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Distal Tibia Fracture

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Other Names

  • Pilon Fracture
  • Tibial Plafond Fracture

Background

History

Epidemiology

  • Incidence
    • Distal tibial fractures represent 3% to 10% of all tibial fractures (need citation)
    • They represent 1% of lower extremity fractures (need citation)
    • 5-10% are bilateral (need citation)
    • 20% are open (need citation)
  • Co-injuries
    • Fibula fracture is seen in about 70-85% of cases[1]
    • Up to 50% of patients may have additional lower extremity injuries (need citation)
    • About 6% of patients may also have multiple system injuries (need citation)

Pathophysiology

  • General
    • Most common patient is middle aged male
    • Commonly associated with comminution, intra-articular extension, and significant soft tissue injury
    • Challenging injury pattern for orthopedic surgeons because there is a high rate of complications (see complications below)
  • Pilon Fracture[2]
    • Also known as tibial plafond fracture
    • Indicates the involvement of the weight-bearing surface of the ankle joint
    • Usually results from an axially directed force

Etiology

Illustration of foot position affecting fracture pattern in distal tibia fractures[3]
  • Rotational forces (torsion)
    • Usually lead to a spiral fracture which may be intra- or extra-articular
    • These are usually closed, resulting from low energy
    • Associated soft-tissue injuries are not usually severe
    • Examples: alpine skiing
  • Axial compression (high energy)
    • High energy axial forces lead to intra-articular fractures of the distal tibia
    • Occurs when the convex talar dome impacts the concave plafond of the distal tibia
    • The severity of the injury depends on the amount of energy, position of foot at the time of impact.
    • Examples: fall from height, motor vehicle accident

Associated Conditions

Pathoanatomy

Risk Factors

  • Male age
  • Age ~40
  • Needs to be updated

Differential Diagnosis

Clinical Features

  • History
    • Significant trauma (MVC, fall from height) is typical
    • Patients report significant pain, swelling, bruising, deformity
    • Inability to walk after injury
  • Physical Exam: Physical Exam Ankle
    • Inspect for swelling, bruising, deformity, soft tissue injuries
    • Up to 50% of distal tibia fractures are open (need citation)
    • Careful neurovascular assessment
    • Careful evaluation of other soft tissue structures
    • Ensure compartments are soft
    • ROM is limited
  • Special Tests
    • Not applicable

Evaluation

  • Medial malleolus fracture

  • Medial malleolus fracture

  • Salter Harris 2 and pilon fracture of distal tibia

  • Tibial plafond fracture[4]

Radiographs

  • Standard Radiographs Ankle, Standard Radiographs Tibia Fibula
    • Standard imaging
    • Sufficient if the fracture is extra-articular
  • Strongly consider extending into foot, knee
  • Four classic findings
    • Medial malleolus
    • Anterior malleolus (chaput)
    • Lateral malleolus (wagstaffe)
    • Posterior malleolus (volkmann)

CT

CT of ankle demonstrating distal tibia fracture. Case courtesy of Dr Bruno Di Muzio[5]
  • Indications
    • Intra-articular extension on standard radiographs
    • Pre-operative planning
  • More than 80% of CT scans provide additional information[6]
    • Changes initial surgical approach in up to 64% of cases
  • Findings
    • 'Mercedez Benz' sign on axial cuts

Classification

AO OTA classification of distal tibia fractures[7]

AO/OTA Classification

  • 43-A Extra-articular
    • 43-A1 simple
    • 43-A2 wedge
    • 43-A3 complex
  • 43-B Partial articular
    • 43-B1 pure split
    • 43-B2 split depression
    • 43-B3 multifragmentary depression
  • 43-C Complete articular
    • 43-C1 articular simple, metaphyseal simple
    • 43-C2 articular simple, metaphyseal multifragmentary
    • 43-C3 articular multifragmentary

Ruedi and Allgower Classification

  • Type I: Nondisplaced
  • Type II: Simple displacement with incongruous joint
  • Type III: Comminuted articular surface

Management

Prognosis

  • Poor outcomes associated with (need citation)
    • Lower level of education
    • Pre-existing medical comorbidities
    • Male sex
    • Work-related injuries
    • Lower income levels

Acute

  • Follow ATLS algorithm for all patients with significant injuries or mechanism
  • Imaging
  • Temporary splinting
  • External Fixation
    • Sometimes used definitely until definitive surgical management

Nonoperative

  • Indications
    • Overall, few
    • Stable fracture patterns without articular extension
    • Poor surgical candidates, sedentary individuals
  • Treatment
    • Long Leg Cast typically for 6 weeks
    • Subsequent fracture brace and gentle ROM exercises

Operative

  • Surgical goals
    • Restore the tibial anatomy
    • Fix the epi-metaphyseal block with the diaphysis
    • Avoid complications
  • Technique
    • Open reduction and internal fixation (ORIF)
    • External fixation with or without limited internal fixation (temporizing)
    • Intramedullary nailing
    • Minimally invasive plate osteosynthesis (MIPO)
    • Primary ankle arthrodesis

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications

  • Overall
    • Complications affect 20-50% of patients[8]
    • Complication rate appears to correlate with initial fracture severity[9]
  • Infection
  • Wound complications
    • Wound slough, dehiscence
  • Nonunion
  • Malunion
  • Post-traumatic Arthritis
  • Acute Compartment Syndrome
  • Chondrolysis

See Also

References

  1. ↑ Luk PC, Charlton TP, Lee J, Thordarson DB. Ipsilateral intact fibula as a predictor of tibial plafond fracture pattern and severity. Foot Ankle Int 2013;34:1421-1426.
  2. ↑ Krettek C, Bachmann S. Pilon- fractures. Part 1: Diagnostics, treatment strategies and approaches. Chirurg 2015;86:87-101.
  3. ↑ Sitnik, Alexandre, Aleksander Beletsky, and Steven Schelkun. "Intra-articular fractures of the distal tibia: current concepts of management." EFORT open reviews 2.8 (2017): 352-361.
  4. ↑ https://radiopaedia.org/cases/26987
  5. ↑ https://radiopaedia.org/cases/14337
  6. ↑ Tornetta P III, Gorup J. Axial computed tomography of pilon fractures. Clin Orthop Relat Res 1996;323:273-276.
  7. ↑ Sitnik, Alexandre, Aleksander Beletsky, and Steven Schelkun. "Intra-articular fractures of the distal tibia: current concepts of management." EFORT open reviews 2.8 (2017): 352-361.
  8. ↑ McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma. 1992;6:195–200.
  9. ↑ Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res. 1993;292:108–117.
Created by:
John Kiel on 5 June 2021 20:57:55
Authors:
Last edited:
3 October 2022 23:48:55
Categories:
Lower Extremity | Trauma | Leg | Ankle | Fractures | Acute

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