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Tibial plateau fracture

107 citationsUpdated Sep 2026

Overview

Tibial plateau fractures result from varus or valgus forces combined with axial loads, typically during weight-bearing activities such as falls from height [13]. The magnitude, type, and direction of these forces dictate the fracture pattern, with axial loading releasing greater energy than angular forces [2]. Lateral condyle injuries are more common due to the knee’s natural valgus alignment and lateral exposure, while varus forces cause medial plateau failure [2]. Younger patients with good bone quality tend to sustain split fractures, whereas elderly patients with osteopenic bone exhibit greater compression components [2]. Bicondylar patterns occur when axial load predominates [2]. Clinically, the knee presents with swelling and haemarthrosis, and traction injuries to the peroneal or tibial nerves are not uncommon [13]. High-energy injuries carry a risk of vascular injury and compartment syndrome, and associated ligamentous damage is frequent in Schatzker types IV, V, and VI [2].

Nonoperative management is indicated for undisplaced or minimally displaced fractures, small lateral depressions without instability, and patients with significant comorbidities or low functional demands [1]. Properly selected fractures with articular step-offs up to 4 mm can achieve good functional outcomes without surgery, challenging the traditional 2-mm limit [81]. However, knee instability, predictable deformity, and displaced medial injuries are relative contraindications to nonoperative care [1]. Medial plateau fractures have a greater propensity to subside, potentially leading to varus deformity [1].

Operative treatment is a viable option for displaced fractures, including in patients older than 55 years, provided meticulous technique and adequate bone grafting are used to prevent collapse [32][12]. Post-operative complications are common, often stemming from inadequate surgeon experience, inaccurate diagnosis, or improper implant selection [23][6]. Older patients and those with severe fractures are more likely to require total knee arthroplasty, particularly if instability or nonunion develops [22][132].

Anatomy & Pathophysiology

Bony Anatomy

The knee possesses an average anatomic axis of 6° of valgus [19]. The proximal tibia is positioned in 3° of varus, with the lateral plateau sitting slightly higher than the medial plateau [19]. Morphologically, the lateral tibial plateau is smaller and convex, while the medial plateau is larger and concave [19]. The medial plateau accommodates 60% of the weight distributed through the knee [19]. According to Wolff's law, this distribution of weight results in increased bone density of the medial plateau [19]. Fracture distribution reflects these biomechanics: the lateral plateau is affected exclusively in 55% to 70% of tibial plateau fractures [19]. Medial plateau unicondylar fractures occur in 10% to 23% of cases [19]. Bicondylar fractures occur in 10% to 30% of cases [19].

The proximal articular surface slopes from the front (proximal) to the back (distal) relative to the shaft [25]. The range of varus coronal slope is between −1 and 6 degrees [25]. The range of sagittal slope is from 0 to 14 degrees on the lateral side and −3 to 10 degrees on the medial side [25]. The tibial shaft is triangular in cross section [64]. The tibial tubercle is located anterolaterally about 3 cm distal to the articular surface and serves as the attachment point for the patellar tendon [64]. Gerdy’s tubercle is located laterally on the proximal tibia and serves as the insertion point for the iliotibial band [64]. The pes anserinus is located medially on the proximal tibia and serves as the insertion point for the sartorius, gracilis, and semitendinosus muscles [64].

The proximal fibula buttresses the lateral plateau [25]. Associated fractures of the proximal fibula result in a greater degree of valgus instability and indicate a more severe lateral fracture [25]. The proximal tibiofibular joint is a synovial joint that may communicate with the knee joint [25].

Soft Tissue & Neurovascular Anatomy

Both the medial and lateral articular surfaces are covered by hyaline cartilage [25]. Both plateaus are partially covered by fibrocartilaginous menisci attached by the menisci tibial ligaments (coronary ligaments) [25]. The intercondylar eminence and medial and lateral tibial spines are nonarticular structures that separate the two plateaus [25]. The ACL attaches anterior to the medial spine and the PCL extends down to the posterior surface of the proximal tibia [25]. The tibial spines are attachment points for the ACL, PCL, and menisci [64]. The medial collateral ligament inserts into the medial proximal tibia [64]. The lateral collateral ligament inserts into the fibular head [64].

The common peroneal nerve courses around the neck of the fibula distal to the proximal tibiofibular joint before dividing into superficial and deep branches [64]. The common peroneal nerve runs under the cover of the biceps femoris and rests on the back of the neck of the fibula [25]. The trifurcation of the popliteal artery into the anterior tibial, posterior tibial, and peroneal arteries occurs posteromedially at the level of the proximal tibia [64]. The anterior tibial artery is bound at the interosseous membrane and is at particular risk in shaft-dissociated fracture patterns [25].

The proximal anterior two-thirds of the tibia are largely subcutaneous [25]. The posterior tibia is deep beneath the structures crossing the popliteal fossa, making direct surgical exposures in this area difficult [25]. The pes tendons, gracilis, sartorius, and semitendinosus insert on the anteromedial portion of the proximal tibia distal to the patellar tendon insertion [25]. The anterior compartment muscles, tibialis anterior, and extensor digitorum longus arise from the inferior surface of the lateral condyle of the tibia [25]. The medial head of the gastrocnemius arises from the posterior femur just above the posterior medial femoral condyle [25].

Mechanisms of Injury

The magnitude, type, and direction of forces that injure the knee dictate the fracture pattern [2]. The greater the energy absorbed by the proximal tibia, the more severe the fracture and the more fragments are displaced and comminuted [2]. In cadavers, pure valgus forces produce typical split fractures, axial forces produce local compression fractures, and combinations of both produce split depression fractures [2]. The intact medial collateral ligament acts like a hinge for the lateral femoral condyle and must be present for the lateral plateau to fracture [2]. A valgus force loads the lateral tibial plateau to failure from direct impact with the lateral femoral condyle [2].

Younger patients with good bone tend to have split fractures with less depression [2]. Elderly patients with osteopenic bone have a greater component of compression with a less prominent split fragment [2]. Varus injuries lead to failure of the medial plateau less commonly than lateral-side fractures [2]. A posteromedial shearing fracture of the medial plateau is a common medial-side pattern and can occur as an isolated split fracture or as part of a bicondylar fracture pattern [2]. The mechanism for posteromedial shearing fractures has been described as knee flexion, varus, and internal rotation of the medial femoral condyle [2]. Bicondylar patterns result when axial load predominates [2]. In a patient with a valgus knee, an axial force may shear the medial tibial condyle and produce a medial plateau fracture or fracture-dislocation [2].

