Tibial plateau fracture

The lateral plateau is split and its articular surface pushed down by the lateral femoral condyle in a valgus load. The joint becomes incongruent and unstable, and the lateral meniscus is often trapped in the gap.

Mechanism

Valgus and axial load ("bumper fracture"); low energy in osteoporotic bone (pure depression), high energy in the young (bicondylar, shaft dissociation).

Clinical findings

• Swollen, painful knee with haemarthrosis (fat droplets on aspiration = lipohaemarthrosis).
• Look for compartment syndrome (especially Schatzker IV–VI) and common fibular nerve injury.
• Test stability in extension under anaesthesia if in doubt.

Imaging

• AP and lateral of the knee.
• Internal and external 45° obliques show the lateral and medial plateaus.
• CT always before surgery: depression, split and fragment map. MRI if a meniscal or ligament injury is suspected.
• Compartment checks and pulses: high-energy patterns (Schatzker IV–VI).

• AP, lateral and oblique X-rays; a cross-table lateral may show a fat–fluid level.
• CT for every plateau fracture to plan the approach; MRI for meniscus and ligaments.

Classification

Schatzker I

Lateral split (young, good bone).

Schatzker II

Lateral split-depression (most common).

Schatzker III

Pure lateral depression (osteoporotic).

Schatzker IV

Medial plateau: high energy, often a knee dislocation equivalent: check the popliteal artery.

Schatzker V

Bicondylar.

Schatzker VI

Plateau dissociated from the shaft.

AO/OTA 41

41A extra-articular, 41B partial articular (B1 split, B2 depression, B3 split-depression), 41C complete articular.

Types shown in 3D

Schatzker I

Lateral split, no depression. Young patients with strong bone. Lag screws or buttress plate.

Schatzker II

Lateral split-depression (the most common): elevate the depressed joint, graft, and buttress the split.

Schatzker III

Pure central depression of the lateral plateau, typical of osteoporotic bone. Elevate through a cortical window and support with graft or raft screws.

Schatzker IV

Medial plateau: high energy, a knee-dislocation equivalent. Check the popliteal artery and the common fibular nerve.

Schatzker V

Bicondylar: both plateaus split, the shaft still attached in the middle. Staged ex-fix, then dual plating.

Schatzker VI

Plateau dissociated from the shaft (metaphyseal–diaphyseal). Highest risk of compartment syndrome.

Treatment

Non-operative

Undisplaced, stable fractures: hinged brace, early motion, toe-touch weight bearing for 6–8 weeks.

Operative

Articular step > 2–3 mm, condylar widening or instability: elevate the depressed fragment through a cortical window, support it with bone graft or substitute, and buttress the split with a lateral locking plate (or raft screws). Bicondylar fractures: staged ex-fix, then dual plating once the soft tissues allow (wrinkle sign).

Aftercare

Early motion, protected weight bearing 8–12 weeks.

Complications

• Compartment syndrome
• Wound breakdown and infection
• Loss of reduction
• Post-traumatic arthritis
• Stiffness