Summary A tibial plafond fracture (also known as a pilon fracture) is a fracture of the distal end of the tibia, most commonly associated with comminution, intra-articular extension, and significant soft tissue injury. Diagnosis is typically made through clinical evaluation and confirmed with plain radiographs. Treatment is generally operative with temporary external fixation followed by delayed open reduction internal fixation once the soft tissues permit. Epidemiology Incidence common 5%-10% of all tibia fractures account for <10% of lower extremity injuries incidence increasing as survival rates after motor vehicle collisions increase Demographics average patient age is 35-45 years males > females Etiology Pathophysiology mechanism high energy axial load (most common) talus is driven into the plafond resulting in articular impaction of the distal tibia falls from height motor vehicle accidents low energy rotational forces (less common) alpine skiing pathoanatomy fracture patterns and comminution determined by position of foot, amplitude of force, and direction of force articular impaction and comminution metaphyseal bone comminution 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 30% have an ipsilateral lower extremity injury 20% are open fractures 5-10% are bilateral pilon fractures 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 Ligaments distal tibiofibular syndesmosis anterior-inferior tibiofibular ligament (AITFL) originates from anterolateral tubercle of tibia (Chaput) inserts on anterior tubercle of fibula (Wagstaffe) posterior-inferior tibiofibular ligament (PITFL) originates from posterior tubercle of tibia (Volkmann) inserts on posterior part of lateral malleolus strongest component of syndesmosis interosseous membrane interosseous ligament (IOL) distal continuation of the interosseous membrane inferior transverse ligament (ITL) Classification AO/OTA Classification 43-A Extra-articular 43-B Partial articular 43-C Complete articular Ruedi and Allgower Classification Type I Nondisplaced Type II Simple displacement with incongruous joint Type III Comminuted articular surface Presentation Symptoms severe ankle pain ankle deformity inability to bear weight Physical exam inspection & palpation ankle tenderness, swelling, abrasions, ecchymosis, fracture blisters, open wounds, and chronic skin/vascular changes examine for associated musculoskeletal injuries motion ankle motion limited neurovascular check DP and PT pulses consider ABIs and CT angiography if clinically warranted look for neurologic compromise check for signs/symptoms of compartment syndrome Imaging Radiographs recommended views AP lateral mortise full-length tibia/fibula and foot x-rays performed for fracture extension lumbar films if appropriate based on exam findings 4 classic fracture fragments medial malleolus anterior malleolus = chaput lateral malleolus = wagstaffe posterior malleolus = volkmann CT scan indications critical for pre-operative planning articular involvement metaphyseal comminution fracture displacement important to obtain after spanning external fixation as ligamentotaxis allows for better surgical planning fine cuts through the distal tibia 3D reconstructions can be helpful findings ‘Mercedes-Benz’ sign on axials Treatment Nonoperative cast immobilization indications stable fracture patterns without articular surface displacement critically ill or non-ambulatory patients significant risk of skin problems (diabetes, vascular disease, peripheral neuropathy) 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 of most length unstable fractures provides stabilization to allow for soft tissue healing and monitoring capsuloligamentotaxis to indirectly reduce the fracture by tensioning the soft tissues about the ankle keeps fracture fragments out to length fractures with significant joint depression or displacement leave until swelling resolves (generally 10-14 days) not always warranted in length stable pilon fractures outcomes placement of pins out of the zone of injury and planned surgical site is important to reduce infection risks open reduction and internal fixation (ORIF) indications definitive fixation for a majority of pilon fractures limited or definitive ORIF can be performed acutely with low complications in certain situations outcomes dependent on articular reduction high rates of wound complications and infections are associated with early open fixation through compromised soft tissue ability to drive brake travel time returns to normal 6 weeks after weight bearing fibula fixation not a necessary step in the reconstruction of pilon fractures may be helpful in specific cases to aid in tibial plafond reduction or augment external fixation higher rates of fibula hardware removal external fixation/circular frame fixation alone indications select cases where bone or soft tissue injury precludes internal fixation outcomes thin wire frames and hybrid fixators have high union rate high rates of pin tract infections osteomyelitis and deep infection are rare meta-analysis comparing this method with open reduction and internal fixation found no difference in infection or complication rates between the two groups intramedullary nailing with percutaneous screw fixation indications alternative to ORIF for fractures with simple intra-articular component outcomes minimizes soft tissue stripping and useful in patients with soft tissue compromise high union rates increased valgus malunion and recurvatum seen with IMN compared to plate osteosynthesis primary ankle arthrodesis indications no definitive indications potential indications severely comminuted, non-reconstructable plafond fractures select elderly populations who cannot tolerate multiple surgeries or prolonged immobilization manual laborers techniques plate and screw fixation retrograde intramedullary TTC nail outcomes theorized quicker recovery process and decreased long term pain