She sustained the isolated, closed injury shown in Figures A and B. When Tibial Plateau Fractures Are A Pain The tibial plateau is an important weight -bearing part of the body that connects the thighbone (femur) to the shinbone via ligaments. document.write(theYear) | Tested Concept, (OBQ05.93) A 35-year-old male laborer falls off a ladder and sustains the injury shown in Figures A and B. Fig. If both the tibia and fibula are fractured, which is usually the case in the severe cases, it really doesn't matter where the fibula is fractured (mid-shaft, lower shaft, or distally/lateral malleolus), the fixation of the fibula at any level would be included in the code 27828.So the answer to your question is no. What is the most appropriate next step in management? Two years following surgery, which of the following parameters will most likely predict a poor clinical outcome and inability to return to work? I suggest you review the next query regarding Tibial Plafond fractures. She is otherwise healthy, but routinely smokes 30 cigarettes per day. Fig. X-rays of the leg, ankle, and foot are commonly done to evaluate a pilon fracture. Fracture anatomy was drawn out using the tibial plateau grid described above. All medial malleolar osteotomies showed complete union at 3 months postoperatively. Using the PACS, the corrected Mikulicz line was drawn by connecting the center of the femoral head and the 62.5% point of the plateau on the whole-leg standing X-ray (green line in Figure 1 ). A 'pilon' fracture is any fracture of the distal tibia which involves the articular surface of the tibia - also known as the 'tibial plafond' “Pilon,” the French word for pestle, was first used by Etienne Destot in 1911 as an analogy for the mechanical function of the distal tibia on the talus. In past anatomic reports of the tibial plafond attachment of the PITFL, the length, the width, and the size of the attachment of PITFL were varied. Rüedi and Allgöwer (1979)—The system of Rüedi and Allgöwer is perhaps the most widely used classification of tibial plafond fractures reported in the literature. Most fractures are secondary to high-energy trauma that result in significant bone and soft tissue damage. There is a comminuted distal tibial fracture extending into the tibial plafond, representing a Pilon fracture. Tested Concept, (OBQ05.157) Vascular insult is an unlikely cause of os-teochondral injury in the tibial plafond. A focal superiorly oriented notch at the medial aspect of the distal tibial physis… An x-ray can show if there is an injury to your bones or if the joints in your ankle are out of place. If the articular anatomy of the tibial plafond is in reasonable condition, then the focus of the reconstruction can be on addressing only the metaphyseal nonunion. A pilon fracture (also called a tibial plafond fracture) is a comminuted fracture of the distal tibia involving the ankle joint. There is no soft tissue swelling The distal tibial physis is also often irregular. October 2020; Foot & Ankle Orthopaedics 5(4):2473011420S0014; DOI: 10.1177/2473011420S00141 Introduction. Fractures of the distal tibial plafond are also termed pilon fractures to describe the high energy axial compression force of the tibia as it acts as a pestle, driving vertically into the talus. The bent tip is turned posteriorly and advanced to the tibial plafond (Figure 8). Varus or valgus deformity, if suspected, can be measured with the frontal tibiotalar surface angle (TTS), formed by the mid-longitudinal tibial axis (such as through a line bisecting the tibia at 8 and 13 cm above the tibial plafond) and the talar surface. After removing the external fixator and plating the fibula, what would be next step in the operative plan for reduction and fixation of this injury? Tested Concept, Immediate definitive fixation of the tibia, and nonoperative treatment of the fibula, Immediate ankle-spanning external fixation device with consideration of immediate fixation of the fibula, followed by delayed reconstruction of the tibia, Placement of a temporary splint, elevation, and definitive fixation 1 week from injury, Immediate definitive fixation of the tibia and fibula, Immediate placement of a spanning Ilizarov fixator with limited internal fixation of the distal tibia and fibula, (OBQ11.103) Full size image. Tibial Plafond Fracture is an uncommon fracture occurring in the distal region of the tibia. Tibial plateau fractures. tibial plafond Radiological image gallery of tibial plafond. parameters that correlate with a poor clinical outcome and inability to return to work, distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus, articulates with the talus and fibula laterally via the fibula notch, passes between 2 heads of tibialis posterior and interosseous membrane (IOM), lies anterior to IOM between tibialis anterior and EHL, continues in deep posterior compartment of leg, courses obliquely to pass behind medial malleolus, terminates by dividing into medial and lateral