Injury 53 (2022) 2207–2218

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Injury
journal homepage: www.elsevier.com/locate/injury

Revisiting the management of tibial plateau fractures

Joseph Schatzker a,∗, Mauricio Kfuri b,∗
a
Division of Orthopedics, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada
b
Department of Orthopedics, University of Missouri, Columbia, MO, United States

a r t i c l e i n f o a b s t r a c t

Article history: Three-dimensional imaging has changed the understanding and management of tibial plateau fractures.
Accepted 7 April 2022 In the 1970s, Schatzker proposed a classification for tibial plateau fractures, which highlighted the mor-
phology of the six principal types. More recently, this original classification was complimented by an
Keywords: extended one underscoring the importance of understanding where the split wedge fragment(s) is/are
Tibial plateau fracture located in three dimensions. The extended classification introduced the split wedge fragment and the
Classification continuity of the rim as the determinants of joint stability and the critical role that this plays in the
Tomography management of tibial plateau fractures. The current manuscript re-emphasizes contemporary concepts of
Three-dimensional tibial plateau stability and depicts key issues which must be considered when planning the definitive
Decision making
surgical fixation of tibial plateau fractures.
© 2022 The Author(s). Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction
Tibial plateau fractures are serious articular injuries that may
result in permanent functional impairment of the knee joint [1–
3]. In the 1950s, there was no standardization of surgical tech-
niques for fracture fixation [4,5]. The casting of tibial plateau frac-
tures could not prevent shortening, which made late attempts at
reducing the displaced fragments difficult, if not impossible. Trac-
tion was used to control shortening. The tension generated with
traction resulted in ligamentotaxis, which led to the reduction of
the fragments with retained soft tissue attachment. Impacted artic-
ular fragments without soft tissue attachment remained unreduced
[6,7]. Subsequently, in early 1960s, the AO publicized its principles
guiding the surgical care of articular fractures with emphasis on
the anatomical reduction of the articular surface, absolute stabil-
ity, correction of axial deformity, and early motion [8]. Most of the
early studies considered joint stability as the most critical goal in
treating tibial plateau fractures, but failed to indicate which frag-
ment(s) was/were responsible for joint stability nor how to restore
it [9–11].
In 1974, Schatzker published a classification for tibial plateau
fractures consisting of six principal types presented in an ascend-
ing order of severity according to the fracture’s complexity, the age
of the patients, and the quality of bone [12]. The Schatzker classi-
∗
Corresponding authors.
E-mail addresses: joseph.schatzker@sunnybrook.ca (J. Schatzker),
kfurim@health.missouri.edu (M. Kfuri).
fication was based mainly on plain radiographs and two plane to-
mography. Most of the principal fracture planes were thought to be
anteroposterior. Schatzker recognized the importance of instability
as an indication for surgery and advised a knee examination under
anesthesia if the stability of the joint was in doubt [13]. In 2018,
Kfuri and Schatzker revisited the classification for tibial plateau
fractures, defining the importance of the three-dimensional loca-
tion of the split wedge fragment for the decision making in regards
to the surgical approach and optimal placement of the buttress
plate. Noteworthy, it became evident that the split wedge fragment
was the key element for the joint stability [14].
In the herein study, we revisit the important concepts of tibial
plateau stability and re-emphasize the key issues that one must
consider when planning the definitive surgical fixation of tibial
plateau fractures.
The anatomy of the proximal tibia
The tibial articular joint surface and the attached soft tissues
provide two functions: (a) stability: the ability of the tibial plateau
to contain and retain the femoral condyles in their normal position
in their natural relation to the articular surfaces of the plateau and
(b) weight transmission: the restoration of normal weight-bearing
capacity [13,14].
The proximal tibial epiphysis has two separate condyles with
their respective cartilage surfaces. The lateral condyle is convex
and smaller, while the medial condyle is concave and larger. Each
articular surface is partially covered by its corresponding meniscus.

