para>The elderly population is susceptible to low-energy trauma due to osteopenia or osteoporosis. é á
Commonly Associated Conditions
- Degloving/crushing (common in high-energy trauma)
- Compartment syndrome
- Skin necrosis
- Injuries to the contralateral leg and foot
- Peroneal nerve damage
- Associated multisystem traumatic injuries (pelvic, spinal, abdominal, thoracic, or cranial)
Diagnosis
History
- Recognize potential tibial plafond fracture based on description of detailed history of inciting event (MVA, fall, skiing accident).
- Pain
- Edema
- Bleeding
- Loss of sensation/mobility
- Assess for comorbidities that may impair wound healing and affect the treatment plan (tobacco use, diabetes mellitus, alcoholism, corticosteroid use, peripheral vascular disease, osteoporosis).
Physical Exam
- Initial trauma assessment " öadvanced trauma life support (ATLS) primary survey (airway, breathing, circulation, disability, exposure/environmental control); ATLS secondary survey (head/skull, maxillofacial, neck, chest, abdomen, pelvis, perineum/rectum, musculoskeletal) (3)[C]
- Inspect for bleeding, blisters, discoloration, edema.
- Palpate for peripheral pulses and assess neurovascular status bilaterally.
- Palpate compartments and measure pressures if compartment syndrome is suspected.
- Wrinkle test: Look for wrinkle of the skin when pinched, which may aid in determining status of edema.
Differential Diagnosis
- Ankle fracture
- Fibular fracture
- Talus fracture
- Forefoot fracture
- Midfoot fracture
- Calcaneus fracture
- Tibial shaft fracture
Diagnostic Tests & Interpretation
Initial Tests (lab, imaging)
- Labs " ötrauma profile if mechanism consistent
- Complete blood count (CBC)
- BMP
- Urinalysis
- Type and screen
- Crossmatch if transfusion is imminent.
- Order additional labs as appropriate for the severity of injury and organ systems affected.
- Imaging
- Plain radiographs:
- Anteroposterior (AP), lateral, mortise views of the ankle
- AP and lateral of the foot
- Tibia " ôfibula series
- Traction radiographs (provided by application of external fixator, which often allow better visualization of individual fracture fragments)
- Computed tomography (CT) scan
- Preoperative CT scan aids in determining fracture pattern and identifying fracture line and cortical fragments, severity of impaction, displacement, and comminution.
- When obtained after placement of a provisional bridging external fixator, fragment alignment is improved through ligamentotaxis, making the CT scan easier to read and providing the most useful information (5)[A].
- Angiography, if vascular compromise is suspected
Treatment
General Measures
- The severity of associated soft tissue injury can often influence the timing of nonsurgical/surgical treatment.
- Nonoperative methods involve closed reduction and immobilization with plaster and traction using a calcaneal pin.
- Plaster alone can fail to maintain alignment and can prevent joint motion, leading to stiffness and osteodystrophy.
- Treatment with plaster is often a temporizing measure to allow soft tissue healing prior to definitive surgical repair.
- Surgical treatment options involve external fixation, internal fixation, or a combination (includes limited internal fixation of the fibula or articular surface of the tibia).
Medication
Tibial plafond fractures can result in tremendous pain. Ensure adequate pain control, often with judicious implementation of opioid-based pain regimen. é á
Issues for Referral
Orthopedic referral for surgical management. é á
Consider infectious disease consult if infection is suspected, especially postoperatively in the setting of open fractures. é á
Additional Therapies
- Physical therapy to improve strength, range of motion (ROM), and gait once patient is weight-bearing and fractures have healed
- Consider early active ROM of the foot and ankle (minimum of 48 hours, usually 5 " ô7 days).
Surgery/Other Procedures
- Consider surgical treatment for open fractures, compartment syndrome, and any fracture with articular incongruity greater than 2 mm or malalignment greater than 10 degrees in any plane.
- Malalignment of greater than 5 degrees portends a poor clinical outcome (4)[B].
- There are three different surgical options available:
- Open reduction internal "rigid " Ł fixation (ORIF)
- External fixation (ExFix) with or without minimal osteosynthesis of articular joint)
- Closed reduction internal "biologic " Ł fixation (CRIF) with minimal periosteal stripping and preservation of soft tissues (minimally invasive plate osteosynthesis [MIPO] technique)
- Severe soft tissue injury may warrant staged protocols consisting of temporary external fixation of the ankle, followed by ORIF with plates and screws, usually 2 " ô3 weeks after injury.
