Tibial plateau fractures are complex intra-articular injuries involving the proximal tibia and are often associated with significant soft-tissue damage. These fractures account for approximately 1% of all fractures and typically result from high-energy trauma such as road traffic accidents or low-energy falls in osteoporotic individuals [1]. The lateral tibial plateau is more frequently affected due to its relative anatomical weakness and the valgus orientation of the knee joint [2]. Soft tissue injuries commonly accompany tibial plateau fractures, particularly involving the lateral meniscus and anterior cruciate ligament (ACL) [3]. Magnetic resonance imaging studies have demonstrated that a large proportion of these fractures have concurrent meniscal or ligamentous tears, which can influence both surgical management and prognosis [4]. The severity of soft-tissue involvement often correlates with the mechanism and magnitude of force, emphasizing the importance of accurate injury pattern assessment before surgical intervention [5]. Experimental and cadaveric studies have shown that specific fracture configurations correspond to distinct injury mechanisms and vector orientations of applied force [6]. The knee position at the time of trauma whether in valgus, varus, or flexed alignment plays a critical role in determining the fracture morphology [7]. Given the wide variability of fracture patterns and associated soft-tissue damage, there is no single gold-standard technique for the management of tibial plateau fractures. Instead, surgical planning should be individualized based on the fracture type, bone quality, and associated injuries [8]. Understanding the underlying injury mechanism aids in formulating an optimal surgical strategy and postoperative rehabilitation plan, thereby minimizing complications and improving functional outcomes [9]. Herein, we present a rare variant of Schatzker type II tibial plateau fracture with a posteriorly depressed fragment. To the best of our knowledge, no similar case has been previously described in the literature. This report aims to review the clinical and radiological findings, analyze the injury mechanism, and discuss the surgical approach and outcomes.

A 52-year-old female presented with pain, swelling, and restricted movement of the right knee following a slip and fall at home. She initially received conservative management at a local hospital, where an intra-articular fragment was overlooked, and treatment consisted only of immobilization, limb elevation, and oral analgesics. After persistent pain and functional limitation for one week, she was referred to our institution for further evaluation. On examination, there was localized tenderness and diffuse swelling over the right knee, with restriction of both flexion and extension. Distal neurovascular status was intact. Radiographic assessment with anteroposterior and lateral views of the right knee (Figure 1) revealed a split-depression fracture of the lateral tibial plateau consistent with a Schatzker type II pattern, showing posterolateral depression with an intact medial condyle. The diagnosis was confirmed with computed tomography, which delineated the extent of the articular depression and cortical breach. Surgical management was undertaken under spinal anesthesia on the second day after admission. The patient was placed supine on a radiolucent table with the affected limb elevated on a rectangular cushion. A pneumatic tourniquet was applied, and the operative field was prepared from mid-thigh to foot. A standard anterolateral approach to the knee was used. Under fluoroscopic guidance, a 7 cm skin incision was made at the lateral tibial surface overlying the depressed zone. A 4 mm Steinmann pin was introduced as a pilot pin and used as a lever to elevate the depressed articular surface in a cephalad-to-caudal direction until the plateau was restored to its normal level. This controlled maneuver, known as the pin leverage technique, allowed anatomical restoration of the articular surface without the need for a metaphyseal window or bone grafting. Following satisfactory reduction confirmed under fluoroscopy, the fracture was fixed with a proximal tibial locking compression plate and subchondral cancellous screws to buttress the elevated fragment. Intra-operative fluoroscopic anteroposterior and lateral images (Figures 2 and 3) demonstrated precise restoration of the joint line and secure plate positioning along the lateral tibial cortex, with screws providing robust subchondral support. Wound closure was performed in layers over a suction drain, and a sterile dressing was applied. In a proximal tibia depressed fracture, a Steinmann pin can be passed from the medial metaphyseal region to elevate the depressed articular fragment. This is a technique for minimally invasive reduction where the pin is used with a leveraging .The pin is inserted into the medial aspect of the tibia, just below the fracture zone, and then used to lever the depressed fragment back into its normal position under image guidance. Why and How It's Used Percutaneous Elevation: The primary goal is to elevate the depressed segment of the tibial plateau without needing a large open surgical approach, reducing the disruption to the soft tissues and articular cartilage. Traumatic Mechanism: Depressed fractures of the tibial plateau often result from high-energy axial loading forces on the knee. Levering Action: A Steinmann pin is inserted into the medial side of tibia below the fracture line. Once in position, it can be used to apply leverage or a "joy-stick" action to push the depressed fragment upwards. Procedure Steps Marking: The trajectory for the pin is marked on the skin. Insertion: A Steinmann pin is inserted through a small skin nick using image guidance. Leverage: The pin is then inverted and used to gently lever the depressed bone fragment upwards. Confirmation: The position of the elevated fragment is confirmed with image intensification. Postoperatively, the limb was supported in a hinged knee brace with 20° flexion, and the patient was advised non-weight-bearing for 12 weeks. Gentle range-of-motion exercises were initiated after four weeks, progressing gradually to full flexion as tolerated. At 12 weeks, partial weight-bearing was allowed, and by three months, the patient achieved near-normal ambulation. At the 12-month follow-up, radiographs (Figure 4) showed complete union with maintained joint congruity and no evidence of hardware failure or secondary displacement. Clinically, the patient was pain-free, demonstrated full extension and 120° flexion at the knee, and had stable ligaments on anterior, posterior, varus, and valgus stress testing. Functional outcome according to the Rasmussen knee score was excellent. This case illustrates that the percutaneous pin leverage technique is a simple, minimally invasive, and effective method for elevating depressed fragments in Schatzker type II tibial plateau fractures, allowing accurate reduction with minimal soft-tissue dissection and excellent radiological and functional outcomes.

