What is Tibial Plafond Fracture?
A Tibial Plafond Fracture is an uncommon fracture occurring in the distal region of the tibia. It is also known as Pilon fracture and explosion fracture. It involves the articular surface of the ankle joint. The cause of Tibial Plafond Fracture is axial or rotational forces occurring from motor vehicle accidents or falling from a height. Any type of forceful impact to tibia, which causes significant damage to the soft tissue and bone, can result in a Tibial Plafond Fracture. Tibial Plafond Fractures involve a large area of Tibia’s weight bearing region in the ankle joint due to which it is difficult to repair or fix this type of fracture and because of the difficulty incurred in fixing Tibial Plafond Fractures, they are often associated with poor outcome and higher rates of complications.
Anatomy of Tibial Plafond
Plafond is the name of the distal part of the tibia. Plafond together with the lateral and medial malleoli forms the mortise, which articulates with the talar dome. The plafond is convex in the lateral plane and concave in the anteroposterior plane. In the anterior plane, it is wider, so that it can provide more stability, especially during the process of weight-bearing. The tibiofibular ligament, the strong deltoid ligament and the interosseous ligament provides support to the distal tibia.
Classification of Tibial Plafond Fracture
Tscherne Classification of Tibial Plafond Fracture
Grade 0 Tibial Plafond Fracture: - In this stage, there is minimal damage to the soft tissue with indirect injury to the limb. The pattern of the fracture is simple.
Grade 1 Tibial Plafond Fracture: - There is superficial contusion or abrasion to the bone and the pattern of the fracture is also mild.
Grade 2 Tibial Plafond Fracture: - There is deep abrasion with contusion to the skin or muscle. The pattern of the fracture is severe. There is direct trauma to the limb.
Grade 3 Tibial Plafond Fracture: - There is severe contusion to the skin or crush injury with extensive damage to the underlying muscle. Patient also has subcutaneous avulsion with compartment syndrome.
Ruedi and Allgower Classification of Tibial Plafond Fracture
Type A: There is very mild or no articular displacement.
Type B: There is displacement of the articular surface with absence of comminution.
Type C: There is intra-articular displacement with marked impaction/comminution.
Signs & Symptoms of Tibial Plafond Fracture
- Patient with tibial plafond fracture experiences symptoms of pain and swelling at the site of the fracture.
- There is deformity of the ankle.
- Patient with tibial plafond fracture is unable to weight bear.
- There is crepitus heard upon movement of the ankle.
Physical Exam for Tibial Plafond Fracture
Soft tissue integrity: During physical exam, the soft tissue integrity is examined. The patient’s ankle is also checked for abrasions, swelling, fracture blisters, ecchymosis and open wounds.
Other injuries: Checkup is also done to look for other associated musculoskeletal injuries. The knee joint is evaluated for any damage to the soft tissue or any bony disruption.
Alignment and Stability: The stability and range of motion of the ankle joint is examined. The alignment of the ankle joint is assessed.
Neurovascular Exam: The dorsalis pedis and posterior tibial pulses and capillary refill are checked. The doctor also looks for any neurologic compromise. The patient is also checked for any signs of compartment syndrome. Patient’s sensation in the ankle and the ability to move his/her toes is also assessed.
Diagnosis of Tibial Plafond Fracture
Radiographs: Radiographs, such as x-rays of the foot, tibia, ankle and knee are taken. Traction radiographs are taken in both the lateral and anteroposterior planes. Contralateral ankle radiographs are also beneficial in diagnosis. Recommended views in radiographs of ankle include anteroposterior, lateral and mortise views. X-rays of the foot with full-length of tibia and fibula should be taken to look for fracture extension.
CT Scans: CT scans are also important and are needed in many cases. CT scan helps in delineating the articular involvement. CT scan also helps in planning of the surgery.
Treatment for Tibial Plafond Fracture
The aim of treatment for Tibial Plafond Fracture is stable fixation of the metaphysis to the diaphysis and reestablishment of articular congruity in a satisfactory alignment. Treatment for Tibial Plafond Fracture is also done with the thought of preventing complications as much as possible.
Non-Operative Treatment for Tibial Plafond Fracture
Immobilization of the ankle joint is done where there is stable fracture pattern without displacement of the articular surface. This method of treatment is also adopted in patients who are nonambulatory and who are critically ill. There is substantial risk of skin problems with immobilization, especially if the patient is suffering from vascular disease, diabetes and neuropathy.
Technique of Immobilization
Long leg cast is placed for about six weeks after which a fracture brace is used. Range of motion exercises are also started under the guidance of a qualified physiotherapist.
Prognosis in Non-Operative Treatment for Tibial Plafond Fracture
The chances of reduction of intra-articular fragment are less in manipulation of the displaced fractures. Loss of reduction commonly occurs and there is difficulty in monitoring the injuries to the soft tissue.
Operative Treatment for Tibial Plafond Fracture
Temporizing external fixation is done across the ankle joint. This is done in acute cases and helps in stabilizing the fractured bone along with helping in the healing of the soft tissues. Patients who have fractures with substantial joint displacement or depression benefit from this procedure. This is left until the swelling subsides, which takes around 10 days to two weeks.
Open Reduction Internal Fixation (ORIF)
This surgical procedure is done in severe cases of bone fracture including the Tibial Plafond Fracture. It is a method of definitive fixation in most of the cases of Tibial Plafond Fracture. Low complications are associated in certain situations with limited or definitive ORIF.
External Fixation is done in select cases. Intramedullary nail fixation along with percutaneous screw fixation is done. External fixation can be done as an alternative to ORIF in certain cases.
Complications of Operative Treatment for Tibial Plafond Fracture
- Wound slough and dehiscence is one of the complications of surgery in Tibial Plafond Fracture. It is important to wait till the soft tissue edema recedes before performing ORIF.
- Some of the other complications of tibial plafond fracture include infection and varus malunion.
- Nonunion of the tibial plafond fracture commonly occurs at the metaphyseal junction and is often seen in hybrid fixation.
- Patient can also suffer from posttraumatic arthritis, which usually starts a year or two after the Tibial Plafond Fracture.
- Patient also suffers from stiffness and chondrolysis of the fractured bone.