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Knee

Tibial Plateau Fractures

A tibial plateau fracture is a break in the upper part of the tibia (shinbone) that involves the knee joint. These fractures are serious injuries that can affect joint alignment, cartilage, ligaments, and overall knee stability. They may occur from trauma like a fall, car accident, or sports injury, and often require a combination of precise imaging, individualized treatment, and rehabilitation to restore full knee function.

Tibial plateau fractures vary in severity—from nondisplaced (bones remain aligned) to complex, comminuted (shattered) fractures with joint surface disruption. Treatment depends on fracture type, displacement, joint involvement, and the patient’s activity level and overall health.

The tibia is the larger of the two lower leg bones and forms the bottom part of the knee joint. The top portion of the tibia is called the tibial plateau and consists of two parts:

  • Medial plateau: The inner (larger and stronger) part
  • Lateral plateau: The outer part, which is smaller and more commonly fractured

Above the tibia sits the femur (thigh bone), and together they form the tibiofemoral joint. The surface of the tibial plateau is covered in articular cartilage, which provides smooth motion. The menisci (cartilage pads) lie on the plateau and help with shock absorption and joint stability.

The ligaments of the knee—such as the ACL, PCL, MCL, and LCL—may also be injured with these fractures.

Tibial plateau fractures result from direct trauma to the knee joint or forceful compressive loads that exceed the strength of the bone. Common causes include:

  • Falls from a height landing on the feet or knees
  • Motor vehicle accidents
  • Sports injuries involving twisting, impact, or falls (e.g., skiing, basketball, football)
  • Osteoporotic bone in older adults may fracture with lower energy trauma

Typical symptoms of a tibial plateau fracture include:

  • Pain localized to the upper shin and knee
  • Swelling and bruising around the knee
  • Inability to bear weight on the affected leg
  • Stiffness or restricted motion in the knee
  • Visible deformity or loss of normal knee contour in displaced fractures
  • Numbness or tingling if nerves are compressed or injured

In severe cases, there may be open fractures (bone breaks through the skin) or associated injuries such as ligament tears or compartment syndrome (a limb-threatening emergency).

Tibial plateau fractures are classified by the Schatzker system, which describes six types based on severity and location:

  • Type I: Lateral split fracture
  • Type II: Lateral split with depression (most common)
  • Type III: Pure depression of lateral plateau
  • Type IV: Medial plateau fracture (more severe, often unstable)
  • Type V: Bicondylar fracture (both medial and lateral plateaus)
  • Type VI: Fracture with separation between the shaft and joint (severe, high-energy)

Diagnosis is based on history, physical exam, and imaging:

Physical Examination

  • Assessment of pain location, swelling, joint stability
  • Evaluation for neurovascular compromise (checking circulation and sensation)
  • Signs of ligament or meniscus injury

Imaging

  • X-rays: Initial imaging to identify fracture pattern
  • CT scan: Provides detailed visualization of fracture fragments and joint depression
  • MRI: Useful in assessing associated soft tissue injuries (ligaments, menisci)

Not all tibial plateau fractures require surgery. Nonoperative management may be appropriate when:

  • The fracture is nondisplaced or minimally displaced
  • The joint surface is congruent
  • The ligaments are intact
  • The patient is nonambulatory or has high surgical risk

Nonoperative Approach:

  • Immobilization in a brace or cast
  • Strict non-weight bearing for 6–8 weeks to allow healing
  • Use of crutches or walker
  • Regular imaging to monitor healing and ensure the fracture does not displace
  • Physical therapy:
    • Gradual range of motion exercises
    • Quadriceps and hamstring strengthening
    • Weight-bearing progresses after 8–10 weeks, guided by healing status

Outcomes:

  • Many patients heal well with preserved joint function
  • Risk includes joint stiffness, muscle atrophy, and post-traumatic arthritis
  • Close monitoring is essential to ensure the joint remains aligned

Surgery is recommended for unstable fractures or those with displaced joint surfaces, depression of the plateau, or associated soft tissue injury.

Indications for Surgery:

  • Displacement > 3 mm or joint depression > 5 mm
  • Bicondylar or medial plateau fractures
  • Significant joint widening on imaging
  • Associated ligament injuries, meniscal tears, or open fractures
  • Joint instability

Surgical Techniques:

Open Reduction and Internal Fixation (ORIF)

  • Realignment of fracture fragments
  • Fixation using plates, screws, or bone grafts
  • Bone grafting may be needed to restore depressed joint surfaces

Minimally Invasive Fixation

  • Used in select cases to reduce soft tissue damage

External Fixation

  • Temporary stabilization in severe or open fractures, sometimes followed by ORIF

Arthroscopically assisted reduction

  • Useful in managing small depression fractures with minimal displacement

Postoperative Care:

  • Immobilization in a brace or splint
  • Non-weight bearing for 6–12 weeks
  • Early range-of-motion exercises
  • Progressive weight bearing based on healing and surgeon recommendations
  • Physical therapy for strength and mobility

Potential complications of tibial plateau fractures (with or without surgery) include:

  • Joint stiffness and decreased range of motion
  • Post-traumatic arthritis
  • Infection (especially in open fractures or surgical wounds)
  • Malunion or nonunion (bone heals incorrectly or not at all)
  • Nerve or vascular injury
  • Compartment syndrome
  • Hardware irritation or failure

Recovery from a tibial plateau fracture is slow and requires commitment to rehabilitation:

  • 0–6 weeks: Non-weight bearing, range-of-motion exercises begin
  • 6–12 weeks: Gradual increase in weight bearing
  • 3–6 months: Return to low-impact activities
  • 6–12 months: Full recovery; high-impact sports may resume with surgeon approval

With appropriate treatment, most patients recover good function, although outcomes depend on:

  • Fracture severity
  • Quality of reduction and fixation
  • Rehabilitation adherence
  • Presence of soft tissue or cartilage damage

Favorable Outcomes:

  • Full return to work and recreational activities
  • Stable, pain-free joint
  • Minimal long-term limitations

Possible Long-Term Issues:

  • Knee stiffness
  • Residual pain or swelling
  • Post-traumatic osteoarthritis
  • Decreased athletic performance in high-level athletes

Seek immediate care if you experience:

  • A fall or trauma with inability to bear weight
  • Severe knee pain, swelling, or deformity
  • Loss of feeling or circulation in the lower leg or foot
  • Worsening pain, redness, or drainage after surgery

Tibial plateau fractures are serious injuries involving the knee joint and can lead to long-term disability if not properly managed. Treatment may be nonsurgical or surgical, depending on the extent of the fracture and patient factors. With early diagnosis, individualized treatment, and dedicated rehabilitation, most patients regain function and mobility, although recovery may take several months.

At a Glance

Dr. Hasani Swindell

  • Fellowship-Trained Sports Medicine Specialist
  • Board-Certified Orthopedic Surgeon
  • Summa Cum Laude Graduate from the University of Pittsburgh
  • Medical Degree from Columbia University
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