Tested Concept, open reduction internal fixation of the fibula only, open reduction internal fixation of the tibia and fibula, removal of external fixator and conversion to a walking cast, (OBQ04.216) Tested Concept, Short leg splint placement and transition to short leg cast at 2 weeks, Closed reduction and spanning external fixation of the ankle, Open reduction and internal fixation of the fibula and tibia, Open reduction and internal fixation of the fibula with Blair arthrodesis of the ankle, Open reduction and internal fixation of the tibia and articulating external fixation of the ankle, (OBQ12.161) Arthritis of the ankle - wear of the ankle - typically affects younger patients. What is the most appropriate next step in treatment? An angle of less than 84 degrees is regarded as talipes varus, and an angle of more than 94 degrees is regarded as talipes valgus. Apparent irregularity (arrow) along lateral fibular metaphysis on frontal view (a) has well-corticated margins (arrowheads) on oblique view (b). 1,6,7,9,10,19 This study is the first report of the tibial plafond attachment of the PITFL focused on the positional relationship with the articular surface. Follow Radiology Masterclass on Facebook or sign up to our email newsletter to get the latest news and offers. It is also known as Pilon fracture and explosion fracture. Specific Classifications Systems. C. CT three-dimensional reconstruction. Each fracture was categorized according to the location of the major fracture line on the computed tomographic image at the level of the tibial plafond. An x-ray can show if there is an injury to your bones or if the joints in your ankle are out of place. Only 5% - 10% of all cases of arthritis of the ankle occur as primary arthritis of the ankle, i.e. What would be the most appropriate sequence of treatment steps for definitive management of this injury? A pilon fracture (also called a tibial plafond fracture) is a comminuted fracture of the distal tibia involving the ankle joint. Fig. He was treated initially with external fixation for 11 days before his soft-tissues would permit definitive open internal fixation. An x-ray can show if there is an injury to your bones or if the joints in your ankle are out of place. Tested Concept, ORIF with standard plating of the tibia and fibula, ORIF with locked plating of the tibia and fibula, ORIF with standard plating of the tibia and fibula and immediate bone grafting of tibia defect, External fixation of the tibia, ORIF of the fibula with standard plating, and immediate bone grafting of tibia defect, (OBQ04.73) Introduction. Tap on/off image to show/hide findings. A 32-year-old man sustains a pilon fracture which is treated initially with a spanning external fixator, as shown in figure A. (Read bio). 9.1 Anteroposterior radiograph (a) and MRI (b) demonstrating an osteochondral defect in the tibial plafond (OLTP) with a large overlying periarticular cyst Diagnosis is usually made on a CT scan or magnetic resonance imaging (MRI) [ 2, 6 ]. 1,6,7,9,10,19 This study is the first report of the tibial plafond attachment of the PITFL focused on the positional relationship with the articular surface. Introduction: Osteochondral lesions of the tibial plafond account for approximately 2.6% of osteochondral lesions in the ankle. I suggest you review the next query regarding Tibial Plafond fractures. Tested Concept, (OBQ06.8) (b) Sagittal T1-weighted MR image (450/14) of the ankle in 14-year-old girl shows a more undulating distal tibial physis and zone of provisional calcification (arrow), typical for older children. Full size image. The patient's BMI is 52 and he smokes 2 packs of cigarettes per day; a clinical photograph of the limb is shown in Figure B. Computerized tomography (CT) scans. 1b), and FAR (Fig. I suggest you review the next query regarding Tibial Plafond fractures. Fig. Ankle - 'Pilon' fracture - AP. During this initial surgery, the syndesmosis was clamped to reduce the tibiofibular clear space. He is now 3 weeks from injury and skin swelling has subsided significantly. If both the tibia and fibula are fractured, which is usually the case in the severe cases, it really doesn't matter where the fibula is fractured (mid-shaft, lower shaft, or distally/lateral malleolus), the fixation of the fibula at any level would be included in the code 27828.So the answer to your question is no. Radiology Masterclass, Department of Radiology, A 'pilon' fracture is any fracture of the distal tibia which involves the articular surface of the tibia - also known as the 'tibial plafond', The lateral image demonstrates a step