European Journal of Cardiovascular Medicine

The proximal segment of the tibia plays a vital role in forming the knee joint, one of the body's largest and most complex articulations. This region bears significant mechanical loads and contributes crucially to mobility and weight transmission.^[1] If not addressed appropriately, such fractures can lead to wound complications, persistent joint stiffness, infections both superficial and deep, and eventual post-traumatic osteoarthritis, significantly impairing functional outcomes.^[2]

Among these injuries, Schatzker Type V and Type VI fractures are particularly severe, involving bicondylar disruptions and metaphyseal-diaphyseal extensions. Though less frequently encountered than lower-grade tibial plateau injuries (Types I–IV), these high-grade patterns are associated with significant trauma forces, typically resulting from road traffic collisions or falls from substantial heights.^[3] The presence of edema, bruising, and in some cases, open wounds or vascular compromise, necessitates careful timing and planning of surgical intervention to avoid adverse outcomes.^[4]

Although they make up only around 1% of all fractures, their incidence is notably higher in older adults, accounting for approximately 8% of fractures in this age group.^[5] A significant proportion of these injuries affect the lateral tibial condyle-reported in more than half of the cases-while isolated medial condylar involvement is comparatively rare. Studies indicate that lateral condyle fractures account for about 55% to 70% of such injuries, medial condyle involvement occurs in 10% to 23%, and bicondylar fractures appear in 10% to 30% of patients. This variation underlines the importance of accurate classification and individualized treatment planning.^[6]

Staged surgical protocols wherein the first phase of treatment typically includes temporary stabilization, most commonly using an external fixator.^[7] This not only aligns the limb and relieves pain but also creates a protected environment for the soft tissues to recover. Temporizing fixation provides valuable time to allow swelling to subside, wounds to begin healing, and any additional assessments or interventions to be completed before definitive internal fixation. The application of spanning external fixation in the acute setting is a well-accepted strategy to prevent further soft tissue compromise and to monitor the evolution of any compartment syndrome or vascular complications.^[8]

Once soft tissue conditions have sufficiently improved open reduction and internal fixation (ORIF), frequently utilizing pre-contoured locking plates, is employed to achieve anatomic joint surface restoration and stable fixation.^[9] A staged approach-initial external fixation followed by definitive internal fixation after soft tissue recovery-helps reduce risks like infection and joint stiffness.^[10]

This study aims to evaluate the functional outcomes of complex proximal tibial plateau fractures classified as Schatzker Type V and VI, focusing on wound healing and extensor range of motion. The fractures were managed initially with spanning external fixation, followed by definitive internal fixation using locking compression plates while retaining the external fixator in situ. The objective is to assess the efficacy of this staged approach in promoting soft tissue recovery and preserving knee joint mobility in high-energy, bicondylar tibial plateau injuries.

A retrospective observational study was conducted at Dr. B. R. Ambedkar Medical College and Hospital between June 2022 to January 2024. Patients aged 18 to 65 years with complex proximal tibial plateau fractures (Schatzker types V, and VI) presenting to the outpatient or emergency department were included after consent. Data collection involved clinical and radiological evaluation, routine blood workup, and operative details. Follow-up assessments were done at 3, 6  and 9 months postoperatively. Patients with pathological fractures, age below 18, delayed presentation, or medical contraindications for surgery were excluded.

In this study, the highest incidence of complex proximal tibial plateau fractures was observed in the 31–40-year age group (30%), followed by the 41–50-year group (26%), reflecting a predominance among the active, working-age population. A clear male preponderance was noted, with 76.67% of cases occurring in males compared to 23.33% in females, likely due to greater exposure to high-energy trauma in occupational and outdoor activities.

The table illustrates the laterality of injuries among 30 patients, showing a right-sided predominance. Out of the total, 19 patients (63.33%) sustained injuries on the right side, while 11 patients (36.67%) were affected on the left side. This distribution suggests a higher incidence of right sided dominance in the studied population.

Road traffic accidents emerged as the leading cause of injury, comprising 60% of the cases in the study. Injuries resulting from falls accounted for 23.33%, while pedestrian-related incidents contributed 16.67%. This pattern underscores the predominance of road traffic accidents as the major mode of injury, with falls and pedestrian accidents following in frequency.

