# Tibial Plateau Fractures: Imaging, Planning, and Fixation

## Anatomy

### Tibial Plateau Surface

The proximal tibial articular surface is divided into two distinct plateaus with different mechanical properties. The medial plateau is larger, concave, and composed of stronger subchondral bone that resists depression. The lateral plateau is smaller, convex, and has weaker subchondral bone, making it more susceptible to articular depression. The tibial eminence (intercondylar spines) rises between the plateaus and serves as the attachment site for the ACL and menisci. The posterior slope of the tibial plateau measures approximately 7-10 degrees, and restoring this slope is important for maintaining proper sagittal alignment.

### Menisci

The medial meniscus is attached to the MCL and is relatively immobile, making it more commonly injured in association with medial plateau fractures. The lateral meniscus is less tethered and more mobile but is frequently entrapped within depressed lateral plateau fracture fragments. Meniscal pathology accompanies 50-90% of tibial plateau fractures, and MRI or arthroscopy should be considered for assessment.

### Ligamentous Structures

The cruciate ligaments may be injured, especially in high-energy fracture patterns (Schatzker IV-VI). The MCL is commonly injured with lateral plateau fractures from a valgus mechanism. The posterolateral corner (PLC) is at particular risk with Schatzker IV medial plateau fractures and should be carefully assessed.

### Neurovascular Anatomy

The popliteal artery is tethered at the soleal arch and is at risk in high-energy fractures, particularly Schatzker IV and VI patterns. The common peroneal nerve wraps around the fibular neck and is vulnerable in lateral injuries and proximal fibula fractures. Dorsalis pedis and posterior tibial pulses, along with peroneal nerve function, must always be assessed.

## Classification Systems

### Schatzker Classification

| Type | Pattern | Typical Patient | Key Associations | Treatment |
|------|---------|----------------|------------------|-----------|
| I | Pure lateral split | Young, dense bone | Lateral meniscus tear | Percutaneous screws or lateral plate |
| II | Lateral split-depression | Most common overall | Lateral meniscus entrapment | Elevation, bone graft, lateral plate |
| III | Pure lateral depression | Elderly, osteoporotic | Lateral meniscus injury | Elevation, subchondral support, plate |
| IV | Medial plateau | High-energy | PLC injury; vascular injury | Posteromedial plate; assess vascularity |
| V | Bicondylar | High-energy | Ligamentous injuries | Dual plating (lateral + medial) |
| VI | Bicondylar + meta-diaphyseal dissociation | High-energy | Compartment syndrome; vascular injury | Dual plating; staged approach |

The Schatzker system remains the most widely used classification. Type I is a pure lateral split fracture, typically seen in younger patients with dense bone. Type II is a lateral split-depression pattern and is the most common type overall. Type III is a pure lateral depression, typically occurring in elderly patients with osteoporotic bone. Type IV is a medial plateau fracture representing a high-energy injury with associated vascular and ligamentous injuries. Type V is a bicondylar fracture. Type VI is bicondylar with metaphyseal-diaphyseal dissociation. Types IV through VI carry significantly worse prognoses.

### Three-Column Classification (Luo)

The Luo three-column classification divides the tibial plateau on axial CT into three columns. The lateral column lies lateral to the tibial tubercle ridge. The medial column is medial to the popliteal groove. The posterior column occupies the space between the lateral and medial columns, posterior to a coronal reference line. Each column is assessed independently for fracture involvement, and each fractured column may require independent plate fixation. This system is particularly valuable for identifying posterior column fragments that are frequently missed on plain radiographs.

### Moore Classification (Tibial Plateau Fracture-Dislocations)

The Moore classification addresses fracture-dislocations with subluxation, describing five types based on fracture pattern and direction of displacement. These injuries are associated with high rates of ligamentous and vascular injury.

## Imaging

### Plain Radiographs

AP, lateral, and oblique views provide initial fracture assessment including depression depth, condylar widening, and overall fracture pattern. However, plain radiographs are limited in their ability to demonstrate posterior fragments and quantify articular depression.

