Tibia Plafond Fractures

Author: Deborah Allen

Topic updated on 02/17/13 2:30pm

Introduction

Also called tibial pilon fractures
Epidemiology
- account for <10% of lower extremity injuries although incidence increasing
- average patient age is 35-40 years
- more common in males than females
Mechanism is high energy axial load
- motor vehicle accidents
- falls from height
Pathoanatomy
- characterized by
  - articular impaction and comminution
  - metaphyseal bone loss
  - soft tissue injury (open or Tscherne II/III closed fractures)
  - associated musculoskeletal injuries
  - 3 fragments typical with intact ankle ligaments
    - medial malleolar (deltoid ligament)
    - posterolateral/Volkmann fragment (posterior inferior tibiofibular ligament)
    - anterolateral/Chaput fragment (anterior inferior tibiofibular ligament)
Associated conditions
- 75% have associated fibula fractures
Prognosis
- parameters that correlate with a poor clinical outcome and inability to return to work
  - lower level of education
  - preexisting medical comorbidities
  - male sex
  - work-related injuries
  - lower income levels

Anatomy

Osteology
- tibia
  - distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus
  - articulates with the talus and fibula laterally via the fibula notch
Vascular anatomy
- anterior tibial artery
  - first branch of popliteal artery
  - passes between 2 heads of tibialis posterior and interosseous membrane (IOM)
  - lies anterior to IOM between tibialis anterior and EHL
  - terminates as dorsalis pedis artery
- posterior tibial artery
  - continues in deep posterior compartment of leg
  - courses obliquely to pass behind medial malleolus
  - terminates by dividing into medial and lateral plantar arteries
- peroneal artery
  - main branch takes off 2.5 cm distal to popliteal fossa
  - continues in deep posterior compartment between tibialis posterior and FHL
  - terminates as calcaneal branches
Nerves
- tibial nerve (L4-S3)
  - crosses over popliteus from the popliteal fossa and splits 2 heads of gastrocnemius
  - passes deep to soleus coursing to the posterior aspect of the medial malleolus
  - terminates as medial and lateral plantar nerves
  - muscular branches supply posterior leg (superficial and deep posterior compartments)
- common peroneal nerve (L4-S2)
  - winds around neck of fibula and runs deep to peroneus longus
  - divides into superficial and deep peroneal nerves
- superficial peroneal nerve
  - courses along border between lateral and anterior compartments of leg
  - supplies muscular branches to peroneus longus and brevis (lateral compartment)
  - terminates as medial dorsal and intermediate dorsal cutaneous nerves
- deep peroneal nerve
  - courses along anterior surface of IOM
  - supplies musculature of anterior compartment and sensation to first web space
- saphenous nerve (L3-L4)
  - continuation of femoral nerve of the thigh
  - becomes subcutaneous on medial aspect of knee between sartorius and gracilis
  - supplies sensation to medial aspect of leg and foot
- sural nerve (S1-S2)
  - formed by cutaneous branches of tibial (medial sural cutaneous) and common peroneal (lateral sural cutaneous) nerves
  - lies on lateral aspect of leg and foot

Classification

AO/OTA Classification
43-A	Extra-articular
43-B	Partial articular
43-C	Complete articular
Each category is further subdivided based on amount and degree of comminution

Ruedi and Allgower Classification
Type I	Nondisplaced
Type II	Simple displacement with incongruous joint
Type III	Comminuted articular surface
Each category is further subdivided based on amount and degree of comminution

Presentation

Symptoms
- ankle pain, inability to bear weight, deformity
Physical exam
- inspection
  - examine soft tissue integrity
    - swelling, abrasions, ecchymosis, fracture blisters, open wounds
  - examine for associated musculoskeletal injuries
- ROM & stability
  - examine stability and alignment of the ankle joint
- neurovascular
  - check DP and PT pulses
  - look for neurologic compromise
  - check for signs of compartment syndrome

Imaging

Radiographs
- recommended views
  - AP, lateral, mortise views of ankle
  - full-length tibia/fibula and foot x-rays performed for fracture extension
CT scan
- delineate articular involvement
- surgical planning
- with complex articular injuries, CT is most useful after ligamentotaxis is provided by a spanning external fixator