Metaphyseal region fractures occur from direct trauma and/or a combination of axial load and bending forces [2]. Metaphyseal region fractures involve the tibial shaft being separated from the condyles with proximal extensions of fracture lines into the plateau [2]. Tibial plateau fractures are caused by a varus or valgus force combined with axial loads, usually from a fall from height [13]. Tibial plateau fractures result from direct axial compression—usually with a valgus (more common) or varus (less common) moment—and indirect shear forces [64]. The direction, magnitude, and location of the force as well as the position of the knee at impact determine the fracture pattern, location, and degree of displacement [64]. Tibial plateau fractures demonstrate distinct, mechanism-associated 3-dimensional pattern characteristics [5]. The impressive mechanisms of injury associated with tibial plateau fractures result in equally extensive injuries to the affected joint [9].

In younger patients with more robust bone quality, the plateau is broken into various fragments after high-energy trauma, typified by more comminution and less joint line depression [19]. Trademarks of high-energy fractures include involvement of the medial plateau and the tibial spine and complete dissociation of the proximal tibial metaphysis [19]. In the elderly, low-energy mechanisms result in lateral plateau fractures with articular depression [19]. Split or wedge fractures occur in younger patients with stiffer bone, whereas depression fractures occur in older bone which is less able to withstand compression [30]. High-energy proximal tibia injuries result in increased comminution and less predictable fracture patterns [30]. High-energy fractures are often associated with medial plateau involvement [30]. Isolated medial plateau injuries typify the higher level of damage associated with more severe mechanisms of injury [30]. Isolated medial plateau injuries typically involve both lateral collateral and anterior cruciate ligament injuries and can result in a fracture dislocation of the knee [30]. Fractures of the tibial spine correlate to cruciate ligament dysfunction [57]. Different angles of knee flexion under axial impact loading are possibly the interpretations for the two fracture patterns (split and depression) [130].

Associated Injuries

Patients with tibial plateau fractures frequently have associated injuries that may influence how the plateau fracture is managed [2]. MCL injuries can be associated with lateral tibial plateau fractures [2]. Serious disruption of the stabilising structures of the knee are associated with relatively innocuous appearing marginal fractures of the tibial plateau [16]. The combination of shearing and compressive loads imparts a high risk of injury to the menisci, ligaments, peroneal nerve, and popliteus vessels [19]. Over the past decade, the ubiquity and severity of soft-tissue damage related to these fractures have become more apparent and have affected the way these fractures are managed [19].

Meniscal tears are associated with up to 50% of tibial plateau fractures [64]. Associated injury to the cruciate or collateral ligaments occurs in up to 30% of patients [64]. Skin compromise is frequently present in high-energy fracture patterns [64]. In a review of 190 proximal tibial articular fractures, 67% of meniscal injuries occurred in plateau fracture patterns [33]. In a review of 190 proximal tibial articular fractures, 96% of cruciate injuries occurred in fracture-dislocation patterns [33]. In a review of 190 proximal tibial articular fractures, 85% of medial collateral ligament injuries occurred in fracture-dislocation patterns [33]. Peroneal nerve injury was twice as common in fracture-dislocation patterns compared to pure plateau fracture patterns [33]. Complex fractures involving the femoral and tibial surfaces had a 25% incidence of vascular injury and 25% incidence of compartment syndrome [33]. In 19 complex fractures with severe soft-tissue injury, vascular injury occurred in 31%, compartment syndrome in 31%, and peroneal nerve injury in 23% [33].

A 2005 series using MRI evaluation of surgical tibial plateau fractures found that the incidence of intracapsular soft-tissue injuries was almost universal [57]. In a 2005 series using MRI evaluation, lateral meniscus injury was the most common intracapsular soft-tissue injury at 91% [57]. In a 2005 series using MRI evaluation, ligamentous injury was noted in most fractures at 77% [57]. Intraoperative correlation has shown that only 30% of fractures have lateral meniscus tears that actually require surgical repair [57]. The presence of posterolateral tibial plateau fractures is associated with increased anterolateral rotational knee laxity and a high probability of concomitant anterolateral complex injuries [95].

Pathophysiology & Clinical Consequences

Tibial plateau fractures are intra-articular fractures that affect the alignment, stability, and movements of the knee joint [14]. Any possible motional limitation and change in the alignment may cause deterioration in walking and other functions [14]. Tibia plateau fractures, if not treated effectively and properly, result in permanent deformities and disability [14]. Progressive incapacitating posttraumatic arthritis is actually very unusual in properly selected nonoperatively treated fractures [1]. Malalignment may be cosmetically unacceptable and increases the propensity for knee instability, causing balance issues and leading to falls [1]. The risk of development of deformity is related to the articular depression, but this relationship is not 1:1 [1].

Gait limitations in patients with intra-articular tibial plateau fractures are mainly related to the inability to extend the knee [17]. While kinetic variables improved over time, there were no improvements observed in kinematic variables in a longitudinal study of gait following tibial plateau fractures [101]. Tibial plateau fractures decrease the function of the knee when compared with the contralateral side and to the preoperative condition [87]. Bicondylar fractures are associated with worse functional outcomes compared to other tibial plateau fracture types [87]. Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome for medial tibial plateau fractures [46]. Severe medial tibial plateau fractures are devastating knee injuries that challenge the functional outcome of patients due to multiple concomitant injuries [43].

Classification

Schatzker Classification

Schatzker: Published in 1979 based on data from 94 lateral tibial plateau fractures, this system categorizes injuries by morphology [21]. Type I is a pure cleavage or split fracture of the lateral plateau forming a wedge-shaped fragment without articular crush, generally seen in young patients with good bone quality [21]. Type II involves a lateral split and depression; in a sports return study, these fractures caused poorer results than isolated lateral split (Type I) or lateral depression (Type III) fractures [77]. Type III fractures are usually the result of lower-energy injury in older patients and carry a low risk of ligamentous damage [48]. Type IV is a fracture of the medial tibial condyle, which may present as a depressed crush fracture in osteoporotic bone or a high-energy oblique split [13]. These injuries are often the result of high-energy trauma and may be associated with peroneal nerve traction lesions [48]. Type V is a bicondylar fracture where both condyles are split but a column of the metaphysis remains in continuity with the tibial shaft [13]. These fractures typically consist of split fractures of both plateaus without articular depression [48]. Type VI results from high-energy injury, is often comminuted, and may be associated with popliteal artery disruption [48]. In a study of 89 tibial plateau fractures, 25.8% were classified as Schatzker Type VI [77]. Type I fractures carry a high risk of ligamentous disruption and may be associated with meniscal trapping [48]. Various Schatzker types differ in the location and depth of depression, suggesting operative approaches should be based on the morphological characteristics of individual types [84]. A 2018 study proposed a new three-dimensional classification system based on the Schatzker classification, utilizing CT to define a virtual equator and quadrants for preoperative planning [114].