- R â ╝edi and Allg â Âwer type I and II fractures (with no soft tissue damage): allow the application of a minimal invasive internal fixation within the first 12 " ô24 hours, to achieve anatomic reduction and restore early function of the ankle joint (5)[A]
- R â ╝edi and Allg â Âwer type III fractures or open fractures: require a two-step approach, involving temporary fixation, followed later by an internal biologic osteosynthesis or by a definitive external fixation (5)[A]
Inpatient Considerations
Nursing
Schedule neuromuscular checks, pain assessment, and compartment syndrome checks. é á
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Deep vein thrombosis (DVT) prophylaxis during hospitalization
- Elevate affected extremity for 2 " ô3 days.
- If an external fixator is used, pin cleaning and stabilization of the pin " ôskin interface with dilute hydrogen peroxide, normal saline, or dry dressing
- After wounds have matured, patients may shower on a daily basis.
- After soft tissues have healed and edema has diminished, patient can ambulate (non " ôweight-bearing [NWB]) with crutches. NWB status usually lasts 6 " ô8 weeks).
- May wear elastic stockings to minimize edema
- Fracture consolidation and healing is monitored with serial plain films.
- Full ambulation normally by 3 months. Severe comminution and significant articular involvement may require prolonged NWB status.
Prognosis
- Simple fractures have better outcomes than complex fractures.
- Patients with anatomic reductions have good to excellent outcomes in 41% of cases, fair in 31%, and poor in 27% of cases (6)[A].
- Plafond or talar/chondral damage and osteonecrosis contribute to posttraumatic arthrosis.
- Other prognostic factors include presence of open injury, soft tissue damage, multisystem injuries, significant preexisting comorbidities, and loss of bone stock.
Complications
- Early complications
- Skin necrosis
- Hematoma
- Wound dehiscence
- Skin sloughing
- Chronic edema
- Stasis ulceration
- Infection
- Late complications
- Nonunion
- Malunion
- Posttraumatic arthritis
- Chronic osteomyelitis
- Chronic pain
References
1.R â ╝edi é áTP, Allg â Âwer é áM. The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res. 1979;(138):105 " ô110. é á
[]
2.Marsh é áJL, Slongo é áTF, Agel é áJ, et al. Fracture and dislocation classification compendium " öOrthopaedic Trauma Association Classification, Database and Outcomes Committee. J Orthop Trauma. 2007;21(10)(Suppl):S1 " ôS33. é á
[]
3.American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Program for Doctors. 8th ed. Chicago, IL: American College of Surgeons; 2008.4.Watson é áJT, Moed é áBR, Karges é áDE, et al. Pilon fractures. Treatment protocol based on severity of soft tissue injury. Clin Orthop Relat Res. 2000;375:78 " ô90. é á
[]
5.Calori é áGM, Tagliabue é áL, Mazza é áE, et al. Tibial pilon fractures: which method of treatment? Injury. 2010;41(11):1183 " ô1190. é á
[]
6.Teeny é áSM, Wiss é áDA. Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res. 1993;292:108 " ô117. é á
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Additional Reading
- Dujardin é áF, Abdulmutalib é áH, Tobenas é áAC. Total fractures of the tibial pilon. Orthop Traumatol Surg Res. 2014;100(1)(Suppl):S65 " ôS74. é á
[]
- Matthews é áS. Fractures of the tibial pilon. Orthopaedics and Trauma. 2012;26:171 " ô175.
Codes
ICD09
- 824.8 Unspecified fracture of ankle, closed
ICD10
- S82.876A Nondisplaced pilon fracture of unsp tibia, init for clos fx
- S82.873A Displaced pilon fracture of unsp tibia, init for clos fx
- S82.874A Nondisplaced pilon fracture of right tibia, init for clos fx
- S82.875A Nondisplaced pilon fracture of left tibia, init for clos fx
- S82.871A Displaced pilon fracture of right tibia, init for clos fx
- S82.872A Displaced pilon fracture of left tibia, init for clos fx
SNOMED
- 263240009 Pilon fracture (disorder)
- 446298003 Closed pilon fracture (disorder)
Clinical Pearls
- Tibial plafond fractures can involve high energy injuries (motor vehicle collision [MVC], fall from a height) and low-energy injuries (torsional injuries from skiing, injuries in elderly patients).
- Tibial plafond fractures may involve significant soft tissue injuries, neurovascular compromise, and concomitant multisystem trauma. In such cases, a thorough trauma evaluation is indicated.
- Evaluation should include plain radiographs of the foot and ankle and CT scanning for preoperative planning of surgical repair.
The opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the US Army. é á