Injury, Int. J.

Care Injured 49 (2018) 2252–2263

Contents lists available at ScienceDirect

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

Revisiting the Schatzker classification of tibial plateau fractures

Mauricio Kfuria,b,* , Joseph Schatzkerc
a
Department of Orthopedics, University of Missouri, Columbia, MO, United States
b
Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão
Preto, Brazil
c
Division of Orthopedics, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Tibial plateau fractures have a broad spectrum of presentations, depending on the mechanism and
Tibial plateau fracture energy of the trauma. Many classification systems are currently available to describe these injuries. In
Classification 1974, Schatzker proposed a classification based on a two-dimensional representation of the fracture. His
Tomography
classification with the six-principles types became one of the most utilized classification systems for
Decision making
tibial plateau fractures. More than four decades after this original publication, we are revisiting each
fracture type in the light of information made available by computed tomography, which today comprises
a standard tool in assessing articular fractures. The classification we are proposing relies on the fact that
the tibial plateau has two anatomical columns, lateral and medial. We are introducing a virtual equator
which splits the articular surface in the coronal plane. The equator divides each column into two
quadrants, the anterior (A) and the posterior (P). Unicondylar fracture types (I to IV) have now additional
modifiers A (anterior) and P (posterior) to describe the exact spatial location of the primary fracture
plane. Bicondylar fracture types (V and VI) have the modifiers (A and P) of the main fracture plane for
each column, and lateral (L) and medial (M) to denote the column. We are introducing the concept of the
main fracture plane. Recognition of the exact location of the principal fracture plane is essential for
preoperative planning of patient positioning, surgical approach and for determining where to apply the
hardware to achieve stable fixation. The new three-dimensional classification is based on the template of
the original Schatzker classification. It covers the mechanism of the injury, the energy of the trauma, the
morphologic characteristics of the fracture and its location in three dimensions.
© 2018 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 The Schatzker classification was based on a two-dimensional

representation of the fracture. The fracture types in his classifica-
Tibial plateau fractures are articular injuries which have a broad tion were organized according to their essence; namely, age of the
spectrum of clinical presentations and are frequently associated patient, the bone quality, the morphologic architecture of the
with long term complications [1,2]. In recent years these fracture, and the energy of the trauma. The types I to III are
challenging fractures have become a topic of great interest not fractures of the lateral tibial plateau. Type I is a cleavage fracture
only regarding their classification but also fixation methods and type of the lateral column. It is more common in younger people,
expected outcomes [3–10]. who have a denser cancellous bone which resists impaction.
The complete understanding of the personality of these Frequently, this fracture is oriented in the sagittal plane and may be
fractures is the key element in the decision-making process when addressed by anatomical reduction and absolute stability of the
choosing the best possible treatment [11]. At least 38 classification joint surface with lag screws. In cases where a long split is
systems have been used to describe tibial plateau fractures [12]. In identified an anterolateral buttress plate should be used in
1974, Schatzker published his classification of fractures of the tibial addition. Type II is a split wedge fracture of the lateral column
plateau and described six principle types [13] (Fig. 1). associated with depression. It has the same mechanism of injury as
Type I, axial and valgus shearing and loading forces but in older
patients, who have a less dense metaphyseal bone, the articular
surface fails and impaction and depression of the articular surface
* Corresponding author at: 1100 Virginia Ave, Missouri Orthopedic Institute, results. Type II fractures are managed by open reduction and
Columbia, MO, 65212, United States.
internal fixation. The aim is to restore the articular surface and the
E-mail address: kfurim@health.missouri.edu (M. Kfuri).

https://doi.org/10.1016/j.injury.2018.11.010
0020-1383/© 2018 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/).
 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263 2253

Fig. 1. The six principle tibial plateau fracture types as described by Schatzker. Type I, split wedge of the lateral tibial plateau; Type II, split wedge depression of the lateral
tibial plateau; Type III, pure depression of the lateral tibial plateau; Type IV: split wedge of the medial tibial plateau; Type V: bicondylar tibial plateau fracture, where there is
continuity between the epiphysis and the diaphysis; Type VI: bicondylar fracture with complete dissociation between the epiphysis and the diaphysis.

