Vertex-based classification for tibial plateau fractures: Guiding the surgical approach through CT mapping

doi:10.21203/rs.3.rs-7446038/v1

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Vertex-based classification for tibial plateau fractures: Guiding the surgical approach through CT mapping

https://doi.org/10.21203/rs.3.rs-7446038/v1

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Objectives: To introduce a vertex-based classification system for tibial plateau fractures that links CT-defined fracture geometry to surgical approach selection.

Design: Retrospective diagnostic study.

Setting: Urban academic level one trauma center.

Patient selection criteria: Patients 18 years or older with surgically treated tibial plateau fractures between 2025 and 2024, having available preoperative CT scans.

Outcome measures and comparisons: Distribution of fracture vertices across predefined anatomical zones and corresponding surgical approaches.

Results: Among 103 patients, vertex mapping revealed the most common location was the lateral anterior zone (55.3%), followed by medial posterior (14.6%) and posterior medial (12.6%). Each zone correlated with a preferred surgical approach, facilitating procedural planning. Fracture and depression maps were consistent with known biomechanical patterns.

Conclusions: This CT-guides classification identifies mechanical relevant fracture vertices, supporting the selection of optimal surgical approaches. It enhances current classification systems by incorporating operative strategy into preoperative planning.

Level of Evidence: Level III, diagnostic study.

Tibial plateau fracture

fracture mapping

surgical planning

CT imaging vertex classification

Tibial plateau fractures are among the most challenging injuries associated with orthopedic trauma and often involve complex articular and metaphyseal damage that requires careful evaluation and precise surgical planning.¹ Effective treatment hinges not only on accurate imaging and anatomical understanding but also on selecting the most appropriate surgical approach to restore joint congruity, stability, and alignment. While classification systems play a fundamental role in fracture assessment, their ability to guide the surgical decision-making process remains limited.^2–4

Over the years, multiple classification systems have been proposed to describe tibial plateau fractures. The Schatzker classification remains the most widely used method due to its simplicity and accessibility,⁵ but it lacks the detail needed for complex fracture patterns. The OTA/AO classification offers more comprehensive categorization,⁶ yet its complexity often reduces its practical utility in the operating room. More recent classifications, such as the three-column theory⁷ and 10-segment mapping,⁸ have enhanced our understanding of fracture morphology, and spatial distribution. Despite these advances, none of these frameworks are specifically designed to guide the selection of the surgical approach. They help surgeons describe and communicate the fracture but do not necessarily treat it.

This disconnection between anatomical classification and surgical strategy represents a persistent gap in the literature and in clinical practice. In particular, existing classifications often fail to account for the mechanical directionality and spatial orientation of the fracture, especially the sheared fragment vertex, which is identified as critical determinant in planning exposure and fixation. Importantly, many authors recommend placing the buttress place precisely at the point of the fragment’s vertex, as it is the region of maximum instability and mechanical leverage;^9–11 this characteristic makes it a reliable marker not only for the fixation strategy but also for determining the most appropriate surgical corridor.

This consideration leads to the central research question of this study: can a classification system based on the vertex of the sheared fragment provide a more practical and reliable guide for selecting the surgical approach for tibial plateau fractures?

The objective is to propose a new classification framework that uses the location and orientation of the sheared fragment’s verted as its defining feature. It was hypothesized that this geometric landmark has direct implications for the surgical approach, making it a more functional tool for the operative planning than current system that prioritize descriptive anatomy over surgical relevance.

A retrospective cross-sectional diagnostic study was performed to evaluate the characteristics of tibial plateau fractures that were treated at a level one urban university trauma centre between January 2015 and December 2024. Ethics approval was obtained from the institutional review board, with a waiver of informed consent granted since the study was based exclusively on archived imaging data and involved no patient contact or risk.

Patients were eligible if they met the following criteria: were aged ≥ 18 years, had high-quality preoperative radiographs and computed tomography (CT) scans available, underwent surgical treatment, had Schatzker and OTA/AO classification data recorded in the medical records, and had a minimum postoperative follow-up of six-months.

The excluded patients were patients with periprosthetic or peri-implant fractures, skeletally immature patients, highly comminuted fractures not amenable to buttress plating at the vertex, and fractures that had been treated nonoperatively.

Among the 119 tibial plateau fracture patients treated during the study period, 103 met all inclusion criteria and were included in the analysis. Sixteen patients were exclude based on the predefined criteria.

CT imaging was performed using a Siemens spiral CT scanner (Siemens, berlin, Germany). For fracture line and depression analysis, axial slices were used at levels 3 mm and 5 mm below the articular surface. The method was based on the approach described by Molenaars et al. (2015)¹² involving the manual superposition of fracture lines and comminution zones to generate visual maps of consistent fracture patterns.