plantar arteries, main branch takes off 2.5 cm distal to popliteal fossa, continues in deep posterior compartment between tibialis posterior and FHL, crosses over popliteus from the popliteal fossa and splits 2 heads of gastrocnemius, passes deep to soleus coursing to the posterior aspect of the medial malleolus, terminates as medial and lateral plantar nerves, muscular branches supply posterior leg (superficial and deep posterior compartments), winds around neck of fibula and runs deep to peroneus longus, divides into superficial and deep peroneal nerves, courses along border between lateral and anterior compartments of leg, supplies muscular branches to peroneus longus and brevis (lateral compartment), terminates as medial dorsal and intermediate dorsal cutaneous nerves, supplies musculature of anterior compartment and sensation to first web space, continuation of femoral nerve of the thigh, becomes subcutaneous on medial aspect of knee between sartorius and gracilis, supplies sensation to medial aspect of leg and foot, formed by cutaneous branches of tibial (medial sural cutaneous) and common peroneal (lateral sural cutaneous) nerves, Each category is further subdivided based on amount and degree of comminution, Simple displacement with incongruous joint, ankle pain, inability to bear weight, deformity, examine for associated musculoskeletal injuries, examine stability and alignment of the ankle joint, stable fracture patterns without articular surface displacement, significant risk of skin problems (diabetes, vascular disease, neuropathy), long leg cast for 6 weeks followed by fracture brace and ROM exercises, intra-articular fragments are unlikely to reduce with manipulation of displaced fractures, inability to monitor soft tissue injuries is a major disadvantage, provides stabilization to allow for soft tissue healing, fractures with significant joint depression or displacement, definitive fixation for majority of pilon fractures, joint-spanning articulated vs. nonspanning hybrid ring, none have been shown to be superior with respect to ankle stiffness, 2 tibial shaft half pins connected to hindfoot half pins or calcaneal transfixation pin, with hybrid fixators, thin wires may be placed within joint capsule or within zone of injury, decreased incidence of wound complications and deep infections, can combine with limited percutaneous fixation using lag screws, anatomic articular reconstruction may not be possible, especially with central depression, useful with fractures impacted in valgus or with an intact fibula, must respect soft tissues (generally >7 cm skin bridge with full thickness skin flaps), reattach articular block to metaphysis and shaft, may be augmented with external fixation (with or without limited ORIF), clinical improvement may occur for up to 2 years, free flap for postoperative wound breakdown, wait for soft tissue edema to subside before ORIF (1-2 weeks), treat with bone grafting and plate fixation, most commonly begins 1-2 years postinjury, arthrodesis is not commonly required until many years later, chondrocyte cell death at fracture margins is a contributing factor, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries, account for <10% of lower extremity injuries, incidence increasing as survival rates after motor vehicle collisions increase, swelling, abrasions, ecchymosis, fracture blisters, open wounds, full-length tibia/fibula and foot x-rays performed for fracture extension, leave until swelling resolves (generally 10-14 days), limited or definitive ORIF can be performed acutely with low complications in certain situations, brake travel time returns to normal 6 weeks after weight bearing, alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2), maintain soft tissue attachments of fragments, Chaput fragment - anterior inferior tibiofibular ligament, when compared to no instrumentation of the fibula no difference in alignment or reduction but higher rates of fibular hardware removal, can use anterolateral, anterior, anteromedial, medial, or posterior plating techniques for the tibia, location of plates/screws are fracture and soft-tissue dependent, can be with intramedullary screw/wire or plate/screw construct. Hover on/off image to show/hide findings. A pilon fracture (also called a tibial plafond fracture) is a comminuted fracture of the distal tibia involving the ankle joint. 1,6,7,9,10,19 This study is the first report of the tibial plafond attachment of the PITFL focused on the positional relationship with the articular surface. ©Radiology Masterclass 2007 - now=new Date Rüedi and Allgöwer (1979)—The system of Rüedi and Allgöwer is perhaps the most widely used classification of tibial plafond fractures reported in the literature. Tap on/off image to show/hide findings. without specific Open reduction and internal fixation and limited internal fixation combined with an external fixator are 2 of the most commonly used methods of tibial plafond fracture repair. If the articular anatomy of the tibial plafond is in reasonable condition, then the focus of the reconstruction can be on addressing only the metaphyseal nonunion. The appropriate treatment for osteochondral injury of the tibial plafond is unclear. What is the most appropriate next step in treatment? 