Tibial Pilon Fracture Flashcards
What are tibial pilon fractures?
Tibial pilon fractures, also known as plafond fractures, are severe injuries affecting the distal tibia.
They are caused by high energy axial loads as the tibial plafond is injured by the talus punching up into it.
Briefly describe the pathophysilogy of tibial pilon fractures
These fractures are characterised by articular impaction, severe comminution, and are often associated with considerable soft tissue injury. As such, they are complex injuries and often require specialist input.
What are the clinical features of tibial pilon fractures?
Patients will present with a history of trauma, usually that of a high-energy road traffic accident or a fall from a height. The patient will complain of severe ankle pain and an inability to weight-bear.
On examination, there may be an obvious ankle deformity, with associated significant swelling and bruising are common. In addition, skin blistering (fracture blisters) may occur over several hours.
It is very important to look for any evidence of an open fracture and for any signs of compartment syndrome, as these will significantly affect the management of these injuries.
Peripheral pulses should be assessed for vascular injury, whilst a peripheral nerve examination should be performed to test the superficial peroneal, deep peroneal and tibial nerves.
Briefly describe The Ruedi and Allgower classification of tibial pilon fractures
The Ruedi and Allgower classification is a simple classification system used to describe the severity of pilon fractures:
- Type I – undisplaced intraarticular fracture
- Type II – displaced intraarticular fracture
- Type III – comminuted or impacted fracture
What investigations should be ordered for tibial pilon fractures?
Patients presenting following a major trauma should be investigated and managed as per the ATLS protocol.
Urgent bloods, including a coagulation and Group and Save, should be sent. Where a pathological cause is suspected, further work-up bloods, such as a serum calcium and myeloma screen, may be warranted.
Plain film radiographs of the ankle should be requested, with antero-posterior, lateral, and mortise views; full length views of the tibia and knee are also required. CT imaging is often subsequently required for further anatomical assessment and pre-operative planning
What is shown in the image?
Plain film radiograph showing a right pilon fracture.
Briefly describe the initial management of tibial pilon fractures
Initial management of a pilon fracture involves realignment of the limb and application of a below-knee backslab. After which, a repeat neurovascular assessment and check plain film radiographs should be performed.
The limb must be elevated and monitored for compartment syndrome, and the patient kept nil by mouth with IV fluids in preparation for surgery.
Briefly describe the conservative management of tibial pilon fractures
Simple undisplaced pilon fractures are rare but may be treated non-operatively, particularly in elderly patients and patients to whom an operation is very high risk. However, as these injuries are intrinsically unstable, loss of reduction and subsequent malunion is common.
Briefly describe the surgical management of tibial pilon fractures
The vast majority of pilon fractures are treated operatively, the timing of which depends on the degree of soft tissue involvement and the presence of any emergency complications (such as neurovascular injury).
Surgery aims to reconstruct the articular surface, restore the alignment of the ankle mortise and protect the soft tissues around the ankle joint.
A staged approach is often the preferred management option, especially if significant soft tissue swelling. This involves the application of a temporary spanning external fixator followed by definitive fixation (ORIF) 7-14 days later once the soft tissues have had the opportunity to heal.
When definitive fixation does take place, it is best performed under traction, such as that provided by an external fixator.
What are the complications of tibial pilon fractures?
Common complications following surgical repair include compartment syndrome, wound infection or dehiscence, delayed or non-union and post-traumatic arthritis.
What differentials should be considered for tibial pilon fractures?
If sustained by a high-energy mechanism, it is important to look for other orthopaedic injuries. Commonly affected areas include the spine, pelvis, femur, tibial plateau or tibial shaft.