mechanical axis of the lower extremity. In the Type III the [13,17–19]. Until the 1970’s, plain X-rays and biplane tomography
metaphyseal containing cortex remains intact. It is a pure joint were the only available imaging modalities to study the architecture
depression and most of the time the joint is stable. If, however, the of a fracture. Computed assisted tomography (CAT) was a later
joint depression consists also of impaction and depression of the development. Before the advent of the CATscan many of the fractures
plateau rim the joint becomes unstable. Regarding surgical in the coronal plane, often the result of high velocity trauma, were
treatment, in case the depression is completely contained by the not recognized. Therefore, the knowledge of the prevalence of some
cortex, the joint is normally not opened, the distal metaphyseal tibial plateau fractures oriented in the coronal plane was very low.
cortex is windowed, and a bone tamp is inserted and directed The aim of this article is to revisit the Schatzker classification,
upwards to tap the depressed fragments back in the place. If the four decades after its description and to examine each fracture type
rim is involved it must be reduced and mechanically supported. in the light of information made available by CAT scan, which today
Types IV to VI are high energy injuries associated with knee joint comprises a standard and essential tool in assessing articular
instability ranging from a subluxation to dislocation. Type IV is the fractures. Further we aim also to incorporate the new information
isolated fracture of the medial column of the tibial plateau. The made available by CAT and present the six fracture types of
mechanism of injury is a varus shearing force. As the medial tibial Schatzker with a new notation which allows a three-dimensional
plateau is denser than the lateral one, a higher force is required to representation of the architecture of the fractures. We are
fracture it thus the energy of trauma for a type IV is normally high. proposing to extend the Schatzker classification to encompass
A type IV is most often a fracture dislocation of the knee, with the third dimension.
potential for neurovascular complications. Bicondylar tibial
plateau fractures, types V and VI, are also high energy injuries. The purpose of a classification system
The essence of a Type V fracture is the preservation of continuity
of the shaft with some part of the overlying metaphysis and The purpose of a classification system Audigé et al. listed the
joint. The preserved portion is usually its middle. This differ- criteria that should apply to a classification system; namely, it
entiates the Type V bicondylar fracture from the Type VI which is should lead to an improvement in the understanding, communi-
also bicondylar, but in type VI the continuity of the metaphysis cation, documentation, and decision making about a set of fracture
is disrupted, and the articular surface loses contact with the categories [20]. According to Audigé et al., the validation of a
diaphysis. The types IV, V and VI because of the high energy classification system involves the objective measurement of
required to produce them are usually associated with significant quality parameters, such as clinically relevant diagnostic elements,
compromise of the soft tissues envelope. accuracy, and reliability. Accuracy measures how well the
For Schatzker, the indication for surgery was joint instability described types translate to real cases frequently seen in practice.
and not the degree of depression, which was a criterion for surgery Reliability measures how repeated utilizations of the classification
in other publications. Schatzker recommended that if a surgeon for a given fracture type is consistent, leading to agreement either
was in doubt whether the joint was stable or not, an examination by the same observer (intra-observer reliability), or by different
under anesthesia was indicated. In 1979, Schatzker et al. published ones (inter-observer reliability). A measure has a high reliability if
their experience with the management of 94 tibial plateau it produces similar results under consistent conditions. Although
fractures [14]. Since then, the six basic types have been validated many classification systems have been published, Schatzker and
and accepted universally as fulfilling the criteria of a useful and AO/OTA are the most studied regarding their reliability. In most
practical classification [15,16]. studies of reliability using only plain radiographs, the reliability of
The AO classification system for long bone fractures was Schatzker and AO/OTA classification systems was rated as fair or
introduced later and was based on an alphanumeric representa- moderate [16,21].
tion. The tibial plateau fractures were described as partial articular,
when compromising one of the tibial condyles, and complete The role of tridimensional image studies
articular, when compromising both tibial condyles [17]. The
Orthopedic Trauma Association and the AO Foundation published a The advent of CAT, a tridimensional imaging modality, has set a
unified classification system for long bone fractures with the goal new standard for the understanding of articular fractures. Brunner
of establishing an internationally standardized method of com- et al. demonstrated that computed tomography improves the
munication for those involved with documentation and research intra- and inter-observer reliability of Schatzker and AO/OTA
on fractures and dislocations [18]. Tibial plateau fractures were classification systems [22]. Two-dimensional computed tomogra-
described as the types 41B, to describe unicondylar fractures, and phy allows for a better characterization of the main fracture planes
41C, to describe bicondylar fractures. as compared to plain radiographs. The superiority of three-
The first available classification systems for tibial plateau dimensional computed tomography reconstructions over two-
fractures placed a great of emphasis on the antero-posterior dimensional computer tomography, however, has not been
radiograph and relied on the sagittally oriented fracture patterns confirmed [23]. The use of magnetic resonance image (MRI) in
2254 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263

the management of tibial plateau has been reported as beneficial fibular collateral ligament and the insertion of the popliteus
for the understanding of associated soft tissues injuries. In fact, all tendon. On the medial side, the superficial medial collateral
image modalities when used together provide a complete ligament should not be peeled off anteriorly to gain access to the
assessment to the extent of the damage [24–27]. The most posteromedial corner of the tibia.
significant impact and contribution of three-dimensional imaging
in the assessment of tibial plateau injuries was the recognition and The virtual equator of the tibial plateau
characterization of fractures in the coronal plane. In 1998, Carlson
highlighted the challenge of managing coronal plane oriented In the last two decades, we have seen an increase in the
fractures and recommended dedicated surgical approaches to recognition of fractures in the coronal plane of the tibial plateau.
access the posterior aspect of the knee joint [28]. In the early Yang et al. in a series of 525 tibial plateau fractures, reported the
2000’s a number of articles raised the importance of a three- compromise of the posterior rim of the tibia in 28.8% of the cases
dimensional understanding of the tibial plateau fractures, with [39]. These authors used the Schatzker classification to describe
emphasis on the accuracy of the diagnosis, decision making when the energy of the trauma and noted the higher prevalence of
determining surgical approaches and fixation methods [29–32]. coronal plane fractures in Schatzker Type VI than Type IV. In the
The incidence of the posteromedial fragment in bicondylar light of the emerging new information regarding the fractures in
fractures and the importance of proper imaging for an accurate the coronal plane we decided to revisit the Schatzker classification
diagnosis and decision making became a relevant topic [30,31]. in order to add the third dimension and see what impact the new
Luo et al. utilizing computed tomography divided the surface of information would have on the existing six principle types. Our
the tibial plateau into three columns, while emphasizing the intent is to keep it simple, universal, but also applicable to the
relevance of coronal plane oriented fractures [32]. Chang et al. reality of a higher incidence of coronal plane fractures. As the
proposed to divide the surface of the tibial plateau into four lateral and medial columns of the tibial plateau are clearly defined,
quadrants aiming to bring further clarity when addressing we determined anatomical landmarks which could establish a
complex high energy bicondylar fractures [33]. Tridimensional virtual anatomic equator dividing the surface of the tibial plateau
imaging modalities allowed not only for the detection of fracture into two halves, anterior and posterior. On the lateral side of the
lines which were frequently not evident in plain radiographs but knee, the anatomical reference is the lateral tubercle of the fibula,
lead also to the development of new classification systems. which corresponds to the insertion of the fibular collateral
Molennars et al. proposed a computed mapping of tibial plateau ligament. On the medial side of the joint, the virtual equator
fractures, identifying the most recurrent fracture patterns [34]. intersects the tibial plateau posterior to the attachment of the
Krause et al. proposed that the tibial plateau should be split into 10 superficial medial collateral ligament, which also coincides distally
segments, based on computed tomography analysis. These authors with the posterior tibial crest (Fig. 2).
presented a three-dimensional, segment-based mapping of the These landmarks may be determined with computed tomogra-
tibial plateau in order to determine specifically the areas of the phy or MRI and are therefore reproducible (Fig. 3).
articular surface compromised by the fracture [35]. The virtual equator does not split the tibial plateau into two
symmetrical halves, since the posterior one is significantly smaller.
The anatomy of the proximal tibia Since the tibial plateau has two anatomical columns, the virtual
equator splits the proximal tibia into four articular quadrants
The proximal epiphysis of the tibia has two axial columns, a (Fig. 4).
medial and a lateral column. Each column supports a correspond- Each of the four quadrants has peculiar anatomical character-
ing condyle with its horizontally oriented articular surface. The istics and may be accessed through dedicated surgical approaches,
two anatomical columns are completely different in terms of their while preserving the integrity of the collateral ligaments of the
architecture. The medial one is denser in terms of bone trabeculae knee and the neurovascular structures around the joint. Crist et al.
and is stronger when subjected to forces. Thus, fractures published our concept of virtual equator in their book chapter
compromising the medial column of the tibial plateau are in dedicated to the management of tibial plateau fractures [40].
general associated with higher energy. Kellam et al. in their review of the AO/OTA Fracture and Dislocation
The proximal tibia articulates with the fibular head. This Classification Compendium-2018, also acknowledged the concept
articulation is located posteriorly to the medial - lateral axis of the described in this manuscript [41].
tibia. The fibular head is pyramidal in shape and has three
anatomical areas, the articular surface for the tibia, the fibular The three-dimensional classification of tibial plateau fractures
styloid and the lateral tubercle. The lateral tubercle of the fibular
head is the site of the attachment of the fibular collateral ligament The advent of computed tomography allows for three-
[36,37]. On the medial side of the knee, the superficial medial dimensional imaging of the proximal tibia together with the
collateral ligament has one femoral attachment and two tibial characterization of anatomical landmarks which delineate the four
attachments. The femoral attachment is slightly proximal and anatomical quadrants. This has made it possible to determine the
posterior to the center of the medial femoral epicondyle. The architecture of the fracture and its spatial topography within the
proximal tibial attachment of the superficial medial collateral tibial plateau. We revisited the Schatzker classification applying
ligament is at the insertion of the anterior arm of the semi- the results of three-dimensional imaging.
membranosus tendon. Its distal broad attachment is slightly The six principle fracture types of Schatzker remain the same.
anterior to the posterior tibial crest on the medial aspect of the We are adding a new set of modifiers “A” (anterior) and “P”
tibia and is deep to the tendons of the pes anserine and separated (posterior) to denote the quadrants involved in the six principle
from them by a bursa [38]. The deep medial collateral ligament is a types. These modifiers are denoted in upper cases. In order to
thickening of the medial joint capsule and consists of two arrive at a three-dimensional localization of the fracture the
components, the meniscofemoral and the meniscotibial. The surgeon must identify the main plane of the fracture and the place
attachments of the collateral ligaments of the knee determine where the plane bisects the articular rim of the tibial plateau. Split
the limits for surgical approaches to the tibial plateau. On the wedge fractures of the tibial plateau will disrupt the articular rim
lateral side, an anterolateral approach does not expose properly the at two points and will exit the metaphysis distally to the joint, at
posterolateral corner of the tibial plateau without risking the the apex of the wedge. The points where the wedge bisects the rim
 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263 2255

