High Yield Topics

Tibial Plafond Fracture

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Tibial Plafond Fracture

Tibial Plafond Fracture
Jason W. Hammond MD
Peter R. Jay MD
Basics
Description
  • Tibial plafond (or pilon) fractures, a
    subset of ankle fractures, are intra-articular fractures of the distal
    tibia involving varying degrees of articular and metaphyseal injury (Fig. 1).
    • The word “pilon” comes from the French
      root meaning “pestle” or “rammer,” conveying the idea that the talus
      drives into the tibial articular surface.
    • The distal tibia also is known as the plafond (roof) over the talus; thus, these fractures also are called “plafond fractures.”
  • These high-energy, often-devastating injuries:
    • Often are associated with marked soft-tissue injury
    • Can be associated with substantial neurovascular compromise
    • Can be associated with other lower extremity, spinal, pelvic, abdominal, thoracic, or cranial injuries
    • Are associated with the population at risk for high-level trauma (i.e., young males)
  • Practitioners should be even more
    vigilant about open injuries and vascular or tissue compromise in
    elderly or debilitated patients.
  • Multiple classification systems exist, but the Ruedi and Allgower (1) system is the most commonly used:
    • Type I: Nondisplaced or minimally displaced intra-articular fracture
    • Type II: Displaced intra-articular fracture with minimal comminution
    • Type III: Displaced fracture with marked comminution
  • The Ruedi and Allgower (1) classification system has clinical and prognostic implications:
    • Type I can be treated with splint or cast immobilization; good prognosis
    • Types II and III require surgical intervention; associated with a more guarded prognosis
      Fig. 1. Tibial plafond fracture.
Epidemiology
Incidence
  • These rare injuries are associated with high-energy trauma.
  • Anecdotally, the incidence has been increasing with the advent of the automobile airbag.
Risk Factors
  • Individuals at risk for high-level trauma (e.g., young males, alcohol abuse, drug use)
  • Individuals who work at heights
Etiology
  • High-energy injuries:
    • Motor vehicle accident
    • Fall from height
    • High-energy axial loading is the common denominator.
  • Some low-energy (e.g., skiing) injuries
Associated Conditions
Patients are at high risk for associated pelvic, spinal, abdominal, thoracic, or cranial injuries.
Diagnosis
Signs and Symptoms
History
  • Severe pain
  • Swelling
  • Inability to bear weight
Physical Exam
  • 1st, perform a complete trauma assessment
    with a primary survey of airway, breathing, circulation and then a
    secondary survey of the head, neck, chest, abdomen, spine, pelvis, and
    all extremities per the ATLS protocol (2).
  • Evaluate soft-tissue status, including swelling, fracture blisters, open fracture.
  • Perform a careful neurovascular examination.
  • Monitor for compartment syndrome.
  • Use the wrinkle test: Swelling is decreased and ready for surgery when the skin wrinkles with pinching.
Tests
Lab
  • Order appropriate tests for the level of injury:
    • Hematocrit
    • Type and cross-match
    • Urine and stool check for blood, as indicated
    • All preoperative laboratory tests necessary for age group, level of injury, and institution
Imaging
  • Plain radiographs:
    • AP, lateral, and mortise views of the ankle
    • AP and lateral views of the foot
    • Tibia-fibula
    • Some surgeons find that radiographs of the opposite extremity assist in reconstruction in severe cases.
  • If displacement or comminution is present, a CT scan can be helpful for surgical planning.
Differential Diagnosis
  • Ankle fracture
  • Talus fracture
  • Tibial shaft fracture
  • Calcaneus fracture
  • Midfoot fracture
  • Forefoot fracture
Treatment
General Measures
  • The soft tissue often is the limiting factor, as well as the major cause for complications.
  • Type I: Nondisplaced fracture:
    • Responds well to closed therapy, including a well-padded splint, ice, elevation, nonweightbearing
    • The splint can be converted to a cast when swelling begins to subside.
  • Types II and III: Displaced fractures:
    • Require surgical intervention
    • Are associated with poor results and multiple complications
    • Debate continues on whether to perform
      open reduction with internal fixation or external fixation with or
      without limited internal fixation.
    • The current trend is toward external
      fixation with limited internal fixation because of its equivalent
      clinical results and lower complication rate.
    • Treatment may use a staged approach.
      • Initial treatment with an external fixator is important to prevent limb shortening.
      • Limited percutaneous fixation may provide some fracture fixation.
      • After soft-tissue swelling has decreased, the fixator may be removed, and the fracture may be plated.
    • With severe injuries, primary arthrodesis rarely has a role.