Treatment

Nonoperative
- immobilization
  - indications
    - stable fracture patterns without articular surface displacement
    - critically ill or nonambulatory patients
    - significant risk of skin problems (diabetes, vascular disease, neuropathy)
  - technique
    - long leg cast for 6 weeks followed by fracture brace and ROM exercises vs. early ROM
  - outcomes
    - intra-articular fragments are unlikely to reduce with manipulation of displaced fractures
    - loss of reduction is common
    - inability to monitor soft tissue injuries is a major disadvantage
Operative
- temporizing spanning external fixation across ankle joint
  - indications
    - acute management
      - provides stabilization to allow for soft tissue healing
    - fractures with significant joint depression or displacement
    - leave until swelling resolves (10-14 days)
- ORIF
  - indications
    - definitive fixation for majority of pilon fractures
  - outcomes
    - ability to drive
      - brake travel time returns to normal 6 weeks after weight bearing
- external fixation alone
  - indications
    - may be indicated in select cases

Techniques

External fixation
- fixation
  - joint-spanning articulated vs. nonspanning hybrid ring
    - none have been shown to be superior with respect to ankle stiffness
  - 2 tibial shaft half pins connected to hindfoot half pins or calcaneal transfixation pin
  - with hybrid fixators, thin wires may be placed within joint capsule or within zone of injury
- soft tissues
  - maintain soft tissue attachments of fragments
    - Chaput fragment - anterior inferior tibiofibular ligament
- pros
  - decreased incidence of wound complications and deep infections compared to ORIF
  - can combine with limited percutaneous fixation using lag screws
- cons
  - pin and wire tract infections
  - loss of ankle motion
  - injury to neurovascular structures
  - anatomic articular reconstruction may not be possible, especially with central depression
ORIF (AO technique)
- approach
  - use of multiple small incisions that can include
    - direct anterior approach to ankle
    - anterolateral approach to ankle
      - useful with fractures impacted in valgus or with an intact fibula
      - puts the deep peroneal nerve at risk during exposure and dissection in the anterior compartment
      - superficial peroneal nerve at risk during superficial dissection in the lateral compartment
    - anteromedial approach to ankle
    - medial approach
    - posteromedial approach
    - posterolateral approach
    - lateral approach
  - must respect soft tissues (7 cm skin bridge with full thickness skin flaps)
- goals
  - restore length
  - reconstruct metaphyseal shell
  - bone graft
  - reattach metaphysis to diaphysis
- steps
  - reduce and plate fibula to establish lateral column length
  - reduce articular surface
  - apply low profile medial buttress plate to fix articular fragment to shaft
- fixation
  - may be augmented with external fixation (with or without limited ORIF)
  - ORIF of fibula to maintain length
- pros
  - direct anatomic reduction
  - rigid fixation
  - early motion of ankle
  - clinical improvement may occur for up to 2 years
- cons
  - high incidence of soft tissue complications and infection without staged ORIF

Complications

Wound slough (10%)
- free flap for postoperative wound breakdown
Dehiscence (9-30%)
- wait for soft tissue edema to subside before ORIF (1-2 weeks)
Infection (5-15%)
Varus malunion
Nonunion
- usually at metaphyseal junction
- treat with bone grafting and plate fixation
- more common with hybrid fixation
Posttraumatic arthritis
- most commonly begins 1-2 years postinjury
- arthrodesis is not commonly required until many years later
Chondrolysis
Stiffness

Please Rate Educational Value!

3.0

Average 3.0 of 22 Ratings

Qbank (7 Questions)

TAG

(OBQ11.103) Which of the following statements is true regarding brake travel time after surgical treatment of complex lower extremity trauma? Topic

Review Topic

1. Brake travel time is significantly reduced until 6 weeks after patient begins weight bearing
2. Return of normal brake travel time takes longer after long bone fracture compared to articular fractures
3. Normal brake travel time correlates with improved short musculoskeletal functional assessment scores
4. Brake travel time is significantly reduced until 8 weeks after patient begins weight bearing
5. Brake travel time returns to normal when weight bearing begins

PREFERRED RESPONSE ▶

DISCUSSION: Brake travel time (BTT) has been shown to be significantly reduced until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity.

Egol et al used a computerized driving simulator to compare BTT in three groups of patients; 1)control group, 2)long bone lower extremity fracture group, 3)lower extremity articular fracture group. They concluded that BTT was significantly reduced until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity, and that short musculoskeletal functional assessment scores improved with respect to function and other indexes, but did not correlate with improvement in BTT.

An earlier study by Egol et al looked at total brake time as it related to distance traveled by the automobile before braking at 6, 9, and 12 weeks after operative fixation of a right ankle fracture. When compared with controls, braking time was shown to return to normal by 9 weeks post-operatively, and no significant association was found between the functional scores and this normalization.

