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) login to view 3 more bullets low energy rotational forces (less common) login to view 1 more bullet pathoanatomy fracture patterns and comminution determined by position of foot, amplitude of force, and direction of force login to view 6 more bullets 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) login to view 2 more bullets posterior-inferior tibiofibular ligament (PITFL) login to view 3 more bullets interosseous membrane interosseous ligament (IOL) login to view 1 more bullet 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 login to view 1 more bullet 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 login to view 4 more bullets CT scan indications critical for pre-operative planning login to view 4 more bullets important to obtain after spanning external fixation as ligamentotaxis allows for better surgical planning fine cuts through the distal tibia login to view 1 more bullet findings ‘Mercedes-Benz’ sign on axials Treatment Nonoperative cast immobilization indications login to view 3 more bullets outcomes login to view 3 more bullets Operative temporizing spanning external fixation across ankle joint indications login to view 7 more bullets outcomes login to view 1 more bullet open reduction and internal fixation (ORIF) indications login to view 2 more bullets outcomes login to view 8 more bullets external fixation/circular frame fixation alone indications login to view 1 more bullet outcomes login to view 4 more bullets intramedullary nailing with percutaneous screw fixation indications login to view 1 more bullet outcomes login to view 3 more bullets primary ankle arthrodesis indications login to view 1 more bullet potential indications login to view 3 more bullets techniques login to view 2 more bullets outcomes login to view 2 more bullets 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 login to view 2 more bullets joint-spanning articulated vs. nonspanning hybrid ring login to view 1 more bullet 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 login to view 3 more bullets distal fixation login to view 4 more bullets can include limited internal fixation if soft tissues permit consider the need for soft tissue coverage with position of the fixator hydroxyapatite coated pins login to view 1 more bullet 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 login to view 3 more bullets anteromedial approach to ankle medial approach posteromedial approach posterolateral approach lateral approach technique reduction and fixation login to view 12 more bullets postoperative care login to view 2 more bullets Primary ankle arthrodesis approach direct anterior technique plate and screw fixation login to view 17 more bullets tibiotalocalcaneal (TTC) fusion with retrograde intramedullary nail login to view 3 more bullets 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 Posterior tibial tendon entrapment commonly missed best visualized on preoperative CT on soft-tissue windows can occur with posteromedial fracture fragments 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 fractures with associated syndesmotic injury, particularly if unaddressed, have inferior outcomes clinical improvement seen for up to 2 years after injury Return of vehicle braking response time 6 weeks after initiation of weight bearing