Tibial Plateau


Schatzker Classification


I.  Lateral Spilt 

- seen in young patient

- lateral meniscus can be incarcerated in fracture


Tibial Plateau Schatzker 1Schat 1schat 1 ct


II.  Lateral Split Depression

- often seen in young patients with high energy injuries

- vary in severity


Schatzker 2 Split DepressionTibial Plateau Joint Depression


III.  Lateral Depression 

- central depression usually seen in elderly

- have to create lateral cortical window in order to elevate fragment


Tibial Plateau DepressionSchatzker IIISchatzker III


IV.  Medial plateau & intercondylar eminence 

- high velocity injury associated with ACL / LCL / CPN injury

- can be low injury / osteoporotic and often unreconstructable


Schatzker 4 Tibial PlateauTibial plateau Type IV


V.  Bi-condylar + intact metaphysis

- unstable

- requires ORIF


Schatzker VISchatzker 5 Bicondylar CT


VI.  Bi-condylar + metaphyseal fracture

- fracture separating metaphysis from diaphysis

- highest incidence of vascular injury


Schatzker 6 Schatzker 6 CT


3 column concept of tibial plateau fractures


Luo et al. Orthop Trauma 2010

- introduces the 3 column concept

- medial column / lateral column / posterior column

- posterior column can be splint into medial and lateral fragments (posterolateral / posteromedial)

- imporant as any surgery must address these fragments

- typically require additional posteromedial or posterolateral approaches



Posterolateral Tibial Plateau3 column tibial plateau classification




Most common is Type II split depression

- 80%


Type IV medial condyle

- 10 - 20%


Type V, VI bicondylar

- 10 - 20%



- young people splits / wedges

- older people joint depression




Medial plateau larger than lateral

- medial is concave in sagittal plane (golf tee)

- lateral is convex & more proximal (golf ball)


Creates 3o of varus proximal tibia

- important to be created in any reconstructive tibial plateau surgery


Normal posterior slope

- 10o


Knee Normal AP


Lateral plateau is covered by meniscus

- tolerates incongruity better than medial plateau




Lateral plateau more commonly fractures

- medial plateau more resistant to fracture

- due to its larger surface and increased weight bearing

- thicker stronger subchondral bone

- any fracture of medial plateau indicates high energy 

- high incidence of soft tissue complications & poor outcomes


Associated Injures


Meniscal injury


Stahl et al. J Orthop Trauma 2015

- 602 patients

- 30% had a lateral meniscus tear requiring intervention

- 45% in split depression Type II



Ligament injury


Gardner et al. J Orthop Trauma 2005

- MRI of 103 patients with tibial plateau booked for surgery

- 57% complete tear of ACL

- 28% complete tear of PCL

- 29% complete tear of LCL

- 32% complete tear of MCL


Tomas-Hernandez et al. Injury 2016

- case series of patients with anteromedial tibial plateua fractures

- these patients have posterolateral corner ligament injuries



Compartment syndrome


Increased incidence in high energy injuries

- Type V and VI bicondylar fractures

- Type IV medial fracture dislcations


Gamulin et al. BMC Musculoskeletal Disorders 2017

- 28/265 (10%) tibial plateua fractures had compartment syndrome

- more common in higher grade tibial plateau fractures

- more comon in young patients



Popliteal artery damage




Factors affecting outcome


1.  Severity of intial injury

2.  Residual Articular step

3.  Alignment

4.  Meniscus

5.  Instability


Blokker et al. CORR 1984

- >5 mm step 0% good or excellent results

- <5 mm 75% good or excellent results

- < 2 mm 85% good or excellent results



Biz et al. Orthop Surg 2019

- worse outcomes with more severe injuries

- daily pain associated with residual articular step and malalignment



Honkonen et al. J Orthop Trauma 1995

- meniscectomy during ORIF resulted in 74% osteoarthritis

- if meniscus intact or repaired, 37% osteoarthritis







NV examination


Soft tissue examination

- Tscherne / closed soft tissue injury classification

- Gustillo / open soft tissue injury classification


Exclude compartment syndrome


CT scan


Assess joint line

- predetermine fracture pattern before fixation

- will pick up medial condyle / bicondyle / metaphyseal fractures not seen on xray