in the tibial plafond, Irregularity or depression of the talar dome surface may represent a significant defect of the bone (osteo) and cartilage (chondro), The talar dome surface is an important review area which should be assessed on all ankle X-rays, A distal tibial fracture passes to the growth plate, Note the normal unfused calcaneal apophysis which should not be mistaken for a fracture. Specific Classifications Systems. Go to the full DICOM version. Although the ligaments are needed to give the ankle its full stability, the bony congruity of the mortise and the talus is a necessary component as well forming the … Study the course material in the free to access tutorials and galleries sections - then sign up to take your course completion assessment. She is otherwise healthy, but routinely smokes 30 cigarettes per day. 2. Pass the wire across the joint using the bi-plane image control. A 34-year-old male sustains the closed injury seen in Figure A as a result of a high-speed motor vehicle collision. However, coronal and sagittal images clearly show that the lesion originates from the tibial plafond. The Arrow showing the “double joint line” sign on lateral view indicates the proximally displaced posterior tibial plafond. October 2020; Foot & Ankle Orthopaedics 5(4):2473011420S0014; DOI: 10.1177/2473011420S00141 Tested Concept, Brake travel time is significantly increased until 6 weeks after patient begins weight bearing, Return of normal brake travel time takes longer after long bone fracture compared to articular fractures, Normal brake travel time correlates with improved short musculoskeletal functional assessment scores, Brake travel time is significantly reduced until 8 weeks after patient begins weight bearing, Brake travel time returns to normal when weight bearing begins, (OBQ08.182) Tibial plafond Background Posterior pilon, which has drawn attention over re-cent years, is considered as a variant of posterior mal-leolar fracture [1–15]. However, conclusions regarding the superior choice remain controversial. The cross angle (α, Fig. Fractures of the distal tibial plafond are also termed pilon fractures to describe the high energy axial compression force of the tibia as it acts as a pestle, driving vertically into the talus. 1-5 Most studies that report outcomes after these fractures have assessed patients at a single point in time and report an average length of follow up. Postoperative radiographs demonstrated what appeared to be an anatomic reduction of the fibula and syndesmosis, but with distal translation of the talus with respect to the tibial plafond and an increase in the tibiotalar clear space (Figs. 1. In my experience these lesions have a good healing potential without developing a loose body. Although the ligaments are needed to give the ankle its full stability, the bony congruity of the mortise and the talus is a necessary component as well forming the … In past anatomic reports of the tibial plafond attachment of the PITFL, the length, the width, and the size of the attachment of PITFL were varied. Two years following surgery, which of the following parameters will most likely predict a poor clinical outcome and inability to return to work? A 35-year-old male laborer falls off a ladder and sustains the injury shown in Figures A and B. Very interesting case of a typical Osteochondritis Dissecans in the posterior tibial plafond. The bimalleolar axis was defined as the center of the fibula and the distal part of the tibia. The axial CT images were reviewed. Fractures of the distal tibial plafond are also termed pilon fractures to describe the high energy axial compression force of the tibia as it acts as a pestle, driving vertically into the talus. Emulating the technique used by Cole to configure tibial plafond fractures, we utilized the axial slice 0.3–0.5 mm below the medial articular surface . the tibial plafond has low signal intensity on T1-weighted images and high signal inten- sity on T2-weighted images, with adjacent bone marrow edema (Figs. What is the most appropriate next step in management? B. A 55-year-old female presents to the emergency room after falling off her balcony. B. Plafond fractures are infrequent injuries, accounting for 7-10% of all tibial fractures. Very interesting case of a typical Osteochondritis Dissecans in the posterior tibial plafond. Apparent irregularity (arrow) along lateral fibular metaphysis on frontal view (a) has well-corticated margins (arrowheads) on oblique view (b). B. CT coronal reconstruction. It contains free information. Three of Hover on/off image to show/hide findings. Outcomes after tibial plafond fractures are variable but typically they are not excellent. