Issues
Complex / high energy injuries
Management of soft tissues critical
- restore length with external fixation
- await for swelling to reduce
Restoration of alignment & joint surface imperative
Outcome guarded
- can still develop arthritis with good joint surface restoration
- initial injury to chondral surfaces
Epidemiology
35 - 40 years
Males 3 x
Aetiology
Rapid axial load
Very high energy
Anatomy
Soft tissues very poor
- thin skin
- absence of muscle and adipose tissue
- lack of deep veins
Especially vunerable over anteromedial tibia
Reudi Classification
1. Undisplaced
2. Displaced Simple
3. Displaced Complex
OTA Classfication
43-B Partial Articular
43-C Complete Articular
CT scan
Critical to planning
- helps to guide surgical approach
- main fracture configuration
- plating configuration
Commonly 3 fracture configurations
- medial malleolus
- posterolateral fragment / Volkmann
- anterolateral fragment / Chaput
Associated injuries
Compound wounds
Silluzio et al. Injury 2019
- 14 open tibial plafond fractures
- 28% deep infection
- 43% delayed union
https://pubmed.ncbi.nlm.nih.gov/31171351/
Fibula fractures
Bonnevialle et al. Orthop Traumatol Surg Res 2010
- may aid reduction
- however, may contribute to nonunion
- if fibular fracture is malreduced, can contribute to tibial malreduction and malunion
https://pubmed.ncbi.nlm.nih.gov/20851076/
Syndesmotic / Syndesmotic equivalent injuries
Haller et al. J Orthop Trauma 2019
- 14/735 (2%) had missed syndesmotic injuries
- 93% of these patients developed post traumatic osteoarthritis
- syndesmotic equivalent injuries more common with Chaput (AITFL Ligament) / Volkmann fragments (PITFL) or fibular avulsion
https://pubmed.ncbi.nlm.nih.gov/30768532/
Management
1. Soft tissue algorithm
Management of the soft tissues is the key to a good outcome
Long delays
- wait until swelling down
- wrinkled skin, blisters resolved
- wait 3 weeks plus if needed
- operating early can be a disaster
Spanning external fixation
- holds out length
- helps soft tissues recover
- patient can mobilise
- allows surgery on planned elective list
Technique
- ankle bridging delta frame
- two pins in the tibia away from surgical site
- transcalcaneal threaded pin placed medial to lateral
- pin in first meta-tarsal to keep foot in neutral position
AO foundation surgical technique
2. Surgical Algorithm
A. Restore fibula length
- holds fracture out to length
- may prevent fracture malunion
B. Reduce articular surface
C. Restore bony alignment
D. Bone graft any defects
- can be done as a delayed procedure at 6 weeks
Surgical options
ORIF with plates
Circular external fixation
Malik-Tabassum et al. Injury 2020
- meta-analyis of ORIF v circular external fixation
- increased rate of hardware removal for ORIF
- reduced rate of osteoarthritis with ORIF
- no difference in superficial or deep injection, or secondary fusion
- no obvious difference in outcomes
- more severe injuries tended to be treated with circular external fixation
https://pubmed.ncbi.nlm.nih.gov/32430194/
ORIF with Plates
Surgical Approaches
Varied surgical approach
A. Anterolateral approach
- to apply an anterolateral plate
- indicated with valgus configuration
- anteolateral / Chaput fragment
Incision centred on ankle joint
- in line with 4th metatarsal
- preserve branches superficial peroneal nerve
- divide extensor retinaculum
- all extensor tendons reflected medially, including peroneus tertius
B. Anteromedial approach
- indicated with varus configuation
- large medial fragment
- medial to tibialis anterior
- can make small anterolateral incision to fix small Chaput fracture
C. Posterolateral approach
- indicated if large posterior tibial fragment requiring buttress
Techniques to minimise complications
1. Long delays until definitive surgical treatment using initial spanning external fixation
2. The use of small, low-profile, anatomical implants
3. Avoidance of incisions over the anteromedial tibia
4. The use of indirect reduction techniques minimizing soft tissue stripping / MIPO
5. Careful surgical management of the soft tissues at all times
Surgical Technique Plating
Position
- supine on radiolucent table
- IV antibiotics
- tourniquet for 2 hours then release
ORIF fibula
- holds fracture out to length
- via posterolateral incision
- need wide skin bridge from anterior incision
Anterolateral approach skin incision
- 10 cm long incision centred over jont line
- must be 7 cm from posterolateral incision
- expose distal tibia
- minimise stretch on wound edges at all times
Anatomical reduction joint surface
- open fracture site / open joint / washout haematoma
- can apply femoral distractor to view joint surface
- 4 mm Shanz pins in talar neck laterally, and into tibia proximal to plate
- examine talar dome using periosteal elevator
- ORIF small osteochondral fragments with small modular screws (1.5 - 2 mm)
Attach metaphysis to diaphysis
- anatomically contoured low profile locking plate
- MIPO techniques
- anterolateral L shaped plate via anterior wound
- small incisions proximally to insert screws
- 4 cortices above fracture
- small medial incision to insert medial plate percutaneously
Postoperatively
- elevate +++
- NWB
- early ROM
- consider bone grafting defects at 6/52
Outcomes
Bonato et al. Injury 2017
- 1 year outcome of 91 plafond injuries
- 57% return to work at 1 year
- 27% reported residual moderate to severe pain
https://pubmed.ncbi.nlm.nih.gov/28233519/
Pollack et al. JBJS Am 2003
- 80 patients at a mean of 3.2 years post injury
- 35% reported ongoing stiffness and pain
- 43% not working
- https://pubmed.ncbi.nlm.nih.gov/14563795/
Complications
Wound breakdown
Deep infection
Duckworth et al. Bone Joint J 2016
- 9% (9/102) rate of deep infection
- associated with co-morbities, open fractures, initial external fixation
https://online.boneandjoint.org.uk/doi/pdf/10.1302/0301-620X.98B8.36400
Stiffness
Osteoarthritis
Harris et al. Foot Ankle Int 2006
- 79 pilon fractures with mean follow up 2 years
- 40% developed post traumatic arthritis
https://pubmed.ncbi.nlm.nih.gov/16624215/
Malunion
Nonunion
Haller et al. J Orthop Trauma 2019
- incidence of nonunion 14% (72/518)
- associated with open fractures, bone loss, and smoking
https://pubmed.ncbi.nlm.nih.gov/31094937/
Case Examples
Case 1
Fracture configuration
- characteristic Chaput fragment
- otherwise lateral column mostly intact
- large medial fragment / medial column disruption
Plan
- small anterolateral approach
- joint reduction and cannulated screws into Chaput fracture
- medial plate inserted and fixed with MIPO technique
Example 2
Severe plafond fracture
- large medial fragment
- characteristic Chaput / syndesmotic fragment
- articular fragments driven up into joint
- both columns disrupted
Plan
- anterolateral approach
- use femoral distractor
- remove fragments from joint
- restore articular fragments with screws
- anterolateral plate (separate proximal incision for proximal screws)
- percutaneous medial plate (leg was ultimately too swollen, percutanous screws inserted)