Giddins et al provide a review of the literature, the law and the views of the major motor insurers related to driving after injury or operations.

REFERENCES:

1. Egol KA, Sheikhazadeh A, Koval KJ. Braking function after complex lower extremity trauma. J Trauma. 2008 Dec;65(6):1435-8. PMID: 19077638 (Link to Abstract)

2. Egol KA, Sheikhazadeh A, Mogatederi S, Barnett A, Koval KJ. Lower-extremity function for driving an automobile after operative treatment of ankle fracture. J Bone Joint Surg Am. 2003 Jul;85-A(7):1185-9. PMID:12851340 (Link to Abstract)

3. Giddins GE, Hammerton A. "Doctor, when can I drive?': a medical and legal view of the implications of advice on driving after injury or operation. Injury. 1996 Sep;27(7):495-7. PMID:8977836 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Jan Szatkowski MD, Ben Taylor MD,

Please Rate Educational Value!

2.0

Average 2.0 of 9 Ratings

TAG

(OBQ08.182) A 34-year-old male sustains the closed injury seen in figure A as a result of a high-speed motor vehicle collision. What is the most appropriate next step in treatment? Topic

Review Topic

FIGURES: A

1. Open reduction and internal fixation
2. Spanning external fixation
3. Percutaneous internal fixation
4. Closed reduction and cast placement
5. Ankle arthrodesis

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph shows a comminuted pilon fracture, which is associated with high-energy trauma and significant soft tissue injury. The tested concept here is the importance of avoiding definitive reduction and fixation of this high-energy injury, which has been shown to be associated with an increased risk of wound complications and deep infections (as compared to staged treatment with usage of a spanning external fixator).

REFERENCES:

1. Nork S: Distal tibia fractures, in Stannard JP, Schmidt AH, Kregor PJ, (eds): Surgical Treatment of Orthpaedic Trauma, ed 1. New York, NY, THieme,2007, pp767-791.

2. Bartlett CS, Winer LS: Fractures of tibial plafond, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, WB Saunders, 2003, pp2257-2306.

Question Authors:

Ben Taylor MD, Patrick McCulloch MD,

Please Rate Educational Value!

4.0

Average 4.0 of 9 Ratings

TAG

(OBQ06.8) A 33-year-old male sustains the injury shown in Figure A. He is initially treated with a spanning external fixator followed by definitive open reduction internal fixation of the tibia and fibula. His wounds healed without infection or other complications. Two years following surgery, which of the following parameters will likely predict a poor clinical outcome and inability to return to work? Topic

Review Topic

FIGURES: A

1. Joint line restoration
2. Degree of fracture displacement
3. Time before definitive ORIF
4. Open fracture
5. Lower level of education

PREFERRED RESPONSE ▶

DISCUSSION: To determine what fracture- and patient-specific variables affect outcome, Williams et al evaluated 29 patients with 32 tibial plafond fractures at a minimum of 2 years from the time of injury. Outcome was assessed by four independent measures: a radiographic arthrosis score, a subjective ankle score, the Short Form-36 (SF-36), and the patient’s ability to return to work. The four outcome measures did not correlate with each other. Radiographic arthrosis was predicted best by severity of injury and accuracy of reduction. However, these variables did not show any significant relationship to the clinical ankle score, the SF-36, or return to work. These outcome measures were more influenced by patient-specific socioeconomic factors. Higher ankle scores were seen in patients with college degrees and lower scores were seen in patients with a work-related injury. The ability to return to work was affected by the patient’s level of education.
Pollak et al performed a retrospective cohort analysis of pilon fractures. Patient, injury, and treatment characteristics were recorded. The primary outcomes that were measured included general health, walking ability, limitation of range of motion, pain, and stair-climbing ability. A secondary outcome measure was employment status. Multivariate analyses revealed that presence of two or more comorbidities, being married, having an annual personal income of less than $25,000, not having attained a high-school diploma, and having been treated with external fixation with or without limited internal fixation were significantly related to poorer results as reflected by at least two of the five primary outcome measures.

REFERENCES:

1. Williams TM, Nepola JV, DeCoster TA, Hurwitz SR, Dirschl DR, Marsh JL. Factorsaffecting outcome in tibial plafond fractures. Clin Orthop Relat Res. 2004 Jun;(423):93-8. PMID:15232432 (Link to Abstract)

2. Pollak AN, McCarthy ML, Bess RS, Agel J, Swiontkowski MF. Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am. 2003 Oct;85-A(10):1893-900. PMID:14563795 (Link to Abstract)

Question Authors:

Derek Moore,

Please Rate Educational Value!