    • P.455


  • Weightbearing is delayed until fracture union, no matter what mode of therapy is used.
  • The time frame often is 3–4 months, but it can be shorter for type I fractures treated nonsurgically.
Activity
Fractures should be splinted and the limb kept elevated.
Nursing
  • Always evaluate the neurovascular and soft-tissue status.
  • Compartment syndrome checks
Special Therapy
Physical Therapy
Physical therapy to address ankle ROM, leg strengthening, and gait after fracture healing
Medication
Patients require pain medication in the acute setting.
Surgery
  • In general, most plafond fractures are treated using a staged surgical protocol.
  • Staged treatment using initial external
    fixation followed by later internal fixation has decreased complication
    rates, especially those related to soft-tissue healing (3).
  • External fixation:
    • A spanning fixator is placed using calcaneal transfixion PINS and tibial half-pins.
    • A ringed fixator may be used with thin wires.
    • The fibula must be brought out to length.
    • If the lateral skin is not too swollen, the fibula should be fixed with a plate.
    • The tibial articular surface should be aligned with traction and ligamentous taxis.
    • Limited percutaneous fixation should be considered to reduce the fracture further.
    • The external fixator allows the soft tissues to heal for later definitive plating and bone grafting.
  • Open reduction and internal fixation:
    • Soft-tissue swelling must be resolved before an open approach to the distal tibia, which may require waiting several weeks.
    • An anterior approach often is necessary to expose the fracture and allow precise reduction.
    • Reconstruct the distal tibial articular surface with lag screws.
    • Bone graft the tibial metaphyseal defect.
    • Stabilize the distal articular surface to the proximal tibia.
    • Contoured plates are available that fit the medial or lateral surface of the tibia.
    • Modern plates allow for percutaneous subperiosteal placement and the use of locking technology.
Follow-up
Prognosis
  • High-energy pilon fractures have a devastating effect on patients.
    • In 1 study at 3 years after injury, patients had decreased SF-36 scores, and 40% were not able to work (4).
    • Negative effects of the fracture can remain at the 5-year follow-up (5).
Complications
  • Chronic ankle pain
  • Early ankle degenerative joint disease
  • Need for revision operations or ankle arthrodesis
  • Compartment syndrome
  • Soft-tissue coverage issues
  • Wound dehiscence
  • Superficial wound infection
  • Pin infection with external fixation
  • Deep wound infection
  • Osteomyelitis
  • Posttraumatic arthrosis
Patient Monitoring
  • Patients are monitored for wound-healing
    problems, maintenance of fracture reduction, radiographic union of
    fracture, and advancement of weightbearing status.
  • Patients should be treated with DVT prophylaxis after injury and while immobilized.
References
1. Ruedi TP, Allgower M. Fractures of the lower end of the tibia into the ankle-joint. Injury 1969;1:92–99.
2. American
College of Surgeons Committee on Trauma. Advanced Trauma Life Support
Program for Doctors, 6th ed. Chicago: American College of Surgeons,
1997.
3. Sirkin
M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue
management in the treatment of complex pilon fractures. J Orthop Trauma 2004;18:S32–S38.
4. Pollak AN, McCarthy ML, Bess RS, et al. Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg 2003;85A:1893–1900.
5. Marsh JL, Weigel DP, Dirschl DR. Tibial plafond fractures. How do these ankles function over time? J Bone Joint Surg 2003;85A:287–295.
Additional Reading
Borrelli J Jr, Ellis E. Pilon fractures: Assessment and treatment. Orthop Clin North Am 2002;33:231–245.
Miscellaneous
Codes
ICD9-CM
823.8 Tibial plafond fracture
Patient Teaching
Patients are counseled on the risk of posttraumatic arthritis and the risk of long-term pain and disability.
FAQ
Q: Is a pilon fracture more severe than an ankle fracture?
A:
Yes. A pilon fracture is a high-energy fracture affecting the
weightbearing articular surface of the ankle. Patients are at high risk
for long-term ankle pain and dysfunction.
Q: Should all pilon fractures be treated with open reduction and internal fixation?
A:
No. Skin integrity is the overriding concern. If the ankle is very
swollen, open reduction should be delayed and the ankle treated in a
staged manner with external fixation and limited percutaneous fixation.

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