Fig. 2. The virtual equator of the tibial plateau. a: Representation of the axial view of the tibial plateau. The fibular collateral ligament (~) and the superficial medial collateral
ligament ($) attachments are represented in green. The virtual equator is represented in yellow and is determined by the lateral tubercle of the fibula, which is the site of
insertion of the fibular collateral ligament, and the posterior crest of the tibia, which is the posterior limit of the superficial medial collateral ligament. The equator divides the
surface of the tibial plateau into two halves, anterior (A) and posterior (P); b: Representation of the lateral view of the upper tibia. The equator is depicted in yellow and is
represented in three dimensions, anteriorly to the insertion of the fibular collateral ligament (~) and posterior to the superficial medial collateral ligament ($) c:
Representation of the medial view of the upper tibia. The equator represented in yellow is located posteriorly to the superficial medial collateral ligament ($), at the
projection of the posterior tibial crest. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3. Computed tomography of a tibial plateau – axial view. A and B are axial images of the tibial plateau obtained by computed tomography. The arrows indicate the
attachments of the fibular collateral ligament (fcl) and of the superficial medial collateral ligament (smcl); The virtual equator is represented in yellow.

are identified by lowercase letters which denote the location or the

points in relationship to the virtual equator, namely anterior (“a”)
or posterior (“p”). The third point where the fracture exits at the
metaphyseal area is denoted as “x”. This metaphyseal exit point
could be anterior (ax) or posterior (px). These three points, being
two on the rim and one on the metaphysis, determine the main
fracture plane. In case of unicondylar fracture types, the new
denotation of the fracture will include the Roman numerals, which
describes the lateral column (I to III) or the medial column (IV), and
the upper-case letter A (anterior) or P (posterior) (Fig. 5).
Sagittally oriented fractures will typically bisect the rim in two
points one being anterior and the other one posterior. Therefore,
the rim compromise will have in its description the letters “a” and
“p”. Coronally oriented fractures, fractures in the frontal plane, will
have an orientation mostly parallel to the virtual equator. They may
bisect the tibial plateau rim twice anteriorly (“a” and “a”) or twice
Fig. 4. The anatomical quadrants of the tibial plateau. The virtual equator,
posteriorly (“p” and “p”). For example, the typical posteromedial
represented in yellow, divides the tibial plateau into two halves, anterior and
posterior. Since the tibial plateau has two articular surfaces, lateral and medial, the
fragment of a bicondylar tibial plateau fractures normally
equator delineates four anatomical quadrants. AL: anterolateral; AM: anteromedial; intersects the rim twice posteriorly. The rim compromise is
PL: posterolateral; PM: posteromedial. (For interpretation of the references to described as “p” and “p” and the metaphyseal exit point is located
colour in this figure legend, the reader is referred to the web version of this article.) posteriorly (px) (Fig. 6).
2256 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263

