Adjunct rim plating for selected pilon fracture patterns: Lessons from hyperextension tibial plateau fractures.

BACKGROUND: Pilon fractures frequently involve small anterior or anterolateral marginal fragments that are susceptible to shear displacement and may not be reliably controlled by conventional periarticular plates. Rim plating is a fragment-specific, low-profile juxta-articular buttress technique that has demonstrated favorable biomechanical and clinical results in selected tibial plateau fracture patterns. This review examines the rationale for extending this concept to selected pilon fracture patterns.

METHODS: We performed a narrative review of clinical, cadaveric, and biomechanical studies describing rim-based constructs in tibial plateau fractures, with emphasis on hyperextension and posterolateral patterns, as well as computed tomography (CT)-based studies of pilon fracture morphology and fragment capture by precontoured plates. Relevant studies were identified through PubMed and reference screening and synthesized qualitatively to inform a technical proposal for adjunct rim plating in selected pilon fractures.

RESULTS: The reviewed tibial plateau literature consistently identified peripheral regions that may remain unsupported by conventional periarticular plates, particularly in hyperextension and posterolateral fracture patterns, where adjunct rim plating has been associated with maintained reduction and favorable clinical outcomes. In the distal tibia, CT-based studies suggest that commonly used anatomically precontoured plates may not reliably capture the anterolateral (Tillaux-Chaput) fragment when fragment height is less than 15 mm. In this setting, an adjunct rim plate may serve as a peripheral buttress to improve support of the articular margin, distribute subchondral stress, and prevent displacement of the articular block.

CONCLUSIONS: Rim plating may be best conceptualized as a joint-line buttress strategy for improving peripheral containment of shear-dominant marginal fragments. Extrapolation of this concept to selected pilon fracture patterns is mechanically plausible and supported indirectly by CT-based fragment-capture data. This technique may be useful in carefully selected anterior or anterolateral distal tibial rim fractures that are not adequately controlled by standard periarticular plating.