### CT with 3D Reconstruction

CT is essential for all operatively managed tibial plateau fractures. It quantifies articular depression and fragment displacement, identifies posterior column fractures (commonly missed on radiographs), guides surgical approach selection and plate positioning, and allows detailed preoperative planning. Three-dimensional reconstructions with axial cuts are the current standard of care.

### MRI

MRI is useful for assessing associated soft tissue injuries including meniscal tears and ligament disruptions. It is not routinely required for fracture classification but should be considered when ligamentous instability is clinically suspected.

## Nonoperative Management

### Indications

Nonoperative treatment is appropriate when articular step-off is less than 2-3 mm, condylar widening is less than 5 mm, there is no associated ligamentous instability, the fracture is stable to varus and valgus stress under anesthesia, and alignment is acceptable on full-length radiographic views.

### Protocol

Treatment involves a hinged knee brace allowing range of motion with non-weight-bearing or touch-down weight-bearing for 6-8 weeks. Weight-bearing is progressively advanced based on radiographic evidence of healing. Close radiographic follow-up is necessary to detect late subsidence.

## Operative Management

### Timing

Soft tissue assessment is critical to timing. Surgery should be delayed until the "wrinkle sign" appears (indicating resolution of soft tissue swelling). A temporary spanning external fixator is applied if surgery must be delayed due to polytrauma or soft tissue compromise. Definitive fixation for high-energy patterns is typically performed at 7-14 days after injury.

### Surgical Approaches

#### Anterolateral Approach

The anterolateral approach is the standard workhorse for lateral plateau fractures (Schatzker I-III). A submeniscal arthrotomy allows direct visualization of the articular surface. The depressed lateral plateau can be elevated through a cortical window below the fracture. Fluoroscopic assessment confirms reduction quality using traction and stress views.

#### Posteromedial Approach

The posteromedial approach addresses medial plateau and posteromedial fracture fragments. The surgical interval lies between the pes anserinus anteriorly and the medial gastrocnemius posteriorly. It allows direct plating of the posteromedial column and is often combined with an anterolateral approach for bicondylar fractures.

#### Posterior Approaches

The Frosch or Lobenhoffer posterolateral approach provides access to posterolateral fragments. Performed in prone or lateral decubitus positioning, these approaches have become increasingly utilized as the three-column concept has highlighted the importance of addressing posterior fragments with direct plate application.

#### Dual Approaches

Bicondylar fractures (Schatzker V-VI) typically require dual approaches. The anterolateral plus posteromedial combination is most common. A skin bridge of at least 7 cm must be maintained between incisions to minimize wound complications. Both approaches can be performed with the patient supine using a bump under the hip.

### Fixation Techniques

#### Lateral Locking Plate

Anatomically contoured periarticular locking plates are applied to the lateral column through the anterolateral approach. A subchondral raft of locking screws supports the articular surface against subsidence. MIPO technique reduces soft tissue stripping.

#### Medial Buttress Plate

For medial plateau fractures or medial column involvement, a buttress plate is applied through the posteromedial approach. Options include 3.5 mm reconstruction plates or anatomically designed medial tibial plates.

#### Dual Plating

Lateral and medial (or posteromedial) plates are used for bicondylar fractures. This configuration is biomechanically superior to a single lateral locked plate for bicondylar patterns because each plate independently addresses its respective column.

#### Subchondral Rafting Screws

Multiple screws placed parallel to and just beneath the articular surface support elevated fragments against secondary subsidence. They are an essential component of lateral locked plating constructs.

#### Bone Grafting / Bone Substitutes

After elevation of depressed articular fragments, the resulting subchondral void must be filled to prevent secondary subsidence. Options include autograft (iliac crest), allograft (cancellous chips), or calcium phosphate cement. Calcium phosphate cement provides immediate structural support and is particularly useful in osteoporotic bone.

### Arthroscopic-Assisted Fixation

Arthroscopy provides direct visualization of articular reduction without requiring a large arthrotomy. It is useful for Schatzker I-III fractures, allows identification and treatment of meniscal tears simultaneously, and enables percutaneous screw fixation and subchondral bone grafting through a cortical window. While minimally invasive, it requires arthroscopic experience and is limited for complex fracture patterns.

