Updated: 6/3/2022

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
      • 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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Technique Guides (2)
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Questions (20)
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(SBQ18TR.27) A 45-year-old male construction worker presents with right ankle pain after falling from a two-story building and landing on his right leg. He noticed immediate pain and inability to bear weight on the affected limb. Physical examination reveals diffuse soft tissue swelling around the ankle joint without any open injuries. The patient reveals he never completed a high school degree, smokes 1/2 a pack of cigarettes per day, and occasionally uses marijuana recreationally. Injury radiographs are shown in figures A and B. The patient undergoes an ankle-spanning external fixator placement for soft tissue stabilization and then undergoes definitive fixation shown in figures C and D. Which factor suggests a poor clinical outcome and failure to return to work?

QID: 211397

Use of a temporizing external fixator



Varus collapse of the distal tibia at the time of injury



Recreational marijuana use



Lower level of education



Use of more than one plate for definitive fixation of the tibia




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(SBQ18TR.26) A 37-year-old construction worker falls off a rock and lands on his right leg. He reports severe pain and inability to bear weight on the right leg. Current imaging is shown in figures A-C. On examination, the injury is closed, but there is substantial soft tissue swelling. An ankle spanning external fixator is placed on the right leg to allow for soft tissue stabilization. The treating surgeon decides to perform an open reduction internal fixation (ORIF) through combined anterolateral and medial approaches. What is true regarding the anterolateral approach for this injury?

QID: 211386

The entire articular surface cannot be visualized through the anterolateral approach



Anterior compartment tendons are retracted laterally to protect the neurovascular structures



Anterolateral approach is contraindicated with central dome comminution



Dorsal foot numbness is the most common associated neurologic complication



Fibular fixation is usally performed through the same incision



L 3 A

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(OBQ13.135) A 34-old-male was involved in a high speed MVC. He sustained an injury to his right leg as seen in Figures A and B. He was treated initially with external fixation for 11 days before his soft-tissues would permit definitive open internal fixation. After removing the external fixator and plating the fibula, what would be next step in the operative plan for reduction and fixation of this injury?

QID: 4770

Application of an anterolateral pre-contoured plate with distal locking screws to the tibia



Anatomical reduction and stabilization of the tibial articular surface



Application of a medial pre-contoured plate with distal non-locking screws to the tibia



Anatomical reduction and stabilization of the tibial metaphyseal segment



Proximal screw insertion with non-locking screws to distract the metaphyseal fracture comminution



L 2 B

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(OBQ12.161) A 46-year-old male falls 15 feet from a ladder while working. He presents with the radiographs shown in Figures A and B. The injury is closed, and soft tissues are intact upon arrival. Which of the following treatment regimens has been shown to decrease wound complications in the definitive management of these injuries?

QID: 4521

Immediate definitive fixation of the tibia, and nonoperative treatment of the fibula



Immediate ankle-spanning external fixation device with consideration of immediate fixation of the fibula, followed by delayed reconstruction of the tibia



Placement of a temporary splint, elevation, and definitive fixation 1 week from injury



Immediate definitive fixation of the tibia and fibula



Immediate placement of a spanning Ilizarov fixator with limited internal fixation of the distal tibia and fibula



L 2 A

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(SBQ12TR.30) A 55-year-old female presents to the emergency room after falling off her balcony. She sustained the isolated, closed injury shown in Figures A and B. She is otherwise healthy, but routinely smokes 30 cigarettes per day. What would be the most appropriate sequence of treatment steps for definitive management of this injury?

QID: 3945

Closed reduction and splinting followed by delayed casting



Immediate open reduction internal fixation



Closed reduction and splinting, CT scan, and immediate open reduction internal fixation



Closed reduction and splinting, CT scan, external fixation, delayed open reduction internal fixation



Closed reduction and splinting, external fixation, CT scan, delayed open reduction internal fixation



L 2 A

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(OBQ12.199) A 52-year-old carpenter falls off of a balcony while at work and sustains the injury shown in Figure A. The patient's BMI is 52 and he smokes 2 packs of cigarettes per day; a clinical photograph of the limb is shown in Figure B. What is the most appropriate next step in management?

QID: 4559

Short leg splint placement and transition to short leg cast at 2 weeks



Closed reduction and spanning external fixation of the ankle



Open reduction and internal fixation of the fibula and tibia



Open reduction and internal fixation of the fibula with Blair arthrodesis of the ankle



Open reduction and internal fixation of the tibia and articulating external fixation of the ankle



L 1 A

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

QID: 3526

Brake travel time is significantly increased until 6 weeks after patient begins weight bearing



Return of normal brake travel time takes longer after long bone fracture compared to articular fractures



Normal brake travel time correlates with improved short musculoskeletal functional assessment scores



Brake travel time is significantly reduced until 8 weeks after patient begins weight bearing



Brake travel time returns to normal when weight bearing begins



L 2 C

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(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?

QID: 568

Open reduction and internal fixation



Spanning external fixation



Percutaneous internal fixation



Closed reduction and cast placement



Ankle arthrodesis



L 1 A

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(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 most likely predict a poor clinical outcome and inability to return to work?

QID: 19

Joint line restoration



Degree of fracture displacement



Time before definitive ORIF



Open fracture



Lower level of education



L 4 D

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

QID: 1043

Interosseous ligament



Anterior inferior tibiofibular ligament



Posterior inferior tibiofibular ligament



Deltoid ligament



Tibiotalar ligament



L 1 C

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(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?

QID: 979

open reduction internal fixation of the fibula only



open reduction internal fixation of the tibia and fibula



removal of external fixator and conversion to a walking cast



dynamization of the external fixator



tibio-talar arthrodesis



L 1 D

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(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?

QID: 1178

Immediate open reduction and internal fixation



Closed reduction and casting



Irrigation and debridement and external fixation



Irrigation and debridement and splinting






L 1 A

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(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?

QID: 1321

ORIF with standard plating of the tibia and fibula



ORIF with locked plating of the tibia and fibula



ORIF with standard plating of the tibia and fibula and immediate bone grafting of tibia defect



External fixation of the tibia, ORIF of the fibula with standard plating, and immediate bone grafting of tibia defect



External fixation of the tibia



L 1 A

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