Table Of Contents
Tibia Plafond (Pilon) Fracture
Tibia plafond fracture is a severe fracture involving the distal end of the tibia. This fracture is usually comminuted with intra-articular extension and significant soft-tissue injury. Surgery is usually delayed for unstable fractures to allow soft-tissue swelling to subside, fracture blisters to heal and compromised soft-tissue to slough off.
Mechanism of plafond fractures
| Mechanism | Description |
|---|---|
| Axial load | Usually high-energy e.g. fall from height or MVA. The talus is driven into the plafond causing impaction of the articular surface +/- comminution with a die-punch fragment |
| Rotational force | Usually low-energy e.g. sporting accident. Torsion and valgus stress produces 3 large fragments with minimum comminution +/- fibula fragment |
| Shear force | Talus shears against the plafond either in dorsiflexion or plantarflexion resulting in posterior/anterior shear fractures respectively |
Ruedi and Allgower Classification of Pilon Fractures – based on severity of comminution and displacement of the articular surface
| Classification | Description |
|---|---|
| Type I | Non-displaced fracture |
| Type II | Displaced fracture. Minimal comminution of articular surface (ncongrious joint) or metaphyseal impaction |
| Type III | Displaced fracture. Significant comminution of articular surface and metaphyseal impaction |
- Associated fractures
- Fibula fracture (35%)
- Ipsilateral lower extremity injury (30%)
- Calcaneal fracture
- Tibial plateau fracture
- Pelvic fracture
- Open fracture (20%)
- Bilateral pilon fracture (5 – 10%)
- Vertebral fracture
- Signs and symptoms
- Inability to bear weight
- Severe ankle pain
- Gross deformity of the distal leg
- Ankle in varus if the fibula remains intact
- Open wound
- Massive and rapid swelling
- Physical examination
- Assess skin intergrity, necrosis and fracture blisters (since there is significant swelling from soft-tissue injury)
- Ankle motion
- Dorsalis pedis and posterior tibial pulse
- Compartment syndrome
- Investigations
- X-ray: AP, Lateral and Oblique mortise view. Contralateral side for reconstruction. Lumbar X-ray if indicated.
- Medial malleolus fragment
- Anterolateral fragment (chaput)
- Lateral malleolus fragment (wagstaffe)
- Posterolateral fragment (volkmann)
- CT scan: Coronal and sagittal reconstruction to evaluate pattern and articular surface. Important for pre-operative planning.
- Mercedes benz sign on axial view
- Ankle-Brachial Index or CT angiography if indicated
- X-ray: AP, Lateral and Oblique mortise view. Contralateral side for reconstruction. Lumbar X-ray if indicated.
- Non-operative treatment of plafond fracture
- Cast immobilization (long leg cast) ****for 6 weeks → fracture brace + range of motion exercises
- Operative treatment of plafond fracture
- Temporary spanning external fixation across the ankle joint for length unstable fractures. Delay surgery for 1 – 3 weeks.
- Open reduction and internal fixation with plates and screws
- External fixation or circular frame fixation only for significant soft tissue injury precluding internal fixation
- Intramedullary nail with percutaneous screw fixation
- Primary ankle arthrodesis
- Goals of operative management of plafond fractures
- Stabilize the distal tibia
- Restore articular surface of tibia
- Perform bone grafting of metaphyseal defects
- Maintain fibula length and stability
Complications of plafond fracture
| Timeline | Complications |
|---|---|
| Early | Neurovascular injury, ligamentous injury, infection, wound slough and dehiscence |
| Late | Malunion, nonunion, post-traumatic arthritis, chondrolysis, stiffness, posterior tibial tendon entrapment |
