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Tibial Plafond Fracture

Pilon fractures are defined as intra-articular fractures of the distal tibial plafond and being in a load bearing joint they are serious and usually life changing fractures. The fracture is produced by a mixture of shear and compressive loads to the distal tibial metaphysis. Often such fractures are associated with other severe injuries to the ipsilateral limb, pelvis or lumbar spine.

Pilon fractures make up between 5 and 10% of all lower limb fractures and because of the energy involved are associated with a high (15 – 55%) complication rate.

Significant rotational force alone can also cause distal tibial fractures involving the plafond and these are also Pilon fractures. This mechanism though usually results in less severe soft tissue damage and less compromise to the articular surface in terms of comminution and cartilage damage.

The most frequent mechanism of injury is a fall from height though road traffic accidents also account for a good proportion of high energy Pilon fractures. This patient  also sustained an ispilateral open femoral fracture which was plated on day one of the injury when a temporising external fixator was applied in a delta construct to the ankle.

In terms of operative management, the big debate is when to use ORIF or minimally invasive plate osteosynthesis (MIPO), and when to use an external fixation frame (such as an Ilizarov or other fine wire construct) as definitive treatment. It is with this in mind that there is currently a multi-centre randomised control trial comparing these two forms of treatment,  funded by the NIHR (National Institute for Health Research) in the UK. This study is called the ACTIVE Trial (Articular Type C Pilon Trial Internal Vs External Fixation) being run by the York Trials unit.  This patient was recruited into this trial and randomised to Internal Fixation.

In my hands and working in a unit with excellent fine wire fixation skills we treat those cases where there is very severe soft tissue damage, or where the articular surface is grossly comminuted, with a frame. Those cases where the degree of articular comminution is less severe are usually treated with plate fixation as with the case presented here.

Readers will also find of interest Chris Blundells other OrthOracle instructional technique for surgical treatment of a Pilon fracture Internal fixation of distal tibial Pilon fracture using Stryker AxSOS 3Ti plate. and also Paul Fentons technique Open reduction and internal fixation of C-type Pilon fracture using Smith and Nephew EVOS small fragment system.

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- Discussion:              (w/ assistance and narration by Dr Kyle Dickson MD)

- term pilon (hammer) fracture was introduced to describe these compression injuries by Destot in 1911;
- ref:  High-energy tibial pilon fractures: an instructional review.

- 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
- Acute compartment syndrome of the foot following fixation of a pilon variant ankle fracture
- 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%;
- large number of patients will have pain even after 2 years post injury;
- references:
- Tibial Plafond Fractures. How Do These Ankles Function Over Time?
- Outcomes After Treatment of High-Energy Tibial Plafond Fractures.
- Outcome Following Open Reduction and Internal Fixation of Open Pilon Fractures
- The Sequential Recovery of Health Status after Tibial Plafond Fractures

- 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 a traction x-rays of extremity to help judge effects of ligamentotaxis on displaced articular fragments;
- CT scan: helps plan surgical fixation of 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 level of the plafond (or ankle joint);
- type B:
- results from severe axial compression force, causing distal tibial bony impaction and comminution;

- Surgical Treatment:

Spiral fractures of the distal tibia can pose a management challenge. Invariably, these are unstable injuries that a surgeon would struggle to manage by non-operative measures such as plaster casts or skeletal traction as achieving and maintaining a reduction is challenging. Moreover, patients do not tolerate the lengthy duration of above knee full casts or the recumbency required for skeletal traction. In addition, plain x-ray imaging reveals fracture extension into the ankle joint in about a third of all cases. Addition of CT assessment of the fracture pathoanatomy raises the appreciation of occult propagation of fracture lines into the ankle to 70%. Therefore, with these partial articular injuries (AO Foundation type 43B, see below), operative measures should be considered to achieve reduction and stability as well as restoring and preserving the articular surface.

In my opinion, I prefer internal fixation techniques that allow accurate reduction of the fracture pattern and, with the Stryker AxSOS 3 plating system, robust internal fixation using anatomically contoured plates. The Stryker distal tibial system has both medial and anterolateral plate conformations that provide surgeons with good treatment options for fixation of both extra-articular and intra-articular fractures of the tibia.

OrthOracle readers will also find the following instructional operative techniques of use:

Pilon fracture: C-type fixed using Smith and Nephew EVOS small fragment system.

Pilon Fracture: C-type fixed with Stryker AxSOS 3 Periarticular Plating System

Pilon fracture: Internal fixation using Stryker AxSOS 3Ti plate.

Ankle fracture: Arthrex tightrope for acute syndesmotic injury and Stryker Variax plate for fibula fracture

Ankle fracture : Fibula pro-tibia fixation technique with Stryker Variax plate.

Ankle fracture: Medial malleolar fixation with ASNIS screws

Ankle fracture: Postero-lateral plating of pronation-external rotation ankle fracture (posterior malleolus))

Ankle fracture: Lateral malleolar fixation using Acumed Fibula Rod System

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- controversies:
- surgical timing and staged reconstruction;
- plate vs ex fix;
- ankle arthrodesis;
- primary arthrodesis is one consideration with severe injuries;
- references:
- Ankle arthrodesis using antegrade intramedullary nail for salvage of nonreconstructable tibial pilon fractures.
- Fracture reduction and primary ankle arthrodesis: a reliable approach for severely comminuted tibial pilon fracture.
- Primary Arthrodesis of the Tibiotalar Joint in Severely Comminuted High-Energy Pilon Fractures.