Temporary Spanning External Fixation


Knee Spanning Ext Fix


Tibial Plateau Temporary External Fixator APTibial Plateau Temporary External Fixator Lateral



- open fracture

- complex pattern / shortening / malalignment

- poor soft tissues / extreme swelling



- pulls out to length with ligamentotaxis

- allows soft tissues to settle / swelling resolves

- subsequent surgery easier and safer



- 2 x 5 mm half pins anterior / anterolateral femur

- 2 x 5mm half pins anterior tibia far from incision

- apply under flouroscopy guidance / reduce / apply traction

- 2 x anterior rods

- slight flexion


AO Foundation Surgical Technique



Definitive Management


Indications for surgery


1.  Step > 2mm

2.  Malalignment


Type I


Percutaneous fixation

- beware trapped lateral meniscus

- consider arthroscopic inspection initially

- difficult to see because of haematoma 

- also risk of compartment syndrome so need careful fluid management


Tibial Plateau Schatzker 1 Percutaneous ScrewsTibial Plateau Schatzker 1 Percutaneous screws Lateral


Type II Split Depression


Tibial Plateau ORIF



- blisters epithelialised

- skin wrinkled

- 2-3 weeks


Set up

- prone on radiolucent table

- knee flexed over bolster or triangle

- tourniquet, antibiotics

- remove frame, scrub leg and apply sterile dressings to pin sites to remove from operative field

- some surgeons leave frame on to aid reconstructive surgery

- may need to use femoral distractor




Anterolateral Approach KneeTibia Anterolateral Approach 2


Anterolateral approach

- lateral longitudinal incision

- split ITB proximally

- open anterior fascia distally and elevate tibialis anterior from tibia

- perform submeniscal arthrotomy by incising capsule and coronary ligament from proximal tibia

- elevate capsule / ligament / and lateral meniscus via 1 vicryl stay sutures

- inspect joint and lateral meniscus via varus force

- can use femoral distractor



- elevate and restore joint line

- compress with bone reduction forcep

- stabilise joint line with 2 x 6.5 mm cannulated partially threaded screws

- check fluoroscopy

- restore alignment via application anatomically contoured 4.5 mm locking plate

- often use BG or substitutes under depression fractures laterally



- must assess at end of operation


Type III Depression


Type III tibial plateauType III tibial plateauType III tibial plateau ORIFType III tibial pateau ORIF III




Anterolateral approach

- visualise joint line

- create cortical window

- elevate fracture

- support with bone graft (autograft / allograft / bone substitute)


Type IV Medial Condyle




Medial approach

- make incision 1 cm from posterior edge of tibia

- release and reflect MCL posteriorly

- partially release pes anserinus / reflect inferiorly

- T plate

- can slide under the pes


Schatzker 4 Medial Plate0001Schatzker 4 Medial Plate0002


Type V Bicondylar



1. Medial and Lateral plating

2. Circular Fixator


Canadian Orthopedic Trauma Society JBJS Am 2006

- RCT of ORIF (two plates) with circular external fixation in 83 knees

- comparable fracture reduction in both

- no difference in outcomes

- reduced blood loss / hospital stay / infection / reoperation with external fixation

- 7/40 (18%) of patients undergoing ORIF had an infection



Zhao et al. Int J Surg 2017

- meta-analysis of external fixation v ORIF for complex tibial plateua fractures

- no difference in DVT/PE, outcomes, deep infection between two groups

- external fixation does have an overall higher rate of infections due to pin site infections



1. Medial and Lateral Plating



- depends on which of the three columns affected

- anterolateral approach for lateral column

- posteromedial appraoch for medial / posterior column


Tibial Plateau Bicondylar ORIF APTibial Plateau Bicondylar ORIF Lateral


2. Circular external Fixation



- poor soft tissues

- compound wound



- hybrid fixation

- wire fixation proximally

- pin fixation distally

- use olive wires to compress fracture fragments

- place wires 14mm from joint surface to avoid placing intra-articular


Schatzker VI Ilizarov


Type VI Bicondylar with Metaphyseal Fracture



- long locking plate minimally invasive with locking jig / MIPO

- proximal lag screws

- ensure correct alignment

- often use small medial buttress plate


Tibial Plateau Schatzker 6 ORIF APTibial Plateau Schtazker 6 ORIF LateralSchatzker 6 ORIF APSchatzker 6 ORIF Lateral.jpg


