Tibial Plafond

IssuesSevere Tibial Plafond


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



35 - 40 years

Males 3 x




Rapid axial load

Very high energy




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


Tibial Plafond External Fixator


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


Tibial plafond common fragmentsTibial plafond fragments


Associated injuries


Compound wounds


Silluzio et al. Injury 2019

- 14 open tibial plafond fractures

- 28% deep infection

- 43% delayed union



Fibula fractures


Fibular fracture tibial plafondTibial plafond fibular fracture


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



Syndesmotic / Syndesmotic equivalent injuries


Syndesmotic equivalent fractures tibial plafondChaput fragment syndesmotic equivalent


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





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


Tibial Plafond Pre External Fixator APTibial Plafond Pre External Fixator Lateral


Tibial Plafond Post External Fixator APTibial Plafond Post External Fixator Lateral



- 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


Tibial Plafond external fixator


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



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


Anterolateral fragment and valgus injuryTibial plafondTibial plafond anterolateral plate


B. Anteromedial approach

- indicated with varus configuation

- large medial fragment

- medial to tibialis anterior

- can make small anterolateral incision to fix small Chaput fracture


Tibial plafond medial plate 1Tibial plafond medialTibial plafond medial plate 3


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



- 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



- elevate +++


- early ROM

- consider bone grafting defects at 6/52




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



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/




Wound breakdown


Tibial Plafond 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







Harris et al. Foot Ankle Int 2006

- 79 pilon fractures with mean follow up 2 years

- 40% developed post traumatic arthritis





Distal Tibial Malunion APDistal Tibial Malunion LateralDistal Tibial Malunion CTDistal Tibial Malunion Correction



Haller et al. J Orthop Trauma 2019

- incidence of nonunion 14% (72/518)

- associated with open fractures, bone loss, and smoking



Case Examples


Case 1


Fracture configuration

- characteristic Chaput fragment

- otherwise lateral column mostly intact

- large medial fragment / medial column disruption



- small anterolateral approach

- joint reduction and cannulated screws into Chaput fracture

- medial plate inserted and fixed with MIPO technique


Tibial Plafond CT AxialTibial Plafond CT SagittalTibial Plafond CT Axial


Tibial Plafond ORIF APTibial Plafond ORIF Lateral


Example 2


Severe plafond fracture

- large medial fragment

- characteristic Chaput / syndesmotic fragment

- articular fragments driven up into joint

- both columns disrupted



- 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)


Severe Tibial Plafond CT CoronalSevere Tibial Plafond CT SagittalSevere Tibial Plafond CT Axial


Severe Tibial Plateau Post Op