- initial treatment and timing of surgery
- current thinking: external fixation (with or without fibular fixation) followed by delayed definitive fixation at 12-24 days;
- Does a staged posterior approach have a negative effect on OTA- 43C fracture outcomes?
- Clinical and radiographic outcomes in patients operated for complex open tibial pilon fractures.

- Surgical Fracture Fixation: surgical technique:


Pilon fractures are fractures of the distal tibial plafond and by definition are intra-articular and in a load bearing joint, this renders them serious and often life changing fractures. The fracture is sustained by a mixture of shear and compressive loads to the distal tibial metaphysis.

Pilon fractures make up between 5 and 10% of all lower limb fractures and because of the energy involved are associated with a high (15 – 55%) complication rate. Significant rotational force can also cause distal tibial fractures which involve the plafond and these are also pilon fractures. This mechanism though usually has less severe soft tissue damage and less compromise to the articular surface in terms of comminution and cartilage damage.

The most frequent mechanism of injury is a fall from height and this case demonstrates this , being sustained after a 4 metre fall onto concrete through a weak roof .

The big debate is when to use ORIF or minimally invasive plate osteosynthesis (MIPO), and when to use an external fixation frame (such as an Ilizarov or other fine wire construct) as definitive treatment. In my hands and working in a unit with excellent fine wire fixation skills locally we tend to treat those cases where there is very severe soft tissue damage or where the articular surface is grossly comminuted with a frame. Those cases where the degree of articular comminution is less severe are usually treated with plate fixation as was the case presented here.

OrthOracle readers will also find the following instructional operative techniques of use:

Pilon fracture: C-type fixed using Smith and Nephew EVOS small fragment system.

Pilon Fracture: C-type fixed with Stryker AxSOS 3 Periarticular Plating System

Pilon fracture: Internal fixation using Stryker AxSOS 3Ti plate.

Ankle fracture: Arthrex tightrope for acute syndesmotic injury and Stryker Variax plate for fibula fracture

Ankle fracture : Fibula pro-tibia fixation technique with Stryker Variax plate.

Ankle fracture: Medial malleolar fixation with ASNIS screws

Ankle fracture: Postero-lateral plating of pronation-external rotation ankle fracture (posterior malleolus))

Ankle fracture: Lateral malleolar fixation using Acumed Fibula Rod System

Read more »

This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

Take the Tour

View this procedure on OrthOracle.com

- reduction and ORIF of fibula;
- exposure of tibial articular surface
- restoration of tibial articular surface
- Treatment of AO/OTA 43-C3 Pilon Fracture: Be Aware of Posterior Column Malreduction.
- fixation of metaphysis to diaphysis:
- Risk Factors for Tibial Plafond Nonunion: Medial Column Fixation May Reduce Nonunion Rates.

- Implants:
- plate fixation
- IM Nail: (see Nail fixation of distal tibia)
- references:
- Is there a role for intramedullary nails in treatment of simple pilon fractures? Rationale and preliminary results.
- Intramedullary Nailing in a Tibial Shaft Fracture With Distal Articular Extension
- Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing..
- [Combination of intramedullary nail and covered screw osteosynthesis for managing distal tibial fracture with ankle joint involvement].
- Extra-articular distal tibia fractures: a mechanical evaluation of 4 different treatment methods.
- Intramedullary nailing of unstable diaphyseal fractures of the tibia with distal intraarticular involvement.

- uniplanar external fixation
- external fixation - foot inclusion
- circular wire fixators
- theoretically, there is some danger of osteomyelitis in having transfixation wires pass through the fracture segments
since 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;
- references:
Treatment of displaced pylon fractures with circular external fixators of Ilizarov.
- External Fixation Versus ORIF for Distal Intra-articular Tibia Fractures.
- cancellous bone grafting of metaphyseal defect
- wound closure:

- ref: The management of the soft tissues in pilon fractures.

 


- Complications:
- wound complications and infection: (see soft tissue coverage for tibia fracture)
- w/ tranditional early ORIF of the tibial articular surface the occurrance of wound slough and infection
has ranged from 10 to 50%;
- some 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 and Wiss (1993));
- unplanned surgery for complications (Wyrsch (1996))
- 55% for ORIF
- 18% for external fixation and limited ORIF
- degenerative joint disease:
- rates for secondary ankle arthrodesis after attempted ORIF of type 3 fractures approaches 30%.
- syndesmotic injuries:
- Syndesmosis and Syndesmotic Equivalent Injuries in Tibial Plafond Fractures.

- references:
Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications.
- Complications encountered in the treatment of pilon fractures.
- Delayed wound healing, infection, and nonunion following open reduction and internal fixation of the tibial plafond fractures.
- The management of the soft tissues in pilon fractures.
- Early complications following the operative treatment of pilon fractures with and without diabetes.
- Operative Treatment of Fractures of the Tibial Plafond. A randomized, prospective study

***


The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement.

Fractures of the tibial pilon.

Intraarticular "pilon" fracture of the tibia.

Pylon fractures of the distal tibia.

Pilon fractures of the tibia: a study based on 19 cases.

Fractures of the tibial plafond. Evolving treatment concepts for the pilon fracture.

Tibial pilon fractures: a comparative clinical study of management techniques and results.

Salvage technique for treatment of periplafond tibial fractures: the modified fibula-pro-tibia procedure.

Unilateral external fixation for severe pilon fractures.