Fractures of the tibial plateau represent a complex injury pattern involving both the osseous and soft-tissue structures of the knee. Understanding the mechanism of injury and precise morphology of the fracture is critical in determining the optimal surgical approach and fixation method. The advent of computed tomography (CT) and three-dimensional imaging has significantly improved classification accuracy and preoperative planning for these fractures [10]. The Schatzker classification, introduced in 1979, remains one of the most widely used systems, categorizing fractures based on morphology and mechanism. Schatzker type II injuries characterized by a lateral split with articular depression are the most common, often resulting from valgus and axial loading forces [11]. The lateral plateau is particularly vulnerable due to its thinner cortex and the physiological valgus alignment of the knee [12]. Associated soft-tissue injuries are frequent in these fractures, with studies reporting lateral meniscal and anterior cruciate ligament (ACL) involvement in up to 50–70% of cases [13]. MRI evaluation has become an essential adjunct for preoperative assessment, as it helps identify occult chondral and ligamentous lesions that may affect prognosis [14]. Traditionally, depressed lateral plateau fractures have been managed through a medial metaphyseal window, where a bone tamp or elevator is used to raise the articular surface [15]. While effective for centrally depressed or coronal-plane fractures, this technique is technically challenging for posteriorly located depressions, where proper perpendicular access cannot be achieved. In such cases, attempts to elevate from a medial approach may result in incomplete reduction or fragmentation of the subchondral bone [16]. To address these limitations, several minimally invasive methods have been developed, including arthroscopic-assisted reduction, balloon tibioplasty, and percutaneous elevation techniques. Arthroscopic-assisted reduction allows direct visualization of the articular surface and precise elevation but requires specialized instruments and expertise, which may not be available in all centers [17]. Balloon tibioplasty provides controlled elevation and cavity creation but adds cost and carries a risk of balloon rupture and cement leakage [18]. The pin leverage technique, as used in the present case, is a simple and cost-effective percutaneous method for reducing a depressed fragment under fluoroscopic control. A 4 mm Steinmann pin is inserted in the plane of depression and gently levered to restore the articular congruity. This technique is especially useful for posterior or central depressions where the posterolateral cortex remains intact, as the intact cortex serves as a hinge during elevation [19]. This method minimizes soft-tissue dissection and eliminates the need for a separate metaphyseal window, thereby reducing the risk of cortical void formation and potential need for bone grafting. The concept aligns with modern minimally invasive strategies, such as MIPPO (Minimally Invasive Percutaneous Plate Osteosynthesis), which emphasize indirect reduction and biological fixation [20]. Biomechanical studies by Boisrenoult et al. (2013) demonstrated no significant difference in fixation stability between conventional and locking plates, suggesting that stability can be achieved effectively even with minimally invasive techniques [21]. Furthermore, Kfuri and Schatzker (2018) highlighted the importance of understanding three-dimensional fracture morphology to select the most suitable approach, reinforcing that not all lateral plateau depressions require extensive exposure [22]. In the present case, the pin leverage technique allowed controlled and anatomical elevation of the depressed lateral plateau, as confirmed intraoperatively (Figures 2 and 3) and radiographically (Figure 4). The absence of postoperative complications and excellent functional recovery at one year correspond with outcomes reported in similar minimally invasive approaches [23]. Clinical Implications and Limitations The key advantages of the pin leverage technique include: • Minimal invasiveness with no additional soft-tissue stripping. • Elimination of metaphyseal void, reducing the need for grafting. • Controlled elevation along the fracture plane. • Short operative time and low complication rate. However, the method has limitations. It is not recommended for comminuted, osteoporotic, or grossly displaced fractures, as the anterior cortex may not provide adequate fulcrum for leverage, increasing the risk of pin cut-through [24]. In such cases, direct posterolateral or extended anterolateral approaches with buttress plating are preferred [25]. Overall, this case supports previous reports emphasizing that individualized management guided by imaging, fracture morphology, and bone quality remains the cornerstone of successful outcomes in tibial plateau fractures. The pin leverage technique provides a valuable addition to the armamentarium of minimally invasive strategies, particularly for selected Schatzker type II fractures with posterior or central depression.

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