(w/ assistance and narration by Dr Kyle Dickson MD)
- Discussion:
- term pilon (hammer) fracture was introduced to describe these compression injuries by Destot in 1911;
-
frx components:
- combination of ankle frx & distal tibial metaphyseal frx, usually w/ intra articular comminution;
- frx of medial malleolus;
- frx of anterior margin of tibia;
- transverse frx of posterior tibial surface;
- 20-25% of these will be open;
-
mechanism of injury:
- vertical loading drives talus into distal tibia;
- position of foot & rate of loading affect injury pattern;
- it is important to distinguish between low energy frx (from skiing) vs high energy frx (as from MVA);
- plantar flexion: posterior articular damage;
- dorsiflexion: anterior articular damage;
-
fibular frx:
- if fibula is frxed, then force involved is usually valgus shear w/ severe injury to the lateral aspect of the joint;
-
fibula intact: (25% of injuries);
- pilon frx w/o assoc frx of fibula occur in approx 15 % of cases;
- w/ compression injuries fibula may remain intact, which never happens w/ shearing type injury;
- w/ intact fibula, ankle is often driven into varus w/ severe impaction of the medial part of the tibial plafond;
-
associated injuries: (30% will have ipsilateral injuries and 5-10% will have bilateral injuries;)
-
compartment syndrome
-
compression frx of vertebral column, particularly L1;
- contralateral fractures of: os calcis, tibial plateau, pelvis, or acetabulum (
verticle shear injuries):
- vascular injuries:
-
Vascular Abnormalities as Assessed with CT Angiography in High-Energy Tibial Plafond Fractures.
-
outomes:
- with operative treatment, high energy pilon fractures will take 4 months on average to heal;
- 75% of patients who do not develop wound complications may expect a good result;
- subsequent arthrodesis rate may be as high as 10%;
- ref:
Tibial Plafond Fractures. How Do These Ankles Function Over Time?
- Exam:
-
soft tissue: note presence of swelling and any
fracture blisters;
- perform an Allen test using a pulse oximeter for the foot vasculature (pulse ox is placed on the toe);
- note function of
posterior tibial pulse while the
dorsalis pedis pulse is occluded and vice versa;
- ideally, the pulse ox should demonstrate normal mp3e forms even w/ occlusion of either vessel;
- reference:
The management of the soft tissues in pilon fractures.
- Radiographs: 
- consider taking a traction x-rays of extremity to help judge effects of ligamentotaxis on displaced articular fragments;
- note whether fibula is intact or fractured;
- w/ comminuted fibular fracture it is important to bring fibula out to length (
talo-crural angle)
- w/ fibula intact, carefully evalute the
syndesmosis;
-
classification: and degree of articular comminution;
-
type I: pilon frx
-
type II: pilon frx
-
type III: pilon frx
-
type A:
- minimal or no anterior tibial cortical communition, two or more large tibial articular fragments, and usually an
oblique or transverse fibular fracture at the level of the plafond (or
ankle joint);
-
type B:
- results from severe axial compression force, causing distal tibial bony impaction and comminution;
-
CT scan: helps plan surgical fixation of articular fragments;
- Surgical Treatment:
- controversies:
- surgical timing and staged reconstruction;
- plate vs ex fix;
- role of bone grafting;
- role for primary
ankle arthrodesis;
- ref:
Ankle arthrodesis using antegrade intramedullary nail for salvage of nonreconstructable tibial pilon fractures.