## Posteromedial Fragment Management

### Importance

The posteromedial fragment is a critical determinant of varus alignment and overall knee stability. If left unaddressed, it leads to varus subsidence and instability over time. It is best visualized on axial and sagittal CT cuts and requires a direct posterior or posteromedial surgical approach with plate fixation. It cannot be adequately addressed from an anterolateral approach alone.

## Postoperative Management

### Rehabilitation

Early range of motion (0-90 degrees) begins within the first week. Patients remain non-weight-bearing or touch-down weight-bearing for 8-12 weeks. Weight-bearing is advanced progressively based on radiographic evidence of healing, with full weight-bearing typically permitted by 12 weeks. Quadriceps strengthening and proprioceptive training are essential components of rehabilitation.

### Complications

Articular subsidence (loss of reduction) occurs particularly when subchondral support is inadequate. Infection rates range from 2-10% depending on fracture severity and soft tissue status. Compartment syndrome occurs in 5-10% of cases and requires a high index of suspicion. Malunion with varus, valgus, or flexion deformity can significantly impair function. Post-traumatic arthritis develops in 20-40% of patients at long-term follow-up. Stiffness is common, making early ROM and aggressive therapy essential. Hardware prominence, particularly lateral plates irritating the iliotibial band, sometimes necessitates removal.

<image>A diagram of the Schatzker classification of tibial plateau fractures (Types I through VI). Show anteroposterior views of the proximal tibia for each type: Type I (lateral split), Type II (lateral split-depression), Type III (pure lateral depression), Type IV (medial plateau), Type V (bicondylar), and Type VI (bicondylar with metaphyseal-diaphyseal dissociation). Label each type and include arrows showing the direction of displacement or depression.</image>

<image>An axial CT diagram of the three-column classification (Luo) of the tibial plateau. Show an axial view of the proximal tibia divided into three columns: lateral column (anterior to the fibular head), medial column (medial to the popliteal groove), and posterior column (between the two, posterior to a coronal reference line through the posterior tibial cortex). Color-code each column and indicate the typical plate placement for each column when fractured.</image>

<image>A surgical illustration showing dual plating of a bicondylar tibial plateau fracture (Schatzker V). Display an anteroposterior view with a lateral periarticular locking plate applied through an anterolateral approach and a medial buttress plate applied through a posteromedial approach. Show subchondral raft screws supporting the articular surface beneath each plateau. Include a cross-sectional inset showing the bone graft filling the subchondral void after articular elevation.</image>

## Clinical Pearls

CT is mandatory for operative planning of tibial plateau fractures because plain radiographs underestimate depression and miss posterior fragments. The posteromedial fragment is a critical determinant of varus alignment, and failure to address it leads to malunion. Soft tissue condition dictates timing; never operate through tense, blistered skin, and use temporary spanning external fixation instead. Dual plating is biomechanically superior to a single lateral locked plate for bicondylar fractures (Schatzker V-VI). Meniscal injuries are present in the majority of tibial plateau fractures, warranting consideration of MRI or arthroscopy for assessment and treatment. Schatzker IV (medial plateau) fractures are high-energy injuries that require vascular assessment and evaluation for posterolateral corner injury. Calcium phosphate cement is a useful void filler in osteoporotic bone, providing immediate structural support after articular elevation. A minimum 7 cm skin bridge must be maintained between dual incisions to minimize wound complications.

## References

- Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto experience. *Clin Orthop Relat Res*. 1979;(138):94-104.
- Luo CF, et al. A new concept of tibial plateau fracture: the three-column classification. *Chin Med J*. 2010;123(21):2978-2983.
- Metcalfe D, et al. Tibial plateau fractures: a systematic review of fixation methods. *J Orthop Traumatol*. 2015;16(4):287-297.
- Barei DP, et al. 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.
- Marsh JL, et al. Articular fractures: does an anatomic reduction really change the result? *J Bone Joint Surg Am*. 2002;84(7):1259-1271.