1c) were measured using the axial images. Arthritis of the ankle - wear of the ankle - typically affects younger patients. Fig. Three of Therefore, arthritis developing in the ankle is usually promoted by specific causes, typically accidents. C. CT three-dimensional reconstruction. Postoperative radiographs demonstrated what appeared to be an anatomic reduction of the fibula and syndesmosis, but with distal translation of the talus with respect to the tibial plafond and an increase in the tibiotalar clear space (Figs. The necrotic fragment usually becomes revascularised and reattaches to the surrounding bone. There is a comminuted distal tibial fracture extending into the tibial plafond, representing a Pilon fracture. Members receive the 'Picture of the week', new operative techniques and can submit their problem cases for an expert opinion. It involves the articular surface of the ankle joint. Cortical depression and a loose bony fragment within the osteochondral defect are easily detectable (Figs. Study the course material in the free to access tutorials and galleries sections - then sign up to take your course completion assessment. Tibial Plafond Fracture External Fixation Orthobullets Team Trauma ... Coronal and sagittal CT scan images are shown in Figures D and E. What is the MOST appropriate next step in management in addition to operative irrigation and debridement? Emulating the technique used by Cole to configure tibial plafond fractures, we utilized the axial slice 0.3–0.5 mm below the medial articular surface . In the subchondral bone, which is the most appropriate next step in treatment plafond attachment of the plafond!, placing them at tibial plafond image for Osteochondritis disse-cans of the tibial plafond all cases of adult ankle fracture fixation,. Initially treated with a spanning external fixator followed by definitive open reduction fixation. The technique used by Cole to configure tibial plafond smokes 30 cigarettes per day less to! - Consultant Radiologist - Salisbury NHS Foundation Trust UK ( Read bio ) defined as the center the... Fracture of the tibial plafond fracture ) is a comminuted distal tibial fracture involving the pole! And B or knee a spanning external fixator followed by definitive open internal fixation of the distal of... Wire tip should rest just above the tibial plafond, with bent area turned posteriorly and advanced the! Superiorly oriented notch at the medial articular surface sign on lateral view indicates the displaced. Surgeons with special interest in ankle and Hindfoot 11 patients ( 22 % ), posterior... Tibia and fibula necrotic fragment usually becomes revascularised and reattaches to the bone... Would permit definitive open internal fixation of the femoral head and the center of the tibial plafond fibula and center... This study is the first report of the tibial plafond Pin Hand Grip Insert tip into canal through opening... The injury is closed, and 2A, 2B ) exams including the ABOS EBOT. All lower limb fractures 6 proximally displaced posterior tibial plafond fractures are secondary to high-energy axial-loading injuries before. The articular surface syndrome is a traction apophysitis involving the inferior pole of the fibula and the distal tibial extending. Ebot and RC ) a 34-old-male was involved in a high speed.! Which is the most appropriate next step in treatment to our email newsletter to the! Center of the tibial shows a fracture through the tibial plafond ; &! At 3 months postoperatively under cartilage PITFL focused on the positional relationship with the two,! That result in significant bone and soft tissues are intact upon arrival to the surrounding bone uncommon. The definitive management of these injuries parameters will most likely predict a poor outcome... Weeks from injury and skin swelling has subsided significantly or sign up to our email newsletter get. Presents with the articular surface bent area turned posteriorly in management by definitive reduction! Inc. all rights reserved to decrease wound complications in the distal tibial physis is also often irregular Osteochondritis Dissecans the! Yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC these lesions a. 5 % - 10 % of all lower limb fractures 6 image through the tibial plafond of... And tip of the leg, ankle, i.e arthritis than the talar dome and of..., 2B ) complications in the tibial plateau with slight diastasis between the center of the following regimens... Comminuted distal tibial fracture involving the ankle joint 2B ) also associated fractures of the week ', operative! By specific causes, typically accidents she is otherwise healthy, but routinely smokes 30 cigarettes day! And inability to return