AO/OTA Classification

AO/OTA: This system is more comprehensive than the Schatzker classification and is commonly used in scientific publications [21]. It is more reliable between observers than the Schatzker classification for tibial plateau fractures seen on plain x-ray [60]. In a study of 89 tibial plateau fractures, 69.7% were graded as AO Type B and 27.0% as AO Type C [77]. Bicondylar AO Type C fractures showed significantly greater losses in the Lysholm score and pain levels compared with Type A or B fractures [77]. Higher AO/OTA classification was highlighted as a parameter related to the occurrence of acute compartment syndrome in tibial plateau fractures [71].

Limitations and Reliability

Reliability: Frequently used systems for classification of tibial plateau fractures display moderate intra- and inter-observer reliability [96]. Current classification systems have suffered from disappointing interobserver reliability [58]. CT scan is better than X-rays for analyzing and classifying tibial plateau fractures [79]. Subtraction of unfractured bones in 3DCT did not improve interobserver agreement in tibial plateau fracture classification systems [61]. The use of 3D printing decreases measurement error and improves intraobserver and interobserver reliability in the classification of tibial plateau fractures [126]. However, the authors of a 2022 study cannot recommend the use of 3D-printed models in practice and research for classification of tibial plateau fractures [104]. Currently available classification systems may lead to frequent misclassifications, and the use of 3D-printed models may not be helpful for education or preoperative planning [108].

Alternative and Emerging Classifications

Hohl and Moore: This classification distinguishes between five primary fracture patterns and five fracture-dislocation patterns [33]. It includes Type 1 (minimally displaced), Type 2 (local compression), Type 3 (split compression), Type 4 (total condyle), and Type 5 (bicondylar) [33]. The Schatzker classification closely corresponds to the Hohl and Moore fracture patterns with the addition of Type VI, metaphyseal-diaphyseal dissociation [33]. Tscherne and Lobenhoffer: This classification assesses fractures on the basis of soft-tissue injuries [14]. Cotton and Berg: This was the first classification to take into account the mechanism by which the fracture occurred [14]. Other Considerations: A "four-column and nine-segment" classification has been proposed as a beneficial system for clinical diagnosis, statistical analysis, and prognostic judgment [40]. An updated Three-Column Concept assessing fracture morphology and injury mechanism in tandem can be used to guide surgical treatment of tibial plateau fractures [74]. A four-quadrant/column classification differentiates posteromedial and posterolateral tibial plateau fractures, which differ in mechanism, morphology, and surgical approaches [105]. A detailed segment classification system may delineate tibial plateau fractures more accurately when combined with knowledge of articular and non-articular area proportion [97]. Tibial plateau fracture maps show recurrent patterns of fracture lines, revealing four major fracture characteristics [4]. Geriatric tibial plateau fractures have a unique distribution in classification [41].

Clinical Presentation

Mechanism of Injury

Tibial plateau fractures result from varus or valgus forces combined with axial loads, typically from a fall from height [13]. Historically common in young patients after high-energy trauma, these injuries now frequently arise from low-energy falls in older patients with osteoporotic bone [64]. The demographic profile remains predominantly male, peaking in the 30s and 40s, with motorcycle traffic accidents as a primary cause [65]. Specific mechanisms dictate fracture patterns: varus forces cause medial plateau failure, potentially extending to the lateral plateau [2]. Posteromedial shearing fractures occur as isolated splits or within bicondylar patterns [2]. Bicondylar patterns result from predominant axial loads, with severity correlating to force magnitude [2]. Split lateral plateau fractures typically stem from low-energy falls and twisting injuries [27]. High-energy mechanisms, such as motor vehicle accidents or pedestrian strikes, carry a higher risk of associated neurovascular injury or compartment syndrome [27]. Metaphyseal region fractures from direct trauma or combined axial and bending forces are associated with open fractures, severe soft tissue injury, trifurcation injury, and compartment syndrome [2]. Clinicians must remain vigilant, as relatively high-energy fractures can occur despite seemingly innocuous mechanisms [27].

Physical Examination

Inspection: The knee is swollen and may be deformed with the doughy feel of a haemarthrosis [13]. Hemarthrosis is typically present, though capsular disruption may cause extravasation into the surrounding soft-tissue envelope [64]. The soft tissue envelope requires careful examination, particularly when open reduction is planned [27]. Key features include swelling severity, visible contusions, and the size, character, and location of fracture blisters [27]. A positive wrinkle sign, indicating normal skin wrinkling, suggests resolved swelling [27]. Evaluation must also assess for edema, effusion, abrasions, and blisters [57]. Subtle findings may indicate severe injury, and high-energy mechanisms should heighten suspicion for soft-tissue damage [57]. The subcutaneous anteromedial surface of the proximal tibia is susceptible to open injury and must be checked routinely [57]. Communicating open wounds must be identified on physical examination [27].

Palpation and Neurovascular Assessment: The examiner palpates over potential fracture or ligamentous disruption sites to elicit tenderness [64]. A thorough neurovascular examination is mandatory in all injured limbs [27]. Traction injury of the peroneal or tibial nerves is not uncommon [13]. Cutaneous sensation to tibial, superficial peroneal, saphenous, and sural nerves must be documented as a baseline and repeated periodically during the first day or two after injury [27]. Pulse examination can be misleading, as pulses may remain normal despite vascular injury in up to 15% of cases [57]. If pulses are not palpable, Doppler ultrasonographic studies should be performed [64]. Any asymmetry in pulses mandates an assessment of the ankle-brachial index (ABI) [57]. For high-energy injuries, a thorough vascular assessment with documentation of an ABI is advisable [27]. An ABI less than 0.9 requires further vascular workup with CT arteriogram, conventional angiography, or duplex ultrasonography, and a vascular consult is indicated [27, 57, 64]. Failure to recognize vascular injury promptly is associated with a lower extremity amputation rate as high as 86% [57].

Range of Motion and Stability: If the knee is subluxated, it should be reduced and the neurovascular examination repeated [64]. In lateral tibial plateau fractures, assessing for valgus instability may guide the need for surgical treatment [27]. However, pain often makes it difficult to examine the knee for coronal instability, limiting the value of this assessment [27]. Widening of the femoral-tibial articulation of more than 10° on varus or valgus stress examination, compared with the other leg, indicates instability [64].