The area of maximum depression was identified on the same axial slices and marked on the periarticular fracture map. The vertex of the sheared fragment was determined by following the fragment margins distally on the CT images until they converge at a single point. This point was marked on a metaphyseal map of the tibia and classified into one of the following anatomical regions: lateral anterior (LA), posterior lateral (PL), medial anterior (MA), medial posterior (MP), and posterior medial (PM).

To standardize the classification of the vertex location of the sheared fragment, the proximal tibial metaphysis was divided into five anatomically defined zones based on cortical landmarks and ligament anatomy. The division was designed to be reproducible and aligned with the most commonly used surgical approaches to the tibial plateau.

The tibial plateau was first divided into lateral and medial halves by a straight line connecting two reference points: the midpoint of the patellar tendon insertion anteriorly and the centre of the posterior cortex. Each hemi plateau was then subdivided int zoned using fixed cortical and ligament structures as boundaries.

On the lateral side, the two zones were defined as follows (Fig. 1):

Lateral anterior (LA): from the medial edge of the patellar tendon insertion to the anterior border of the fibular head.
Posterior lateral (PL): from the posterior border of the fibular head to the posterior midline of the tibia.

On the medial side, the zones were defined as follows (Fig. 1):

Medial anterior (MA): from the patellar tendon insertion medially to the posterior border of the medial collateral ligament (MCL).
Medial posterior (MP): from the posterior border of the MCL to the posterior border of the posterior oblique ligament (POL).
Posterior medial (PM): from the POL to the posterior midline of the tibia.

This five-zone division was applied consistently to the axial CT cuts below the articular surface, where the vertex of the sheared fragment was visualized; it was used to assign each vertex to a specific zone, forming the basis of the proposed classification system.

All mapping was performed manually using CT image data. Image analysis was conducted independently by two of the study authors. In cases of disagreement, a third author reviewed the findings to reach consensus, ensuring methodological reproducibility.

Three composite maps were created for each case:

Periarticular fracture line distribution
Articular depression locations
Vertex position of the sheared fragment

Based on the vertex distribution map, it was developed a novel classification system centred on the location of the sheared fragment vertex. A practical decision-making guide was subsequently proposed to demonstrate how classification can support surgical approach selection and fixation planning for tibial plateau fractures.

Fracture mapping was analyzed descriptively. Summary statistics, including means and standard deviations for demographic variables, were collected. Unpaired t tests were used to compare continuous variable, and chi-square testes were applied for categorial data where appropriate. Statistical significance was defined as p < 0.05. All the analyses were performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA).

A total of 103 patients with tibial plateau fractures were included in the study. The mean age was 45.5 ± 14.0 years, ranging from 22 to 75 years. Among the patients, 70 (68.0%) were male and 33 (32.0%) were female (Table 1).

The fractures were nearly evenly distributed in terms of laterality, with 55 (53.4%) involving the right tibia and 48 (46.6%) affecting the left tibia. According to the Schatzker classification, the most common fracture types were type II in 39 patients (37.9%), type VI in 30 patients (29.1%), and type IV in 12 patients (11.7%). The less frequent include type V in 11 patients (10.7%), type III in 6 patients (5.8%), and type I in 5 patients (4.9%) (Table 1).

A composite fracture line map was generated from axial CT slices approximately 3 mm below the articular surface, illustrating the cumulative pattern of articular involvement in the 103 included cases. The resulting image revealed that the lateral side demonstrated a markedly greater concentration of fracture lines than did the medial plateau, especially in the region corresponding the Schatzker type II fractures. The fracture lines on the lateral plateau were both more numerous and more varied in direction. The most prominent pattern consisted of oblique lines running from the anterolateral cortex towards the posterolateral region of the plateau, with few crossing medially. The convergence of lines in the central plateau further suggests frequent involvement of the tibial eminence in lateral sided injuries. On the medial plateau, there were fewer fracture lines, which were more directionally uniform. Most lines followed a posterior-to-anterior trajectory, which was consistent with posteromedial shear injuries (Fig. 2).

The distribution of the depressed fragments on the axial CT images is illustrated in the composite depression map (Fig. 3). Each black triangle represents the point of maximum articular depression per case, as manually identified from CT images. The anterolateral quadrant of the lateral tibial plateau has the highest concentration of depression points, forming a denser cluster. Notably, the central and posterolateral quadrants also presented a moderate density of depression points, indicating frequent involvement of these zones. The medial plateau demonstrated a relatively sparse distribution of depression points, with scattered involvement observed mostly in the posteromedial quadrant (Fig. 3).

