, valgus alignment on injury films or clinically, and varus–valgus instability on examination. A fixed number of millimeters of depression is unreliable as an indication, because plain-film measurement varies widely between observers.
Nonoperative treatment remains reasonable for many patterns with stable knees, particularly in elderly, low-demand or medically unfit patients; most need 4–8 weeks of non–weight bearing in a hinged brace with early motion (Rockwood). Some Schatzker II fractures with small fragments can be treated nonoperatively (Rockwood).
Timing
Staged treatment (emergency closed reduction and knee-spanning external fixation, then definitive fixation) for open fractures, acute vascular injury, severe closed soft tissue injury, and damage control in polytrauma (AO).
Definitive surgery is safe once swelling has resolved, usually at 10–14 days; skin wrinkling is a good clinical sign (AO).
Rockwood's authors have good experience with early definitive treatment when the soft tissue envelope is well preserved, reserving temporary spanning fixation for the most severe injuries; place tibial pins away from planned incisions.
Preoperative Planning (Rockwood)
Radiolucent table, supine; C-arm from the opposite side, able to rotate under the table for lateral views.
Equipment: reduction clamps, femoral distractor, long K-wires, osteotomes, bone tamps.
Implants: precontoured 3.5 mm lateral plateau plates, cannulated and noncannulated screws, void fillers.
Use the axial CT to locate and quantify the depression; the location of the split fragment guides the incision and access to the depressed fragments.
Useful Adjunct: Large Distractor
Place the femoral pin bicortically just anterior to the lateral femoral epicondyle (Campbell), or in the distal femoral condyles perpendicular to the mechanical axis (Rockwood), parallel to the joint.
Place the tibial pin in the lateral tibial cortex, well distal to the planned fixation, in the midcoronal plane and perpendicular to the tibia (Campbell; Rockwood).
Lengthening the distractor achieves much of the reduction by ligamentotaxis and improves the view into the joint (Campbell; AO). Apply the threaded bar posteriorly so it does not obstruct imaging (Rockwood).
Because the femoral pin is near the center of rotation of the femoral condyle, knee flexion and extension disturb the fracture very little (Campbell).
Surgical Technique
Positioning
Supine on a radiolucent table with the hip in neutral rotation; elevate the leg on a radiolucent platform or sterile bumps (Rockwood). Flex the knee about 30° for the approach (AO).
Perform the procedure under tourniquet control (Campbell; AO). A cordless headlight helps visualization (Rockwood).
Approach (Anterolateral)
Make a straight or slightly curved anterolateral incision, starting 3–5 cm above the joint line just anterior to the lateral femoral epicondyle and extending toward Gerdy's tubercle and distally just lateral to the tibial crest, below the inferior end of the fracture (Campbell; AO; Rockwood). A proximal S- or hockey-stick extension can be used (Rockwood).
Incise the fascia (iliotibial band) in line with the skin; avoid unnecessary undermining. Reflect the iliotibial band anteriorly and posteriorly off Gerdy's tubercle (Campbell). Preserve a soft tissue cuff next to the tibial crest to ease closure (Rockwood).
Submeniscal arthrotomy: Locate the joint line with a hypodermic needle and incise the coronary (meniscotibial) ligament (Campbell; Rockwood). Place nonabsorbable meniscocapsular tagging sutures and retract the meniscus superiorly (Campbell).
Inspect any meniscal tear; repair it whenever possible (AO; Rockwood) or debride it, preserving as much meniscus as possible (Campbell). A displaced meniscal tear trapped between fragments can block anatomic reduction (AO).
Expose the longitudinal fracture line by elevating the extensor muscle origin extraperiosteally from the anterolateral condyle (Campbell).
Elevating the Depressed Articular Surface
Book-opening: Retract the lateral fragment; it often hinges open like a book, exposing the depressed articular surface and cancellous bone (Campbell; Rockwood). Avoid stripping its posterior soft tissue attachments (Rockwood). An Inge lamina spreader is helpful (Campbell).
Alternative – cortical window: Make a cortical window below the depression; this needs less soft tissue dissection (Campbell; AO).
