Neurovascular injuries in tibial plateau fractures: Rare in Schatzker IV, predominant in complex patterns

Background Neurovascular complications after tibial plateau fractures are rarely reported, despite their clinical relevance. While Schatzker type IV fractures have traditionally been considered the most at risk, supporting evidence is limited. This is the first large-scale study systematically evaluating neurovascular injuries in tibial plateau fractures. The aim was to determine the incidence of arterial and neurological injuries and to identify fracture patterns most frequently associated with these complications. Methods We conducted a retrospective review of patients who underwent open reduction and internal fixation for tibial plateau fractures at a level I trauma center between January 2015 and December 2023. Eligible patients had complete records, radiographs, CT angiography, and ≥12 months follow-up. Fractures were classified using both Schatzker and AO/OTA systems. Arterial injury was defined as a CT angiography confirmed lesion requiring surgical repair, and neurological injury as a motor or sensory deficit documented clinically or by electromyography within 1 month. Results: A total of 320 patients were included (mean age 44.3 years; 71.3 % male). Vascular injury occurred in 2 cases (0.62 %), both high-energy open fractures classified as Schatzker VI and AO/OTA C3. Five additional patients (1.56 %) had arterial occlusions without rupture or clinical ischemia, all of which resolved without surgery. Neurological injury was observed in 13 patients (4.06 %), 84.6 % related to high-energy trauma. Ten cases corresponded to Schatzker VI, predominantly AO/OTA C3 (n = 8). No neurovascular complications occurred in Schatzker IV fractures. Proximal fibular fracture was present in 61.5 % of neurological cases with a OR of 4.46 (CI 1.41–14.03, p = 0.010). Conclusions Neurovascular complications in tibial plateau fractures are uncommon (<5 %) but are associated with high-energy, open, and complex patterns, particularly Schatzker VI and AO/OTA C3. Contrary to traditional belief, Schatzker IV fractures were not associated with neurovascular compromise. Proximal fibular fracture may serve as a clinical marker for neurological risk. CT angiography should not be performed routinely, but is especially recommended in open and high-energy fractures. Further prospective studies are needed to validate these associations and optimize imaging strategies.