https://doi.org/10.1016/j.injury.2022.04.006
0020-1383/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
J. Schatzker and M. Kfuri
Fig. 1. Anatomy of the tibial plateau. A: Superior and anterior perspective of the proximal tibia. B Superior and posterior perspective of the proximal tibia – TR: Tibial plateau
rim; TI: Tibial intercondylar eminence; TT: Tibial tuberosity; FH: Fibular head; L: Lateral tibial plateau; M: Medial tibial plateau. Observe that there is a definite distinction
between areas that are covered by cartilage (L and M), and the sites of soft tissues attachments (TT, TR, TI, FH). FH is the area of the attachment of the fibular collateral
ligament. The TR descri is the site of attachment of the capsule and meniscotibial ligaments; TI is a broad raised area which serves as the attachment of the anterior cruciate
ligament (ACL) and posterior cruciate ligament (PCL). TT is the site of attachment of the patellar tendon. Areas not covered by cartilage are distinct functionally from weight
bearing articular surfaces.
Between the two articular condyles are areas of bone that are not
covered by cartilage, which are extra-articular. There is a difference
in the mechanical function between the areas covered by cartilage
which serve as the weight bearing areas and are responsible for
stability of the joint and those that are simply bone and serve as
points of attachment of soft tissues such as ligaments and capsule
[15]. The articular surfaces, which are covered by cartilage should
be reduced anatomically. The bony areas that are not covered by
cartilage but serve as attachment sites for the soft tissues are not
directly involved in weight transmission and do not require the
same degree of reduction as, here, anatomical reduction is likely
not a critical factor, see Fig. 1.
Biomechanical factors governing the location of fractures and their
anatomical patterns
The angulation of the knee at the time of the injury, the energy
of the trauma and the bone density, are the determinant factors in
the production of the fracture patterns. The position of the knee
at the moment of force application, whether flexed or extended,
determines which part of the articular surface of the tibial plateau
is loaded [16,17]. If the force is sufficient the bone breaks. If the
knee is in flexion, as is most common, the posterior quadrants of
the knee are loaded, and the resulting fractures will be posterior.
If the knee is extended the fractures will be in the anterior quad-
rants. Varus and valgus forces determine which of the condyles is
fractured. A varus force results in disruption of the medial column
while a valgus force disrupts the lateral column. If the knee is in
extreme flexion or extension, it is the rim of the joint which comes
under load and if the force is sufficient the rim is crushed.
The patterns of tibial plateau fractures
Torsion produces fractures of the diaphysis and ligamentous in-
juries around the joint. Articular fractures are the result of shear-
ing and compressive forces [8,12,13]. A shearing force acting on the
tibial plateau gives rise to a split wedge fragment. As the force con-
tinues, it displaces and depresses the split wedge fragment and
drives it further away from the joint center. This results in dis-
placement and depression of the split wedge and in a widening
of the metaphysis and of the joint. The split wedge is anatomi-
cally a three-dimensional structure [14]. It is defined by the points
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Injury 53 (2022) 2207–2218
where shearing force acting in the direction of the principal frac-
ture plane bisects the rim of the plateau in two places and then
exits the metaphysis at a third place, the tip of the split wedge.
These three places where the continuity of the proximal tibia has
been disrupted determine the main fracture plane and define the
split wedge, see Fig. 2.
The femoral condyle follows the displaced split wedge because
of its retained soft tissue attachment. This results in joint sublux-
ation and instability. The compressive force is not only responsible
for the displacement, but it is also responsible for the fragmen-
tation of the adjacent articular surface and its impaction into the
metaphysis.
Pure articular depression patterns, or Type III injuries, are usu-
ally associated with low energy forces and osteopenic bone and,
most typically, do not involve the rim.
If the depression or crushing takes place at the rim, the seg-
ment that is crushed behaves like a split wedge. The peripheral
length of the rim discontinuity is the width of the split wedge
fragment, and the height of the cortical and metaphyseal crush
represents the metaphyseal component of the split wedge. It does
not end in an apex but in the width of the cortical and metaphy-
seal crush, which is continuous with the non-fractured metaphy-
seal bone, see Fig. 3.
Joint stability
The aim of treating an articular fracture of the tibial plateau
is to restore the joint to normal function, which means a pain
free stable and secure platform for weight-bearing activities, with
a normal range of motion [8,12,13].
Kfuri and Schatzker in designing the three-dimensional exten-
sion of the original Schatzker classification faced the following
questions: “What is the essential lesion responsible for joint sta-
bility?” “Does every part of the tibial plateau have the same im-
portance?” “And if not, in what way do they differ?” [14]. To an-
swer these questions the authors reviewed computed tomography
(CT) images of their own patients and carried out a comprehen-
sive search of the pertinent literature [18–24]. The authors ob-
served that in several cases the patients did well, despite failure
of an anatomic reduction of the articular surface because it was
shattered beyond the possibility of anatomical reduction. These pa-
tients, had not limiting pain, presented an acceptable range of mo-
tion, and felt their joint to be stable allowing them to walk and
J. Schatzker and M. Kfuri Injury 53 (2022) 2207–2218

