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The objective of treatment of tibial plateau fractures is precise reconstruction of the articular surfaces, stable fragment fixation allowing early motion, and repair of all concomitant lesions. A classification scheme is employed to include the high incidence of concomitant lesions in specific fracture types. The term “complex trauma” is used for extensive injuries involving multiple structural elements of the knee joint. Exact grading of the soft-tissue injury is crucial for the treatment plan. The authors suggest a four-grade classification system of closed and open soft-tissue injury. Preferred treatment is open reduction and internal fixation (ORIF) in all displaced and unstable tibial plateau fractures. A stepwise approach is used in complex knee trauma. Primary treatment includes closed reduction, wound debridement, if necessary, and external fixation of the femur and lower leg (“transfixation”). Open reduction and internal fixation and complex bone and soft-tissue reconstructions are performed in a second operation after recovery of the soft tissues. A follow-up study of 190 of 244 cases of tibial plateau fractures treated in the authors' institution from 1981 to 1987 showed good results after operative treatment, even in extensive fractures, with a tolerable complication rate. The functional recovery was relatively impaired in multiple injured patients and in complex knee trauma.