Compartment Syndrome: Certain fracture patterns carry a high risk for compartment syndrome, especially medial tibial condyle fractures which are variants of knee dislocation [27]. The rate of acute compartment syndrome in high-energy tibial plateau fractures requiring staged treatment has been reported to be as high as 27% [57]. Acute compartment syndrome disproportionately affects patients with medial plateau fracture-dislocations and concomitant vascular injuries [57]. Patient factors associated with development include younger age, high-energy mechanism, and comminution [57]. Increased odds are associated with Schatzker VI fractures, concomitant fibula fracture, and a higher ratio of fracture length to tibia length [57]. The presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification, are also related parameters [71]. The compartments of the lower leg should be evaluated with serial examinations for tense compartments and pain with passive stretching [27]. Out-of-proportion pain is the most sensitive predictor of impending compartment syndrome [64]. Other signs include pain on passive stretch of the toes, pallor, pulselessness, or impaired neurologic status [64]. Compartment pressures should be measured directly if the patient is unconscious and has a tense, swollen leg [64]. Measuring compartment pressures is indicated in patients who are not responsive to clinical signs [27]. If the diagnosis is clear on physical examination, fasciotomy may be performed without pressure measurements [27]. Patients with high-energy fracture patterns who are unable to provide a history or are difficult to examine may benefit from compartment pressures measured at presentation [27]. Serial clinical examination focused on swelling, motor function, sensation, and stretch pain is advisable because patients with intact arteries may develop compartment syndrome during the first few days after injury or surgery [27]. Shear wave elastography can reliably and noninvasively detect high compartment pressure in tibial plateau fractures [72].

Imaging

Plain radiographs should include a knee trauma series (AP, lateral, and oblique views) and a plateau view (10° caudal tilt) [64]. The major reasons for overlooking tibial plateau fractures were difficulty in recognizing them on X-rays and failure to employ X-ray decision rules [44]. CT provides improved assessment of fracture pattern, aids in surgical planning, and improves the ability to classify fractures [64]. CT should be ordered when better visualization of bone fragments is required or to confirm a suspected traumatic arthrotomy [64]. Fractures of the posterior tibial plateau are not uncommon, especially in high-energy trauma [15]. MRI is of limited use in the acute setting [64].

Associated Injuries

In a 2005 series using MRI evaluation of surgical tibial plateau fractures, the incidence of intracapsular soft-tissue injuries was almost universal, with lateral meniscus injury being the most common (91%) and ligamentous injury noted in most fractures (77%) [57]. High-energy medial tibial plateau fractures are commonly accompanied by lateral collateral ligament and anterior cruciate ligament injuries, which can result in a combined fracture-dislocation of the knee [57]. In a review of 190 proximal tibial articular fractures, 67% of meniscal injuries occurred in plateau fracture patterns, whereas 96% of cruciate injuries and 85% of medial collateral ligament injuries occurred in fracture-dislocation patterns [33]. Peroneal nerve injury was twice as common in fracture-dislocation patterns [33]. Ligamentous injuries occur more frequently in minimally displaced, local compression, and split compression fractures [33]. Medial articular impaction is present in approximately 8% of tibial plateau fractures [69]. The presence of a tibial plateau fracture in conjunction with a ligamentous knee injury did not have a negative effect on postoperative patient-reported outcomes [66].

Functional Outcomes and Prognosis

Tibial plateau fractures are complex intra-articular injuries where fracture morphology, trauma mechanism, and soft tissue condition critically influence treatment complexity and injury prognosis [42]. Severe medial tibial plateau fractures are devastating knee injuries, posing a challenge to functional outcomes due to multiple concomitant injuries [43]. Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome [46]. Patient-reported outcomes continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically [18]. This study demonstrates a high rate of subjective instability following tibial plateau fractures [20]. These limitations are mainly related to the inability to extend the knee [17].

Investigations

Plain radiography: Plain radiographs enable a rapid assessment that helps differentiate high-energy and low-energy mechanisms of injury [113]. The AP knee radiograph should be tilted 7° to 10° caudal to match the posterior slope of the proximal tibia and accurately assess the articular surface [113]. Contralateral AP and lateral knee radiographs should be obtained to assess for baseline coronal and sagittal plan alignment [107].

CT: CT with coronal and sagittal reconstructions is typically obtained for preoperative assessment of tibial plateau fractures [113]. Three-dimensional CT is a more reliable radiographic modality than 2D CT in evaluation of fracture patterns in tibial plateau fractures [137]. Substantial improvements in interobserver and intraobserver reliability have been shown in determining the AO/OTA and Schatzker classifications when using three-dimensional reconstructions compared with two-dimensional CT [113]. However, the added value of 3D CT after 2D CT is limited and does not significantly improve reliability of characterisation and classification of tibial plateau fractures [91]. The addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of tibial plateau fractures [156]. Subtraction of unfractured bones did not improve interobserver agreement in tibial plateau fracture classification systems or recognition of fracture characteristics [61]. The study demonstrates that the addition of 3D-CT reconstructions to the preoperative workup of tibial plateau fractures did not change management plans when compared to plans made using traditional CT-scans [150]. CT scan is deferred until after external fixation when using a staged treatment protocol [107].

MRI: MRI is not obtained routinely at most centers for tibial plateau fractures [113]. MRI can improve the early diagnosis of accompanying ligamentous and meniscal injuries [113]. MRI can enhance interobserver reliability when compared with two-dimensional CT [113]. Magnetic resonance imaging is generally recommended with respect to associated soft-tissue injuries, especially in cases with distinct tibial plateau fracture depression on multi-detector computed tomography scans [135].

Other Considerations: Both the AO and Schatzker classification systems show limitations due to fracture complexity [60]. The novel 'four-column and nine-segment' classification is a beneficial classification system for clinical diagnosis, statistical analysis and prognostic judgment of tibial plateau fractures [40]. Shear wave elastography (SWE) can reliably and noninvasively detect high compartment pressure in tibial plateau fractures [72]. SWE provides superior diagnostic accuracy and clinical applicability for detecting high compartment pressure in tibial plateau fractures [72].

Treatment

Non-Operative

Nonoperative management is indicated for undisplaced or minimally displaced tibial plateau fractures [1]. Small depressions of the lateral plateau without deformity or instability on clinical examination also warrant conservative treatment [1]. Significant medical comorbidities that preclude surgical intervention, as well as elderly patients with low functional demands who tolerate subtle deformities, are candidates for nonoperative care [1]. Knee instability serves as a relative contraindication to this approach [1]. For undisplaced type 1 fractures, conservative treatment involves a hinged cast-brace or ROM brace to facilitate early mobilization, with initial restriction of weight-bearing [13]. Type 2 fractures may be managed nonoperatively if the knee is stable and depression is less than 5 mm, focusing on regaining mobility rather than anatomical restitution [13]. This approach is also appropriate for low-demand patients or those with osteoporotic bone [13]. Midterm follow-up data show no differences in patient-reported outcomes between surgical and nonsurgical groups for fractures with displacement up to 4 mm [24]. The arbitrary 2-mm limit for gaps and stepoffs should be revisited [109].

