A tibial plafond fracture (also called a tibial pilon fracture) is a break at the bottom of the shin bone (tibia) that involves the ankle joint. It happens when the talus, the main central bone in the ankle, is forced up into the tibia, so the bone breaks through or near the joint surfaces.
A great deal of force is usually needed to cause a tibial plafond fracture, so there are often other injuries, to the fibula, pelvis and spine and occasionally the internal organs. It is seen in motor vehicle accidents, skiing accidents and falls from a height onto your feet.
When a fracture goes into or around a joint surface, that joint is at high risk of osteoarthritis because of the injury. Unfortunately, even if the bone and cartilage surfaces line up perfectly, there is still a risk of arthritis because the cartilage cells are injured.
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 reduce 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
Causes
A great deal of force is usually needed to cause a tibial plafond fracture. It may be seen after:
- 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 risk a fall from a height, such as rock climbing or working on construction sites
- Downhill skiing and snowboarding
- Car accidents
Investigations
Diagnosis is confirmed by X-rays of the ankle joint. They also give the surgeon information about the fracture site, whether the bones have moved apart (displaced), and whether there are bony fragments floating in the joint.
As well as X-rays of the ankle, the surgeons may need X-rays of the lower leg up to the knee. If the cause was a major event, such as a car accident, X-rays of the hips (pelvis) and spine may be needed to look for other fractures.
A CT scan is often ordered before surgery because it gives a great deal of detail about the fracture and lets the surgeon plan treatment. It also shows some detail of the surrounding soft tissue.
Angiography – in some people the blood vessels around the ankle need to be checked. Sometimes a Doppler ultrasound is used instead. These extra tests are often not needed, because your surgeon can check 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 an unacceptable position. If this happens, your surgeons may decide that secondary or ‘revision’ surgery is needed, but 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 particularly of fractures through the joint surface, as in tibial plafond fractures.
- Damaged nerves – nerves around the ankle may be cut during the fracture itself, or may be squeezed or cut off from their blood supply in the days after it. The result can range from loss of feeling to paralysis of muscles, but major nerve injury is very rare.
- Infection
- Muscle damage
- Skin damage and fracture blister formation – Fracture blisters are swellings in the skin over the fracture site. They usually occur where there is not much muscle or fat between the skin and bone, such as the ankle and elbow. Fracture blisters can slow 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 are well aligned
- traction (continuous force along the bone) is used if the skin is in poor condition and the person is 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 in poor condition (plates and screws raise the chance of infection in this case)
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, using crutches. At this stage certain exercises are recommended to keep the joint flexible. The ankle is often splinted at night to stop equinus deformity (the foot 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’ can involve ‘irrigation’ (flushing the area with water) and ‘debridement’ (trimming muscles and tendons damaged during the injury).
For severe open fractures, two surgeries may be needed. External fixation is used first to hold the bones in place while the soft tissue and skin heal. Then an internal fixation method is used to fix the fracture permanently, 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. Do not try to stand on the injured foot. It is best to call an ambulance so that you are safely taken to the hospital.
Prevention
These fractures are usually caused by car accidents or by sports with high impact injuries, such as downhill skiing or rock climbing. So prevention involves using the right equipment and taking care in these activities.
F.A.Q. | Frequently Asked Questions
How can the complications be prevented?
Complications can be prevented by aligning and fixing the fracture as early as possible. If there is a delay of a few hours in reaching hospital, you can take these steps:
- 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 can take several months. Because the cartilage surface of the joint is involved, the ankle must be protected from weight until the fracture has healed. Most people are allowed to move the ankle joint but not put weight on the leg for about three months. The exact time varies with the fracture type and how much healing takes place.
Tibial plafond fractures are complex. Even with completely successful treatment, there are risks of long term loss of function, pain and/or instability. Some common complaints after tibial plafond fractures include:
- Long term pain and osteoarthritis – this is unfortunately a common complaint. Studies have shown that pain, stiffness and swelling after the fracture is fixed keep improving for years, but they remain a problem for many people. Pain can be managed with physical therapy and orthotics. Medicines from the chemist, such as Panadol and Nurofen, can be very helpful. GPs can also prescribe stronger painkillers or refer you back to the orthopaedic team if your pain is severe. In a minority of people, more surgery is needed to correct osteoarthritis. This may be arthrodesis or, rarely, total ankle replacement.
- Difficulty walking – the treatments aim to make walking as easy as possible. Despite this, some people become dependent on walking aids.
- Difficulty bearing weight – this can make walking difficult, but the other leg can usually take the extra load.
- Difficulty running
When can I go back to work?
Despite surgery and physical therapy, you may need to adjust the way you work. There are a number of reasons, but the team managing your fracture will go to great lengths to prevent this. If you have concerns about returning to work, discuss them with your surgeon or GP.
Why are the soft tissues a concern with tibial plafond fractures?
Because there is little muscle and skin around the ankle joint, severe fractures of the tibial plafond can be a problem. If the soft tissues are too swollen and damaged, surgery may not be possible through them. In these cases, definitive surgery may be delayed until the swelling goes down and the soft tissues improve.
While the soft tissue heals, the fractured bone and ankle joint are immobilised. This may be done with a cast, splint or external fixator. An external fixator is a device placed surgically around the swollen and damaged soft tissue. It secures the bone above and below the fracture while avoiding the soft tissue that needs to heal. The advantage is that it holds the bones rigidly still and lets your surgeon 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, pp. 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.