Overview
The tibial plateau is the top of the shinbone: two shallow concave surfaces of bone covered by cartilage that carry the rounded ends of the femur. A tibial plateau fracture breaks that surface. It is a joint fracture rather than a shaft fracture, and that governs everything that follows: the surface has to be put back flat and level so the femur rolls on it evenly, and it has to be kept off load while it heals so a fragment that was raised does not sink again. A plateau that heals with a step or a tilt wears out early, which is why this fracture is treated with more care than its X-ray sometimes suggests.
Treatment depends on the CT scan. A crack without displacement, with a level joint surface and a knee that is stable to sideways stress, heals in a brace with protected weight bearing. A surface that has been depressed or split, a widened plateau, a medial or bicondylar fracture, or a knee that opens on stress testing needs open reduction and internal fixation. The soft tissue around the knee, often badly bruised or blistered in higher-energy injuries, decides when surgery can safely be done.
Common Symptoms
- Severe knee pain and rapid swelling after a fall, a collision or a ski crash, from bleeding into the joint
- Inability to put weight on the leg
- Bruising over the upper shin and, within a day or two, down the calf
- A knee that looks bowed or knock-kneed compared with the other side
- Limited bending from the effusion, and in higher-energy injuries numbness on the top of the foot or a tense, painful calf
The same fall can tear ligaments instead of breaking bone. Rapid swelling with a pop and a normal X-ray suggests an ACL tear; a blow to the outside of the knee with inner-side tenderness and a stable X-ray suggests an MCL injury; and a lateral plateau fracture is accompanied by a lateral meniscus tear in a substantial share of cases, which is looked for on MRI and at surgery.
Causes & Risk Factors
The femur is driven down into the plateau, usually with the knee pushed sideways. In younger patients that takes high energy: a motor-vehicle or motorcycle collision, a fall from height, a bumper striking the outside of the knee, or a high-speed ski crash. In older patients with thinner bone, a fall from standing or a twist with the foot planted is enough, and the lateral plateau crumples rather than cracks. Lateral plateau fractures are the most common and follow a valgus force; medial fractures need more energy and carry a higher rate of ligament and nerve injury; bicondylar fractures involve both sides and come from axial loading in high-energy trauma. Skiers, cyclists and motorcyclists make up most of the sports cases Dr. O'Donnell treats.
How It Is Diagnosed
The exam begins with the limb rather than the fracture. Dr. O'Donnell checks the pulses and skin, tests sensation and movement in the foot for peroneal nerve injury, and assesses the calf for compartment syndrome, which is a surgical emergency in high-energy plateau fractures. A tense knee is aspirated; fat globules floating in the blood confirm a fracture into the joint. Once pain allows, the knee is stressed sideways at 0° and 30°, because a plateau fracture that lets the knee open more than about 10 degrees is unstable and is fixed regardless of how the X-ray looks.
X-rays show the fracture and the overall alignment. A CT scan is obtained for every tibial plateau fracture, because it measures what X-rays cannot: the depth of joint-surface depression, the width of the split, the number and position of fragments, and the plan for the plate and screws. MRI is added when a ligament or meniscus injury is suspected, which is common with lateral fractures and in higher-energy patterns. Patients transferred from elsewhere can upload their CT through mymedicalimages.com before the visit.
Treatment Options
Non-operative care
A fracture with less than about 2 to 3 mm of joint-surface depression, no widening of the plateau and a knee that is stable on stress testing is treated in a hinged knee brace, non-weight-bearing or touch-down on crutches for 6 to 8 weeks, with knee motion from the first week. X-rays are repeated at 1 to 2 weeks and again at 6 weeks to be sure the surface has not settled. This suits many low-energy lateral fractures in older patients and undisplaced cracks in younger ones.