Operative

Indications: Operative treatment is indicated for displaced unstable tibial plateau fractures where near-normal limb alignment cannot be predicted based on fracture pattern or physical examination [52]. In young healthy patients, surgery includes almost all bicondylar and shaft dissociated patterns, all but minimally displaced medial plateau fractures, and lateral plateau patterns where valgus alignment or instability will occur without surgical reduction and fixation [52]. Strong indications for surgery in lateral tibial plateau fractures include the presence of a split fragment, depression affecting over half of the lateral articular surface, a fibular head fracture, valgus alignment on injury radiographs, and clinical valgus alignment on examination [52]. The number of millimeters of depression measured on radiographs is not reliable and too simplistic to determine surgical indications [52]. In elderly, less active, or medically unfit patients, indications are narrower, and risks and benefits must be assessed case-by-case [52]. Displaced type 1 fractures must be reduced and fixed [13]. Type 2 fractures that do not meet nonoperative criteria require open reduction with elevation of the plateau and internal fixation [13]. Total knee arthroplasty holds promise as a primary treatment for older persons with osteoporotic bone, offering immediate stability, early mobilization, and decreased reoperation rates [115].

Surgical Approach / Technique: The overall goal is to promote fracture healing that allows return of knee function with good motion while eliminating residual pain or instability [89]. Articular reduction remains the guiding principle because tibial plateau articular defects affect knee biomechanics [89]. Joint stability and axial alignment are important prognostic indicators [89]. Reduction of displaced type 1 fractures may require removal of incarcerated fragments or cartilage [13]. Joint surface inspection via submeniscal arthrotomy or arthroscopically is recommended for type 2 fractures requiring open reduction [13]. Impacted fragments should be elevated with an osteotome or bone tamp during articular reconstruction [140]. Isolated depression fragments require an osteotomy [140]. The metaphyseal-diaphyseal relationship should be reestablished to preserve mechanical alignment, often using traction, reduction tool placement, and indirect plate reduction [140]. Early knee movement is encouraged after fixation of type 2 fractures to minimize joint stiffness [13]. Arthroscopic-assisted reduction and internal fixation (ARIF) is a reliable, effective, and safe method, especially with concomitant injuries [70]. ARIF offers enhanced visualization, more accurate reduction, and potentially faster postoperative recovery compared to open reduction internal fixation (ORIF) [120]. Complex fractures treated with ARIF achieve excellent and good clinical outcomes with low complication rates [123]. Arthroscopic surgery for fractures with associated soft-tissue injuries is safe, reproducible, and effective in a 1-stage procedure [129]. Surgeons should consider the arthroscopic approach [31]. A posterior reversed L-shaped approach can be recommended as a routine approach for fractures involving the posterior column [102]. A posterior inverted L-shaped approach is safe and effective for posterior bicondylar fractures [112]. Fixation of hyperextension varus bicondylar fractures is performed through posteromedial and anterolateral approaches [140]. The posteromedial approach reduces posterior tension failure [140]. In these fractures, the anterior metaphysis is disimpacted, the articular segment reduced, and voids filled with bone graft or a substitute [140]. An anteromedial-based buttress plate is placed after reduction [140]. A laterally based plate maintains coronal plane reduction [140]. One author advocates performing posteromedial fixation first to provide a stable medial column for lateral reduction and fixation [140]. Column specific fixation for two or more column injuries includes assessment of three columns and achieves good outcomes [3]. Percutaneous plating of low energy unstable fractures is a novel method that can be safely practised at a District General Hospital [111]. Arthroscopy-assisted management of Schatzker type III fractures with interference screw fixation causes less soft-tissue trauma and allows fast mobilization [148]. Intraoperative 3D imaging leads to a substantial revision rate, revealing indications for limited analysis of fracture reduction and implant placement using conventional fluoroscopy [54].

Implant Selection: Fixation of displaced type 1 fractures can be achieved with lag screws in good bone or a buttress plate in poorer bone [13]. Partially threaded 6.5-mm screws work well for major plateau fracture lines, although smaller screws may work equally well [53]. Anterolateral plates are used as a buttress and to substitute for the damaged lateral cortex in lateral split depression plateau fractures [53]. 3.5-mm implants and screws are the most common size for anterolateral plates, having largely supplanted 4.5-mm implants [53]. "Rafting screws" are placed parallel and close to the articular surface to support the reduced articular surface and minimize postoperative settling [53]. Screws can be placed in parallel just beneath the subchondral bone to support the articular surface in type 2 fractures [13]. The rafting screw concept supports articular reconstruction by spreading screws across the subchondral region to prevent articular subsidence [140]. The wedge of the lateral condyle in type 2 fractures is fixed with a buttress plate [13]. Posteromedial plates function as an antiglide device to resist shearing forces [53]. Locking screws to lateral plates have been a major advance in resisting mechanical forces in bicondylar and Schatzker type VI fractures [53]. Lateral plates for bicondylar fractures must prevent the tendency of bending forces to create a varus deformity [53]. Unicondylar fractures in healthy bone generally should be managed with nonlocked buttress plate fixation [140]. Biomechanical evaluation showed that the use of posterolateral rim plating in addition to lateral precontoured plates significantly increased area of articular support [140]. Combining a lateral nonlocked plate with a posteromedial buttress plate is superior to the lateral locking plate for bicondylar fractures involving a posteromedial fragment, with a higher load to failure [140]. Lateral locked plating for medial fractures is related to varus failure and articular subsidence [140]. The LISS system could be considered for the management of tibial plateau fractures [63].

Adjuncts: Bone graft may help support the articular surface in type 2 fractures [13]. The treatment of depressed tibial plateau fractures with a calcium phosphate cement provides equivalent or better stability than conventional open reduction and internal fixation in pure depression tibial plateau fractures [122]. Calcium-phosphate synthetic bone grafts provided suitable mechanical support as part of the surgical treatment of tibial plateau fractures [146]. Both intravenous and topical tranexamic acid regimens are safe and effective for reducing blood loss in complex tibial plateau fracture surgery [106].

