The incidence of tibial plateau fractures in the elderly is increasing with the progression of an aging population. The choice of treatment plan should take into account the patient’s pre-injury activity level, the presence of comorbid arthropathy or other physical co-morbidities. Therefore, an individualized treatment plan should be developed for tibial plateau fractures in the elderly. History and physical examination If the patient complains of a proximal tibial fracture caused by a fall while standing, then the patient needs to be on high alert for pre-existing bone loss or osteoporosis. For high-energy trauma due to a fall from a height or a car accident, the patient should be observed for soft tissue reactions, including osteofascial compartment syndrome and vascular injury, and should also be closely monitored 24 hours a day. The incidence of tibial plateau fractures complicated by osteofascial compartment syndrome is as high as 31% and correlates with the severity of the fracture. Although severe tibial plateau fractures are rare in older patients, there is still a need to be vigilant for the development of osteo-fascial compartment syndrome. In fact, low-energy trauma in older patients may also increase the chance of tibial plateau fracture dislocation because the bone is much weaker than the ligamentous structures surrounding the knee capsule in older patients. If there is no arterial pulsation on palpation, then the ankle-brachial index (ABI) needs to be measured, and less than 0.9 indicates vascular injury and requires further management. Imaging A frontal and lateral radiograph of the knee is the imaging test of choice. If the plain radiograph of the knee is normal, a full-length radiograph of the femur should be added, as hip injury may also present as knee pain. After a definitive diagnosis is made, a 3D CT scan should be performed. When temporary fixation with an external fixation brace and correction of shortening or angular deformity is required, CT examination may be temporarily postponed. Three-dimensional CT scans are essential for accurate fracture staging and treatment planning. x-ray plain films depict static images and do not reflect well the maximum displacement of the fracture fragment and fracture instability unless stress radiographs are performed. gardner et al. used MRI to examine soft tissue injuries and found that 99% of patients had combined meniscal or ligamentous injuries. Treatment goals It should be clear to the attending physician that the primary goal of treatment is life, followed by limb integrity, and finally limb function. However, tibial plateau fractures are rarely life-threatening or compromise limb integrity, especially in older adults with low activity levels. Osteofascial compartment syndrome can seriously affect the life or the safety of the limb and can occur in patients with tibial plateau fractures. Good treatment outcomes are mainly reflected in the protection of the joint surface, avoidance of knee osteoarthritis, and restoration of knee function and stability. The recovery of the mechanical axis, the recovery of the width of the tibial condyle, the treatment of soft tissue injuries and the degree of recovery of the articular surface are the main factors affecting the patient’s prognosis. In older patients, preexisting pre-injury joint pathology, chronic meniscal injury, other co-morbidities, and pre-injury limb function can also be important factors affecting the patient’s functional recovery. Non-operative treatment Non-operative treatment is indicated for incomplete, non-significantly displaced tibial plateau fractures with stable articular surfaces. Schatzker type I, II, and III fractures with a coronal plane deformity of <10° are also amenable to nonoperative treatment, especially in elderly patients who do not have high functional requirements of the knee. Patients may wear a stranded brace to gradually start moving the knee 8-12 weeks after the injury. Partial weight-bearing ambulation can be started when the fracture line is blurred on x-ray and bone scabs are formed. Although some Schatzker type IV fractures and medial tibial plateau fractures may present as nondisplaced fractures, early surgical fixation of the fracture fragments is still required, otherwise fracture redisplacement and epiphyseal bone loss can make fracture repositioning and fixation more difficult. For high-energy trauma, length-unstable Schatzker type V and VI fractures, surgery should be the treatment of choice, except in patients who are bedridden for long periods of time.