Posterior tibial plateau fractures: distinguishing valgus and varus patterns to guide surgical management

Tibial plateau fractures (TPFs) remain challenging injuries due to their complex three-dimensional morphology, frequent posterior column involvement, and high incidence of associated soft-tissue lesions.

Flexion-type fractures represent a distinct and often under recognized entity that is inadequately addressed using traditional classification systems. Flexion-valgus and flexion-varus mechanisms generate fundamentally different fracture configurations and soft-tissue injury profiles, with important implications for surgical management and prognosis. This narrative review provides a practical, literature- and experience-based overview of the distinguishing features of flexion-valgus and flexion-varus tibial plateau fractures, focusing on fracture morphology, associated ligamentous and meniscal injuries, and key treatment principles.

Flexion-valgus injuries predominantly involve the posterolateral tibial plateau, commonly presenting as split-depression or rim impaction fractures, and are frequently associated with anterior cruciate ligament (ACL) and lateral meniscal pathology. In contrast, flexion-varus injuries typically result in posteromedial shear fractures with metaphyseal comminution, often extending into the posterolateral central segment, demonstrating significantly higher rates of concomitant ligamentous and meniscal injuries, poorer functional outcomes, and increased risk of conversion to total knee arthroplasty (TKA).

Accurate recognition of the underlying injury mechanism and fracture morphology, distinguishing flexion-valgus from flexion-varus injuries, is essential to guide preoperative planning, surgical exposure, fixation strategy, and soft-tissue management, with the goal of optimising clinical outcomes.