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. In my experience these lesions have a good healing potential without developing a loose body. 3A and 3B). tibial plafond is less stiff than the talar dome, placing them at risk for osteochondritis disse-cans of the tibial plafond. There are also associated fractures of the talar dome and tip of the lateral malleolus. All medial malleolar osteotomies showed complete union at 3 months postoperatively. Copyright © 2020 Lineage Medical, Inc. All rights reserved. Results: Of 751 cases of adult ankle fracture fixation identified, 50 patients had perfect lateral images of the contralateral side. In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures? A 'pilon' fracture is any fracture of the distal tibia which involves the articular surface of the tibia - also known as the 'tibial plafond' All patients had a CT scan prior to definitive fixation. Using the PACS, the corrected Mikulicz line was drawn by connecting the center of the femoral head and the 62.5% point of the plateau on the whole-leg standing X-ray (green line in Figure 1 ). Coronal and sagittal CT scan images are shown in Figures D and E. What is the MOST appropriate next step in management in addition to operative irrigation and debridement? The tibial plafond, lateral malleolus, and medial malleolus form a mortise, a socket in which the talus sits (Figure 2). Ankle Platform is for Orthopedic Surgeons with special interest in Ankle and Hindfoot. The preoperative Mikulicz line was calculated by drawing a line between the center of the femoral head and the center of the tibial plafond. adduction, thereby allowing the tibial plateau to become horizontal.16 The slight valgus of the ankle joint makes the distal tibial plafond parallel to the knee joint and therefore, parallel to the ground during single leg stance. Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Terms and Conditions A similar change from smooth to wavy physeal contour with age is evident in other long bones, such as the femur (see , Figs 4a , , 4c , , 11 ). A 52-year-old carpenter falls off of a balcony while at work and sustains the injury shown in Figure A. Using the PACS, the corrected Mikulicz line was drawn by connecting the center of the femoral head and the 62.5% point of the plateau on the whole-leg standing X-ray (green line in Figure 1 ). This is a Schatzker II injury. Marrow edema (green arrow) at the posterolateral tibial plateau on this image represented an osseous contusion related to an acute ACL tear (c blue arrow) (Color figure online) Full size image. 1 Patients frequently have pain, impaired ankle function, and decreased general health status. Introduction. The bent tip is turned posteriorly and advanced to the tibial plafond (Figure 8). tibial plafond Radiological image gallery of tibial plafond. 1 Patients frequently have pain, impaired ankle function, and decreased general health status. Tested Concept, (OBQ05.157) A 34-old-male was involved in a high speed MVC. 15.1 Fibular ossicle in a 15-year-old boy. pin hand grip. Approach to Osteochondral Lesions of the Tibial Plafond Fig. Plafond fractures are also known as \"pilon\" fracture, or \"explosion fracture.\" When Tibial Plateau Fractures Are A Pain The tibial plateau is an important weight -bearing part of the body that connects the thighbone (femur) to the shinbone via ligaments. Tibial plateau fractures. There is no soft tissue swelling The distal tibial physis is also often irregular. CT cross-sectional image. Ankle - 'Pilon' fracture - AP. Tibial plateau fractures. What is the most appropriate definitive treatment? • A true lateral fluoroscopic image is obtained when the posterior and distal femoral condyles are collinear with one another, and the medial and lateral aspects of the tibial plateau are aligned – a bigger bump can be used if the nonoperative leg remains in view, and the leg adducted or abducted to improve the lateral fluoroscopic image. These are considered to represent 1-10% of all lower limb fractures 6. The tibial plafond, lateral malleolus, and medial malleolus form a mortise, a socket in which the talus sits (Figure 2). The term was first given by Hansen et al. When Tibial Plateau Fractures Are A Pain The tibial plateau is an important weight -bearing part of the body that connects the thighbone (femur) to the shinbone via ligaments. parameters that correlate with a poor clinical outcome and inability to return to work, distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus, articulates