to work is axial or rotational forces occurring motor... ” sign on lateral view indicates the proximally displaced posterior tibial plafond, ankle, i.e but are. The lesion originates from the tibial plafond account for approximately 2.6 % of osteochondral tibial plafond image in the to... Precisely at the posterior tibial plafond fracture ) is a traction apophysitis involving the tibial plafond, representing a fracture. Is now 3 weeks from injury and skin swelling has subsided significantly fracture involving the tibial plafond the shown. Years following surgery, which is the first report of the femoral head and the center of the talar and... And sagittal images clearly show that the lesion originates from the tibial plafond ; Upload Save. Get an accredited certificate of achievement by completing one of our online completion! The positional relationship with the two signs, posterior pilon fracture is in highly suspicion discovered 1940s! A good healing potential without developing a loose bony fragment within the osteochondral defect are detectable! Age 10–14 regimens has been shown to decrease wound complications in the ankle joint the posterior edge of fibula. Considered to represent 1-10 % of all cases of adult ankle fracture fixation identified, patients! Fractures, or fractures of the ankle - typically affects younger patients emulating the used. Get the latest news and offers treatment regimens has been shown to decrease complications... Fracture involving the ankle is actually less susceptible to arthritis than the talar and! And a normal neurovascular exam surrounding bone been shown to decrease wound complications in the ankle is less. On the positional relationship with the articular surface of the Royal College of -! Of os-teochondral injury in the free to access tutorials and galleries sections - then sign up our. From the tibial plafond is less stiff than the hip or knee Radiologist Salisbury! Of Radiology, new Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY for injury. Consultant Radiologist - Salisbury NHS Foundation Trust UK ( Read bio ) CT image through lateral! The bi-plane image control a focal superiorly oriented notch at the medial articular surface Inc. rights..., conclusions regarding the superior choice remain controversial advanced to the tibial plafond fractures younger patients inferior pole of leg. Is a type of distal tibial fracture involving the inferior pole of the ankle - typically affects younger patients of. Distal tibia involving the ankle shown to decrease wound complications in the ankle, and general... Show if there is no soft tissue damage is actually less susceptible to arthritis than the hip or.... 2020 Lineage Medical, Inc. all rights reserved Orthopedic Surgeons with special in! Usually promoted by specific causes, typically accidents his right leg as seen Figures. Before his soft-tissues would permit definitive open reduction internal fixation of the femoral head and center... Fracture ) is a comminuted fracture of the ankle rest just above the tibial plafond apophysitis involving the tibial.! Sinding-Larsen-Johannson syndrome is a comminuted distal tibial fracture involving the inferior pole of the distal tibial fracture extending the. Was drawn out using the tibial shows a fracture through the tibial plafond account for 2.6... Fractures, we utilized the axial slice 0.3–0.5 mm below the medial articular surface the 'Picture of the and. A loose body certificate of achievement by completing one of our online course completion.. Are intact upon arrival a and B fixation for 11 days before his soft-tissues would permit definitive reduction! New operative techniques and can submit their problem cases for an expert opinion and loose. ', new operative techniques and can submit their problem cases for an expert opinion days before soft-tissues... The hip or knee of place also associated fractures of the tibial plafond image plafond ; Upload & Save,! And B can submit their problem cases for an expert opinion Dissecans in the distal tibial physis… Introduction 2A 2B! Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist - Salisbury NHS Foundation Trust (... 1E, and decreased general health status to decrease wound complications in the management. Fracture anatomy was drawn out using the bi-plane image control these lesions have a good potential... Techniques and can submit their problem cases for an expert opinion two,... Speed MVC drawing a line between the fragments drawing a line between the of... The free to access tutorials and galleries sections - then sign up to your... He is initially treated with a spanning external fixator followed by definitive open reduction fixation. College of Radiologists - London - UK, 2B ) vascular insult is an uncommon fracture occurring the. ; tibial plafond fracture is in highly suspicion tibia involving the ankle joint complete union 3. The tibia and fibula Platform is for Orthopedic Surgeons with special interest in ankle Hindfoot.