Fig. 2. The three-dimensional configuration of an anterolateral split wedge depression fracture: Type II A. Observe that the split wedge is defined by two points where the
shearing force bisected the tibial plateau rim and by the third point where the shear exited the metaphysis. These three points determine the main fracture plane, which
in this example is located in the anterolateral quadrant of the tibial plateau, therefore the notation II A. Note that the split wedge is a three-dimensional structure, which
disrupts the continuity of the tibial plateau rim generating instability under axial loading

Fig. 3. Tibial plateau rim crush injury (Type II P). A: Axial view of the tibial plateau revealing lack of continuity of the posterolateral tibial plateau rim. B: Observe that the
crush of the tibial plateau rim generates an impaction, which behaves as a split wedge. The difference from a typical split wedge is that we don’t have one point where the
fracture plane exists the metaphysis, but a broad area where the cortical rim has been impacted; C: The posterolateral crush generates lack of continuity of the tibial plateau
rim with an acute increase of the tibial slope at that site.

participate in weight-bearing activities. The common denominator
of this unusual group of patients was that, despite the poor reduc-
tion of the articular surface, their joints were stable and appeared
to have a satisfactory immediate short-term outcome. The question
which challenged the authors was “Which part of the joint was re-
sponsible for joint stability?” The authors noted that the one fea-
ture that all the successfully treated joints demonstrated was that
the split wedge fragments of these joints had been anatomically
restored. This meant that the split wedge fragments were anatom-
ically reduced, and with that the continuity of the rim had been
restored. The authors concluded that the “key factor” responsible
for joint stability was the anatomical reduction of the split wedge
fragment and with that the restoration of continuity of the artic-
ular rim. With the discovery of the key to joint stability, the au-
thors designed a special alphanumeric system to denote the three-
dimensional location of the split wedge fragment, the key lesion
which determines joint stability. The original principal types of the
Schatzker tibial plateau fracture classification remained the same
but were complemented by a specific notation which pointed im-
mediately to the three-dimensional location of the split wedge
components responsible for joint stability [14].
For Schatzker and Kfuri, the restoration of joint stability is the
most critical step in the management of tibial plateau fractures. In
cases with severe articular surface fragmentation and severe crush-
ing, in which an anatomical reduction is not feasible, the surgical
approach, the reduction, and the fixation should still follow the AO
principles [8]. The challenge which faces the surgeon is where to
begin. While keeping in mind that the most important object of
surgery is to restore joint stability, the surgery should follow log-
ical steps. The first step is to identify the split wedge fragment/s
responsible for joint stability. This will determine the positioning
of the patient and the surgical approach. To gain access to the
impacted articular fragments the split wedge will guide the sur-
geon to the principal fracture plane and working in this plane the
split wedge should be opened like the cover of a book. After the
dis-impaction and reduction and elevation of the articular frag-
ments the resulting metaphyseal defect must be filled with bone
or a bone substitute to support the articular fragments and prevent
their re-displacement. In the next step, the split wedge must be re-
duced anatomically to restore the rim continuity and with that the
stability of the joint. To maintain the reduction the split wedge
fragment is then buttressed with a plate which provides contain-
ment. The reduction of the split wedge and of the metaphysis re-
stores the axial alignment unless there is an extension of the frac-
ture into the diaphysis which then must also be reduced and fixed.
In those cases, in which reduction of the articular surface
was not possible, despite the persistent residual incongruity of
the articular surface, the joint in which stability has been re-

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J. Schatzker and M. Kfuri Injury 53 (2022) 2207–2218

Fig. 4. Restoring Joint Stability. A: Anteroposterior and lateral radiograph projections of the knee. This is a bicondylar fracture of the tibial plateau with a dissociation
between the epiphysis and the metaphysis/diaphysis (Schatzker VI); B: CT images depict the degree of comminution of the articular surface, and the compromise of the four
quadrants of the tibial plateau (Type VI AL+PL+AM+PM). C: Anteroposterior and lateral radiographs of the knee three weeks after his injury. The patient had been initially
treated with a spanning knee external fixator, but the knee re-dislocated. This is the point of his admission to our hospital. D: Intraoperative radiographs at 5 weeks after
the index injury when the joint was being reconstructed. The main goal was to restore stability and alignment of the joint. The articular surface which had been impacted
and crushed could no longer be anatomically reduced and articular congruity could not be restored. E: Radiographs of the knee at 8 months after surgery. The fracture is
healed. The tibial plateau rim continuity was restored and remainedreduced providing stability. The articular surface remains incongruent and not anatomically reduced F:
Clinical photographs at follow-up. Patient has full extension of the knee against the gravity. The knee range of motion is 0–120 degrees of flexion. Patient has no pain and
can bear full weight on the operated lower limb, which has remained in neutral alignment.