Postoperative Management: Permissive weight bearing after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates [55]. Early weight bearing can be considered safe and effective in selected cases after internal fixation [75]. Weight bearing as tolerated does not negatively affect the results of tibial plateau fracture and may therefore be safe for postoperative management [86]. There is no statistically significant difference between bracing and no bracing after open reduction and internal fixation in terms of functional, subjective, and radiographic outcomes [144]. Consensus about the weight bearing aftercare is limited, with a large majority of surgeons not following the AO guideline or their own local protocol [125]. Partial weight bearing is essential in the aftercare, with a standardized protocol of 6 weeks of partial weight bearing used in one study [131].

Other Considerations: Duration of incapacity of work after tibial plateau fracture is affected by work intensity [131]. Tibial plateau fractures are associated with a long-term increased risk of mortality [56]. The 90-day mortality rate for surgically treated adult patients with tibial plateau fractures is reported to be 0.85%, increasing with age [56].

Complications

Soft Tissue and Vascular: Medial tibial condyle fractures, which are variants of a knee dislocation, carry a high risk for compartment syndrome [27]. This complication can result from muscle ischemia due to vascular obstruction (intimal injury and subsequent thrombosis) or secondary to hemorrhage from shearing of the arteries [27]. Open fractures, severe closed soft tissue injury, trifurcation injury, and compartment syndrome are associated with metaphyseal injuries from direct trauma or combinations of axial load and bending forces [2]. High-energy tibial plateau fractures also present a significant risk of soft tissue complications arising from surgical approaches [27].

Infection and Surgical Failure: A high percentage of fractures fail secondarily after fixation, a failure mostly related to plates applied medially or laterally failing to adequately buttress the posterior plateau fracture fragment [21].

Malalignment and Instability: Angular malalignment after a tibial plateau fracture causes more loading of the articular cartilage of the injured condyle [1]. This malalignment may be cosmetically unacceptable, increases the propensity for knee instability, and can cause balance issues and lead to falls [1]. Additionally, a high rate of subjective instability is demonstrated following tibial plateau fractures [20].

Long-Term Outcomes and Mortality: Progressive incapacitating posttraumatic arthritis is actually very unusual in properly selected fractures treated nonoperatively [1]. Older patients and those with more severe fractures are more likely to need total knee arthroplasty after repair of a tibial plateau fracture [22]. Primary TKA for tibial plateau fractures in patients aged 55 or over is associated with lower complication rates and fewer reinterventions compared to secondary TKA, despite a higher short-term mortality rate in the primary group [133]. The 90-day mortality rate for surgically treated adult patients with tibial plateau fractures is 0.85%, increasing with age [56]. Long-term deviations in gait and quality of life exist in patients following tibial plateau fracture [76]. Patient-reported outcomes continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense [18].

Recovery

Other Considerations: In properly selected fractures, nonoperative treatment results in predictably excellent outcomes despite articular irregularities [1]. Progressive incapacitating posttraumatic arthritis is actually very unusual following nonoperative treatment of tibial plateau fractures [1]. Tibial plateau fractures decrease the function of the knee when compared with the contralateral side and to the preoperative condition, with bicondylar fractures associated with worse functional outcomes [87]. Tibial plateau fractures are associated with poor functional outcomes and a low conversion rate to total knee arthroplasty [87]. Fewer than half of skiers who underwent operative fixation of a tibial plateau fracture could return to skiing at a mean 3-year follow-up [85]. The number of patients who returned to participation in recreational athletics gradually increased over time after operative fixation of tibial plateau fractures [92].

