Indications for emergency operative management are open tibial plateau fractures and tibial plateau fractures with associated neurovascular injuries or compartment syndrome. Displaced tibial plateau fractures (>1 cm articular depression) or tibial plateau fractures resulting in an unstable knee joint (more than 10° varus/valgus instability) are indications for operative management. The mainstay of operative care is open reduction and internal fixation (ORIF) with anatomic reduction, which is an important aspect for cartilage regeneration. Minimally invasive approaches (MIPO technique) are the standard of care for surgical management of tibial plateau fractures because the marginal soft tissue envelope predisposes for tissue necrosis and infection.

Delayed internal fixation with primary external stabilization may be necessary in high-energy injuries with severe soft tissue destruction. Nonlocking plates are suitable for simple fracture patterns with minimal comminution, whereas locking plates are indicated for high-energy fractures, those with severe comminution, and in osteoporotic bone. Adequate reduction should be achieved by the use fluoroscopy. Arthroscopic-assisted reduction and internal fixation may be helpful in pure depression fractures; however, extravasation of irrigation fluid, especially in extracapsular fractures, carries the risk of a compartment syndrome and must be used with extreme caution.

Fixation of pure split fractures of the lateral plateau (AO-41-B1//Schatzker I) may be achieved with two or three percutaneously inserted 6.5- or 7.0-mm partially threaded cancellous bone screws with washers. In cases of fracture fragmentation or in osteopenic patients, a lateral buttress plate may be used in an antiglide position (Fig. 25.1). In depression fractures of the lateral plateau (AO-41-B2//Schatzker III), the depression is elevated through a cortical window. Often, bone graft or bone substitute is needed. Stabilization is achieved with two or three 6.5- or 7.0-mm subchondral cancellous bone screws in “rafting” position (Fig. 25.2). In split-depression fractures of the lateral plateau (AO-41-B3//Schatzker II), the depression is elevated through the split component and the application of bone graft or bone substitute may be needed. Stabilization is achieved with lateral plate osteosynthesis with the proximal screws in “rafting” position (Fig. 25.3).