"Free up" the depressed fragments and surrounding bone with osteotomes (Rockwood). Insert a periosteal elevator or osteotome well beneath the fragments and, with slow careful pressure, elevate them en bloc with the compressed cancellous bone (Campbell). The more fragments are elevated from below in situ, and the fewer are freed completely, the better the final reduction (Rockwood).
Use the femoral condyle as a template (AO). Look for marginal impaction, usually more central toward the tibial spines; if it is not reduced, the central fragment cannot be elevated fully (Rockwood).
Hold fragments with K-wires; they can be overdrilled out through the medial skin so they do not interfere with the lateral plate (Rockwood; Campbell).
Height: The lateral plateau should sit slightly higher than the medial plateau on fluoroscopy. Because of the tendency to settle, slight overreduction is better than underreduction; contralateral images help (Rockwood).
Elevation leaves a large metaphyseal cavity, which must be filled; otherwise the fragments redisplace and settle (Campbell; AO; Rockwood).
Options: autograft, allograft, or synthetic substitutes (Campbell; AO; Rockwood).
Campbell's preference: Injectable bone substitute or allograft; recent data support structural allograft to reduce subsidence.
Rockwood's authors: Calcium phosphate cement, which currently has the best mechanical properties of available fillers, in paste form for easier handling and less risk of intraarticular extravasation. Insert screws before the cement, because it becomes brittle when it sets; impact allograft or autograft firmly beneath the fragments with a tamp.
Reduce the split fragment, using large clamps (e.g., a pelvic reduction clamp) to restore condylar width, and fix it temporarily with further K-wires (Rockwood; AO).
Extensile Exposure for Posterolateral Fractures (Campbell)
The standard lateral approach shows only part of the posterolateral plateau and gives no access to its posterior wall. For posterolateral fractures:
Extend the fascial incision along the extensor insertion and over the subcapital fibula.
Expose and protect the peroneal nerve.
Osteotomize the fibular neck with an oscillating saw; retracting the proximal segment backward, or rotating the fibular head upward, exposes the posterolateral plateau.
AO also describes a posterolateral approach (lateral position) with a second window behind the biceps tendon; plating there is difficult and dangerous because of the peroneal nerve and anterior tibial artery.
Mainly Central Depression With Minimal Rim Displacement (Schatzker III / 41B2)
Keep the lateral wall intact and reach the depression through an anterior cortical window, keeping its upper edge below the joint surface (Campbell; Rockwood).
Pass a curved bone tamp through the window into the subchondral bone and elevate the fragments to joint level, viewing through the submeniscal arthrotomy (Campbell) or with fluoroscopy or arthroscopy (Rockwood; AO).
Hold with multiple small K-wires, then stabilize with subchondral raft screws (Campbell). Small depressions can be elevated under fluoroscopy and supported with cannulated screws alone (Rockwood; AO).
Fixation
Apply a buttress plate to the anterolateral proximal tibia (Campbell; AO; Rockwood); a buttress is needed to prevent recurrence of valgus deformity (AO).
Precontoured 3.5 mm plates with 3.5 mm screws are currently preferred (Rockwood); 3.5 or 4.5 mm periarticular plates are available (Campbell).
Place three or four raft screws close to the articular surface to support the reduced fragments; many smaller screws support the fragments better than fewer larger screws (Rockwood). The plate's proximity to subchondral bone partly determines support (Rockwood).
Depending on plate fit, separate raft screws can be placed before the plate (Campbell).
Locking screws: Controversial for unicondylar fractures. Nonlocking screws compress the plate to bone, enhance the buttress effect and narrow the condylar width; fixation into intact medial bone prevents screw settling (Rockwood). For isolated simple lateral condylar fractures, nonlocking 3.5 mm implants are usually enough (Campbell). Rockwood's authors find locking screws unnecessary in most unicondylar fractures.
In good bone, nonlocking (e.g., LC-DCP) plates can buttress; small 2.4 or 2.7 mm locking plates can be used for fragment-specific fixation (AO).
Pure split fractures in good bone can be fixed with screws alone, perpendicular to the fracture, percutaneously (Rockwood; AO).
