The Case:
A 41-year-old male presented to the emergency department after he got into an altercation where he was pushed and twisted on a planted foot and subsequently fell. On exam he had swelling and tenderness to the entire ankle.
Interpretation: Tibial plafond fracture
Patient Course: Radiographs were obtained which showed extensive comminuted fractures of the distal fibula and a Plafond Fracture of the Tibia. The patient was taken to the OR by orthopedic surgery where he underwent a partial ORIF in addition to external fixation. He was unable to get a complete ORIF due to the amount of swelling, but he is scheduled for follow up later this month for definitive internal fixation.
Why it matters:
Plafond fractures are fractures of the distal tibial with intraarticular extension. They are often due to axial compression of the tibia, but can also be from rotational force, as in this patient. They are called plafond fractures, meaning ceiling in French, as this fracture is of the “ceiling” of the ankle joint. When the fracture is due to axial load on the tibia, they are referred to as a pilon fracture. Pilon is the French word for pestle, as in “mortar and pestle”, with the pestle being the distal tibia being compressed down against the mortar of the foot (i.e., talus).
Plafond fractures usually require operative intervention, and CT scan is helpful if obtained in the emergency department as it assists the orthopedist in operative planning. Typically, patients undergo a two-stage ORIF with partial ORIF and external fixation initially, followed later by definitive ORIF. This is due to the high complication rate of immediate ORIF caused by soft tissue swelling leading to soft tissue damage and necrosis.
Written by:
Dr. Katherine Aulis, MD
Emergency Medicine, PGY-2
Cook County Health
Reviewed by:
Dr. Scott Sherman, MD
Associate Program Director
Cook County Health
References:
1. Davenport M, Galasso MM. The Ankle p 534-536. In Sherman SC (8Ed). Simon’s Emergency Orthopedics. McGraw-Hill Education. New York, NY. 2019.
2. Crist, Brett D. MD; Khazzam, Michael MD; Murtha, Yvonne M. MD; Della Rocca, Gregory J. MD pilon Fractures: Advances in Surgical Management, American Academy of Orthopaedic Surgeon: October 2011 - Volume 19 - Issue 10 - p 612-622
3. Jacob N, Amin A, Giotakis N, Narayan B, Nayagam S, Trompeter AJ. Management of high-energy tibial pilon fractures. Strategies Trauma Limb Reconstr. 2015;10(3):137-147. doi:10.1007/s11751-015-0231-5