-
initial treatment and timing of surgery:
-
surgical technique:
-
reduction of fibula;
- some authors will avoid ORIF of the fibula in these injuries if there is excessive fibular comminution (ie poor chance of good fixation) and
if there is excessive varus of the articular surface (ORIF would accentuate the varus);
- note that the fibular incision often must be placed posteriorly indorder to accomodate an adequate skin bridge for the tibial incision;
- in some cases, the fibula can be anatomically reduced along with application of external fixator which allows
fracture to be brought out to length and which allows the talus to be centered under the tibia;
- then 7-21 days later, the medial column and articular surface can be restored once the soft tissues have healed;
-
exposure of tibial articular surface:
-
restoration of tibial articular surface:
-
fixation of metaphysis to diaphysis:
-
plate fixation:
-
uniplanar external fixation
-
circular wire fixators
- theoretically, there is some danger of osteomyelitis in having transfixation wires pass through the fracture
segments since the incidence of pin tract infections in pilon fractures may be as high as 55%;
- other complications with circular wire fixators include ankle stiffness, swelling, RSD, and ankle tendon injury;
- ref: Treatment of displaced pylon fractures with circular external fixators of Ilizarov. K. Aktuglu MD et al. FAI Vol 19. No 4. Apr 1998. p 208.
-
external fixation - foot inclusion;
-
cancellous bone grafting of metaphyseal defect:
- wound closure:
***
- Complications:
- wound complications and infection:
- w/ tranditional early ORIF of the tibial articular surface the occurrance of wound slough and infection has ranged from 10 to 50%;
- some authors feel that this complication can be minimized by delayed ORIF (once the swelling has diminished);
- 37% deep infection rate in tibial plafond Rüedi III (Teeny, Clin Orthop 1993);
- unplanned surgery for complications (Wyrsch, JBJS 1996)
- 55% for ORIF
- 18% for external fixation and limited ORIF
- references:
- Open reduction and internal fixation of tibial plafond fractures: Variables contributing to poor results and complications.
SM Teeny and DA Wiss. CORR. Vol 292. 1993. p 108-117.
- Complications encountered in the treatment of pilon fractures. MA McFerran. J. Orthop. Trauma. Vol 6. 1992. 195-200.
***
The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. NH Burwell and AD Charnley. JBJS. Vol 47-B. 1965. p 634-660.
Ten Common Problem Fractures--Symposium: Fractures of the Tibial Pilon.
Fractures of the tibial pilon.
Fractures of the tibial plafond
ORIF of tibial plafond fractures. Variables contributing to poor results and complications. SM Teeny and DA Wiss. CORR. Vol 292. 1993. p 108-117.
The management of the soft tissues in pilon fractures.
Intraarticular "pilon" fracture of the tibia.
Pylon fractures of the distal tibia.
Complications encountered in the treatment of pilon fractures. MA McFerran et al. J. Orthop. Trauma. Vol 6. 1992. p 195-200.
Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications.
Pilon fractures of the tibia: a study based on 19 cases. JP Ayeni. Injury. Vol 19. 1988. p 109-114.
Unilateral external fixation for severe pilon fractures. SB Bonar. Foot Ankle. Vol 14. 1993. p 57-64.
Fractures of the tibial plafond. Evolving treatment concepts for the pilon fracture. RJ Brumback and WC McGarvery. Orthop Clin. North Am. Vol 26. 1995. p 273-285.
Delayed wound healing, infection, and nonunion following open reduction and internal fixation of the tibial plafond fractures. J. Trauma. Vol 26. 1986. p 1116-1119.
Effects of axial dynamization on bone healing. EL Egger et al. J. Trauma. Vol 34. 1993. p 185-192.
Tibial pilon fractures: a comparative clinical study of management techniques and results. EH crutchfield et al. Orthopaedics. Vol 18. 1995. p 613-617.
A staged protocol for soft tissue management in the treatment of complex pilon fractures.
M. Sirkin et al. Journal of Orthopaedic Trauma. Vol 13. No 2. 1999. p 78-84.
Two staged delayed open reduction and internal fixation of severe pilon fractures. MJ Patterson and JD Cole. Journal of Orthopaedic Trauma. Vol 13. No 2. p 85-91.
Salvage technique for treatment of periplafond tibial fractures: the modified fibula-pro-tibia procedure.
Outcomes After Treatment of High-Energy Tibial Plafond Fractures.
Outcome Following Open Reduction and Internal Fixation of Open Pilon Fractures