Fill the defect with cancellous bone or bone graft substitute (Campbell).
Incorporate the meniscocapsular tagging sutures into the repair, through the plate or the iliotibial band (Campbell); the coronary ligament can be repaired at the end (Rockwood).
Examine knee stability after fixation and record it in the operative note (AO).
Campbell's Concepts: Treating Articular Depression
Campbell prefers to treat articular depression through the primary condylar fracture line, under direct vision.
A bone tamp through a cortical window is rarely used: it depends on precise fluoroscopic triangulation, and the small leading edge of the tamp tends to punch through the depressed segment.
An instrument with a broad surface, such as the side of an osteotome, is preferred so the fragments can be elevated en bloc.
Associated Ligament Injuries
Ligament injuries occur in 4–33% of tibial plateau fractures and in 60% of fracture-dislocations. If missed, they can cause instability and a poor outcome despite a healed fracture (Campbell).
The MCL is most often injured, usually with undisplaced or local-depression lateral fractures; MCL injury is most common with Schatzker II and meniscal injury with type IV (Campbell). An intact MCL is generally required to produce a lateral plateau fracture (Rockwood).
In one prospective series, 56% had an additional soft tissue injury: meniscal tear 20%, MCL 20%, ACL 10%, LCL 3%, peroneal nerve 3% (Campbell).
Stress-examine before and after fixation; residual laxity after anatomic reduction means a ligament injury (Campbell; AO).
Displaced intercondylar eminence fragments: Fix at the same operation with sutures through bone tunnels or a small-fragment screw (Campbell).
Midsubstance ACL tear: Reconstruct later if significant laxity remains after healing (Campbell).
Acute midsubstance MCL tear: Usually heals without surgery; nonoperative management in a hinged brace is generally preferred (Campbell; Rockwood).
Postoperative Care
Use a removable knee immobilizer at rest to prevent flexion contracture (Campbell); many surgeons use a brace locked in extension for 2 weeks for wound healing, or CPM (AO).
Day 1–2: Quadriceps exercises and gentle active-assisted motion or CPM (Campbell; AO). Rockwood teaches unrestricted ROM in a hinged brace.
Weight bearing:
Campbell: no weight bearing for 8–12 weeks.
AO: toe-touch weight bearing for 6–8 weeks (10–12 weeks after very high-energy injuries).
Rockwood: non–weight bearing for 4–10 weeks depending on severity; studies challenging non–weight-bearing protocols are still too small to change practice.
Motion may be delayed after acute collateral ligament repair (Campbell).
Complications
Wound complications are the main early problem after high-energy fractures; minimize them with careful soft tissue assessment, timing, full-thickness flaps, extraperiosteal dissection and minimal stripping (AO).
Loss of reduction / articular settling: Postoperative collapse into valgus is more likely with severe depression and osteopenic bone; prevent it with complete reduction, raft screws close to the joint, and adequate void filling (Rockwood).
Stiffness and arthrofibrosis: If 90° of flexion is not reached within 12 weeks, consider gentle manipulation and arthroscopic lysis of adhesions (AO).
Nonunion at the metaphyseal–diaphyseal junction or late articular collapse; correct the mechanical axis and significant depression (AO).
Posttraumatic arthritis: Causes include axial malalignment, ligamentous instability, primary cartilage damage, meniscectomy, joint incongruity and infection; knee stability is believed to be the most important factor for long-term outcome (AO).
Intraarticular screw placement and anterior tibial artery injury during posterolateral dissection (Rockwood).
Unstable fixation that does not allow early motion may give worse results than nonoperative treatment (AO).
References
Rudloff MI. Fractures of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 59, Technique 59.12.
Luo CF. Tibia, proximal. In: Buckley RE, Moran CG, Apivatthakakul T, eds. AO Principles of Fracture Management. 3rd ed. Stuttgart: Thieme; 2017. Chapter 6.8.1. (Turkish edition: AO Kırık Tedavisinin Prensipleri.)
Maniar H, Horwitz DS. Tibial plateau fractures. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 62. (Turkish edition: Erişkin Kırıkları.)