Fig. 5. Left tibial plateau malunion. A and B are radiographs of the patient 18 months after a Type IVP tibial plateau fracture. The posteromedial fragment was left unreduced,
Note the varus alignment and the posteromedial subluxation of the joint; C: Intraoperative X-rays depicting the reduction of the posteromedial split wedge after osteotomy
and its elevation and reduction. This corrected the varus and flexion deformity and subluxation of the joint. Note the proper alignment of the buttress plate parallel to the
main fracture plane, which was re-created by means of an intraarticular osteotomy which followed the original fracture line; D: Final intra operative X-rays which reveal
the anatomic reduction of the posteromedial split wedge, which restored the continuity of the tibial plateau rim. The tibial plateau rim is in continuity and the split wedge
fragment is buttressed, which secures its containment. E and F: Post-operative radiographs at 9 months which reveal marked improvement of the alignment of the knee
obtained just by reducing the posteromedial split wedge which had been left primarily unreduced and went on to a malunion. G: Clinical photographs of the patient 9
months after his surgery. The left lower limb has a neutral alignment. The patient has full range of motion and a stable joint.

stored is ready for early motion and rehabilitation. In time it
may develop post-traumatic arthritis but that is a late complica-
tion. A stable joint is relatively pain free and mobile and this not
only makes early rehabilitation of the soft tissue envelope possi-
ble, but it also makes future reconstructions much easier should
they become necessary because mobility has been preserved,
see Fig. 4.
In clear distinction to this are those cases in which there has
been failure to reduce anatomically the split wedge fragment/s and
with that joint stability. These joints remain subluxated, painful
and functionless and cannot be rehabilitated [13,19]. A stiff and
painful joint cannot be reconstructed surgically with any degree
of success. The reason is that these joints are surrounded by a
scarred and shrunken soft tissue envelope and the joint itself has