Fig. 5. Anatomical topography of a split wedge fracture. A: Axial view of the tibial plateau. The fracture line intersects the rim at two points, one being anterior to the virtual
equator “a”, and the other one posterior to the equator “p”. Fibular collateral ligament (fcl); Superficial medial collateral ligament (smcl); B: Lateral view of the proximal tibia.
The main fracture plane is determined by three points. The two points where the split wedge bisect the rim and the exit point “x” at the metaphyseal area. In this image, the
main fracture plane is represented in red. This case illustrates a simple split wedge of the lateral tibial plateau, which corresponds to a Type I of Schatzker. Since the points at
which the fracture plane bisects the rim are located in the anterolateral quadrant of the tibial plateau, according to the new three-dimensional classification we determine this
to be a Type I A. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 6. Characteristics of a frontal plane-oriented fracture. A: Axial view of the tibial plateau. The fracture line bisects the rim twice posteriorly, namely “p” and “p”; B: Medial
view of the proximal tibia. The main fracture plane is denoted by the two points of intersection of the tibial plateau rim (“p” and “p”), and by the exit point at the metaphyseal
area (“px”). It is represented in red. The superficial medial collateral ligament is depicted on the anteromedial aspect of the tibia. (smcl). This is a Type IV of Schatzker.
According to the new three-dimensional classification, the main fracture plane is located at the posteromedial quadrant of the tibial plateau. Therefore, it is named a Type IV P.
(For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

In the decision making the special orientation of the main A split wedge may be separate as an entity or it may also be
fracture plane determines where to place the hardware and associated with comminution and depression of the articular
therefore the surgical approach. Split wedge fractures are surface. The goals in the management of tibial plateau fractures are
inherently unstable under axial load. As a principle, the fracture the restoration of joint stability and this involves the anatomical
should be anatomically reduced, and the wedge should be reduction of the articular surface, the reconstruction of rim
buttressed and thus contained. A buttress plate may be used for stability and the restoration of the mechanical axis of the lower
this purpose and ideally, it should be placed parallel to the main limb [42]. The new nomenclature allows the identification of the
fracture plane (Fig. 7). most important issue: the discontinuity of the rim integrity and
Although the virtual equator is helpful in determining the the consequent loss of joint instability. Each fracture type is
anterior and posterior halves of the tibial plateau, fracture lines do associated typically with its characteristic joint instability, the
not necessarily respect anatomical landmarks. It is not rare that in result of discontinuity of the tibial plateau rim.
a unicondylar fracture more than one quadrant of the tibial plateau Most of the times, the surgical approach used to reduce the
is compromised. In these cases, we have more than one split wedge split component of the fracture allows for direct or indirect
component and we must ideally determine where each fracture reduction of the depressed fragments of the articular surface. In a
plane is located (Fig. 8). typical Type II A, a split wedge depression of the lateral plateau
In case of bicondylar fractures types, one has to pay attention to there is a compromise of the anterolateral quadrant of the tibial
each column of the tibial plateau, medial and lateral, and plateau. An anterolateral approach allows for the “open book” like
determine which quadrants are compromised in each column. lateral retraction of the wedge and direct visualization and
The new denotation of the fracture includes the Roman numerals reduction of the depressed fragments of the articular surface
(V or VI), and the spatial location of the main fracture plane noted (Fig. 10).
with an upper-case letter (A and/or P) in each of the two The Type III of Schatzker is described as a pure depression of the
anatomical columns, lateral (L) and medial (M) (Fig. 9). lateral tibial plateau. There is no wedge component which would
allow an “open book” type exposure of the depressed fragments.
 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263 2257

Fig. 7. Clinical application of the three-dimensional anatomical classification of tibial plateau fractures. A: Medial view of the proximal tibia. A coronal plane-oriented fracture
with compromise the posteromedial quadrant of the tibial plateau is depicted. B: The ideal location for a buttress plate coincides with the area where the surgeon would like to
apply his thumb to keep the wedge in its place. In this case, the thumb has to be applied on the posteromedial aspect of the tibia, as this is a Type IV P fracture; C: The best
location for a buttress plate is parallel to the main fracture plane. If the surgeon knows where the ideal location for the hardware should be, the decision for the surgical
approach becomes logical.

Fig. 8. Illustration of a comminuted lateral tibial plateau fracture. A and B are a representation of a comminuted lateral tibial plateau fracture: Axial and lateral views of the
tibial plateau reveal two main fracture planes. One wedge is described as a/p/ax (depicted in black) This tells us that the rim in bisected in the sagittal plane once anteriorly and
once posteriorly and distally the exit point in the metaphyseal area is anterior to the equator. The quadrant mostly compromised by this wedge is the anterolateral. The second
wedge also bisects the rim on two points, but the orientation of its fracture plane is more parallel to the virtual equator and the exit point at the metaphyseal area is posterior
to the equator. Its description is a/p/px (depicted in red). The quadrant which is mostly compromised by this second wedge is the posterolateral. Although this is a Type II of
Schatzker, the three-dimensional anatomical classification allows for a better understanding about the areas of instability by denoting the places where the articular rim is
disrupted. According to the three-dimensional anatomical classification this would be a Type II A + P (one wedge anterior and one posterior). The identification of the
posterior wedge (a/p/px) is of great importance. To deal only with the anterior wedge would leave the joint unstable posteriorly. (For interpretation of the references to colour
in this figure legend, the reader is referred to the web version of this article.)

The anatomical classification may be applied considering the alignment and hyperextension. In this scenario, an association
location of the depressed area. Most commonly one will identify a between posterolateral corner ligament injury and anteromedial
Type IIIA or a Type IIIP, depending on whether the major area of the tibial plateau rim depression may take place. Axial loading applied
depression is located anteriorly or posteriorly to the virtual to the knee positioned in valgus alignment and flexion may result
equator. If the rim is intact, a metaphyseal window suffices to in posterolateral crush of the rim. In cases where the rim has been
permit the reduction of the depressed joint fragments with a compromised, besides reducing the depression, the shattered
punch type of an instrument. Some authors have reported the use cortex below the rim should be reduced and supported by a
of arthroscopy in these cases to control the reduction of the horizontally oriented rim plate [45,46]. The horizontal plate is an
articular surface [43,44]. Pure depression type fractures are example of the “hoop plate” principle which provides containment
normally reduced by means of a bone tamp or punch, which is for the reduced crushed cortex. To elevate the crush without
introduced through a metaphyseal window under guidance of supporting the reduced cortex is to invite failure due to loss of
fluoroscopy (Fig. 11). reduction since there would be nothing to hold the bone graft
A situation which requires particular attention is the pure supporting the rim in place.
depression fracture which compromises the articular rim. A typical The posterolateral quadrant of the tibial plateau is unique due
situation happens when axial load is applied with the knee in varus to its associated anatomical characteristics. Fractures or surgical
2258 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263

