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Updated: Feb 29 2024

Tibial Plafond Fractures

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  • 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
  • Prognosis
    • Poor outcomes and lower return to work associated with
      • 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
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