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J. Schatzker and M. Kfuri
Fig. 6. Illustration of a Type IV P with PL extension. This fracture is the result of varus and flexion loading to the knee. There are multiple variants of this fracture pattern.
Frequently the fracture plane crosses the midline. The tibial spines may be avulsed, and the fracture extends to involve the posterolateral rim of the tibial plateau. As a
principle, an anatomical reduction of the main medial split wedge restores stability of the joint.
a shrunken capsule and is filled with dense scar the so called
‘arthrofibrosis’.
Specific fracture patterns and the associated surgical challenges
The posteromedial fractures
The advent of CT has made it possible to study fractures in
the coronal plane which until then were mostly unrecognized
[14,17,18,24–30]. Special attention has been given to the morphol-
ogy of the split wedge fractures of the posteromedial tibial plateau
[31–33]. It has been acknowledged that a failure to reduce prop-
erly and buttress a posteromedial tibial plateau split wedge frag-
ment results in immediate joint instability and failure. The joint
remains subluxated. If not corrected, such fractures lead to an ar-
ticular malunion, with persistent joint instability, pain, and loss of
function. Salvage of such a situation requires an intra-articular os-
teotomy that follows the original fracture plane [34–36]. Initially
if the tibial plateau rim is not properly reduced and the articular
surface is left unreduced with wide gaps, the gaps will fill with
callus during healing. This callus at reconstruction must be ex-
cised to narrow the metaphysis and restore width. This will allow
then the anatomic reduction of the split wedge fragments which
restores continuity to the rim and thus stability to the knee. A
case of a posteromedial tibial plateau malunion is illustrated in
Fig. 5.
Fractures of the medial tibial plateau may at times cross the
midline and extend to the posterolateral quadrant of the joint, the
so-called Type IV P with a posterolateral (PL) extension, see Fig. 6.
This fracture pattern was observed by Moore, who reported a
higher risk of associated neurovascular injuries if the main frac-
ture plane extended lateral to the tibial spines [37]. Wahlquist et
al. proposed a subclassification for the principal Type IV, where
the variant “C” in his subclassification corresponds to a fracture
of the medial tibial plateau with the principal fracture plane ex-
iting lateral to the tibial spines [38]. These authors reported this
variant in 9 patients with a type IV fracture. None of these pa-
tients had anterior cruciate ligament (ACL) or meniscal tears. Un-
der load the medial condyle of the femur stays together with
the medial tibial plateau and displaces medially and posteriorly,
while the lateral tibial plateau displaces laterally and cranially. The
cruciate ligament in these cases is usually not torn in its sub-
stance but avulses with its bony attachment from the tibial spine,
which is an extraarticular part of the plateau. Once the medial
plateau is reduced and buttressed, the knee alignment and sta-
bility are restored. The avulsed tibial spine fragments which are
part of the joint not covered by articular cartilage reduce spon-
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Injury 53 (2022) 2207–2218
taneously as the medial plateau is reduced. They eventually unite,
but the soft tissues may not be restored to their original length and
pre-stress.
In this Type IV P, the posterolateral extension involves mostly
the non-articular part of the lateral tibial condylar rim. It is thus
questionable if an anatomic reduction of this non articular portion
of the rim is necessary. It may represent only a small portion of the
tibial plateau surface and is secondary to the main split wedge ar-
ticular fracture. Most of the lateral extension is not covered by car-
tilage and the portion covered by cartilage is only a small portion
of the weight-bearing area which is covered by the posterior horn
of the lateral meniscus. We raise this issue because the surgical
access to this quadrant is challenging, so that special approaches
have been developed to help in accessing this area [39–46].
It is our impression, based on the observation of a large number
of cases treated at a time when posterior approaches were not fre-
quently used, we believe that not all posterolateral extension pat-
terns require dedicated approaches, as in many cases the compro-
mised area is non articular representing a secondary wedge and
not the principal medial split wedge which governs joint stability.
If the reduction of the posteromedial split is blocked by pos-
terolateral fragments caught in the main fracture plane one may
consider using a tamp introduced through the posteromedial split
to mobilize those fragments prior to reduction of the split wedge,
see Fig. 7.
The crushed posterolateral tibial plateau rim
The crushed rim is a split wedge which needs to be elevated
and buttressed and because its height is low this is best achieved
with a horizontally applied malleable plate, like a 1/3 tubular plate,
applied under some tension which adapts the plate to the frag-
mented cortical bone and helps to support it. It acts like a hoop
of a barrel and contains and buttresses the periphery of the tib-
ial plateau [45–49]. Fig. 8 illustrates the concept of horizontal but-
tressing of the tibial plateau rim.
The pure depression fracture (Type III)
The impacted articular surface of Type III is best elevated from
below, often best from the other side of the joint, with a curved
punch introduced through a cortical window. The resulting void
in the metaphysis must be filled with either bone graft or bone
substitute. If rafting is used to support the elevated articular frag-
ments, the screws used must be flexible and not stiff. Small or
mini fragment cortical screws should be used as they are more
flexible. Angular stable screws anchored in a plate are much stiffer
and should not be used for rafting as they stiffen the subchondral
J. Schatzker and M. Kfuri Injury 53 (2022) 2207–2218

Fig. 7. Illustration of a Type IV P with a PL extension of the fracture. A: Admission radiographs show that there is a posteromedial split, which crosses the midline and is
associated with avulsion of the tibial spines and with a fracture of the posterolateral rim. B: The computed tomography images show that the lateral extension involves an
area between the medial and lateral articular surfaces which are bare bone not covered by cartilage; C: The three-dimensional computed tomography surface reformation
facilitates the understanding that it is the posteromedial fracture which is the main contributor to joint instability. D: Intraoperative fluoroscopic view. The patient is in prone
position. A bone tamp has been inserted through the main posteromedial split to mobilize a small area of depression located in the posterolateral tibial plateau rim which
was blocking reduction. The elevation of the rim facilitated the reduction of the posteromedial split and improved the alignment of the joint. E: Intraoperative fluoroscopic
images show that the main posteromedial split wedge is buttressed with a medial and a posteromedial tibial plate. F: Postoperative images seven years after the index
surgery. Patient has neutral alignment. The joint stability was restored, as the main posteromedial split wedge was anatomically reduced and contained by its corresponding
buttress plate; G: The patient was able to resume his professional and physical activities.

Fig. 8. Illustration of a Type II P fracture pattern, a lesion mainly of the rim of the lateral tibial plateau. A, B and C: Views of the tibial rim depression located in the posterior
quadrant of the tibial plateau. This type of injury is the result of flexion and anterior translation of the tibia in relationship to the femur at the time of injury, a mechanism
of injury leading to potential rupture of the anterior cruciate ligament. The lateral femoral condyle crushes the posterior rim. If this fracture results in rotational instability,
to restore stability, one must elevate the depressed tibial rim, fill the defect in the metaphysis with bone graft, and buttress the crushed cortex with a horizontal plate, (D,
E and F).

