A tibial plafond fracture (also called tibial pilon fracture) occurs at the bottom of the shin bone (tibia), and involves the ankle joint. This fracture occurs when the talus, the key central bone in the ankle, is forced up into the tibia causing the bone to break through or near the joint (articular) surfaces.
For a tibial plafond fracture to occur, a great deal of force is usually required, and for this reason there are often secondary injuries to the fibula, pelvis and spine and occasionally the internal organs. This injury is seen in motor vehicle accidents, skiing accidents and after falling from a height on your feet.
When a fracture occurs into or around a joint surface, that joint is at high risk of developing osteoarthritis due to the injury. Unfortunately, even if the bone and cartilage surfaces are lined up perfectly, there is still a risk of developing arthritis due to injury to the cartilage cells.
This fracture is an emergency and requires urgent treatment that includes
- alignment of the bones and a cast applied
- elevation of the leg
- use of ice and anti-inflammatory medication
These measures help in reduction of pain and swelling.
Symptoms
Symptoms are similar to other ankle fractures and include:
- pain
- swelling
- bruising
- deformity – the foot may look different to the uninjured side due to the fracture
Causes
For a tibial plafond fracture to occur, a great deal of force is usually required. This injury may be seen following:
- a motor vehicle accident
- skiing accidents
- falling from a height and landing on your feet
Risk Factors
Risk factors for fractures of the Pilon include:
- Activities that involve a risk of falling from a height such as rock climbing, or working on construction sites
- Down hill skiing and snow boarding
- Car accidents
Investigations
Diagnosis is confirmed by x rays of the ankle joint. This will also give the surgeon information about the fracture site, whether the bones have moved apart (displaced) and whether there are any obvious bony fragments floating in the joint.
In addition to X-rays of the ankle, the surgeons may need X-rays of the lower leg up to the knee. If the cause of the fracture was a major event, such as a car accident, it may be necessary to get X-rays of the hips (pelvis) and spine to see if minor fractures have also occurred there.
A CT scan is often ordered pre-operatively because it gives a great deal of detail about the fracture itself and allows the surgeon to plan treatment. It also shows some detail about the surrounding soft tissue.
Angiography – in some people it is important to assess the blood vessels around the ankle. Sometimes a Doppler ultrasound is used instead. These extra tests are often not needed as your surgeon can assess blood flow around your ankle by examining your foot.
Complications
Tibial plafond injuries are serious injuries and potentially have many complications.
Complications can be short or long-term, and include
- Mal-union or union of the fracture in a unacceptable position. When mal-union occurs your surgeons may decide secondary or ‘revision’ surgery is required, however this is not always possible.
- Non-union – that is failure of the fracture to unite. There are a number of reasons why this may occur.
- Arthritis of the ankle joint. This is unfortunately a common complication of any fracture, and in particular in fractures through the joint surface, as in tibial plafond fractures.
- Damaged nerves – nerves around the ankle may become severed during the fracture itself or may be compressed or cut off from their blood supply in the days following the fracture. The results of nerve injury can vary from loss of sensation through to paralysis of muscles, but major nerve injury is very rare.
- Infection
- Muscle damage
- Skin damage and fracture blister formation – Fracture blisters are a swelling in the skin that occurs over the site of fractures. They usually occur in areas where there is not much muscle or fat between the skin and the bone such as the ankle and the elbow. Fracture blisters can prolong healing and make surgery more difficult.
Long term complications include ongoing infection, crooked ankles and debilitating arthritis.
Treatment
Treatment of pilon fracture depends upon
- age and functional level of the patient
- presence of osteoporosis
- status of the skin and tissues
Treatment can be operative or non-operative.
Non-operative treatment includes
- a plaster cast is used if the bones well aligned
- traction (continuous force applied along the bone) is used in patients in which the vitality of the skin is questionable and they are unfit for surgery
Operative treatment includes
- plate and screw fixation if the surrounding skin is in good condition
- external fixation with a frame applied to the bone if the skin is not good; using plate and screws in such a condition increases the chances of infection
The Stages of Treatment and Recovery
- Cleaning the wound and protecting the soft tissues.
- Fixing the fracture through operative or non-operative treatments (see below)
- Non-weight bearing recovery – ie crutches. At this stage, certain exercises are recommended to maintain flexibility around the joint. Often,splinting of the ankle at night time is used to avoid equinus deformity (foot is stuck pointing down).
- Mobilisation of the ankle with partial then full weight-bearing. Full weight-bearing is usually only possible after three months.
Treatment of Open Fractures
A fracture is called ‘open’ when the skin has been broken. An open fracture is much more likely to be contaminated or infected, so surgery may need to be delayed until the surgeons are sure the wound is clean. ‘Cleaning’ the area can involve ‘irrigation’, or flushing water in the area, and ‘debridement’, or trimming of muscles and tendons damaged during the injury.
