Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Tibial Plafond Fracture

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 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.
  • 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.
  • 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.
    • Negative effects of the fracture can remain at the 5-year follow-up.
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.
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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