The distribution of the vertices of the sheared fragments across the five defined zones is shown in the Figure 4 and Table 2. A total of 103 vertices were mapped. The lateral zones accounted for the majority of cases, with the lateral anterior (LA) zone being the most common zone, representing 57 cases (55.3%). This zone was followed by the posterior lateral (PL) zone in 10 patients (9.7%) (Fig. 4).

On the medial side, the medial posterior (MP) zone accounted for 15 patients (14.6%), followed by the posterior medial (PM) zone in 13 patients (12.6%), and the medial anterior (MA) zone in 8 patients (7.8%) (Fig. 4).

These findings support the mechanical relevance of the vertex location and its potential utility as a guide for surgical access. The consistent regional clustering of the vertices serves as the basis for the proposed five-zone vertex-based classification system.

Fracture of the tibial plateau are among the most complex articular injuries, and they demand individualized surgical strategies. While widely used classifications such as Schatzker⁵, OTA/AO⁶, the three-column model by Luo⁷, and the four-column model by Kfuri¹³ have contributed significantly to understanding fracture morphology, their ability to guide surgical decision-making remains limited. As demonstrated by Rossmann et al.¹⁴, none of these classifications showed a consistent correlation with the chosen surgical approach in a multicenter analysis. Despite 45.7% of the fractures involving the posterior column per Luo’s classification, only 14.7% of the selected surgical approach addressed the posterior plateau.

Similarly, Sidhu et al.¹⁵ emphasized that while fracture classification helps describe patterns, it should not be the sole determinant of the approach; rather, surgical access must be driven by fragment behaviour and stability requirements. This disconnect highlights a critical limitation in the current classification framework: they describe the fracture but not sufficiently inform low to surgically approach or stabilize it.

This study aimed to address this gap by introducing a new classification system based on the vertex of the sheared fragment, as defined as the distal convergence point of the sheard fragment, which was identified on the axial CT scans from below the articular surface.

The result shows that the vertex was most commonly located in the lateral anterior (LA) zone (55.3%), followed by the posterior lateral (PL) zone (9.7%). The medial-sided vertices were less common, with a medial posterior (MP) zone (14.6%), posterior medial (PM) zone (12.6%), and medial anterior (MA) zone (7.8%) distribution. These results highlight a consistent pattern, which is the primary target for the shear forces and the preferred site for buttress plating.

In the proposed vertex-based classification system for tibial plateau fracture, the plateau is divided into five anatomically grounded zones guided by reproducible bony and ligament landmarks and the mechanical vector of shear. Each hemiplateau (lateral and medial) is subdivided into three zones:

Lateral side:

Lateral anterior (LA) – from the patellar tendon anteriorly to the anterior border of the fibular head.
Posterior lateral (PL) – between the posterior border of the fibular head and the posterior centreline.

Medial side:

Medial anterior (MA) – anterior to the MCL.
Medial posterior (MP) – between the MCL and the POL.
Posterior medial (PM) – from the posterior border of the POL and the posterior centreline.

Each vertex zone correlates with a commonly employed surgical approach, allowing the classification to serve as both a diagnostic and procedural guide (Table 3).

Table 3
Vertex zone classification linking the anatomical location of the sheared fragment’s vertex to the corresponding surgical approach.
Vertex zone	Anatomical location	Suggested approach
LA	Lateral anterior	Anterolateral
PL	Posterior lateral	Posterolateral
MA	Medial anterior	Anteromedial
MP	Medial posterior	Posteromedial
PM	Posterior medial	Direct medial posterior

Fractures with vertices in the lateral anterior (LA) zone are best addressed using the anterolateral approach. This approach involves a lazy “S”-shaped incision starting from the iliotibial band, curving around Gerdy’s tubercle, and extending distally approximately 1 cm lateral to the tibial crest.^16,17 Depending on the exact vertex location, the buttress plate may need to be positioned more anteriorly or laterally to ensure that the antiglide screw aligns precisely with the vertex for optimal shear control.

Fractures with the vertex in the posterior lateral (PL) zone are typically accessed through the posterolateral approach described by Carlson.¹⁸ This fibula-sparing technique involves dissection between the lateral head of the gastrocnemius (retracted medially) and the biceps femoris (retracted laterally along with the common peroneal nerve). When additional visualization is needed, exposure can be extended through a fibular head osteotomy or via subcutaneous dissection, as described by Frosh et al.¹⁹

On the medial side, the medial posterior (MP) zone is the most frequent vertex location. These fractures are commonly addressed through the posteromedial approach first described by Lobenhoffer et al..²⁰ The incision begins approximately 3 cm proximal to the joint line and is carried distally along the posteromedial tibial border. This approach provides direct access to the posteromedial corner, where the buttress plate must be positioned at an optimal angle to achieve secure screw fixation in the vertex region.

