A Comprehensive Approach to Flexion–Varus Tibial Plateau Fractures: Principles of Systematic Management

Tibial plateau fractures (TPFs) are complex intra-articular injuries frequently accompanied by significant soft tissue injury. Existing medical literature has shown that TPFs resulting from a flexion–varus injury mechanism, affecting the posteromedial column primarily, are associated with worse clinical outcome scores and a higher risk of conversion to total knee arthroplasty. This narrative review aims to explain why this specific subgroup has a poorer prognosis compared with other TPFs subtypes. Four key factors are examined in this review: fracture morphology, biomechanics, soft tissue involvement, and surgical management. The complex fracture morphology of flexion–varus TPFs can be most accurately assessed using three-dimensional computed tomography–based reconstructions. The mechanism of injury helps to better understand fracture morphology and potential soft tissue injury. Soft tissue injuries are frequent in these type of fractures, such as anterior cruciate ligament (ACL) avulsion fracture, lateral meniscus tears, and entrapment. These three elements are important for better understanding TPFs and adequately planning surgical strategy. The severity of the fracture and the involvement of the posterolateral depression complicate surgical treatment. Visualization of the posteromedial compartment is essential but remains challenging. Anatomical reduction and stable fixation of the posteromedial and posterolaterocentral tibial plateau, with consideration of any meniscal injury, should be performed with care. An ACL avulsion fracture should ideally be fixed. Although preoperative magnetic resonance imaging (MRI) provides valuable information about the soft tissue involved, this examination is not yet routinely performed. Given the high incidence of ACL and (lateral) meniscal injury, an MRI is highly recommended.