Fig. 9. The application of the three-dimensional anatomical classification in bicondylar tibial plateau fractures. A: Axial view of the tibial plateau depicts three main fracture
lines. There are two split wedges compromising the lateral tibial plateau and one disrupting the medial tibial plateau. B: Medial view of the proximal tibia. The split wedge on
the medial side is a type p/p/px. (depicted in blue). Therefore, on the medial side the instability is located on the posteromedial quadrant; C: Lateral view of the proximal tibia.
One split wedge is described as a/p/ax (depicted in black) – which means main compromise of the anterolateral quadrant – and the other one is described as a/p/px (depicted in
red) – which translates the instability of the posterolateral quadrant. This is a bicondylar tibial plateau fracture where there is continuity between the epiphyseal area and the
diaphyseal area throughout the anterior tibial tubercle. It is a type V of Schatzker. According to the anatomical classification this is a Type V AL + PL + PM. The way to apply the
anatomical classification to bicondylar tibial plateau fractures consists in the description of the quadrants where the rim has been disrupted, and where the instability is a
concern. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 10. Illustrative case of a Type II A tibial plateau fracture. a,b: Plain radiographs in the anteroposterior and lateral projections reveal a split wedge depression fracture type
of the lateral tibial plateau; c-e: Computed tomography images reformed in the axial, frontal and sagittal planes. The CAT scan allows for precise location of the split and
depression components of the fracture.; f: Tridimensional reconstruction of the CAT scan allows for a clear understanding of the surface topography of the fracture
components; g: schematic representation of the axial view of the tibial plateau depicting the anatomical classification of this particular fracture type; h,i: Post-operative
radiographs in the anteroposterior and lateral projections confirm the restoration of the articular surface, and of the mechanical axis by open reduction and internal fixation.
An anterolateral approach and an anterolateral buttress plate were used to manage this Type II A fracture.
 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263 2259

Fig. 11. Illustrative case of a Type III P tibial plateau fracture. A,B: Plain radiographs on the anteroposterior and lateral projections reveal a pure depression fracture type in the
lateral tibial plateau; C–E: Sequence of Magnetic Resonance Imaging depicting a pure depression, in the posterolateral quadrant of the tibial plateau with a significant
articular depression. The key is the intact posterior rim better seen in a CT than MRI; F: schematic representation of the axial view of the tibial plateau illustrating a type IIIP
without compromise of the articular rim; G,H: Intra-operative fluoroscopic views of the anteroposterior and lateral views in which the bone tamp was positioned under the
osteochondral fragments, in the metaphyseal area. It was introduced through an anteromedial window towards posterolateral; I: Reduction was obtained under fluoroscopic
control; J,K: Post-operative images reveal a congruent anatomically reduced joint surface. The metaphyseal bone void was filled up with bone graft; the screws illustrate the
rafting principle in support of an articular reduction. L: Functional outcomes after 12 weeks. Patient is asymptomatic and has full range of motion comparable with the contra-
lateral knee.

approaches in this area may compromise neurovascular structures. approach to reach the posterolateral wedge one is able to buttress
We must consider the peroneal nerve and the trifurcation of the the split wedge but at the expense of a very limited visualization of
popliteal tibial artery. A number of surgical approaches have been the articular surface of that quadrant. The trifurcation of the
described to address fractures located in this quadrant of the tibial popliteal artery is located approximately 6 cm below the joint line.
plateau [28,32,47–50]. If one uses an extended posteromedial This means that a direct lateral approach to the posterolateral

Fig. 12. Illustrative case of a Type II A + P tibial plateau fracture. A. Radiograph on anteroposterior projection of the left knee. A Schatzker type II is illustrated as depicted
schematically in the C. If one does not pay attention to the lateral view of the knee, it is easy to miss the posterior location of some of the main fracture components. The
asterisk marks the two wedge fragments; D. Computed tomography in the axial view with the virtual anatomic equator of the tibial plateau (yellow) drawn in. The rim of the
tibial plateau is disrupted (*) anteriorly and posteriorly to the equator.; E. Tridimensional surface reformation of computed tomography images shows the major area of
instability in this fracture in the posterolateral quadrant, with a significant impaction of the rim. This was the key in the decision making of the best surgical approach. (For
interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
2260 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263

Fig. 13. Continuation of the illustrative case of Fig. 12. A. A direct posterolateral approach was chosen. The patient was placed prone on the operative table and anatomical
landmarks were identified with a marking pen; B: A posterolateral approach was performed, and the peroneal nerve was identified; C. The posterolateral rim was exposed,
and the lateral meniscus was retracted proximally; D,E: Postoperative radiographs, depict the fixation of the posterolateral rim with a buttress plate and of the anterolateral
rim with a lag screw and Kirschner wires; F–H: final clinical outcomes.

quadrant allows only the use of short buttress plates. Anything Quadrants:
longer runs into the vessels. (Figs. 12 and 13)
The virtual equator divides the tibial plateau condyles into two
Terminology of the three-dimensional classification of tibial halves. The anterior one is designated by a capital “A”, and the
plateau fractures posterior one is designated by a capital “P”. The tibial plateau has
two columns, each one supporting its corresponding articular
The following elements and rules have been introduced with surface. The articular surfaces are separated by the extra-articular
the three-dimensional anatomical classification of tibial plateau tibial spines. Since there are two columns which are split by a
fractures: virtual equator, this results in the four anatomical quadrants, as
follows: AL- anterolateral; AM – anteromedial; PL – posterolateral;
Virtual equator of the tibial plateau: PM – posteromedial.