Key Evidence

• [L3] The study concludes that good outcomes were achieved utilizing a modern column specific approach to the treatment of two or more column tibial plateau fracture injuries, which includes assessment of three columns. [3] (10.1016/j.injury.2019.10.069)
• [L4] Tibial plateau fracture maps show recurrent patterns of fracture lines, revealing four major fracture characteristics. [4] (10.2106/jbjs.n.00866)
• [L4] Tibial plateau fractures demonstrate distinct, mechanism-associated 3-dimensional pattern characteristics. [5] (10.2106/jbjs.19.00485)
• [L4] The common reasons for the failure of primary surgery of complex tibial plateau fractures were inadequate experience of the surgeon, inaccurate diagnosis and management, improper selection of implants, and poor surgical techniques. [6] (10.1186/s13018-019-1147-4)
• [L3] Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically. [7] (10.5435/jaaos-d-16-00217)
• [L4] It is a safe and practical method of treating complex tibial plateau fractures with good outcomes. [8] (10.1016/j.injury.2013.11.028)
• [L5] The impressive mechanisms of injury associated with tibial plateau fractures result in equally extensive injuries to the affected joint. [9] (10.1097/tme.0000000000000194)
• [L5] However, these findings cannot be extrapolated to all tibial plateau fracture types, and future studies should consider shared decision-making and longer-term outcomes. [10] (10.1097/corr.0000000000002309)
• [L3] Low bone density was not an independent risk predictor of poor patient-reported clinical outcomes in patients with tibial plateau fractures treated with osteosynthesis and bone grafting. [11] (10.1007/s00402-017-2679-x)
• [L4] Satisfactory results can be obtained in most carefully selected elderly patients with displaced tibial plateau fractures, provided meticulous surgical technique is observed and sufficient quantities of bone graft are filled in the defect to prevent postoperative collapse of the elevated tibial plateau. [12] (10.1016/0020-1383(95)00027-7)
• [L4] [14] (10.1007/s00167-004-0525-5)
• [L4] Fractures of the posterior tibial plateau are not uncommon, especially in high-energy trauma. [15] (10.1007/s00402-013-1735-4)
• [L5] Serious disruption of the stabilising structures of the knee are associated with relatively innocuous appearing marginal fractures of the tibial plateau. [16] (10.1016/j.injury.2004.01.013)
• [L4] These limitations are mainly related to the inability to extend the knee. [17] (10.1186/s12891-021-04577-y)
• [L3] However, patient-reported outcomes continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically. [18] (10.1302/0301-620x.102b5.bjj-2019-1385.r1)
• [L3] This study demonstrates a high rate of subjective instability following tibial plateau fractures. [20] (10.1177/2325967126s00026)
• [L2] Older patients and those with more severe fractures are also more likely to need total knee arthroplasty after repair of a tibial plateau fracture. [22] (10.2106/jbjs.l.01691)
• [L3] Post-operative complications and unplanned outcomes are common following operative treatment of tibial plateau fractures. [23] (10.1016/j.injury.2017.07.016)
• [L3] Regardless of the treatment type, no differences in patient-reported outcomes were seen at midterm follow-up when patients treated surgically and those treated nonsurgically for tibial plateau fractures with displacement up to 4 mm were compared. [24] (10.1097/corr.0000000000003057)
• [L4] Operative treatment of tibia1 plateau fractures is a good option. [29] (10.1016/s0020-1383(97)00064-8)
• [L5] [30] (10.5435/00124635-200601000-00005)
• [L1] Surgeons should consider using this approach when treating patients with tibial plateau fractures. [31] (10.1007/s00167-014-3256-2)
• [L4] Operative treatment of displaced tibial plateau fractures in patients older than 55 years can result in favorable outcomes as evaluated by clinical, radiographic, and self-assessment criteria. [32] (10.1097/01.blo.0000119247.60317.bc)
• [L3] Patients who have elective removal of their surgical implants after open reduction and internal fixation of a tibial plateau fracture have improved clinical outcomes and demonstrate significantly better outcomes than those who have retained implants at final follow-up. [34] (10.1007/s00402-015-2299-2)
• [L4] Impaction bone grafting shows promising results as an adjunct to the surgical stabilisation of osteoporotic tibial plateau fractures. [36] (10.1016/j.injury.2015.02.019)
• [L4] The novel 'four-column and nine-segment' classification will be a beneficial classification system for clinical diagnosis, statistical analysis and prognostic judgment of tibial plateau fractures. [40] (10.1016/j.injury.2018.09.031)
• [L4] Geriatric tibial plateau fractures have unique distribution in classification. [41] (10.1186/s13018-018-0986-8)
• [Paper] Tibial plateau fractures are complex intra-articular injuries where fracture morphology, trauma mechanism, and soft tissue condition critically influence treatment complexity and injury prognosis. [42] (10.1530/eor-2025-0167)
• [L3] However, severe medial tibial plateau fractures are devastating knee injuries, being a challenge to the functional outcome of patients due to multiple concomitant injuries. [43] (10.1186/s13018-026-07100-y)
• [L4] The major reasons for overlooking tibial plateau fractures were difficulty in recognizing them on X-rays and failure to employ X-ray decision rules. [44] (10.1186/s12891-018-2170-z)
• [L3] Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome. [46] (10.1016/j.injury.2017.11.014)
• [L5] [48] (10.5435/00124635-199503000-00004)
• [L3] The study reveals indications for a limited analysis of fracture reduction and implant placement during the operative treatment of dislocated articular tibial plateau fractures using conventional fluoroscopy. [54] (10.1186/s13018-019-1286-7)
• [Paper] Permissive weight bearing after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates. [55] (10.1007/s00402-018-3088-5)
• [L2] [56] (10.1007/s00402-020-03408-4)
• [L5] [58] (10.1097/01.blo.0000132626.13539.4b)
• [L4] The AO classification is more reliable between observers than the Schatzker classification for tibial plateau fractures seen on plain x-ray, although both systems show limitations due to fracture complexity. [60] (10.1007/s00402-003-0573-1)
• [L2] Subtraction of unfractured bones did not improve interobserver agreement in tibial plateau fracture classification systems or recognition of fracture characteristics. [61] (10.1016/j.injury.2020.07.038)
• [L1] The indication is that it is therefore beneficial to use porous titanium granules than autograft bone to fill the void created by reducing a depressed fracture of the lateral tibial plateau. [62] (10.1302/0301-620x.97b6.34552)
• [Paper] The LISS system could be considered for the management of tibial plateau fractures. [63] (10.1007/s00264-006-0176-x)
• [L4] Tibial plateau fractures are common injuries in our setting, primarily occurring in men in their 30s and 40s, and are most often caused by motorcycle traffic accidents. [65] (10.1186/s13018-022-02988-8)
• [L3] The presence of a tibial plateau fracture in conjunction with a ligamentous knee injury did not have a negative effect on postoperative patient-reported outcomes. [66] (10.1177/2325967117723895)
• [L3] Surgeons should be aware that medial articular impaction is present in approximately 8% of tibial plateau fractures. [69] (10.1016/j.injury.2021.04.013)
• [L4] ARIF is a reliable, effective, and safe method for the treatment of tibial plateau fractures, especially when they present with concomitant injuries. [70] (10.1016/j.arthro.2014.06.005)
• [L3] The presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification were highlighted as parameters related to the occurrence of acute compartment syndrome in tibial plateau fractures. [71] (10.1186/s12891-017-1680-4)
• [L3] Our study results indicate that SWE can reliably and noninvasively detect high compartment pressure in tibial plateau fractures, providing superior diagnostic accuracy and clinical applicability. [72] (10.1186/s13018-025-06241-w)
• [L2] An updated Three-Column Concept assessing fracture morphology and injury mechanism in tandem can be used to guide surgical treatment of tibial plateau fractures. [74] (10.1016/j.injury.2016.04.026)
• [L3] EWB can be considered safe and effective in selected cases after internal fixation for tibial plateau fractures. [75] (10.1186/s13018-022-03156-8)
• [L3] Long-term deviations in gait and quality of life exist in patients following tibial plateau fracture. [76] (10.1007/s00402-015-2325-4)
• [L4] [77] (10.1177/0363546512462564)
