Objective To explore the application value of three-dimensional CT reconstruction and MRI in the diagnosis and treatment of tibial plateau occult fracture (TPOF). Methods The clinical data of 125 patients with suspected TPOF admitted to our hospital from November 2016 to November 2018 were collected. Three-dimensional CT reconstruction and MRI images of all patients were analyzed. The sensitivity, specificity and accuracy were compared between the two imaging methods for the diagnosis of TPOF. Results Of the total 125 patients with suspected TPOF, 104 cases were finally diagnosed as TPOF and 21 cases without fracture. The final clinical diagnosis was golden standard. The sensitivity and accuracy of MRI in diagnosis of TPOF (98.08% and 98.40%) were higher than those of three-dimensional CT reconstruction (75.00% and 79.20%) (P<0.05). The specificity of both was 100.00%. For the diagnosis of TPOF involving the cortex of bone, the sensitivity, specificity and accuracy of three-dimensional CT reconstruction [100.00% (73/73), 100.00% (29/29) and 100.00% (102/102)] were superior to those of MRI [80.82% (59/73), 67.44 (29/43), 86.27% (88/102)]. There was no statistically significant difference between three-dimensional CT reconstruction and MRI in satisfaction scores of displaying the site, articular surface collapse and dislocation of fractures (P>0.05). However, the satisfaction scores of MRI in showing surrounding soft tissues (meniscus, ligaments, etc.) were significantly higher than those of CT (P<0.05). Conclusion For patients with suspected TPOF after X-ray examination, MRI can be used as the preferred method for further diagnosis, and the combined use of three-dimensional CT reconstruction can help improve the diagnostic accuracy.