Plane determined by joining the insertion of the fibular Roman numeral:

collateral ligament on the lateral tubercle of the fibular head
and the posterior aspect of the insertion of the superficial medial Two elements determine the use of a Roman numeral. The
collateral ligament, which is distal to the joint in the metaphyseal fracture pattern – split wedge; split wedge depression; pure
area and coincides with the posterior tibial crest. depression – and the column which has been compromised –
lateral or medial. Types I, II and III refer to the lateral tibial plateau.
Tibial plateau condyles: Type IV refers to the medial tibial plateau. Types V and VI are
bicondylar fractures
There are two tibial plateau condyles, the lateral and the medial.
Each one contains the corresponding articular surface of the two Unicondylar tibial plateau fractures:
anatomical columns of the upper tibia. The lateral tibial plateau is
designed by a capital “L”. The medial tibial plateau is designed by a According to the Schatzker classification these are the types I, II,
capital “M”. III (lateral types) and IV (medial type). In the three-dimensional
 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263 2261

anatomical classification, the main fracture plane may be located classification is based on plain radiographs in describing the types
anterior and/or posterior to the virtual equator line. The way to and is further complemented by computed tomography to add the
denote this is by using the Roman numeral first referring to the third dimension. Plain radiographs allow for the understanding of
column which has been fractured, followed by capital “A” or capital the mechanism of injury, as originally described in the six principle
“P”, which denote the area of the plateau where the main fracture types by Schatzker [13,14]. Computed tomography gives us a
plane is located. In cases where the anterior and posterior rim areas detailed information about the exact location of the main fracture
are both compromised we use the denotation A + P as in Fig. 8. plane in each of the four anatomical quadrants which we have
defined in this paper. We recognize the two main patterns of
Bicondylar tibial plateau fractures: articular fractures which compromise the tibial plateau, namely,
the split wedge and the articular depression. In the case of a split,
The types V and VI do not refer to one of the tibial plateau we provide a method to define the main fracture plane by
condyles but to both of them. Therefore, it is important to describe determining the two points where the fracture plane bisects the
the compromise of each condyle. The letters that refer to each tibial plateau rim and the point where the fracture exits the
quadrant are written in capital letters. AL: anterolateral; AM: metaphyseal bone. To our knowledge we are first to provide the
anteromedial; PL: posterolateral; PM: posteromedial. A plus sign is definition of a main fracture plane and how to localize it in each
used to describe the additional compromise of another quadrant. quadrant of the tibial plateau. If one determines the orientation
As an example, a Type V AL + PM, describes a bicondylar tibial and position in three dimensions of the main fracture plane, it is
plateau fracture, where there is continuity between the epiphyseal possible to plan with accuracy the placement of a buttress plate,
and the diaphyseal segments and where there is a compromise of which should be parallel to this main fracture plane. Once the
the tibial plateau, being the compromise of the rim located in the surgeon knows the location of the fracture and the exact
anterolateral and in the posteromedial quadrants. placement of the supporting plate, the surgeon has the necessary
and proper guidance of where to perform the surgical approach.
Wedge and articular rim intersecting points: The extension of the original classification, when it comes to pure
depression, allows for its precise location. If the depression is
The points where the wedge, defined by the principle fracture located centrally, metaphyseal bone windows should be opened
plane, disrupts the rim are described in lowercase letters. “a” granting access to the metaphysis and the compressed bone deep
depicts anterior, “p” describes posterior. The point where the to the subchondral bone plate, which can then be elevated by bone
fractures exits the metaphyseal bone is also “a” or “p” but to pushers. If the depression involves the rim, the rim should be
differentiate, it gets the addition of an “x”. All letters are written in reconstructed in that particular quadrant, restoring the stability of
lower case. the joint. This usually means also the use of a horizontal oriented
plate. We are introducing a three-dimensional complement to the
Discussion Schatzker classification, which not only provides the axial, coronal,
and saggital morphology of the tibial plateau but also the
In the 1950’s the classification systems for tibial plateau mechanisms of injury and the exact spatial localization of the
fractures spoke of simple types as depression and split [12]. In the main fracture planes. The following chart describes how to apply
1970’s, still based on a two-dimensional imaging and two- the new classification system (Fig. 14).
dimensional description of fracture, more detailed systems were
introduced, speaking also of differences between the lateral and Conclusions
medial plateau [13,17]. Schatzker and later the AO/OTA classifica-
tion systems, introduced more fracture types [13,17,18]. The more The new system for the three-dimensional classification of
details a classification presents, the higher the likelihood of tibial plateau fractures is based on the template of the original
disagreement in an inter- and intra-observer basis [16,21,22]. The Schatzker classification, to which we add information obtained
advent of computed tomography allowed for the localization of the from computed tomography. Our goal was to revisit the Schatzker
fracture in the axial plane, identifying for the first time with classification four decades after its description and to extend it to
precision coronal plane-oriented fractures. Since then tibial include the orientation of the injury in the third dimension. The
plateau fractures have become a topic of great interest not only
from the classification point of view but also from the fixation
method and expected outcomes.
Luo et al. introduced the three-column concept with particular
attention to the compromise of the posterior aspect of the tibial
plateau. Luo’s system enhanced the awareness about the
compromise of the posterior rim of the tibial plateau, but it does
not differentiate between the posterolateral and posteromedial
aspects of the rim and does not highlight differences between split
and depression types of fracture [32]. To address the differences
between the posterolateral and the posteromedial quadrants of the
tibial plateau, Chang et al. proposed the four quadrants concept,
but does not provide the description on the mechanisms of injury
and its related fracture patterns causing the compromise of each
quadrant [33]. Krause et al. using the axial view of a computed
tomography divided the articular surface of the tibial plateau into
ten segments but did not offer details about mechanisms of injury
related to the compromise of each segment. To our knowledge, the Fig. 14. The mechanics of the tridimensional tibial plateau classification based on
the use of plain radiographs and computed tomography scan. Plain radiographs
most utilized classification systems published so far are based allow for an overall picture of the mechanism and energy of the injury, while
either on plain radiographs or computed tomography, but not on computed tomography determines the exact fracture pattern and location in all
both of them. Our proposed extension of the Schatzker three planes.
2262 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263

