TraumaLower Extremity/Lower Extremity

Tibial Plateau Fractures

·       Associated soft-tissue injuries (meniscus and ligamentous injuries) are frequent and influence management and outcomes. ·       Diagnosis is made with initial radiographs; CT is used for fracture characterization and surgical planning, and MRI is useful for evaluating associated meniscal/ligament injuries when indicated. ·       Treatment is selected based on fracture displacement, stability, alignment, and soft-tissue status; ORIF is preferred when soft tissues permit, while staged fixation (external fixation followed by ORIF) or circular fixation (Ilizarov) may be used when soft tissues are compromised.

Resident Dr. Murat HAKYOLDAS· Umraniye Training and Research Hospital, Istanbul
May 10, 2026

EPIDEMIOLOGY

INCIDENCE

·       1–2% of all fractures

·       10.3 per 100,000 people annually

DEMOGRAPHICS

·       Mean age: 52

·       Bimodal distribution

o   Males in 40s (high-energy trauma)

o   Females in 70s (low-energy falls)

LOCATION

·       Lateral plateau: 70–80%

·       Bicondylar: 10–30%

·       Medial plateau: 10–20%

ETIOLOGY

MECHANISM

·       Fracture location and pattern are determined by the direction/magnitude of applied load and bone quality.

·       Lateral plateau fractures typically occur with valgus loading.

·       Medial plateau fractures typically occur with varus loading.

·       Bicondylar patterns are commonly associated with axial loading mechanisms.

ASSOCIATED CONDITIONS

·       Lateral meniscus tears occur more frequently than medial tears and are commonly associated with Schatzker type II fractures.

·       Medial meniscus tears are more commonly associated with Schatzker type IV fractures.

·       Most frequently associated ligament injury: medial collateral ligament (MCL), followed by anterior cruciate ligament (ACL).

·       Posterior cruciate ligament (PCL) injuries occur more frequently in Schatzker type IV and VI fractures.

·       Schatzker type IV fractures show higher association with neurovascular injuries, most commonly involving the peroneal nerve.

ANATOMY

·       The lateral tibial plateau is convex, while the medial tibial plateau is concave.

·       Posterior tibial slope is typically 6–10°, and the proximal tibia demonstrates approximately 3° of varus alignment relative to the mechanical axis.

BIOMECHANICS

·       Approximately 60% of the load is transmitted through the medial tibial plateau, while the remaining 40% is borne by the lateral plateau.

KINEMATICS

·       Normal knee flexion–extension arc is approximately 140°.

·       Posterior femoral rollback and the screw-home mechanism are key contributors to normal knee kinematics.

CLASSIFICATION

Schatzker Classification

·       Type I – Lateral split fracture

·       Type II – Lateral split-depression fracture

·       Type III – Pure depression fracture

·       Type IV – Medial plateau fracture

·       Type V – Bicondylar fracture

·       Type VI – Plateau fracture with metaphyseal–diaphyseal dissociation

Hohl and Moore Classification

·       Type I – Coronal split fracture

·       Type II – Entire condylar fracture

·       Type III – Rim avulsion fracture

·       Type IV – Rim compression fracture

·       Type V – Four-part fracture

3-Column Concept

·       Lateral column

·       Medial column

·       Posterior column

PRESENTATION

·       Tibial plateau fractures commonly present with inability to bear weight after injury.

·       Physical examination typically demonstrates tenderness over the proximal tibia, knee swelling and ecchymosis, and restricted range of motion.

·       Careful assessment of neurovascular status and soft-tissue condition is essential, particularly in high-energy injuries.

IMAGING

RADIOGRAPHS

·       Standard evaluation includes AP, lateral, and 10-degree oblique plateau radiographs.

·       Radiographs may demonstrate plateau depression, medial or lateral subluxation, and irregularity or discontinuity of the joint line.

CT

·       CT is critical for fracture characterization and preoperative surgical planning, particularly for articular depression, comminution, and column involvement.

MRI

·       MRI is useful for detecting associated meniscal and ligament injuries, and for evaluating occult soft-tissue injury patterns when management may change.

DIFFERENTIAL

·       Distal femur fracture

·       Knee dislocation

·       Patellar instability

·       Patella fracture

·       Patellar tendon rupture

·       Quadriceps tendon rupture

·       ACL tear

·       Meniscus tear

TREATMENT

·       Management includes both nonoperative and operative strategies and should be individualized according to fracture displacement, stability, alignment, patient factors, and soft-tissue envelope.

NONOPERATIVE

·       Minimally displaced, nondepressed fractures and patients unable to tolerate surgery may be treated with a long-leg cast, splint, or hinged knee brace.

·       Typical protocol includes restricted or non–weight bearing for 6–8 weeks, followed by gradual progression of weight bearing with close clinical and radiographic follow-up.

OPERATIVE

·       Options include closed reduction with cannulated screw fixation, ORIF with plating, and external fixation or Ilizarov techniques in patients with compromised soft tissues.

·       Primary arthroplasty may be considered in selected patients >65 years with osteoporotic fracture patterns or those who develop advanced post-traumatic osteoarthritis.

·       Surgical approaches are selected based on fracture pattern and may include anterolateral, anteromedial, posteromedial, or posterior approaches.

·       Arthrotomy may be performed for meniscal evaluation/repair and to guide elevation of depressed articular segments.

·       Bone void management may include autograft, allograft, or bone substitute depending on defect size and patient factors.

·       Postoperative care commonly includes hinged knee bracing for 8–12 weeks and progressive rehabilitation guided by stability and healing.

COMPLICATIONS

·       Post-traumatic arthritis

·       Compartment syndrome

·       Infection

·       Malunion or nonunion

·       Knee stiffness

·       Deep vein thrombosis

·       Loss of reduction

PROGNOSIS

·       Mortality rate: ~5% at 1 year

·       Return to work: 70–90% at 1 year (residual dysfunction or reduced workload is common)

·       Mean ROM at 1 year: approximately 10–145 degrees

References

1.     Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto experience 1968–1975. Clin Orthop Relat Res. 1979;(138):94–104.

2.     Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium – 2007: Orthopaedic Trauma Association classification. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.

3.     Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am. 2006;88(8):1713–1721.

4.     Hohl M, Moore TM. Articular fractures of the proximal tibia. In: Evarts CM, ed. Surgery of the Musculoskeletal System. 2nd ed. New York: Churchill Livingstone; 1990:3193–3218.

5.     Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury. 2018;49(12):2252–2263.

6.     Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010;24(11):683–692.

7.     Gardner MJ, Yacoubian S, Geller D, et al. Prediction of soft-tissue injuries in Schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma. 2006;60(2):319–323.

8.     Bennett WF, Browner B. Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma. 1994;8(3):183–188.

9.     Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures. 6th ed. Philadelphia: Wolters Kluwer; 2020.

10.  Rockwood CA, Green DP, Bucholz RW, Heckman JD, Tornetta P. Rockwood and Green’s Fractures in Adults. 9th ed. Philadelphia: Wolters Kluwer; 2020.

 

← All TopicsMore in Trauma →