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Fig. 9. Type III P fracture without compromise of the tibial plateau rim. A: anatomical location of the fracture in the posterolateral quadrant of the articular surface; B:
Superior and posterior view of the tibial plateau which illustrate that the rim is intact; C: Lateral projection of the Type III P fracture pattern; D and E: The elevation of the
depressed articular surface with a bone tamp inserted through a window in the metaphyseal area of the proximal tibial. F: Lateral view of the proximal tibia illustrating
the presence of a subchondral bone graft and two raft screws applied in the subchondral area to support the articular surface G: A view from above of the tibial plateau
illustrating the location of the raft screws supporting the elevated osteochondral fragments of the articular surface

bone, and the stiffness may result in mechanical chondrolysis of
the overlying articular cartilage [50]. Fig. 9 depicts a pure postero-
lateral depression fracture pattern.
In severely osteopenic bone, large depressions may occur and
may compromise more than 50% of the weight bearing surface of
the condyle. Radiographs may fail to show an associated fracture
of the cortex but if 50% or more of the weight bearing area of
the tibial condyle is involved and there is widening of the tibial
plateau, the cortex has given way and behaves like a split wedge
which must be reduced and stabilized.
The posterolateral quadrant
The contribution of the posterolateral rim to knee instability is
still a matter of continuing debate. Sohn et al. evaluated the in-
cidence of posterolateral fragments in lateral and bicondylar tib-
ial plateau fractures [51]. After reviewing images of 190 patients,
the authors identified the posterolateral tibial plateau fractures in
44.2% of the cases. These authors stated that in contrast with pos-
teromedial displacements, some posterolateral fractures if unre-
duced had little if any impact on joint stability and on the out-
come. More data is needed to understand the clinical significance
and behavior of fractures of the posterolateral quadrant. In the
“normally” aligned lower extremity, the mechanical proximal tib-
ial angle (MPTA) is +/- 87 degrees, and the mechanical weight-
bearing axis (Mikulicz line) crosses the knee joint slightly me-
dial to the medial tibial spine [52,53]. This means that the me-
dial compartment of the knee carries more load than the lateral
compartment. This also explains the difference in density between
the two tibial condyles with the medial plateau being denser than
the lateral plateau and thus requiring more force to be fractured.
The uneven axial load distribution between the medial and lateral
tibial plateaus, with more of the load being transmitted through
the medial compartment of the knee, is the reason why persist-
ing posteromedial displacements are not tolerated. In distinction,
mild posterolateral displacements are well tolerated, provided the
lateral meniscus and the mechanical axis of the limb are preserved
[54]. Another aspect is that the articular surface area of the pos-
teromedial quadrant is much broader compared to the posterolat-
eral, which represents just one-fifth of the entire articular surface
of the tibial plateau [55]. Recently, the significance of the postero-
lateral rim has been investigated in association with ruptures of
the anterior cruciate as part of the mechanism of these injuries
[56,57]. The specific fracture of the tibial plateau posterolateral rim
has been described as an “apple bite” [58,59]. This fracture is an
impaction fracture of the posterolateral rim which occurs as part of
an excessive anterior translation of the tibia as the anterior cruci-
ate ruptures. It is the result of a direct impact of the lateral femoral
condyle on the tibial plateau’s posterolateral quadrant. This ex-
plains the extensive subchondral cancellous bone edema seen in
association with these injuries. Metzendorf et al. presented a case
series of individuals presenting this injury pattern [59]. These au-
thors indicate that posterolateral tibial plateau rim fractures associ-
ated with anterior cruciate injuries may contribute to rotatory in-
stability. The amount of joint instability is likely proportional to
the size of the lateral tibial condyle, the extent of the rim compro-
mise, the size of the split wedge, and the association of ligament
injuries. However, more evidence is needed before clear guidelines
for surgical care of the posterolateral tibial plateau injuries may be
established.
The MRI for tibial plateau fractures
The prognosis of tibial plateau fractures is affected by the ex-
tent of soft tissues injuries [13,60–62]. In recent years some au-
thors have reported the use of the MRI in the preoperative assess-
ment of tibial plateau fractures [63–65]. The advent of the com-
puted tomography introduced the coronal plane, which revolution-
ized the understanding of tibial plateau fractures as it allowed

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Fig. 10. Decision-making in managing tibial plateau fractures: The personality of the injury will dictate the timing and surgical strategy. Associated vascular injuries and
compartment syndrome imply emergent surgical treatment. Open fractures should be treated urgently. Staged treatment is the preferred management method in the presence
of high-energy trauma and significant soft tissues compromise.