spatial localization of the fracture should help the surgeon when [3] Pätzold R, Friederichs J, von Rüden C, Panzer S, Bühren V, Augat P. The pivotal
carrying out the pre-operative plan to determine with precision role of the coronal fracture line for a new three-dimensional CT-based fracture
classification of bicondylar proximal tibial fractures. Injury 2017;48(October
the surgical approach and fixation methods. We acknowledge that (10):2214–20.
our current manuscript has some limitations. First, we are focused [4] Bertrand ML, Pascual-López FJ, Guerado E. Severe tibial plateau fractures
on the anatomical description of the bony injury, with no mention Schatzker V-VI): open reduction and internal fixation versus hybrid
externalfixation. Injury 2017;48(November (6)):S81–5.
of soft tissues envelope. Soft tissues are key elements in the [5] Elabjer E, Ben9ci 
c I, Cuti T, Cerove9  
cki T, Curic S, Vidovi
c D. Tibial plateau fracture
management of the tibial plateau fractures. We assumed that the management: arthroscopically-assisted versus ORIF procedure – clinical and
reader who is familiar with the Schatzker classification under- radiological comparison. Injury 2017;48(November (5)):S61–4.
[6] Arnold JB, Tu CG, Phan TM, Rickman M, Varghese VD, Thewlis D, et al.
stands the differences and the implications or each type when Characteristics of postoperative weight bearing and management protocols for
considering the severity of the soft tissue injury and the nuances tibial plateau fractures: findings from a scoping review. Injury 2017;48
between the simple fractures – types I to III – and the fracture (December (12)):2634–42.
[7] Sun H, Zhu Y, He QF, Shu LY, Zhang W, Chai YM. Reinforcement strategy for
dislocations – types IV to VI. This study does not make references to
lateral rafting plate fixation in posterolateral column fractures of the tibial
the injuries of the tibial spines and of the anterior tubercle, since plateau: the magic screw technique. Injury 2017;48(December (12)):2814–26.
these are extra-articular structures. We foresee and what is true of [8] Menghi A, Mazzitelli G, Marzetti E, Barberio F, D’Angelo E, Maccauro G.
all classifications, that some fractures will not be easy to classify, Complex tibial plateau fractures: a retrospective study and proposal of
treatment algorithm. Injury 2017;48(October (3)):S1–6.
considering their comminution and atypical patterns. We also [9] Kugelman D, Qatu A, Haglin J, Leucht P, Konda S, Egol K. Complications and
recognize that by adding more details to the classification we make unplanned outcomes following operative treatment of tibial plateau fractures.
it more cumbersome and, therefore, more prone to lack of Injury 2017;48(October (10)):2221–9.
[10] Thewlis D, Fraysse F, Callary SA, Verghese VD, Jones CF, Findlay DM, et al.
reproducibility. Our goal is to provide a three-dimensional Postoperative weight bearing and patient reported outcomes at one year
orientation of the fracture and to facilitate the decision making following tibial plateau fractures. Injury 2017;48(July (7)):1650–6.
in the most typical types regarding to the surgical approach and [11] Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg Br
1964;46(August):373–87.
fixation method. Future studies, taking into consideration inter- [12] Millar SC, Arnold JB, Thewlis D, Fraysse F, Solomon LB. A systematic literature
and intra-observers’ evaluations, are needed to validate the current review of tibial plateau fractures: what classifications are used and how
classification which places emphasis on the three dimensional reliable and useful are they? Injury 201827(January), doi:http://dx.doi.org/
10.1016/j.injury.2018.01.025 pii: S0020-1383(18)30025-1.
localization of the fracture elements and the resultant joint
[13] Schatzker J. Compression in the surgical treatment of fractures of the tibia. Clin
instability. We have introduced some new concepts like the virtual Orthop 1974;105:220–39.
equator, the main fracture plane, the containment of rim support in [14] Schatzker J, McBroom R, Bruce D. The tibial plateau. The Toronto experience
1968–1975. Clin Orthop 1979;138:94–104.
cases of cortical comminution as well as the importance of rim
[15] Honkonen SE, Järvinen MJ. Classification of fractures of the tibial condyles. J
integrity for the stability of the joint. We have also pointed out that Bone Joint Surg Br 1992;74(November (6)):840–7.
buttress plates must be parallel to the main fracture plane. The [16] Maripuri SN, Rao P, Manoj-Thomas A, Mohanty K. The classification systems
advantage of this three dimensional extension of the original for tibial plateau fractures: how reliable are they? Injury 2008;39(10):1216–
21.
Schatzker classification is that it makes use of a widely used and [17] Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of
accepted classification system. In addition, it provides a simple fractures of long bones. Berlin Heidelberg, New York: Springer-Verlag; 1990
method based on computed tomography morphology of the injury ISBN 978–3-642–61261–9.
[18] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture
to localize the fracture and to provide a simple method of notation and dislocation classification compendium–2007: Orthopaedic Trauma
of the details of the injury. It also provides clear guides to Association classification, database and outcomes committee. Injury 2008;39
preoperative planning which should hopefully help to avoid (October (10)):1216–21.
[19] Holhl M, Luck JV. Fractures of the tibial condyle. J Bone Joint Surg Am 1956;38-
surgical mistakes and improve the outcomes of treatment. A(October (5)):1001–18.
[20] Audigé L, Bhandari M, Hanson B, Kellam J. A concept for the validation of
fracture classifications. J Orthop Trauma 2005;19(July (6)):401–6.
Acknowledgment
[21] Charalambous CP, Tryfonidis M, Alvi F, et al. Inter- and intra-observer variation
of the Schatzker and AO/OTA classifications of tibial plateau fractures and a
The authors would like to thank Stacy Turpin Cheavens, MS, proposal of a new classification system. Ann R Coll Surg Engl 2007;89(4):400–
CMI, Certified Medical Illustrator University of Missouri, Depart- 4.
[22] Brunner A, Horisberger M, Ulmar B, Hoffmann A, Babst R. Classification
ment of Orthopedic Surgery for the illustrations in Figs. 1, 2, 4, 5, 6, systems for tibial plateau fractures; does computed tomography scanning
7, 8, 9, 10g, 11f and 12b. improve their reliability? Injury 2010;41(February (2)):173–8.
[23] Doornberg JN, Rademakers MV, van den Bekerom MP, Kerkhoffs GM, Ahn J,
Steller EP, et al. Two-dimensional and three-dimensional computed
Disclosure tomography for the classification and characterization of tibial plateau
fractures. Injury 2011;42(December (12)):1416–25.
None of the authors received payments or services, either [24] Yacoubian SV, Nevins RT, Sallis JG, et al. Impact of MRI on treatment plan and
fracture classification of tibial plateau fractures. J Orthop Trauma
directly or indirectly (i.e., via his or her institution), from a third 2002;16:632–7.
party in support of any aspect of this work. None of the authors, or [25] Gardner MJ, Yacoubian S, Geller D, Suk M, Mintz D, Potter H, et al. The
their institution(s), have had any financial relationship, in the incidence of soft tissue injury in operative tibial plateau fractures: a magnetic
resonance imaging analysis of 103 patients. J Orthop Trauma 2005;19
thirty-six months prior to submission of this work, with any entity (February (2)):79–84.
in the biomedical arena that could be perceived to influence or [26] Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee after tibial plateau
have the potential to influence what is written in this work. Also, fractures. J Knee Surg 2010;23(December (4)):187–92.
[27] Castiglia MT, Nogueira-Barbosa MH, Messias AMV, Salim R, Fogagnolo F,
no author has had any other relationships, or has engaged in any
Schatzker J, et al. The impact of computed tomography on decision making in
other activities, that could be perceived to influence or have the tibial plateau fractures. J Knee Surg 201814(February), doi:http://dx.doi.org/
potential to influence what is written in this work. 10.1055/s-0038-1627464.
[28] Carlson DA. Bicondylar fracture of the posterior aspect of the tibial plateau. A
case report and a modified operative approach. J Bone Joint Surg Am 1998;80
References (July (7)):1049–52.
[29] Bhattacharyya T, McCarty [32_TD$DIFF]3rd LP, Harris MB, Morrison SM,
[1] Papagelopoulos PJ, Partsinevelos AA, hemistocleous GS, Mavrogenis AF, Korres Wixted JJ, Vrahas MS, et al. The posterior shearing tibial plateau fracture:
DS, Soucaos PN. Complicatios after tibia plateau fracture surgery. Injury treatment and results via a posterior approach. J Orthop Trauma 2005;19
2006;37:475–84. (May–June (5)):305–10.
[2] Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE. Population- [30] Barei DP, O’Mara TJ, Taitsman LA, Dunbar RP, Nork SE. Frequency and fracture
based epidemiology of tibial plateau fractures. Orthopedics 2015;38 morphology of the posteromedial fragment in bicondylar tibial plateau
(September (9)):e780–786. fracture patterns. J Orthop Trauma 2008;22(3):176–82.
 M. Kfuri, J. Schatzker / Injury, Int. J. Care Injured 49 (2018) 2252–2263 2263