• [Paper] The commentary concludes that benefits of surgery for minimally displaced tibial plateau fractures (up to 4 mm displacement) were not observed at a mean of 6 years after surgery, suggesting a need for a careful reappraisal of indications for ORIF. [78] (10.1097/corr.0000000000003237)
• [L3] CT scan is better than X-rays for analyzing and classifying tibial plateau fractures. [79] (10.1016/j.otsr.2013.06.007)
• [L5] It is proposed as an advancement over conventional methods for the reduction and internal fixation of depressed tibial plateau fractures, particularly in open surgical indications and rim depressions. [80] (10.1002/atn2.70046)
• [L3] Patients with minimally displaced tibial plateau fractures treated nonoperatively can have good functional outcomes with fracture gaps or stepoffs up to 4 mm, suggesting the arbitrary 2-mm limit could be revisited. [81] (10.1097/corr.0000000000002266)
• [L4] Various Schatzker types of fractures differed in location and depth of depression, suggesting that a proper operative approach should be made based on the morphological characteristics of individual types of tibial plateau fractures. [84] (10.1186/s13018-016-0427-5)
• [L4] Fewer than half of skiers who underwent operative fixation of a tibial plateau fracture could return to skiing at a mean 3-year follow-up. [85] (10.1177/23259671231205925)
• [L4] Weight bearing as tolerated does not negatively affect the results of tibial plateau fracture and may therefore be safe for postoperative management. [86] (10.1016/j.injury.2017.05.024)
• [L3] Tibial plateau fractures decrease the function of the knee when compared with the contralateral side and to the preoperative condition, with bicondylar fractures associated with worse functional outcomes. [87] (10.1002/ksa.12153)
• [L4] The added value of 3D CT after 2D CT is limited and does not significantly improve reliability of characterisation and classification of tibial plateau fractures. [91] (10.1016/j.injury.2011.03.025)
• [L3] The number of patients who returned to participation in recreational athletics gradually increased over time after operative fixation of tibial plateau fractures. [92] (10.1177/2325967117743916)
• [L3] The presence of posterolateral tibial plateau fractures is associated with increased anterolateral rotational knee laxity and a high probability of concomitant anterolateral complex injuries. [95] (10.1002/ksa.70393)
• [L1] Frequently used systems for classification of tibial plateau fractures display moderate intra and inter-observer reliability. [96] (10.1016/j.injury.2018.01.025)
• [L5] The detailed segment classification system may delineate tibial plateau fractures more accurately; combined with knowledge of articular and non-articular area proportion, the fractured part can be calculated more precisely and proportionally, which is helpful in treatment decision making and preoperative planning. [97] (10.1016/j.injury.2019.01.021)
• [L2] While kinetic variables improved over time, there were no improvements observed in kinematic variables. [101] (10.1186/s12891-024-07910-3)
• [L2] It can be recommended as a routine approach for the treatment of the tibial plateau fractures involving the posterior column. [102] (10.1016/j.injury.2015.05.005)
• [L3] Therefore, the authors cannot recommend the use of 3D-printed models in practice and research for classification of tibial plateau fractures. [104] (10.1097/corr.0000000000002137)
• [L5] The four-quadrant classification differentiates posteromedial and posterolateral tibial plateau fractures, which differ in mechanism, morphology, and surgical approaches, providing a useful framework for operative planning. [105] (10.1007/s00264-017-3733-6)
• [L3] Both intravenous and topical tranexamic acid regimens are safe and effective for reducing blood loss in complex tibial plateau fracture surgery. [106] (10.1186/s12891-020-03772-7)
• [L5] The use of 3D-printed models may not be helpful for education and/or preoperative planning in the context of tibial plateau fractures, and currently available classification systems may lead to frequent misclassifications. [108] (10.1097/corr.0000000000002170)
• [L5] The arbitrary 2-mm limit of gaps and stepoffs for tibial plateau fractures should be revisited. [109] (10.1097/corr.0000000000002456)
• [L4] This novel method of internal fixation could be a useful inclusion in the armamentarium for the management of tibial plateau fractures and can be safely practised by an orthopaedic surgeon at a District General Hospital. [111] (10.1016/s0020-1383(00)00118-2)
• [L4] This approach is a safe and effective way for the treatment of posterior bicondylar tibial plateau fractures. [112] (10.1007/s00402-012-1632-2)
• [L5] The authors propose a new three-dimensional classification system for tibial plateau fractures based on the Schatzker classification, utilizing computed tomography to define a virtual equator and quadrants for precise preoperative planning of surgical approach and hardware application. [114] (10.1016/j.injury.2018.11.010)
• [L4] Total knee arthroplasty holds promise as a primary treatment for tibial plateau fractures in older persons with osteoporotic bone, offering immediate stability, early mobilization, and decreased reoperation rates. [115] (10.5435/jaaos-d-16-00565)
• [L1] ARIF holds promise as a superior technique compared to ORIF for managing tibial plateau fractures, offering enhanced visualization, more accurate reduction, and potentially faster postoperative recovery. [120] (10.1177/2325967124s00411)
• [L5] The treatment of depressed tibial plateau fractures with a calcium phosphate cement provides equivalent or better stability than conventional open reduction and internal fixation in pure depression tibial plateau fractures. [122] (10.1097/00005131-200103000-00009)
• [L3] Complex tibial plateau fractures could be treated successfully using arthroscopy-assisted reduction and internal fixation, with most patients achieving excellent and good clinical outcomes and low complication rates. [123] (10.1186/s13018-023-03938-8)
• [L4] [125] (10.1007/s00402-017-2718-7)
• [L4] The use of 3D printing decreases measurement error and improves intraobserver and interobserver reliability in the classification of tibial plateau fractures. [126] (10.5435/jaaosglobal-d-22-00202)
• [L4] Arthroscopic surgery for tibial plateau fractures with associated soft-tissue injuries is a safe, reproducible, and effective procedure that provides precise diagnosis and effective treatment in a 1-stage procedure. [129] (10.1016/j.arthro.2008.02.017)
• [L4] Different angles of knee flexion under axial impact loading are possibly the interpretations for the two fracture patterns (split and depression). [130] (10.1007/s00402-014-2037-1)
• [L3] [131] (10.1186/s12891-018-2209-1)
• [L3] After a fracture of the tibial plateau, patients with instability or nonunion are likely to need TKA earlier than those with malunion of the joint. [132] (10.1302/0301-620x.97b4.34789)
• [L1] Primary TKA for tibial plateau fractures in patients aged 55 or over is associated with lower complication rates and fewer reinterventions compared to secondary TKA, despite a higher short-term mortality rate in the primary group. [133] (10.1016/j.arth.2023.08.016)
• [L4] Magnetic resonance imaging is generally recommended with respect to associated soft-tissue injuries, especially in cases with distinct tibial plateau fracture depression on multi-detector computed tomography scans. [135] (10.1007/s00167-012-2201-5)
• [Paper] Three-dimensional CT is a more reliable radiographic modality than 2D CT in evaluation of fracture patterns in tibial plateau fractures. [137] (10.1016/j.injury.2009.02.015)
• [L2] Our prospective study showed no statistically significant difference between bracing and no bracing after open reduction and internal fixation of tibial plateau fractures in terms of functional, subjective, and radiographic outcomes. [144] (10.5435/jaaos-d-16-00021)
• [Paper] Nevertheless, both provided suitable mechanical support as part of the surgical treatment of tibial plateau fractures. [146] (10.1016/j.injury.2017.10.030)
• [Paper] The presented technique creates alternative possibilities in Schatzker type III tibial plateau fracture management, causing less soft-tissue trauma than other techniques and allowing for fast patient mobilization and recovery. [148] (10.1016/j.eats.2021.01.014)
• [L4] The study demonstrates that the addition of 3D-CT reconstructions to the preoperative workup of tibial plateau fractures did not change management plans when compared to plans made using traditional CT-scans. [150] (10.1186/s12891-015-0608-0)
• [L3] Furthermore, the addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of tibial plateau fractures. [156] (10.1016/j.injury.2015.12.022)

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