Bicondylar (Schatzker V/VI, AO/OTA 41-C) and medial (Schatzker IV, Moore I–IV, or an AO/OTA 41-B) tibial plateau fractures represent 18–39% of all tibial plateau fractures and are commonly due to high energy mechanisms. Isolated medial tibial plateau fractures often represent a knee dislocation variant and carry a high risk of neurovascular injury. Preoperative workup includes close inspection of soft tissues, serial neurovascular examinations, radiographs, and often a CT. The extent of soft tissue injury dictates the timing and treatment approach, as staged management with the placement of a knee-spanning external fixator prior to definitive fixation is often required. Surgical goals include restoring length, alignment, rotation, condylar width, congruency of the articular surface, coronal plane stability, and knee range of motion. Dual incision surgical approaches and multiplanar fixation are often utilized. Respect of the soft tissue envelope can minimize the risk of complications. There is a relatively high risk of complications including infection, post-traumatic arthritis, and arthrofibrosis.