2.0

Average 2.0 of 25 Ratings

TAG

(OBQ05.93) A 32-year-old man sustains a pilon fracture which is treated initially with a spanning external fixator, as shown in figure A. He is now 3 weeks from injury and skin swelling has subsided significantly. What is the most appropriate definitive treatment? Topic

Review Topic

FIGURES: A

1. open reduction internal fixation of the fibula only
2. open reduction internal fixation of the tibia and fibula
3. removal of external fixator and conversion to a walking cast
4. dynamization of the external fixator
5. tibio-talar arthrodesis

PREFERRED RESPONSE ▶

DISCUSSION: External fixation is a temporizing treatment that allows the soft tissues to return to normal while maintaining your overall alignment. A fibular plate can help keep the length. Final treatment involves restoration of the tibial plafond articular surface which can only be done with ORIF +/- bone grafting. There is no role for primary arthrodesis in this young patient.

REFERENCES:

1. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 19-29.

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Derek Moore,

Please Rate Educational Value!

3.0

Average 3.0 of 9 Ratings

TAG

(OBQ05.157) In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures? Topic

Review Topic

1. Interosseous ligament
2. Anterior inferior tibiofibular ligament
3. Posterior inferior tibiofibular ligament
4. Deltoid ligament
5. Tibiotalar ligament

PREFERRED RESPONSE ▶

DISCUSSION: The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament.

Illustrations: A

REFERENCES:

1. Hoppenfeld and de Boer. Surgical Exposures in Orthopaedics. The Anatomic Approach, ed 2. Phila, PA. JB Lippincott, 2003, pp 655-656

Question Authors:

Ben Taylor MD, Patrick McCulloch MD,

Please Rate Educational Value!

4.0

Average 4.0 of 17 Ratings

TAG

(OBQ04.73) A 35-year-old male laborer falls off a ladder and sustains the injury shown in Figures A and B. He has a 2 cm laceration over the medial ankle with exposed bone and a normal neurovascular exam. What is the recommended initial treatment? Topic

Review Topic

FIGURES: A

1. Immediate open reduction and internal fixation
2. Closed reduction and casting
3. Irrigation and debridement and external fixation
4. Irrigation and debridement and splinting
5. Amputation

PREFERRED RESPONSE ▶

DISCUSSION: Severe pilon fractures are generally the result of high energy trauma leading to bony comminution of the articular and metaphyseal bone. They are usually associated with significant soft tissue injury which prevents immediate definitive open reduction and internal fixation. In this situation, due to the soft tissue injury and open fracture, initial treatment should consist of irrigation and debridement and stabilization with external fixation. Definitive management such as open reduction and internal fixation is performed once the soft tissue swelling has improved and there is no evidence of infection. Sirkin et al published their results of a staged protocol for complex pilon injuries. Their data suggests the historically high rates of infection associated with ORIF of pilon fractures are likely due to attempts at immediate fixation through swollen, compromised soft tissues.

REFERENCES:

1. Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 2004 Sep;18(8 Suppl):S32-8. PMID:15472563 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Derek Moore,

Please Rate Educational Value!

4.0

Average 4.0 of 6 Ratings

TAG

(OBQ04.216) A 45-year-old male laborer falls off a 15 foot retaining wall 6 hours ago and sustains an open fracture shown in Figures A through C. He has a normal neurovascular exam. Coronal and sagittal CT scan images are shown in Figures D and E. What is the MOST appropriate next step in management in addition to operative irrigation and debridement? Topic

Review Topic

FIGURES: A

1. ORIF with standard plating of the tibia and fibula
2. ORIF with locked plating of the tibia and fibula
3. ORIF with standard plating of the tibia and fibula and immediate bone grafting of tibia defect
4. External fixation of the tibia, ORIF of the fibula with standard plating, and immediate bone grafting of tibia defect
5. External fixation of the tibia

PREFERRED RESPONSE ▶

DISCUSSION: External fixation of the tibia is the MOST appropriate initial treatment. Some surgeons prefer to defer the fibular fixation until definitive ORIF of the pilon but the common theme is that pilon fractures are treated with external fixation and staged ORIF. If bone grafting of the tibia is necessary it would be performed during the staged ORIF of the tibia.

