Tibial Plafond Fractures

Tibial Plafond Fractures is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Tibial plafond (“pilon”) fractures involve the distal articular surface of the tibia and extend to the metaphysis.
    • Term first introduced as description of the distal tibial metaphysis—pestle-shaped “pilon”
    • Plafond (French for “ceiling”) refers to the horizontal distal tibial articular surface.
    • Tibial plafond fractures often involve significant soft tissue injuries, neurovascular compromise, and concomitant multisystem trauma.
  • Tibial plafond fractures typically result from:
    • High-energy injuries with severe axial load (motor vehicle accident [MVA], fall from significant height), leading to impaction, comminution, and soft tissue injury. Approximately 15–52% have other associated fractures, necessitating a careful primary and secondary trauma survey.
    • Lower energy injuries involve torsional forces, commonly in sporting accidents (skiing, basketball, soccer).
    • Low-energy trauma can also occur in the elderly due to osteopenia.
  • Multiple fracture classification systems exist. The most commonly used is the Rüedi and Allgöwer classification system.
    • Type I: fracture of the distal tibia without significant displacement of the articular surface
    • Type II: significant displacement of the articular surface, but the joint surface is neither crushed nor grossly comminuted
    • Type III: involves both comminution and impaction of the distal tibial articular surface and metaphysis
  • This system has low interrater reliability, especially between types II and III. The AO/OTA classification (1) has superior interrater agreement and has become more prominent.
    • Type A: extra-articular fractures
    • Type B: partial articular fractures
    • Type C: complete articular fractures with metaphyseal–diaphyseal dissociation
    • Further subcategorization describes comminution and impaction.
      • Group 1: no comminution or impaction in both the articular and metaphyseal areas
      • Group 2: impaction involving only the supra-articular metaphysis
      • Group 3: comminution and impaction involving both the articular surface and metaphyseal region

Epidemiology

Incidence
  • Tibial plafond fractures account for 3–10% of tibial fractures and <1% of all lower extremity fractures.
  • Men > women 3:1
  • More common in 4th decade of life
  • Of high-energy injuries, 30–50% are open fractures.
  • The increased incidence of tibial plafond fractures associated with improved survival rate from MVAs

Risk Factors

  • Young males, most common in 4th decade of life
  • Associated alcohol abuse or drug use
  • Working at heights

Geriatric Considerations
Elderly patients are susceptible to fractures associated with low-energy trauma due to osteopenia/osteoporosis.

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)

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