For severe open fractures two surgeries may be required. In these cases, external fixation is used initially to hold the bones in place while the soft tissue and skin heals, then an internal fixation method is used to permanently fix the fracture anywhere between one to three weeks after the first surgery.
Seeking Advice
This type of fracture is a serious injury and will need to be seen at an emergency department of a hospital. It is important not to try to stand on the injured foot and it is best to call an ambulance to ensure that you are safely transported to the hospital.
Prevention
These fractures usually occur due to car accidents or sports that may lead to high impact injuries such as down hill skiing or rock climbing. As such, prevention of Tibial plafond fractures involves ensuring that proper equipment is used and a careful approach is taken when partaking in these activities.
F.A.Q. | Frequently Asked Questions
How can the complications be prevented?
Complications can be prevented by alignment and fixation of the fracture as early as possible. It there is a delay of a few hours in reaching the hospital then the following steps can be taken
- the fracture should be splinted
- limb should be elevated by placing 2 to 3 pillows below the foot and leg
- ice should be used intermittently; never use ice directly over skin, wrap it in a plastic bag
How long will it take to completely recover after a pilon fracture?
In the absence of complications the fracture unites in 2 to 3 months.
What is the recovery from a tibial plafond fracture?
Recovery from a tibial plafond fracture can take several months. Because the cartilage surface of the joint is involved, the knee must be protected from weight until the fracture has healed. Most commonly patients will be allowed to move the knee joint, but not put weight on the leg for about three months. The exact length of time of limitations will vary on the fracture type and the amount of healing that takes place.
Tibial Plafond fractures are complex and even with completely successful treatment, there are risks of long-term loss of function as well as pain and/or instability. Some common complaints following tibial plafond fractures include:
- Long-term pain and osteoarthritis – this is unfortunately a common complaint. Studies have shown that post-fracture pain, stiffness and swelling continue to improve years after the fracture has been fixed, however these remain problematic for many people. Pain can be managed through physical therapy and the use of orthotics. Over the counter medications like panadol and nurofen can be invaluable in controlling pain. GPs are also a good resource – if you have severe pain they can prescribe stronger painkillers or refer you back to the orthopaedic team. In a minority of patients, further surgical intervention may be required to correct osteoarthritis. This may be arthodesis or rarely TAR.
- Difficulty walking – the various form of treatment for tibial plafond fracture aim to facillitate walking as much as possible. Despite this, some people will become dependent on various walking aids.
- Difficulty weight-bearing – this can make walking difficult, but in general the other leg is able to compensate by taking on increased weight.
- Difficulty running
When can I go back to work?
Despite surgical intervention and physical therapy, it may be necessary to adjust your working practices. There are a number of reasons why this may occur, but the team involved in managing your fracture will go to great lengths to prevent this occurring. If you have any concerns regarding returning to work, please discuss these with your surgeon or GP.
Why are the soft-tissues a concern with tibial plafond fractures
Because there is little muscle and skin surrounding the ankle joint, severe fractures of the tibial plafond can be problematic. If the soft-tissues are too swollen and damaged, surgery may not be possible through these damaged tissues. In these cases, definitive surgery may be delayed until the swelling subsides and the soft-tissue condition improves.
While the soft-tissue is healing, the fractured bone and ankle joint will be immobilised. This may be done with the use of a cast, splint, or external fixator. An external fixator is a device placed surgically around the soft-tissues that are swollen and damaged. The external fixator secures the bone both above and below the fracture, while avoiding the soft-tissue that requires healing. The advantage of the external fixator is that is holds the bones rigidly immobilised and allows your surgeon to monitor the soft-tissue healing.
References
Barei D. P, Nork S. E.,’Fractures of the Tibial Plafond’, Foot and Ankle Clinics, 2008, Vol. 13, Iss 4, pp 571-591. www.foot.theclinics.com
Calori G. M., et al., ‘Tibial pilon fractures: Which method of treatment?’, Advances Made in Orthopaedic Trauma in Italy, Vol 41, Iss 11, Nov 2010, pp 1183-1190.
Fearon P. V., Evidence-Based Orthopaedics,The Best Answers to Clinical Questions, 2009, Pages 426-431
Marsh J. L., et al., ‘Tibial Plafond Fractures: How do these ankles function over time?’, The Journal of Bone and Joint Surgery, Vol. 85A, No. 2, Feb 2003, pp 287-295. www.jbjs.org
Pollak A. N., et al., ‘Outcomes After Treatment of High-Energy Tibial Plafond Fractures’, The Journal of Bone and Joint Surgery, Vol. 85A, No. 10, Oct 2003, pp 1893-1900. www.jbjs.org
Thordarson, A. B., ‘Complications After Treatment of Tibial Pilon Fractures: Prevention and Management Strategies’, Journal of the American Academy of Orthopaedic Surgery, Vol. 8, No. 4, July-Aug, 2000, pp 253-265.