increases the risk of adjacent joint arthritis including the subtalar joint and midfoot Techniques Cast immobilization technique long leg cast for 6 weeks followed by fracture brace and ROM exercises close follow-up and imaging needed to ensure articular congruity and axial alignment External fixation (temporary and definitive) technique fixator constructs vary with ‘delta’ and ‘A’ frames assemblies being most common 2 tibial shaft half pins outside the zone of injury connected to a single transcalcaneal pin consider trans-navicular pin if associated calcaneal fracture consider connecting fixator to the forefoot 1st metatarsal to prevent an equinus contracture joint-spanning articulated vs. nonspanning hybrid ring none have been shown to be superior with respect to ankle stiffness can combine with limited percutaneous fixation using lag screws complications pin site drainage pin/wire tract infections pin site fracture ankle stiffness injury to neurovascular structures anatomic articular reconstruction may not be possible, especially with central depression Circular frame fixation technique distraction is the key to reduction proximal fixation tibial shaft is used as a fixation base to reduce the fracture two half-pins in the AP plane with rings in an orthogonal position used to support the distal fixation rings distal fixation determined by the configuration of the fracture and the soft-tissue injury rings placed at the level of the plafond or calcaneus to distract and reduce the fracture pins should be placed at least 1-2 cm from the joint line in order to avoid possible septic arthritis safe zones for wire placement form a 60-degree arc in the medial-lateral plane can include limited internal fixation if soft tissues permit consider the need for soft tissue coverage with position of the fixator hydroxyapatite coated pins provides better fixation and decreases frequency of loosening Open reduction and rigid internal fixation (ORIF) timing to definitive surgery once skin wrinkles present, blister epithelization, and ecchymosis resolution (10-14 days) approach(es) single or multiple incisions based on fracture pattern and goals of fixation keep full thickness skin bridge >7cm between incisions positioning of patient dependent on approach(es) being utilized 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 technique reduction and fixation goal is for anatomic reduction of articular surface location of plates/screws are fracture and soft-tissue dependent restore alignment <5-10 degrees varus/valgus <5-10 degrees procurvatum/recurvatum restore length consider provisionally leaving the external fixator in place reconstruct metaphyseal shell bone graft (if warranted) reattach metaphysis to diaphysis fibula fixation if needed can be with intramedullary screw/wire or plate/screw construct postoperative care ankle ROM exercises beginning 2 weeks post-op non-weightbearing for ~6-12 weeks depending on radiographic evidence of fracture consolidation Primary ankle arthrodesis approach direct anterior technique plate and screw fixation debride fibrous tissue, fracture callous, and cartilage small comminuted articular fragments are removed remove talar dome cartilage pack metaphyseal defects and the tibiotalar joint with autologous or allograft bone graft iliac crest demineralized bone matrix optimal position neutral dorsiflexion 5-10° of external rotation 5° of hindfoot valgus 5 mm of posterior talar translation fixation with an anterior plate and screw construct post-op care apply cast or splint for 8 weeks progress weight bearing between 8 and 12 weeks in removable boot full weight bearing with ankle brace at 12 weeks post-op CT at 3 months to assess for successful fusion tibiotalocalcaneal (TTC) fusion with retrograde intramedullary nail sacrifices subtalar joint motion accelerates transverse tarsal joint arthritis immediate weightbearing permissible Complications Wound slough and dehiscence incidence 9-30% wait for soft tissue edema to subside before ORIF (1-2 weeks) treatment free flap for postoperative wound breakdown Infection incidence 5-15% risk factors significant soft tissue swelling at time of definitive surgery Increasing fracture severity treatment irrigation and debridement, antibiotics, possible hardware removal Malunion incidence 6-14% treatment joint-preserving correction with secondary anatomic reconstruction corrective ankle fusion Nonunion incidence 5% of patients undergoing ORIF usually at the metaphyseal junction risk factors metaphyseal comminution open fractures bone loss tobacco use NSAID use treatment must rule out infected non-union (labs to obtain CRP, ESR, WBC) other non-union labs (PTH, calcium, total protein, serum albumin, vitamin D, TSH) rigid fixation with bone grafting Post-traumatic arthritis incidence chondrocyte cell death at fracture margins is a contributing factor IL-6 is elevated in the synovial fluid following an intra-articular ankle fracture most commonly begins 1-2 years postinjury risk factors sequalae of cartilage trauma non-anatomic articular reduction mal-alignment treatment first line is conservative management (bracing, injections, NSAIDs, activity modification) total ankle arthroplasty ankle arthrodesis Chondrolysis Stiffness Present in up to 33% at three years post-injury risk factors increasing fracture severity obesity ASA of three or greater Prognosis Poor outcomes and lower return to work associated with lower level of education pre-existing medical comorbidities male sex work-related injuries lower income levels Outcomes correlate with severity of the fracture pattern and the quality of reduction at 2 year follow-up, the majority of type C pilon fractures report lower SF-36 scores than patients with pelvic fractures, AIDS, or coronary artery disease clinical improvement seen for up to 2 years after injury Return of vehicle braking response time 6 weeks after initiation of weight bearing