Fractures of the Tibial Plafond

doi:10.1016/j.fcl.2008.09.002

Foot and Ankle Clinics

Volume 13, Issue 4, December 2008, Pages 571-591

https://doi.org/10.1016/j.fcl.2008.09.002 Get rights and content

High-energy fractures of the tibial plafond are a lifechanging event for the patient. Currently, open reduction and internal fixation (ORIF) appears to offer the best chance for obtaining and maintaining anatomic articular reduction and axial alignment to union. Definitive ORIF should be performed in a staged fashion to allow adequate resolution of the associated soft tissue injury. A preoperative plan is essential to a successful outcome and it must include a strategy to access and stabilize the articular and nonarticular components of the injury.

Section snippets

Physical Examination

Examination of the soft tissue envelope is of critical importance in the complete assessment of fractures of the tibial plafond and should be performed in a logical, consistent, and circumferential manner. The degree of swelling, the severity of contusions, and the presence of abrasions, blisters, open wounds, and compartmental syndrome are evaluated and noted. Not infrequently, widely displaced fracture fragments may create excessive skin tension and jeopardize local skin circulation. In these

Nonoperative Treatment

Nonoperative management should be reserved for those fractures that are truly nondisplaced or for those patients that have a significant or absolute contraindication to surgical management. Patients treated using nonoperative methods can be effectively managed with closed manipulative reduction and cast immobilization. Progressive weight-bearing with ankle and subtalar range of motion is initiated based on radiographic healing. Indications for nonoperative management of displaced

Outcomes

Although the outcomes of tibial pilon fractures are affected by numerous variables including the osteochondral injury and treatment method chosen, perhaps no factor is as important as the degree of initial soft tissue injury.²⁹ The initial enthusiasm for ORIF of tibial pilon fractures followed the successful reports by Ruedi.1, 7, 37 When applied to the North American population, however, the associated soft tissue complications after ORIF were disastrous, with frequent soft tissue

Summary

High-energy fractures of the tibial plafond are a life-changing event for the patient. Currently, open reduction and internal fixation appears to offer the best chance for obtaining and maintaining anatomic articular reduction and axial alignment to union. Definitive ORIF should be performed in a staged fashion to allow adequate resolution of the associated soft tissue injury. A preoperative plan is essential to a successful outcome and it must include a strategy to access and stabilize the

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Cited by (21)