Open reduction and internal fixation
When the surface is depressed or split beyond that threshold, when the plateau has widened, when the knee is unstable to stress, or when the fracture is medial or bicondylar, Dr. O'Donnell performs open reduction and internal fixation. The depressed cartilage surface is elevated back to level, the void beneath it is filled with bone graft or a bone substitute, and a contoured plate with locking screws holds the plateau in position while it heals. Depressed lateral fractures can be reduced with arthroscopic assistance through small incisions, which also allows a torn lateral meniscus to be repaired at the same time. Bicondylar fractures need plates on both sides. High-energy injuries with blistered or swollen skin are first spanned with a temporary external fixator, and definitive fixation is done 1 to 3 weeks later once the soft tissue has recovered.
Recovery & What to Expect
Whether treated in a brace or with a plate, treatment follows two rules: keep the surface off load until the bone has healed, and keep the knee moving from the first week so it does not stiffen. Dr. O'Donnell's protocol after fixation runs as follows.
| Phase | Timing | What happens |
|---|---|---|
| Protected motion | Weeks 0–6 | Non-weight-bearing or touch-down on crutches; hinged brace. Passive and active-assisted motion with an early goal of 0–90°, quad sets, straight-leg raises, full passive extension. No loaded flexion. Advance at full extension, 90° of flexion and a good quad set. |
| Weight bearing & motion | Weeks 6–12 | Weight bearing advanced per X-ray healing, usually beginning at 6–8 weeks and full by about 12; crutches weaned. Full motion, closed-chain strengthening in protected ranges, stationary bike, balance. Advance at full weight bearing without pain, full motion and radiographic healing. |
| Strengthening | Months 3–4 | Progressive resistance, single-leg strengthening and balance, low-impact conditioning. Advance at 80% strength of the other leg and a normal gait. |
| Return to activity | Months 4–6 | Advanced strengthening, impact and sport-specific progression as cleared. Full loading on symmetric strength and surgeon clearance. |
Desk work on crutches is possible within 1 to 2 weeks; driving a right-leg patient waits for full weight bearing at about 12 weeks; running and impact sport at 4 to 6 months, and skiing generally the following season. Non-operative fractures follow the same sequence with the same 6 to 8 weeks off weight. The protocol is available as a PDF: tibial plateau fracture fixation.
Frequently Asked Questions
Can a tibial plateau fracture heal without surgery?
Yes, when the joint surface is still level (less than about 2 to 3 mm of depression), the plateau has not widened and the knee is stable on stress testing. Those fractures heal in a hinged brace with 6 to 8 weeks off weight bearing and early motion. Depressed, split, widened, medial or bicondylar fractures and unstable knees are fixed surgically, because a surface that heals uneven wears out early.
Why do I need a CT scan for a tibial plateau fracture?
X-rays show that the plateau is broken; the CT shows how much the surface has sunk, how far the split has opened and how many fragments there are. Those measurements decide whether the fracture can be braced or needs fixation, and they guide placement of the plate and screws. MRI is added when a ligament or meniscus injury is suspected.
How long am I on crutches after a tibial plateau fracture?
Six to eight weeks non-weight-bearing or touch-down, whether the fracture was braced or fixed, until X-rays show healing. Weight bearing is then advanced gradually and is usually full by about 12 weeks. Putting weight through the leg early risks the elevated surface settling, which is the one thing the treatment is designed to prevent.
Will I get arthritis after a tibial plateau fracture?
The risk rises with how uneven the surface heals and with the cartilage damage done at the moment of injury. Restoring the surface to level and keeping it there during healing is how that risk is lowered, which is the reason for fixing displaced fractures and for the long period off weight bearing. Many patients with a well-reduced fracture never develop meaningful arthritis.
When can I drive, ski or run again after a tibial plateau fracture?
Driving a right leg waits for full weight bearing at about 12 weeks; a left leg with an automatic car, often 2 to 3 weeks. Running and impact activity begin at 4 to 6 months once strength is at least 80% of the other leg and the gait is normal. Skiing, which loads the plateau sideways and at speed, is generally deferred to the following season.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.