[31] Higgins TF, Kemper D, Klatt J. Incidence and morphology of the posteromedial [41] Kellam JF, Meinberg EG, Agel J, Karam MD, Roberts CS. Introduction: fracture
fragment in bicondylar tibial plateau fractures. J Orthop Trauma 2009;23 and dislocation classification compendium-2018: international
(January (1)):45–51. comprehensive classification of fractures and dislocations committee. J Orthop
[32] Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial Trauma 2018;32(January (1)):S1–S10.
plateau fractures. J Orthop Trauma 2010;24(November (11)):683–92. [42] Müller M, Algöwer M, Schneider R, Willeneger H. Manual of internal fixation.
[33] Chang SM, Hu SJ, Zhang YQ, Yao MW, Ma Z, Wang X, et al. A surgical protocol for Techniques recommended by the AO-ASIF group. Springer-Verlag Science &
bicondylar four-quadrant tibial plateau fractures. Int Orthop 2014;38 Business Media; 1991.
(December (12)):2559–64. [43] Lobenhoffer P, Schulze M, Gerich T, et al. Closed reduction/percutaneous
[34] Molenaars RJ, Mellema JJ, Doornberg JN, Kloen P. Tibial plateau fracture fixation of tibial plateau fractures: arthroscopic versus fluoroscopic control of
characteristics: computed tomography mapping of lateral, medial, and reduction. J Orthop Trauma 1999;13:426–31.
bicondylar fractures. J Bone Joint Surg Am 2015;97(September (18)):1512–20. [44] Handelberg FWJ, Scheerlinck T. Casteleyn PP: fractures of the upper tibia and
[35] Krause M, Preiss A, Müller G, Madert J, Fehske K, Neumann MV, et al. Intra- arthroscopic techniques. Tech Knee Surg 2003;2(2):109–16.
articular tibial plateau fracture characteristics according to the "ten segment [45] Bermúdez CA, Ziran BH, Barrette-Grischow M-K. Use of horizontal rafting
classification". Injury 2016;47:2551–7. plates for posterior elements of complex tibial plateau fractures: description
[36] Anavian J, Marchetti DC, Moatshe G, Slette EL, Chahla J, Brady AW, et al. The and case reports. J Trauma 2008;65:1162–7.
forgotten joint: quantifying the anatomy of the proximal tibiofibular joint. [46] Giordano V, Schatzker J, Kfuri M. The "hoop" plate for posterior bicondylar
Knee Surg Sports Traumatol Arthrosc 201720(March), doi:http://dx.doi.org/ shear tibial plateau fractures: description of a new surgical technique. J Knee
10.1007/s00167-017-4508-8. Surg 2017;30(July (6)):509–13.
[37] Takahashi H, Tajima G, Kikuchi S, Yan J, Kamei Y, Maruyama M, et al. [47] Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscheme H.
Morphology of the fibular insertion of the posterolateral corner and biceps Particular posteromedial and posterolateral approaches for the treatment of
femoris tendon. Knee Surg Sports Traumatol Arthrosc 2017;25(January tibial head fractures. Unfallchirurg 1997;100(December (12)):957–67.
(1)):184–91. [48] Frosch K, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach
[38] LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop
anatomy of the medial part of the knee. J Bone Joint Surg Am 2007;89 Trauma 2010;24:515–20.
(September (9)):2000–10. [49] Cho JW, Samal P, Jeon YS, Oh CW, Oh JK. Rim plating of posterolateral fracture
[39] Yang G, Zhai Q, Zhu Y, Sun H, Putnis S, Luo C. The incidence of posterior tibial fragments (PLFs) through a modified anterolateral approach in tibial plateau
plateau fracture: an investigation of 525 fractures by using a CT-based fractures. J Orthop Trauma 2016;30(November (11)):e362–8.
classification system. Arch Orthop Trauma Surg 2013;133(July (7)):929–34. [50] Kfuri M, Schatzker J, Castiglia MT, Giordano V, Fogagnolo F, Stannard JP.
[40] Crist BD, Martin SL, Stannard JP. Tibial plateau fractures. In: Stannard P, Extended anterolateral approach for complex lateral tibial plateau fractures. J
Schmidt AH, editors. Surgical treatment of orthopaedic trauma. 2nd ed. New Knee Surg 2017;30(3):204–11.
York: Thieme; 2016. p. 913–45.