Tibial Plateau Fracture (Schatzker Classification and Management)

Tibial plateau fracture is an intra-articular fracture involving the proximal tibial articular surface (medial, lateral, or both plateaus), affecting the weight-bearing surface that articulates with the femoral condyles. Accounts for approximately 1 percent of all fractures and 8 percent of fractures in elderly. Bimodal age distribution: middle-aged-elderly women with osteoporosis sustaining low-energy mechanisms (simple fall, twisting injury) and young men with high-energy mechanisms (motor vehicle collision, fall from height, sports injury, industrial accident).

Mechanism of injury: axial loading combined with valgus or varus force during knee flexion or extension. Valgus force (most common — 70 percent) fractures lateral plateau as femoral condyle drives into less dense lateral tibial bone; varus force (less common, higher energy required as medial plateau cortical bone is denser and stronger) fractures medial plateau, often with associated cruciate avulsion and ligament injury; pure axial loading from height fractures both plateaus simultaneously; combined forces with rotation cause complex bicondylar patterns; high-energy axial loading with diaphyseal extension produces Schatzker Type VI.

Schatzker classification (1979, most widely used, six types of increasing complexity): Type I — Lateral plateau split fracture (wedge separation without depression, classic in younger patients with dense bone allowing split rather than depression — 6 percent); Type II — Lateral plateau split-depression fracture (lateral split with central articular surface depression, most common pattern in middle-aged patients with osteoporosis — 25 percent); Type III — Lateral plateau pure depression fracture (central articular depression without split, classic in elderly with severe osteoporosis from low-energy mechanism — 36 percent); Type IV — Medial plateau fracture (variant from varus mechanism, often associated with cruciate ligament avulsion, fibular head dislocation, common peroneal nerve injury and popliteal vascular injury — high-energy, severe pattern even though appears localized — 10 percent); Type V — Bicondylar fracture (both plateaus involved with Y or T pattern, high-energy — 3 percent); Type VI — Bicondylar fracture with metaphyseal-diaphyseal dissociation (extending into proximal tibial diaphysis, high-energy with severe soft tissue injury, compartment syndrome risk, may be associated with neurovascular injury — 20 percent).

Three-column classification (Luo and colleagues, 2010, complementary to Schatzker, particularly useful for CT-based surgical planning): defines columns based on axial CT (lateral, medial, posterior); identifies posterior column fractures often missed on standard imaging; helps surgical approach decision (anterior approach for lateral and medial column, posteromedial or posterolateral approach for posterior column). Common concomitant injuries occurring in 50 percent: meniscal tears (especially lateral meniscus in Type II — 50 percent or higher rate), anterior cruciate ligament injury (10–20 percent — important to assess and manage), posterior cruciate ligament injury (less common), medial collateral ligament injury (especially in Type IV from varus mechanism), lateral collateral ligament injury, posterior cruciate ligament avulsion, popliteal artery injury (Type IV with knee dislocation pattern, Type V/VI with high-energy — emergent assessment with ankle-brachial index ABI, CT angiography if ABI <0.9), common peroneal nerve injury (Type IV — 5–10 percent), compartment syndrome (Type V/VI especially).