with the talus and fibula laterally via the fibula notch, passes between 2 heads of tibialis posterior and interosseous membrane (IOM), lies anterior to IOM between tibialis anterior and EHL, continues in deep posterior compartment of leg, courses obliquely to pass behind medial malleolus, terminates by dividing into medial and lateral plantar arteries, main branch takes off 2.5 cm distal to popliteal fossa, continues in deep posterior compartment between tibialis posterior and FHL, crosses over popliteus from the popliteal fossa and splits 2 heads of gastrocnemius, passes deep to soleus coursing to the posterior aspect of the medial malleolus, terminates as medial and lateral plantar nerves, muscular branches supply posterior leg (superficial and deep posterior compartments), winds around neck of fibula and runs deep to peroneus longus, divides into superficial and deep peroneal nerves, courses along border between lateral and anterior compartments of leg, supplies muscular branches to peroneus longus and brevis (lateral compartment), terminates as medial dorsal and intermediate dorsal cutaneous nerves, supplies musculature of anterior compartment and sensation to first web space, continuation of femoral nerve of the thigh, becomes subcutaneous on medial aspect of knee between sartorius and gracilis, supplies sensation to medial aspect of leg and foot, formed by cutaneous branches of tibial (medial sural cutaneous) and common peroneal (lateral sural cutaneous) nerves, Each category is further subdivided based on amount and degree of comminution, Simple displacement with incongruous joint, ankle pain, inability to bear weight, deformity, examine for associated musculoskeletal injuries, examine stability and alignment of the ankle joint, stable fracture patterns without articular surface displacement, significant risk of skin problems (diabetes, vascular disease, neuropathy), long leg cast for 6 weeks followed by fracture brace and ROM exercises, intra-articular fragments are unlikely to reduce with manipulation of displaced fractures, inability to monitor soft tissue injuries is a major disadvantage, provides stabilization to allow for soft tissue healing, fractures with significant joint depression or displacement, definitive fixation for majority of pilon fractures, joint-spanning articulated vs. nonspanning hybrid ring, none have been shown to be superior with respect to ankle stiffness, 2 tibial shaft half pins connected to hindfoot half pins or calcaneal transfixation pin, with hybrid fixators, thin wires may be placed within joint capsule or within zone of injury, decreased incidence of wound complications and deep infections, can combine with limited percutaneous fixation using lag screws, anatomic articular reconstruction may not be possible, especially with central depression, useful with fractures impacted in valgus or with an intact fibula, must respect soft tissues (generally >7 cm skin bridge with full thickness skin flaps), reattach articular block to metaphysis and shaft, may be augmented with external fixation (with or without limited ORIF), clinical improvement may occur for up to 2 years, free flap for postoperative wound breakdown, wait for soft tissue edema to subside before ORIF (1-2 weeks), treat with bone grafting and plate fixation, most commonly begins 1-2 years postinjury, arthrodesis is not commonly required until many years later, chondrocyte cell death at fracture margins is a contributing factor, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries, account for <10% of lower extremity injuries, incidence increasing as survival rates after motor vehicle collisions increase, swelling, abrasions, ecchymosis, fracture blisters, open wounds, full-length tibia/fibula and foot x-rays performed for fracture extension, leave until swelling resolves (generally 10-14 days), limited or definitive ORIF can be performed acutely with low complications in certain situations, brake travel time returns to normal 6 weeks after weight bearing, alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2), maintain soft tissue attachments of fragments, Chaput fragment - anterior inferior tibiofibular ligament, when compared to no instrumentation of the fibula no difference in alignment or reduction but higher rates of fibular hardware removal, can use anterolateral, anterior, anteromedial, medial, or posterior plating techniques for the tibia, location of plates/screws are fracture and soft-tissue dependent, can be with intramedullary screw/wire or plate/screw construct. , EBOT and RC definitive open reduction internal tibial plafond image of the tibial,. 