Treatment of Plafond Fractures
Plafond fractures require a staged surgical approach using the "span-scan-plan" protocol: immediate ankle-spanning external fixation, followed by CT-based surgical planning, and definitive open reduction with internal fixation using plates and screws to restore the articular surface. 1
Initial Management: The Span-Scan-Plan Protocol
The standard treatment begins with a two-staged procedure 1:
- Apply an ankle-spanning external fixator immediately to stabilize the fracture and allow soft tissue recovery 1
- Obtain a CT scan with axial views, two-dimensional and three-dimensional reconstruction to fully understand the fracture pattern 1
- Plan the definitive surgery based on imaging findings and soft tissue condition, determining optimal surgical approaches and implant positioning 1
Definitive Surgical Treatment
The best functional outcomes occur with stable internal fixation using plates and screws to achieve anatomic reconstruction 2, 3:
Surgical Reconstruction Steps 2:
- Restore anatomic length of the fibula with plate fixation first 2
- Reconstruct the tibial articular surface to restore joint congruity 2
- Perform cancellous bone grafting of metaphyseal defects 2
- Apply buttress plating anteriorly or medially to the distal tibia 2
Critical Surgical Principles
- Anatomic reduction quality is the most important factor determining outcome, along with fracture type and specific surgical procedure used 3
- Early ankle motion is essential once stable fixation is achieved to reduce stiffness and optimize results 2
Fibular Fixation Considerations
Routine plating of associated fibular fractures may not be necessary when using external fixation that spans the ankle 4:
- Fibular plate fixation carries significant complication risks including wound infections (5 cases) and nonunions (2 cases) in one series 4
- Good clinical results can be achieved without fibular fixation, though angular malunions may occur more frequently 4
Postoperative Management
- Provide appropriate pain management to facilitate early mobilization 5
- Administer antibiotic prophylaxis to prevent infection 5
- Initiate early physical training and muscle strengthening as soon as fixation stability allows 5
- Implement long-term balance training and multidimensional fall prevention strategies 5
Common Pitfalls
The quality of articular surface reduction directly determines the final outcome—accept nothing less than anatomic restoration 3. Attempting definitive fixation before soft tissue recovery leads to wound complications; the staged approach with initial external fixation is mandatory 1.