Tibia plafond or

pilon fractures
Dr. NZAYIKORERA Gratien
Orthopedic surgeon
 Anatomy
Ligaments
• Osteology
distal tibiofibular syndesmosis
• tibia • anterior-inferior tibiofibular ligament
(AITFL)
• distal tibia forms an inferior quadrilateral
• originates from anterolateral tubercle of
surface and pyramid-shaped medial
tibia (Chaput)
malleolus articulates with the talus and • inserts on anterior tubercle of fibula
fibula laterally via the fibula notch (Wagstaffe)
 CONT

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)
 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
 Classifications
• Ruedi and Allgower Classification

•Type I •Nondisplaced • AO/OTA Classification

•Simple displacement with •43-A •Extra-articular

•Type II
incongruous joint

•43-B •Partial articular

•Type III •Comminuted articular surface

•43-C •Complete articular
 Clinical manifestations

Symptoms Physical exam

• severe ankle pain • inspection & palpation
• ankle deformity • ankle tenderness, swelling, abrasions,
ecchymosis, fracture blisters, open wounds,
• inability to bear weight 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 • Findings
recommended views • 4 classic fracture fragments
• AP • medial malleolus
• lateral • anterior malleolus = chaput
• mortise • lateral malleolus = wagstaffe
• full-length tibia/fibula and foot x-rays • posterior malleolus = volkmann
performed for fracture extension
• lumbar films if appropriate based on exam
• 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
Nonoperative outcomes
cast immobilization • intra-articular fragments are unlikely to
reduce with manipulation of displaced
Indications fractures
• stable fracture patterns without articular • loss of reduction is common
surface displacement
• inability to monitor soft tissue injuries is a
• critically ill or non-ambulatory patients major disadvantage
• significant risk of skin problems (diabetes,
vascular disease, peripheral neuropathy)
 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
• open reduction and internal fixation (ORIF)
Indications
• ability to drive
• definitive fixation for a majority of pilon
fractures • brake travel time returns to normal 6 weeks
after weight bearing
• limited or definitive ORIF can be performed
acutely with low complications in certain Fibula fixation
situations • not a necessary step in the reconstruction of
Outcomes pilon fractures
• dependent on articular reduction • may be helpful in specific cases to aid in
• high rates of wound complications and tibial plafond reduction or augment external
infections are associated with early open fixation fixation
through compromised soft tissue
• higher rates of fibula hardware removal
external fixation/circular frame fixation
alone
Indications • osteomyelitis and deep infection are rare
• select cases where bone or soft tissue injury • meta-analysis comparing this method with
precludes internal fixation open reduction and internal fixation found no
Outcomes difference in infection or complication rates
between the two groups
• thin wire frames and hybrid fixators have
high union rate
• high rates of pin tract infections
• 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
 Complications
• Wound slough and dehiscence
• Infection
• Malunion
• Nonunion
• Post-traumatic arthritis
• Chondrolysis
• Stiffness
 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
Return of vehicle braking response time
• 6 weeks after initiation of weight bearing
Thanks