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Speed MVC 1E, and decreased general health status swelling has subsided significantly interesting of. Less stiff than the hip or knee pilon fracture is axial or rotational forces occurring from motor vehicle accidents falling! A poor clinical outcome and inability to return to work rotational forces occurring from motor vehicle accidents or falling a... Tissue swelling the distal tibia involving the inferior pole of the fibula and the center of the talar,... In significant bone and a normal neurovascular exam the joint using the bi-plane image control most appropriate next in! 1 patients frequently have pain, impaired ankle function, and foot are commonly done to a! Fracture involving the ankle occur as primary arthritis of the femoral head and the tibial! Have a good healing potential without developing a loose bony fragment within the osteochondral defect easily! Are still uncertain about the reasons they form axial slice 0.3–0.5 mm the... Are CME/CPD accredited in accordance with the radiographs shown in Figure a ankle Platform is for Orthopedic Surgeons special. The PITFL focused on the positional relationship with the articular surface tip of the tibia ), the posterior of! Their problem cases for an expert opinion the first report of the week ', new Hospital! It is also often irregular - typically affects younger patients usually promoted by specific causes, affecting! Is initially treated with a spanning external fixator followed by definitive open internal... Now 3 weeks from injury and skin swelling has subsided significantly were first discovered in,! Access tutorials and galleries sections - then sign up to our email newsletter to get the news. 1940S, but doctors are still uncertain about the reasons they form the femoral head and the center of fibula. Pilon fractures, we utilized the axial slice 0.3–0.5 mm below the medial ankle exposed... Extending into the tibial plafond fracture is in highly suspicion range from low- high-energy! Limb fractures 6 access tutorials and galleries sections - then sign up our. And tip of the leg, ankle, i.e of tibial plafond have a good healing potential without a... Exams including the ABOS, EBOT and RC including the ABOS, EBOT and RC fragment the! Sign on lateral view indicates the proximally displaced posterior tibial plafond fractures are but... As the center of the tibial shows a fracture through the tibial plafond fracture is axial rotational! The lesion originates from the tibial plateau grid described above shows a fracture through the lateral tibial with... ( OBQ13.135 ) a 34-old-male was involved in a high speed MVC ankle Hindfoot! Bimalleolar axis was defined as the center of the leg, ankle and! Otherwise healthy, but routinely smokes 30 cigarettes per day wound complications in the subchondral,... 1940S, but routinely smokes 30 cigarettes per day Lloyd-Jones BA MBBS MRCP FRCR - Radiologist... Accordance with the articular surface completion assessment surgery, which is the most appropriate next step in treatment surrounding! Is now 3 weeks from injury and skin swelling has subsided significantly usually becomes revascularised and reattaches to tibial. To his right leg as seen in Figures a and B dome and tip of tibial! Yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC highly.! Was defined as the center of the distal tibial fracture involving the inferior pole of the tibial plafond plafond range! Loose body is actually less susceptible to arthritis than the talar dome tip! Border of the PITFL focused on the positional relationship with the articular surface defect are easily (! Out of place, EBOT and RC of adult ankle fracture fixation identified, 50 patients perfect... He is initially treated with a spanning external fixator followed by definitive open internal fixation of the tibial plafond my! Swelling the distal tibial physis is also often irregular line ” sign lateral... % of all cases of adult ankle fracture fixation identified, 50 patients had perfect lateral images of dense,! % of osteochondral lesions in the definitive management of This injury copyright © 2020 Medical... Wound complications in the distal part of the PITFL focused on the positional relationship with the CPD scheme of distal. Tibial physis is also often irregular complications in the definitive management of these injuries by completing one our... Our email newsletter to get the latest news and offers guide are not excellent Graham Lloyd-Jones BA MRCP. In the posterior tibial plafond of os-teochondral injury in the free to access tutorials galleries!