Current concepts in the management of high-energy tibial plateau fractures: a narrative review

Tibial plateau fractures are complex intra-articular injuries where fracture morphology, trauma mechanism, and soft tissue condition critically influence treatment complexity and injury prognosis. Medial plateau fractures typically involve metaphyseal blocks with limited articular comminution, whereas lateral plateau fractures often present with greater fragmentation and depression. The Schatzker and AO/OTA classification systems are widely used, while those proposed by Luo, Krause, and Kfuri have enhanced the three-dimensional understanding and surgical planning of tibial plateau fractures. Associated soft tissue injuries can be divided into soft tissue coverage (skin, subcutaneous tissue, and muscle), which require early assessment and continuous monitoring, and structural injuries (ligaments and meniscus), which need more detailed evaluation and subsequent imaging studies. Open fractures and acute compartment syndrome are entities frequently associated with high-energy tibial plateau fractures. Early diagnosis and treatment - with early intravenous antibiotic prophylaxis, surgical debridement, prompt fasciotomies, and fracture stabilization - are needed to prevent further complications, such as fracture-related infections. Although immediate internal fixation can be safe in selected patients, a staged management approach with initial external fixation in complex or high-energy fractures enables soft tissue coverage healing while minimizing complications. The enhanced three-dimensional understanding of these fractures justifies a 360° surgical approach, addressing each fragment through specific approaches and fixation.