When the vertex is in the posterior medial (PM) zone, a direct posterior approach is recommended. The safest exposure is through a medially based L-shaped skin incision,²¹ which is aligned with the medial head of the gastrocnemius. The muscle is carefully retracted laterally, serving as a soft tissue shield to protect the underlying neurovascular bundle.²²

For fractures with the vertex in the medial anterior (MA) zone, the preferred approach is a direct anteromedial incision. This incision begins at the medial femoral epicondyle proximally and extends distally over the pes anserinus.¹⁵ This approach allows straight forward access to the anterior medial cortex of the tibia for reduction and fixation.

In addition to the vertex-based classification, the two additional maps of the fracture line distribution and depressed fragment location provide critical insights for comprehensive surgical planning.

The composite map of the articular fracture lines revealed a concentration of fracture trajectories on the lateral plateau, particularly oblique lines extending from the anterolateral cortex towards the posterolateral aspect. This finding is consistent with prior studies, such as those by other authors,^23–25 who demonstrated that the lateral plateau exhibits a high density of articular fractures due to valgus loading and shear stress. On the medial plateau, the lines were fewer and tended to follow a more uniform posterior-to-anterior trajectory, reflecting the mechanical nature of posteromedial shear injuries.

The map of depressed fragment locations emphasized the anterolateral quadrant of the lateral plateau as the primary site of articular impaction, followed by the central and posterolateral regions. This pattern is well documented in the literature and aligns with previous mechanical studies showing that valgus injuries and axial loading frequently concentrate impact forces in the region.

Understanding the location of depressions is essential for planning an effective reduction strategy. This approach advocates direct reduction of the depressed fragment through the same incision used for exposing the shear fragment by opening it like a book. This maneuver permits subchondral elevation while avoiding another approach; however, if this is not possible, a minimally invasive metaphyseal window can be created. Through this cortical window, an elevator can be used to restore joint congruency under fluoroscopic control.²⁶

From a clinical standpoint, this system is easy to apply, compatible with routine preoperative imaging, and aligns with how orthopedic surgeons think in the operating room. This technique complements existing systems by adding a decision-making layer and is especially useful in bicondylar or shear-dominant fractures, in which an exposure strategy is critical for achieving stable fixation.

This study is not without limitations. It is retrospective and based on axial CT analysis at a fixed depth, which may not fully capture vertically complex injuries or highly comminuted patterns. There is a lack of clinical correlation, Future validation studies will be necessary to assess the interobserver reliability of the classification and to correlate vertex location with postoperative outcomes.

Despite these limitations, the consistent spatial distribution of vertex locations across cases supports the reliability and relevance of the proposed system.

In conclusion, this study presents a classification system that focuses on the surgical needs of tibial plateau fracture patients. By identifying where to approach and stabilize fractures, vertex-based classification serves not only as a tool for describing fracture anatomy but also as a bridge between diagnosis and surgical execution.

The vertex-based classification system proposed in this study offers practical, CT-guided method for classifying tibial plateau fractures based on the location of the sheared fragment’s vertex. By linking this anatomical point to standard surgical corridors, the system provides direct support for approach selection. It complements existing classifications by adding a decision-oriented layer rooted in mechanical relevance and an operative strategy.

Potential conflicts of interest and funding sources: none are declared.

Author Contribution

KK - conceptualization, methodology, data curation, writing, supervision, final approval GM, LS, DL, RSF - data collection, investigation, data analysis, writingMAG - supervision, data analysis, critical revisionML, JSS - methodology, data analysis, critical revision and final approval

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Table 1. Demographics

Variable

Description

N = 103

Age (years)

Mean and standard deviation

45.4 ± 14.0

Sex, n (%)

Female

Male

33 (32.0)

70 (68.0)

Side, n (%)

Right

Left

55 (53.4)

48 (46.6)

Schatzker classification, n (%)

Type I

Type II

Type III

Type IV

Type V

Type VI

5 (4.8)

39 (37.9)

6 (5.8)

12 (11.6)

11 (10.7)

30 (29.1)

Table 2- Distribution of the vertices of the sheared fragments across the five zones.

Zone	n	%
Lateral anterior (LA)	57	55.3
Posterior lateral (PL)	10	9.7
Medial anterior (MA)	8	7.8
Medial posterior (MP)	15	14.6
Posterior medial (PM)	13	12.6
Total	103	100

n = number of cases

No competing interests reported.

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Vertex-based classification for tibial plateau fractures: Guiding the surgical approach through CT mapping

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Abstract

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INTRODUCTION

MATERIAL AND METHODS

RESULTS

DISCUSSION

CONCLUSION

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Author Contribution

References

Tables

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