Updated: 9/17/2018

Tibial Plafond Fractures

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https://upload.orthobullets.com/topic/1046/images/Xray - AP - Pilon fx - case A- Sagi)_moved.jpg
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https://upload.orthobullets.com/topic/1046/images/ruedi-allgower classification of tibial pilon fractures.jpg
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https://upload.orthobullets.com/topic/1046/images/type ii ruedi allgower ap.jpg
Introduction
  • Also known as pilon fractures
  • Epidemiology
    • incidence
      • account for <10% of lower extremity injuries
      • incidence increasing as survival rates after motor vehicle collisions increase
    • demographics
      • average patient age is 35-40 years
      • more common in males than females
  • Pathophysiology
    • mechanism
      • high energy axial load (motor vehicle accidents, falls from height)
    • pathoanatomy
      • often characterized by
        • articular impaction and comminution
        • metaphyseal bone comminution
        • 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 
      • pre-existing 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
      • full-length tibia/fibula and foot x-rays performed for fracture extension
    • findings
      • 4 characterisic fragments
        • medial malleolus
        • anterior malleolus = chaput
        • lateral malleolus = wagstaffe
        • posterior malleolus = volkmann
  • CT scan
    • delineate articular involvement
    • surgical planning
    • 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
        • alternative treatment is with 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 (generally 10-14 days)
    • ORIF 
      • indications
        • definitive fixation for majority of pilon fractures
        • limited or definitive ORIF can be performed acutely with low complications in certain situations
      • 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
    • intramedullary nailing with percutaneous screw fixation 
      • alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2)
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 (generally >7 cm skin bridge with full thickness skin flaps)
    • goals
      • anatomic reduction of articular surface 
      • restore length
      • reconstruct metaphyseal shell
      • bone graft
      • reattach metaphysis to diaphysis
    • steps
      • reduce and instrument fibula to establish lateral column length (if needed)
        • when compared to no instrumentation of the fibula no difference in alignment or reduction but higher rates of fibular hardware removal 
      • reduce articular surface
      • reattach articular block to metaphysis and shaft
    • fixation
      • may be augmented with external fixation (with or without limited ORIF)
      • can use anterolateral, anterior, anteromedial, medial, or posterior plating techniques for the tibia
        • location of plates/screws are fracture and soft-tissue dependent
      • ORIF of fibula if needed
        • can be with intramedullary screw/wire or plate/screw construct
    • 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
    • chondrocyte cell death at fracture margins is a contributing factor 
  • Chondrolysis
  • Stiffness
 

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Technique Guides (2)
Questions (17)
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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? Review Topic

QID: 1178
FIGURES:
1

Immediate open reduction and internal fixation

1%

(20/1897)

2

Closed reduction and casting

0%

(6/1897)

3

Irrigation and debridement and external fixation

96%

(1827/1897)

4

Irrigation and debridement and splinting

2%

(37/1897)

5

Amputation

0%

(2/1897)

ML 1

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 568
FIGURES:
1

Open reduction and internal fixation

4%

(84/1888)

2

Spanning external fixation

94%

(1767/1888)

3

Percutaneous internal fixation

0%

(4/1888)

4

Closed reduction and cast placement

1%

(25/1888)

5

Ankle arthrodesis

0%

(4/1888)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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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? Review Topic

QID: 4770
FIGURES:
1

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

5%

(209/3906)

2

Anatomical reduction and stabilization of the tibial articular surface

86%

(3363/3906)

3

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

3%

(131/3906)

4

Anatomical reduction and stabilization of the tibial metaphyseal segment

4%

(147/3906)

5

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

1%

(40/3906)

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PREFERRED RESPONSE 2

(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? Review Topic

QID: 3945
FIGURES:
1

Closed reduction and splinting followed by delayed casting

0%

(9/4182)

2

Immediate open reduction internal fixation

1%

(55/4182)

3

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

2%

(89/4182)

4

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

12%

(481/4182)

5

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

84%

(3524/4182)

ML 2

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PREFERRED RESPONSE 5

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

QID: 1043
1

Interosseous ligament

1%

(24/1781)

2

Anterior inferior tibiofibular ligament

81%

(1437/1781)

3

Posterior inferior tibiofibular ligament

13%

(229/1781)

4

Deltoid ligament

3%

(49/1781)

5

Tibiotalar ligament

2%

(30/1781)

ML 2

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PREFERRED RESPONSE 2

(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?
Review Topic

QID: 4559
FIGURES:
1

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

0%

(11/3360)

2

Closed reduction and spanning external fixation of the ankle

92%

(3079/3360)

3

Open reduction and internal fixation of the fibula and tibia

4%

(128/3360)

4

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

1%

(35/3360)

5

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

3%

(96/3360)

ML 1

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PREFERRED RESPONSE 2

(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? Review Topic

QID: 19
FIGURES:
1

Joint line restoration

37%

(198/536)

2

Degree of fracture displacement

8%

(43/536)

3

Time before definitive ORIF

2%

(9/536)

4

Open fracture

9%

(46/536)

5

Lower level of education

44%

(238/536)

ML 4

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PREFERRED RESPONSE 5

(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? Review Topic

QID: 4521
FIGURES:
1

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

1%

(53/4921)

2

Immediate plate fixation of the fibula and placement of a ankle-spanning external fixation device, followed by delayed reconstruction of the tibia

81%

(3981/4921)

3

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

7%

(360/4921)

4

Immediate definitive fixation of the tibia and fibula

2%

(95/4921)

5

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

8%

(403/4921)

ML 2

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PREFERRED RESPONSE 2

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

QID: 3526
1

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

74%

(1900/2561)

2

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

1%

(27/2561)

3

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

6%

(157/2561)

4

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

16%

(410/2561)

5

Brake travel time returns to normal when weight bearing begins

2%

(55/2561)

ML 2

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PREFERRED RESPONSE 1

(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? Review Topic

QID: 1321
FIGURES:
1

ORIF with standard plating of the tibia and fibula

0%

(2/465)

2

ORIF with locked plating of the tibia and fibula

2%

(11/465)

3

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

2%

(8/465)

4

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

10%

(47/465)

5

External fixation of the tibia

85%

(395/465)

ML 1

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PREFERRED RESPONSE 5

(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? Review Topic

QID: 979
FIGURES:
1

open reduction internal fixation of the fibula only

1%

(11/1202)

2

open reduction internal fixation of the tibia and fibula

98%

(1179/1202)

3

removal of external fixator and conversion to a walking cast

0%

(4/1202)

4

dynamization of the external fixator

0%

(3/1202)

5

tibio-talar arthrodesis

0%

(2/1202)

ML 1

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PREFERRED RESPONSE 2
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