The table depicts the distribution of Schatzker’s fracture types among 30 patients. Type 6 fractures were more prevalent, affecting 56.67% of patients, while Type 5 fractures accounted for 43.33%. This indicates a predominance of more severe, complex bicondylar fractures (Type 6) in the study population, highlighting the need for meticulous evaluation and management.

The study found that most Type 6 (64.71%) and Type 5 (53.85%) fractures resulted from high-velocity road traffic accidents, followed by falls from height. These injuries reflect high-energy trauma to the proximal tibia, often due to flexed knee positioning during vehicular impact. The associated age group and right-side predominance further suggest risky driving behaviors in the population.

The table shows average hospital stay of the patients between days 11–15 (50%) and 16–20 (46.67%) after primary surgery. Only one case (3.33%) had an extended stay between days 21–25, indicating severity of the injury.

The table indicates that the majority of patients (80%) started partial weight bearing from the 7–8 weeks, with 76.92% Type 5 and 82.35% Type 6 fractures initiated in this time period. A smaller proportion (16.66%) in weeks 9–10, while only one case (3.33%) was delayed for 5–6 weeks, owing to the severity of the injury and difficulties in attaining and sustaining the articular surface reduction.

In the study, full weight bearing was generally delayed until 12 weeks. Most patients achieved it between 11–12 weeks, including 53.85% of Type 5 and 76.47% of Type 6 fracture cases. Additionally, 30.77% of Type 5 patients tolerated full weight bearing by 9–10 weeks, while one case experienced delayed recovery due to local complications.

The table shows that overall outcomes were favorable, with 33.33% of patients achieving excellent and 60% good results. Among Type 5 fractures, 46.15% had excellent outcomes, while Type 6 had 64.71% good and 23.53% excellent. Only 6.67% had fair outcomes, and none had poor results, indicating effective treatment and recovery in both fracture types.

Tibial plateau fractures are among the most common intra-articular injuries, typically resulting from high-energy trauma such as road traffic accidents, falls, or assaults.^[11] These complex fractures pose significant management challenges due to articular depression, condylar separation, diaphyseal-metaphyseal dissociation, soft tissue compromise, and associated ligamentous injuries. High-impact forces, often ranging from 1,600 to 8,000 pounds/inch, contribute to their explosive fracture patterns. This study aims to evaluate the functional outcomes of 30 patients with complex proximal tibial plateau fractures treated with initial external fixation followed by definitive fixation using locking compression plates, analyzing patient demographics, injury characteristics, fracture types, complications, and recovery outcomes.

Tibial plateau fractures are frequently observed in the active and productive age group of 31–50 years, primarily resulting from high-energy trauma such as road traffic accidents and falls from height. Stable fragment fixation along with appropriate ligament repair is critical to restore full range of motion and joint function. In our study, a male predominance was evident, with 76.67% of cases occurring in males, likely due to higher exposure to physical and occupational activities. Lansinger et al. (1986) reported similar injury patterns, with 31% of cases due to direct trauma, 33% due to falls from height, and 45% resulting from road traffic accidents. Although several patients presented with associated injuries, no direct correlation could be established between the fracture type and the associated injuries. These appeared to be more influenced by the mechanism and severity of the trauma rather than the fracture configuration itself, thereby underscoring the complexity of such injuries.^[12]

In our study, a right-sided predominance was observed in tibial plateau fractures, with 63.33% affecting the right knee and 36.67% the left. Road traffic accidents were the primary cause of injury in younger individuals (60%), while falls from height were more common among the elderly. Type 6 fractures were the most frequent, accounting for 56.67% of cases, followed by type 5. The mean age of patients was 37.1 years, with the majority belonging to the productive age group of 31–50 years. These demographic findings are consistent with those of Cole PA et al. (2004), who reported a mean age of 45 years, and further corroborated by Ricci WM et al. (2005), who found an average age of 53 years, and Stannard JP et al. (2004), whose study documented a mean age of 38 years. Such correlations highlight the global trend of high-energy tibial plateau injuries occurring in the active working population. ^[13-15]

