Distal Tibia Fracture
(Redirected from Tibial Plafond Fracture)
Other Names
- Pilon Fracture
- Tibial Plafond Fracture
Background
- This page refers to fractures of the distal Tibia
- Ankle Fractures are discussed separately
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
- 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
- Ankle Fracture
- Bimalleolar Fracture
- Distal Fibula Fracture
- Calcaneus Fracture
- Ipsilateral lower extremity injury
Pathoanatomy
- Distal Tibia
- Articulates with distal Fibula, Talus to form Ankle Joint
- Static stabilizers include
- Injury patterns and degree of comminution determined by:
- Position of foot
- Amplitude of force
- Direction of force
Risk Factors
- Male age
- Age ~40
- Needs to be updated
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
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]](/w/images/thumb/7/7c/Ankle_XR_Tibial_Plafond_Fracture.png/78px-Ankle_XR_Tibial_Plafond_Fracture.png)
Tibial plafond fracture[4]
![Tibial plafond fracture[4]](/File:Ankle_XR_Tibial_Plafond_Fracture.png)
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
- 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
- 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
- Infection
- Wound complications
- Wound slough, dehiscence
- Nonunion
- Malunion
- Post-traumatic Arthritis
- Acute Compartment Syndrome
- Chondrolysis
See Also
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
- ↑ 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.
- ↑ Krettek C, Bachmann S. Pilon- fractures. Part 1: Diagnostics, treatment strategies and approaches. Chirurg 2015;86:87-101.
- ↑ 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.
- ↑ https://radiopaedia.org/cases/26987
- ↑ https://radiopaedia.org/cases/14337
- ↑ Tornetta P III, Gorup J. Axial computed tomography of pilon fractures. Clin Orthop Relat Res 1996;323:273-276.
- ↑ 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.
- ↑ McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma. 1992;6:195–200.
- ↑ 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.