Posterolateral Tibial Plateau Fractures



- fracture in posterior half of lateral tibial plateau

- very difficult to access with standard anterolateral approach


Posterolateral Tibial PlateauPosterolateral Tibial PlateauPosterolateral Tibial PlateauPosterolateral Tibial Plateau


Posterolateral Tibial PlateauPosterolateral Tibial PlateauPosterolateral Tibial Plateau



1. Trans-fibular neck osteotomy + anterolateral approach

2. Posterolateral approach + anterolateral approach


1. Transfibular osteotomy

- incision based on fibular

- divide ITB

- expose CPN under biceps femoris

- release CPN completely from fibular neck and protect

- maintain ligamentous attachments to fibular head

- predrill fibula for later intra-medullary screw

- chevron osteotomy at fibular neck

- reflect fibular head posteriorly and superiorly on biceps / LCL attachments

- place posterolateral buttress plate

- expose anterolateral tibia and place standard anterolateral plate as needed

- stabilize tibio-fibular joint with screws from fibular into tibia / fibular screw


Pires et al. Injury 2016 Article PDF



2.  Posterolateral approach

- single incision

- identify, release and protect the CPN

- posterolateral window is below CPN

- gastrocnemius posteriorly, tibia and popliteus anteriorly

- ligate inferior geniculate artery on the popliteus

- may need to partially release popliteus tendon and repair later

- place buttress plate posteriorly

- make standard anterolateral window for anterolateral plate


Vumedi video



Posteromedial Tibial Plateau Fractures


Tibial Plateau Type VTibial Plateau Type V ORIF APTibial Plateau Type V ORIF Lateral


Posteromedial approach and buttress plate

- Burks modified posterior approach

- put leg over triangle, can let let flop out to get to medial side

- incision based upon posteromedial tibia

- interval between semimembranosus and medial head of gastrocnemius

- medial head of gastrocnemius retracted laterally

- hamstring tendons retracted medially

- place blunt homann gently across back of tibia to expose fracture

- subperiosteal release of the popliteus muscle

- place posterior anti-glide buttress plate


Posteromedial approach knee 1Posteromedial approach knee 2


Posteromedial approach knee 3Posteromedial plate


Vumedi video



Vumedi video



Arthroscopy assisted Tibial Plateau ORIF



- direct visualisation of joint surface restoration



- Type III depression



- Type IV / V / VI

- risk of compartment syndrome

- ROM < 110o




Athroscopy Techniques PDF and videos





Hinged Brace

NWB 8 weeks






Shao et al. Int J Surg 2017

- systematic review infection rate 9.9%

- risk factors open fractures, compartment syndrome, longer operative times, smoking, external fixation





Wasserstein et al. JBJS Am 2014

- incidence of TKR 10 years post injury of 7.8% compared to 1.8% in matched cohort

- more likely with older patients and more severe fractures



Collapse / Malunion


Tibial Plateau Collapse Malunion Tibial Plateau Collapse Malunion




1. Distal femoral varus osteotomy and fresh osteochondral allograft


Tibial Plateau MalunionTibial Plateau Malunion 2



Lateral Tibial Plateau MalunionDFVO and osteochondral allograft


Abolghasemian et al. JBJS Am 2019

- long term follow up of fresh osteochondral allograft transplantation

- large post traumatic osteochondral defects > 3 cm diameter and > 1 cm in depth

- graft survivorship was 90% at 5 years, 79% at 10 years, 64% at 15 years, and 47% at 20 years



2. TKR


Tibial Plateau OA TKR0001Tibial Plateau OA TKR0002


Scott et al. Bone Joint J 2015

- 31 patients with tibial plateau fracture requiring TKR at a mean of 24 months

- matched to a cohort of primary OA undergoing TKR

- increased rate of wound complications and stiffness in tibial plateau cohort

- otherwise, no significant difference in postoperative outcomes between the two groups