Causes / typical injury mechanism: Tibial plateau fractures are fractures to the articular portion of the proximal tibia. High-energy trauma is the most common mechanism of injury and a key part of the patient's history, especially in younger, active patient populations. These fractures may result from relatively low-energy mechanisms in elderly patients, particularly in the context of osteoporosis, where a fall from standing may result in a tibial plateau fracture.

Common mechanisms include valgus / varus stress due to motor vehicle versus pedestrian collisions, axial compression due to falls from height, or falls onto the knee in elderly, osteoporotic patients. Medial plateau fractures are more common with high-energy mechanisms, while isolated lateral plateau fractures may present in the context of low-energy injury.

A high-energy trauma patient can often present with other life-threatening injuries (eg, spinal or pelvic injury) that take precedence over a tibial plateau fracture. Advanced Trauma Life Support (ATLS) protocol should be implemented when assessing these critically ill patients.

In assessing the tibial plateau fracture, it is important to be aware of compartment syndrome (especially common in fractures involving the medial tibial plateau) and assess for neurovascular injury. The most commonly injured nerve is the peroneal nerve in 1% of cases. Patients should have pedal pulses examined, and providers should have a low threshold for ordering vascular imaging to assess suspected vascular damage.

Classic history and presentation: Patients with tibial plateau fractures commonly present after a trauma-related incident with a painful, swollen knee, limited range of motion (ROM), and inability to bear weight.

Prevalence: Tibial plateau fractures account for a small percentage of all fractures presenting to hospitals (approximately 1%). This fracture is seen across a wide demographic, including male patients younger than 50 years who are more prone to traumatic injury and female patients older than 50 years who have underlying osteoporosis / osteopenia. However, the highest age frequency for fractures is 40-60 years in both sexes. Tibial plateau fractures can occur in almost any demographic.

Risk factors:

• Osteoporosis / osteopenia with low-energy mechanisms such as falls from standing
• Activities at risk for high-energy trauma (skiing, motocross, etc)
• Motorcycle and motor vehicle accidents
• Falls from height (eg, ladders, tree stands, roofs)

Pathophysiology: The tibial plateau is a major weight-bearing surface that can commonly fracture due to a combination of an axial loading force and coronal plane movement (ie, varus / valgus). The lateral aspect of the tibia fractures more commonly (55%-70% isolated lateral aspect fracture) than the medial aspect.

Grade / classification system: The Schatzker classification assigns a type I-VI based on the characteristic fracture patterns on x-ray. There have been several proposed modifications and considerations of other imaging techniques, although the fundamental structure of the classification system has remained similar.

Schatzker classification –

• Type I: Pure cleavage of lateral tibial plateau
• Type II: Cleavage of lateral tibial plateau combined with depression
• Type III: Pure central depression of lateral tibial plateau
• Type IV: Medial condyle fracture
  • A – Medial plateau split off as a wedge
  • B – Medial fragment depressed or comminuted
• Type V: Bicondylar with both plateaus fractured
• Type VI: Medially tilted bicondylar fracture