Fig. 11. Variants of Type I - lateral split wedge tibial plateau fracture. Type IA is a split located anterior to the lateral collateral ligament, while Type IP is a split wedge
located on the posterolateral quadrant of the tibial plateau rim.

clear demonstration of fractures in the coronal plane. We believe
that the MRI with its definition of all associated soft tissue lesions
will greatly improve the understanding and management of the
complex injuries of the tibial plateau. When planning the treat-
ment of a tibial plateau fracture one is helped enormously if one
knows and understands the mechanism of injury. To understand
the mechanism of injury one needs to know the actual associated
soft tissue lesions. The need to know and to understand the role
of soft tissues in the management of tibial plateau fractures high-
lights the importance of obtaining an MRI in addition to the tra-
ditional CT particularly in the high energy fracture dislocations of
the tibial plateaus.
Schatzker has always emphasized that the principal types I, II
and III are fractures, while the principal types IV, V and VI are
fracture-dislocations [12,13]. New MRI studies, especially of the
Types IV, V and VI will help us to have a more detailed under-
standing of the importance of the associated soft tissues injuries
as part of these tibial plateau fractures [63–65]. The knee is a com-
plex structure and the injury to bone is only one aspect of its func-
tion. We must gain a better understanding of all associated soft
tissue injuries such as those to the synovium, cartilage, collateral
and cruciate ligaments, capsule, and menisci, so that a more com-
prehensive plan of care may be carried out [66,67]. We advocate
that MRI should be adopted routinely for high energy tibial plateau
fractures (types IV, V, and VI), where associated ligament injuries
are likely to happen. The MRI, like the definitive CT should be car-
ried out after the initial orthopedic damage control with the ap-
plication of a spanning knee external fixator to achieve provisional
stabilization of the joint. Traditionally CT has been considered the
gold standard for the assessment of bony injuries, while the MRI
is favored for the evaluation of soft tissues. Recent new MRI se-
quences with shorter echo times have been compared to computed
tomography and are considered to provide equal information. This
is a very promising development as it would combine the benefit
of a detailed understanding of soft tissues together with a three-
dimensional mapping of the bone [68,69].

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J. Schatzker and M. Kfuri Injury 53 (2022) 2207–2218

Fig. 12. Type II – lateral split wedge depression tibial plateau fracture variations. The computed tomography indicates where the split wedge has bisected the tibial rim.
Type IIA, anterolateral, Type IIP, posterolateral, and Type II A+P, point to the areas of instability on the tibial plateau rim.

Fig. 13. Type III – pure lateral depression tibial plateau fracture variations. Observe that the area of the depression may be located chiefly on either the anterolateral or
posterolateral quadrants. A metaphyseal window grants access to the articular depression.

Approaching the tibial plateau principal fracture patterns Discussion and conclusion

The decision-making in the management of tibial plateau frac-
tures requires a complete understanding of the personality of the
injury, which is related to the fracture pattern and the extent of
soft tissues compromise, (Fig. 10).
The definitive fixation of tibial plateau fractures should be de-
termined by the principles outlined in this manuscript. We pro-
pose an algorithm based on the six principle Types, emphasizing
the restoration of the tibial rim continuity as a key factor for joint
stability, (Figs. 11–16).
The tibial plateau is a unique anatomical structure. It comprises
two completely different articular surfaces, the medial larger and
concave and the lateral smaller and convex. Each is partially cov-
ered by its meniscus. The tibial plateau surfaces covered by artic-
ular cartilage comprise first the rim, responsible for joint stability,
and then the adjacent articular surfaces which provide the weight
bearing portion of the joint. In addition, there are areas of the
proximal tibia that are simply bone (part of the tibial rim and the
area between the two condylar articular surfaces) which perform

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J. Schatzker and M. Kfuri Injury 53 (2022) 2207–2218

Fig. 14. Unicondylar medial tibial plateau fracture variations. This high-energy fracture pattern is frequently associated with avulsion of the tibial spines and ligament
injuries. Locating the areas of instability on the tibial plateau rim allows for determining the surgical approaches and appropriate buttress technique.