Traumatic Foot and Ankle Injuries
2022, Foot and Ankle Biomechanics
Traumatic injuries to the foot and ankle are common in the general population. Often the result of falls or high-energy events such as car crashes, these injuries occur in all age groups and vary in severity and complexity, and can involve bone fractures and soft tissue injuries. This chapter covers the etiology, symptoms, diagnosis, and treatment of a range of traumatic injuries to the foot and ankle.
New Principles in Pilon Fracture Management: Revisiting Rüedi and Allgöwer Concepts
2020, Foot and Ankle Clinics
Citation Excerpt :
Fractures of the distal tibia with joint involvement are infrequent, less than 1% of fractures of the lower limb, but one of the most challenging injuries in their treatment to be able to achieve good results.1
How do pilon fractures heal? An analysis of dual plating and bridging callus formation
2020, Injury
Citation Excerpt :
In conjunction with this shift, the anterolateral approach has been popularized, allowing for submuscular implants to be placed beneath the anterior compartment, and avoiding exposure of the subcutaneous medial surface of the distal tibia [2–4] In fracture patterns with associated medial shoulder articular impaction or varus alignment at time of injury, medial approaches and/or implants are sometimes preferred [5–8]. In general, the surgical strategy for pilon fractures involves direct reduction and compression of the articular surface followed by restoration of metaphyseal length, alignment and rotation, and fixation with a long implant that spans the often comminuted metaphyseal fracture [2,3]. An anterolateral or medial plate can serve as the primary metaphyseal spanning implant in this situation, and may or may not be supplemented with fixation on the other side of the bone [3].
1) To determine the effect of single versus dual plate metaphyseal fixation for pilon fractures on callus formation and reoperation rates, 2) to determine the effect of biomechanically matched versus unmatched fixation, and 3) to determine whether patient or surgical factors were independent predictors of bridging callus formation or need for reoperation.
Retrospective comparative study.
Single level one trauma center.
Fifty patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation.
Internal fixation with a plate and screw construct, with comparisons made between patients with single versus dual plate fixation, and patients treated with biomechanically matched or unmatched fixation.
Modified RUST (mRUST) scores at three and six months and reoperation rate.
At six months, mean mRUST scores were significantly lower in patients treated with dual metaphyseal plates compared to a single plate (8.7 vs 10.4, p=0.046) There were 15 open fractures; eight were treated with supplemental fixation, while seven were treated with single-column fixation. Open fracture (OR 51.05, p=0.008) was a risk factor for reoperation. Screw density between 0.4 and 0.5 was a protective factor against reoperation (OR 0.03, p=0.026). Biomechanically unmatched fixation did not affect mRUST scores or reoperation rates.
Pilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates. Screw density between 0.4-0.5 was protective against reoperation. These data may serve as the basis of future work to determine the ideal fixation construct for the frequently comminuted metaphysis in pilon fractures. Further work is necessary to determine whether callus formation in these injuries is desirable.
Three
Anterolateral distal tibia locking plate osteosynthesis and their ability to capture OTAC3 pilon fragments
2018, Injury
Intra-articular Pilon fractures remain therapeutically challenging due to osteochondral fracturing and comminution, marginal impaction, and insult to the soft tissue envelope. The purpose of this study was to compare the efficacy of anterolateral distal tibial locking plates in capturing main fracture fragments in tibial plafond fractures.
From May 2011 to Dec 2015, 169 OTA C-type pilon fractures met inclusion and exclusion criteria with computed tomographic (CT) scans performed prior to definitive fixation. For each patient, the fracture lines were mapped, digitized, and graphically superimposed to create a compilation of fracture lines. Based on these average measurements, three distal tibia sawbones had three different anterolateral plates applied. Axial CT scan images were used to determine the efficacy of screw purchase in main fracture fragments in pilon fractures.
The Smith & Nephew PERI-LOC plate secured the largest number of fracture lines (90.1%) but missed the Volkmann fragment with greatest frequency at 3.6%. The Synthes 2.7/3.5 mm VA-LCP captured 87.3% of the fracture lines while missing the Volkmann fragment 3.2% of the time. The Synthes 3.5 mm LCP captured 86.5% of the fracture lines but was the best at securing the Volkmann fragment (1.2% missed). All three implants were deficient in capturing the medial malleolar fragment. The PERI-LOC and 2.7/3.5 mm VA-LCP did not differ with respect to percentage of fragments captured (p = 0.721) but both outperformed the 3.5 mm LCP (p = 0.021 and p = 0.05, respectively).
This study was consistent with prior literature in defining three main fracture fragments: anterior, medial, and posterior. All three plates were deficient in capturing the medial malleolar fragment. The Smith and Nephew PERI-LOC plate secured the most number of fracture lines, while the Synthes 3.5 mm LCP was least likely to miss the Volkmann fragment and most likely to miss the medial malleolar fragment. No plate was found to be superior to the other in capturing all fracture lines of the OTAC3 pilon fragments.
Three.
Quality of fracture reduction assessed by radiological parameters and its influence on functional results in patients with pilon fractures—A prospective multicentre study
2017, Injury
Citation Excerpt :
Pilon, pylon, or “tibial plafond” fractures are fractures of the distal tibia involving the weight bearing articular surface and the adjacent metaphysis. Pilon fractures occur in less than 1% of all fractures of the lower extremity [1,2], but due to the interpersonal variable anatomy, the often-complex fracture pattern including additional cartilage damage, and the delicate soft tissue envelope, management of these fractures remains a complex and challenging issue. Especially in high-energy fractures, anatomical reduction has not always been translated into good functional outcome [3–5].
The management of pilon fractures remains a challenging issue. Due to the complexity of factors that influence the outcome, it has been questioned if anatomical reductions of articular fracture are relevant. The lack of a commonly accepted assessment of quality of fracture reduction compounded the uncertainty of the importance of anatomical reduction in pilon fracture. The current study aimed to define parameters that can better assess the reduction quality and to investigate the influence of reduction quality on functional outcomes.
Patients with unilateral pilon fracture of the AO/OTA type 43-B or 43-C were consecutively recruited to the study and followed up for 2 years after surgery. Postoperative radiographs of the injured and the contralateral joints were evaluated and 13 radiological parameters measured by 2 independent surgeons. The reliability of the measurements for each parameter was assessed by the Intraclass Correlation Coefficient (ICC), and 4 parameters with the highest ICC scores were deemed most reliable and were selected for further analyses. Functional outcome was assessed by the Foot and Ankle Ability Measure (FAAM) for daily living and sports activities. The 4 most reliable radiologic parameters, together with 3 possible baseline confounders (age, AO/OTA fracture type, and open versus closed injury), were analysed using both univariable and multivariable analysis for their association with the FAAM scores. Secondary outcome measures including pain, ankle range of motion (ROM), quality of life (QoL), and adverse events were also reported.
The length of lateral malleolus (LLM), anterior distal tibia angle, anterior talar shift, and length of medial malleolus scored highest on reliability in ICC assessment (ICC = 0.76, 0.72, 0.58, and 0.45, respectively). Only LLM exhibited statistical significant association with the 2-year FAAM results. At the 2-year follow-up, the injured joints on average achieved a ROM of 70.7% (95% CI = 63.9–77.6) when compared to the contralateral joints, and patients did not regain the pre-injury QoL overall.
The multivariable analysis showed that LLM (independent of age, AO/OTA fracture type, and open/closed injury) was a reliable indicator of reduction quality and a prognostic factor for patient outcome in pilon fracture surgery.
Hybrid External Fixation for Arbeitsgemeinschaft für Osteosynthesefragen (AO) 43-C Tibial Plafond Fractures
2015, Journal of Foot and Ankle Surgery
Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p = .256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence.

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Fractures of the Tibial Plafond

Section snippets

Physical Examination

Nonoperative Treatment

Outcomes

Summary

Helv Chir Acta

Fractures of the distal tibial metaphysis with intra-articular extension–the distal tibial explosion fracture

J Trauma

Intra-articular fractures of the distal tibia: the pilon fracture

J Trauma