Sirkin et al reports Level 4 evidence of a staged protocol of immediate (within twenty-four hours) open reduction and internal fixation of the fibula, using a one-third tubular or 3.5-mm DC plate and application of an external fixator spanning the ankle joint. They followed both open and closed pilon fractures that were treated with external fixation until the soft tissue swelling resolved and then underwent ORIF. There was less than an 11% rate of major wound complication or infection in both groups. Their conclusions suggested the historically high rates of wound complication and infection associated with ORIF of pilon fractures are likely due to attempts at immediate fixation through swollen, compromised soft tissues.

REFERENCES:

1. Kellam, J (ed): Orthopaedic Knowledge Update Trauma 2. American Academy of Orthopaedic Surgeons, 2000, pp 191-202

2. Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 2004 Sep;18(8 Suppl):S32-8. PMID:15472563 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD, Jan Szatkowski MD,

Please Rate Educational Value!

4.0

Average 4.0 of 11 Ratings

Cases

	Pilon fracture (C1058) Trauma - - Tibia Plafond Fractures HPI - 45 y/o male sustained this injury after falling 12 ft from a ladder. What w...	9/21/2011 2 responses
	Pilon fracture nonunion (C1157) Trauma - - Tibia Plafond Fractures HPI - 45 year old male who underwent open reduction and internal fixation of a right t... How would you fuse this ankle?	2/18/2012 30 responses
	open infected salter 2 fracture distal tibia (C1224) Trauma - Treatment Consult - Tibia Plafond Fractures HPI - 14 y/o fell from 3 feet sustained open salter 2 fracture. Referred to regional h... treatment going forward	6/15/2012 106 responses

See More Cases

Videos

Approach to pilon fractures

Trauma - Surgical Techniques - Tibia Plafond Fractures

This video contains an excellent discussion of exposures, reduction techniques a...

2/17/2013

718 views

See More Videos

Posts

A staged protocol for soft tissue management in the treatment of complex pilon fractures. Includes Poll

Sirkin M, Sanders R, DiPasquale T, Herscovici D
J Orthop Trauma. 2004 Sep;18(8 Suppl):S32-8. PMID: 15472563 (Link to Pubmed)

Trauma - Journal Club - Tibia Plafond Fractures

3/28/2013

59 responses

See More Posts

Groups

ABOS II: Tibia Plafond Fractures

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 4 (Case Series)

Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 2004 Sep;18(8 Suppl):S32-8. PMID:15472563 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Hoppenfeld and de Boer. Surgical Exposures in Orthopaedics. The Anatomic Approach, ed 2. Phila, PA. JB Lippincott, 2003, pp 655-656
Kellam, J (ed): Orthopaedic Knowledge Update Trauma 2. American Academy of Orthopaedic Surgeons, 2000, pp 191-202

Undefined

Egol KA, Sheikhazadeh A, Koval KJ. Braking function after complex lower extremity trauma. J Trauma. 2008 Dec;65(6):1435-8. PMID: 19077638 (Link to Abstract)
Egol KA, Sheikhazadeh A, Mogatederi S, Barnett A, Koval KJ. Lower-extremity function for driving an automobile after operative treatment of ankle fracture. J Bone Joint Surg Am. 2003 Jul;85-A(7):1185-9. PMID:12851340 (Link to Abstract)
Giddins GE, Hammerton A. "Doctor, when can I drive?': a medical and legal view of the implications of advice on driving after injury or operation. Injury. 1996 Sep;27(7):495-7. PMID:8977836 (Link to Abstract)
Nork S: Distal tibia fractures, in Stannard JP, Schmidt AH, Kregor PJ, (eds): Surgical Treatment of Orthpaedic Trauma, ed 1. New York, NY, THieme,2007, pp767-791.
Bartlett CS, Winer LS: Fractures of tibial plafond, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, WB Saunders, 2003, pp2257-2306.
Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008
Williams TM, Nepola JV, DeCoster TA, Hurwitz SR, Dirschl DR, Marsh JL. Factorsaffecting outcome in tibial plafond fractures. Clin Orthop Relat Res. 2004 Jun;(423):93-8. PMID:15232432 (Link to Abstract)
Pollak AN, McCarthy ML, Bess RS, Agel J, Swiontkowski MF. Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am. 2003 Oct;85-A(10):1893-900. PMID:14563795 (Link to Abstract)
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 19-29.
Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 2004 Sep;18(8 Suppl):S32-8. PMID:15472563 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Tibia Plafond Fractures

Qbank (7 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Cases

Videos

Posts

Groups

Evidence & References Show References

Topic Comments