Fig. 15. Type V bicondylar tibial plateau fracture may have numerous variations. One of the most frequent presentations compromises the continuity of the tibial rim on its
anterolateral and posteromedial quadrants.

essential but different functions. These are the sites for ligaments
and capsular attachments. If disrupted, they may contribute to in-
stability, but the contribution of these areas has not been properly
evaluated. Thus, when one is planning to restore the complex kine-
matics of the knee it is important to differentiate which areas of
the proximal tibia are injured as they differ in function. We don’t
believe that all areas of the proximal tibial epiphysis - those cov-
ered by cartilage and the bare areas - should be addressed equally,
as they do not have the same biomechanical and structural role.
The goal of surgical management in tibial plateau fractures is to
restore joint stability and joint congruency. Reducing anatomically
and buttressing the split wedge(s) restores the continuity of the
rim and joint stability, as well as the alignment of the metaphyseal
segment. Anatomical reduction and stable fixation of the depressed
and fragmented articular surface restores the weight-bearing area,
thus joint congruency. Stability and congruency go hand in hand.
A stable and well-aligned joint is critical for early mobilization
and rehabilitation. In cases of severe comminution with signifi-
cant fragmentation of the articular cartilage, perfect congruency
may not be achievable. However, if the surgeon can only restore
the normal anatomical three-dimensional orientation of the split
wedge fragments and with that the continuity of the tibial plateau
rim and the axial alignment of the joint, a functional knee will
be achieved. Loss of congruency may lead to post-traumatic os-

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J. Schatzker and M. Kfuri
Fig. 16. Type VI tibial plateau fractures are associated with high-energy mechanisms. Multiple presentations are possible, pending which quadrant has been disrupted and,
therefore, where the tibial rim lacks continuity. Unlike Type V, where restoring the tibial rim restitutes alignment and length, in Type VI, one should reduce and bridge the
shaft component.
teoarthritis, but this is a late occurrence. Restoring stability pro-
vides a window of opportunity for rehabilitation not possible if the
joint is subluxated and unstable.
The posterolateral quadrant of the tibial plateau has raised sig-
nificant questions regarding its importance, such as the challenges
to address it when displaced, and when shall we prioritize it as a
source of instability. This is an area open for research and devel-
opment.
Computed tomography provided the coronal plane, which is
critical in evaluation of the continuity of the tibial plateau rim, the
determinant of joint instability.
MRI has been neglected as a tool in the evaluation of tib-
ial plateau fractures. Recent studies have demonstrated its val-
ues in determining the mechanism of injury [70,71]. Modern Mag-
netic Resonance machines are capable not only to provide imag-
ing of the soft tissue detail of the injury but will also provide in-
formation on the amount of damage to the cartilage and a sur-
prising detail of associated bony injury. In our opinion, the MRI
is a valuable tool in the preoperative assessment of individu-
als with complex tibial plateau fractures. The information it pro-
vides will help with detailed preoperative planning if a decision is
made that ligament surgery should complement bony fixation. It
is also instrumental for long-term prospective observations inter-
preting the impact of associated soft tissue injuries in the man-
agement of tibial plateau fractures. Thus, the MRI like the CT
should become a routine part of the pre-operative gathering of
information.
Our aim in this article is to express our clinical and experimen-
tal observations. It complements our extended three-dimensional
classification, which guides the surgeon to the area of instability,
and stresses the priorities while dealing with stability and con-
gruency of the tibial plateau fracture. We also present our obser-
vations and concepts which to some extent may be translated to
other joints of the musculoskeletal system and be of value for sur-
geons managing articular fractures.
Declaration of Competing Interest
None of the authors received payments or services, either di-
rectly or indirectly (i.e., via his or her institution), from a third
party in support of any aspect of this work. None of the au-
thors, or their institution(s), have had any financial relationship,
in the thirty-six months prior to submission of this work, with
any entity in the biomedical arena that could be perceived to in-
fluence or have the potential to influence what is written in this
work. Also, no author has had any other relationships, or has en-
gaged in any other activities, that could be perceived to influ-
2217
Injury 53 (2022) 2207–2218
ence or have the potential to influence what is written in this
work.
Acknowledgments
The authors would like to thank Miquel Videla-Ces, MD, Ph.D
and the associates of the Orthopaedic and Trauma Surgery De-
partment, Hospital Consorci Sanitari Integral, Sant Joan Despí,
Barcelona, Catalonia, Spain for the Fig. 1. The authors would like to
thank Stacy Turpin Cheavens, MS, CMI, Certified Medical Illustrator
University of Missouri, Department of Orthopedic Surgery for the
illustrations in Figs. 2, 3, 6, 8, 9, 11–16.
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