In our study, a standardized immobilization period of four weeks was followed for all tibial plateau fractures. Early mobilization was possible in patients where a congruent articular surface and rigid fixation were achieved, which helped prevent periarticular scarring and joint stiffness. A clear relationship was observed between anatomical reduction, early physiotherapy, and better knee range of motion. Despite the presence of associated bony and ligamentous injuries, 36.67% of patients achieved excellent outcomes and 56.67% had good results, totaling 93.34% acceptable outcomes with standard surgical techniques. Only 3.33% had fair and another 3.33% poor functional outcomes. These results are consistent with those of Hitin Mathur et al., who reported 37% excellent and 51.85% good outcomes with minimal unacceptable results. Our findings emphasize the importance of early rehabilitation and precise fracture fixation in improving functional outcomes in complex tibial plateau fractures, even in the presence of associated injuries and complications.^[16]

Effective management of tibial plateau fractures depends on sound clinical judgment, thorough knowledge of knee anatomy, imaging, and familiarity with surgical techniques. Treatment focuses on articular surface reconstruction, stable fixation for early mobilization, and repair of associated injuries. Complex trauma requires careful soft tissue assessment and a staged approach-initial closed reduction, debridement, and external fixation, followed by internal fixation after soft tissue recovery. This strategy improves alignment, reduces complications, and supports early rehabilitation. The study demonstrated excellent outcomes with no extensor lag at four weeks, indicating successful healing and functional recovery through this two-stage approach in complex cases.

1. Innocenti B. Biomechanics of the knee joint. Human orthopaedic biomechanics. Elsevier 2022:239-63.
2. Mthethwa J, Chikate AJMs. A review of the management of tibial plateau fractures. 2018;102:119-27.
3. Sauhta R, Makkar DJIJoO. Proximal Tibia Fractures in Osteoporosis 2025:1-20.
4. Mavrogenis AF, Panagopoulos GN, Kokkalis ZT, et al. Vascular injury in orthopedic trauma. 2016;39(4):249-59.
5. Pandya NK, Edmonds EW, Roocroft JH, et al. Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment. Journal of Pediatric Orthopaedics 2012;32(8):749-59.
6. Molenaars RJ, Mellema JJ, Doornberg JN, et al. Tibial plateau fracture characteristics: computed tomography mapping of lateral, medial, and bicondylar fractures. JBJS 2015;97(18):1512-20.
7. Canton G, Santolini F, Stella M, Moretti A, Surace MF, Murena LJEJoOS, et al. Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures. 2020;30:671-80.
8. von Keudell AG, Weaver MJ, Appleton PT, Bae DS, Dyer GS, Heng M, et al. Diagnosis and treatment of acute extremity compartment syndrome. 2015;386(10000):1299-310.
9. Bhattacharya VJIjopsopotAoPSoI. Management of soft tissue wounds of the face. 2012;45(3):436.
10. Popa M, Cursaru A, Cretu B, Iordache S, Iacobescu GL, Spiridonica R, et al. Enhancing osteoporosis management: a thorough examination of surgical techniques and their effects on patient outcomes. 2024;16(5).
11. Kaur S, Tyrrell PN, Cassar-Pullicino VN. The Knee: Bone Trauma. Imaging of the Knee: Techniques and Applications: Springer; 2023. p. 171-200.
12. Lansinger O, Bergman B, Körner L, Andersson GJJ. Tibial condylar fractures. A twenty-year follow-up. 1986;68(1):13-9.
13. Tscherne H, LOBENHOFFER PJCO, Research® R. Tibial plateau fractures: management and expected results. 1993;292:87-100.
14. Ricci WM, Collinge C, Streubel PN, McAndrew CM, Gardner MJJJoot. A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures. 2013;27(12):722-5.
15. Stannard JP, Wilson TC, Volgas DA, Alonso JEJJoot. The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: short-term results. 2004;18(8):552-8.
16. Mathur H, Acharya S, Nijhawan V, Mandal SJIJO. Operative results of closed tibial plateau fractures. 2005;39(2):108-12.