Tibial Plafond Fracture - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Plafond fracture is a fracture of the shin bone of the foot. Plafond fracture is also called "pilon fracture'' given by Etienne Destot in the year 1911 as it is derived from the French word "pilon," which means "pestle" from the mortar and pestle. It is called so because the fracture shows a high-intensity increased compression in the axial direction on the tibial bone concerning the talus bone, driving it vertically like a pestle. In contrast, the distal part of the tibial bone, along with the fibula (smaller bone of the lower limb between the knee and ankle), bony capsule, and associated ligaments, form the motor. Plafond fracture compromises around one to ten percent of overall fractures of the lower leg. Plafond fractures can also extend up to the long bones and associated fibrous structures.

What Are the Types of Plafond Fractures?

Plafond fractures are classified into two different classifications based on the displacement and level of breakage of the bone.

Ruedi-Allgower Classification: This classification is based on the displacement of the fractured bone and is sub-classified into three types.

• Type 1: Here the tibial bone is not displaced, which is also called cleavage fracture.

• Type 2: These are fractures having a simple displacement of the tibial bone without involving the surface of the bony joint

• Type 3: These fractures include communication of the bony joint, causing impaction of the bony shaft. It is the most commonly occurring fracture seen in almost 20 to 70 percent of plafond fractures.

AO/OTA Classification: This classification is given for fractures of the long bone where plafond fractures are classified as:

• Extra Articular: Fracture without involving the bony joint.

• Partial Articular: Fracturepartially involving the bony joint.

• Intra-Articular: Fracture between two joints.

This classification is further subclassified based on the degree of fracture breakage like single or multiple fragments.

What Causes Plafond Fracture?

Plafondfractures often occur due to high-intensity injuries, although they are also seen minorly in low-intensity trauma. The fracture occurs when a force directly acts in the axial direction along the bone, causing compression and impaction on the distal part of the tibial bone. Low-intensity fractures occur due to rotational forces acting on the tibial bone resulting in lesser sectional fracture (comminution), displacement, and soft tissue damage. Lower energy fractures are also seen in older patients due to low bone density conditions. Some of the factors causing plafond fractures are:

• Vehicle accidents.

• Fall from great heights.

• Skiing injuries.

• Osteoporosis (weakening of the bone due to decreased bone density).

Plafond fractures comprise almost ten percent of lower limb fractures. It is seen in patients between the age group of 25 to 50 years. Plafond fractures are commonly seen in males around 50 to 70 percent compared to female patients.

How Does a Pilon Fracture Occur?

The mechanism by which the plafond fracture occurs can be explained based on the intensity of the injury. Low-intensity injuries occur as rotational injuries, whereas in the case of high-intensity injuries, the force from an impact is given as an axial compression pushing the joint's articular surface toward the bone shaft. In such fractures, the fractured segment usually remains intact with the subchondral bone as the ligament holds them in place. The fracture line appears in the shape of Y, showing three significant fragments when the image is made from an axial direction. The ligaments in relation to the broken bony pieces are:

• Chaput or anterior fragment attached to the anteroinferior tibiofibular ligament.

• The Volkmann or posterior fragment attached to the posteroinferior tibiofibular ligament.

• The medial malleolar fragment attached to the deltoid ligament.

In case of the absence of Y-shaped pattern, the injury is said to be ligamentous. 20 percent of the plafond fractures are open-type fractures where the fracture surface is exposed to the outer environment. High-intensity injuries are often accompanied by severe soft tissue injury, which may lead to severe complications.

How Is a Pilon Fracture Seen Clinically?

The pilon fracture has the following clinical features:

• Multi-system injury.

• Inability to bear weight.

• Bruises.

• Swelling.

• Structural deformity.

• Skin blisters.

What Are the Methods of Evaluating Pilon Fracture?

The following are the methods to evaluate pilon fracture:

• Physical Examination: It is essential to examine the plafond fracture thoroughly as it can lead to injuries that might even lead to the removal of the leg. So it is necessary to investigate for compartment syndrome (a condition occurring due to increased pressure due to excessive blood pooling) and any nerve injury. The other examinations include pedal pulse and motor function assessment of the leg.

• Radiographic Imaging (X-Ray): Multiple radiographic images of the entire leg are taken to assess the length, form, and position of the foot. The other associated radiographs of the spine, pelvis, and foot will also be taken.

• Computed Tomography (CT): It is used to assess the adjoining ligaments spurring the tibial bone and the level of damage, tear, or inflammation.

How Is a Plafond Fracture Treated?

The management of plafond fractures is quite a complicated procedure and should be done with proper care. Plafond fracture is often associated with multiple bodily injuries; hence it is essential to restore airway breathing and circulation along with emergency management like advanced life support. Plafond fracture is managed by both surgical and non-surgical methods, depending on the fracture type.

Conservative Management: The conservative or non-surgical management of plafond fracture is done using a cast or braces holding the leg in position. Although non-surgical treatment is possible, the treatment often shows secondary displacement of joints and poor healing outcomes.

Surgical Management: Surgical management follows Ruedi and Allgower techniques proposed in 1968. The approach is made in four stages, namely

• Reduction of the anatomic deformity by restoring the length of the bone.

• Stabilization by holding the reduced fracture and re-establishing the structure.

• Grafting by placing a graft in the injured site to fill the bone defect.

• Fixation to place the repaired segment, prevent it from collapsing and allow healing.

What Are The Complications of Plafond Fracture?

The Complications associated with plafond fractures are:

• Increased wound complications and infections as it is an open type of fracture.

• Swelling.

• Stiffness of the bony joints.

• Arthritis - Inflammation of the bone or bony cartilage occurring after the injury. It can occur due to the number of broken segments or the level of bone displacement.

• Graft Rejection - Sometimes, the body might reject the graft placed.

• Damage to nerve or blood vessels.

The outcomes after a plafond fracture are average as it occurs as a complex injury involving fracture of multiple body parts. However, there is a significant improvement in treatment modalities. Patients still experience a little pain during walking, which is managed with conservative management, rehabilitation, and painkillers.

Conclusion

Plafond fracture, also known as pilon fracture, occurs due to injuries that result in multiple complex injuries. A multi-specialty approach to treating it manages this fracture. Although it is a challenging and strenuous procedure, requiring proper follow-up alongside rehabilitation, physiotherapy, and post-operative care.