Tibial Plafond

IssuesSevere Tibial Plafond


Complex / High energy injuries


Management of soft tissues critical

- restore length with external fixation

- await swelling to dissipate


Restoration of alignment / Joint surface imperative


Outcome guarded

- can still develop arthritis with good joint surface restoration

- initial injury to chondral surfaces



French for Pestle


Fracture of tibial weight bearing surface due to axial compression




35 - 40 years

Males 3 x


Up to 50% incidence of associated injuries




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


CT scan


Critical to planning

- helps to guide surgical approach

- minimise dissection

- main fracture configuration

- plating configuration


Tibial Plafond External Fixator




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


2.  Surgical Algorithm


A.  Restore fibula length

- holds fracture out to length

- prevents fracture malunion


B.  Varied surgical approach

- anterolateral / anteromedial / posterolateral

- depends on fracture configuration

- posterolateral if large posterior tibial fragment requiring buttress


C. Reduce articular surface


D. Restore bony alignment


1.  Anterolateral +/- medial plate

- percutaneous proximal fixation with indirect reducture

- restore alignment and length / provide stability


2.  Ilizarov Frame


E.  Graft any defect

- often as a delayed procedure at 6 weeks


Techniques to minimise complications


1.  Long delays until definitive surgical treatment using initial spanning external fixation 


2.  The use of small, low-profile 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 ABx

- tourniquet for 2 hours then release


ORIF fibula

- holds fracture out to length

- via posterolateral incision

- need wide skin bridge from anterior incision


Anterior skin incision

- small longitudinal incision centred over jont line

- 10 cm long

- usually anteromedial (between T Ant and EHL)

- 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

- apply femoral distractor to view joint surface

- pins in tibia and calcaneus

- examine talar dome using periosteal elevator

- open joint and inspect

- ORIF small osteochondral fragments with modular hand 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


Early ROM


Bone graft defects at 6/52






Devastating wound complications

- 0% to 6% in four recent series

- with best practice


Tibial Plafond Wound Breakdown


Deep Infection






Excellent results rare


Fair to good are the norm

- develop AKJ OA over time (50%)

- related to cartilage injury at time of trauma

- AKJ arthrodesis rare



- most have some pain

- most return to work

- cannot run or play sports

- pain continues to improve for long times (up to 92 months)

- delay arthrodesis

- x-ray appearances not always related to clinical picture


Case Examples


Example 1


Fracture configuraiton

- characteristic Tillaux fragment

- otherwise lateral column mostly intact

- large medial fragment / medial column disruption



- small anterolateral approach

- joint reduction and cannulated screw from Tillaux fragment medially

- medial percutaneous plate


Tibial Plafond CT AxialTibial Plafond CT SagittalTibial Plafond CT Axial


Tibial Plafond ORIF APTibial Plafond ORIF Lateral


Example 2


Severe plafond

- large medial fragment

- characteristic Tillaux / 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


Case 3


In this case can alter incision

- anterolateral

- anterolateral plate only required


Tibial Plafond Fracture


Case 4


Distal tibial fracture with fibular fracture

- fibular ORIF for additional stability and improved alignment


Tibial Plafond with Fibular Fracture PreTibial Plafond with Fibular Fracture Post ORIF