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Tibial Pilon Fracture

 

Tibial pilon fractures are high energy axial load injuries. Soft tissue injuries are bad; they can be open or closed fractures. The ankle joint and the metaphysis of the tibia are usually involved. There is no immediate open reduction and internal fixation (because the soft tissue is usually bad). Early ORIF is not recommended. Initially, the treatment is usually closed reduction and a splint followed by staged of ORIF. In the operating room, start by applying external fixator (delay the ORIF). This decreases the incidence of wound complication and deep infection. When internal fixation is used, it is better to use minimally invasive fixation.


 The soft tissue condition should improve before definitive surgery. Wait 1-3 weeks depending on the magnitude of the injury, the anticipated surgery, and the presence of the wrinkle test. After application of the external fixator, get a CT scan to check the joint and the fragments. This will help you to select the best operative approach in the future after the soft tissue condition improves. The physician needs to be aware that the AP radiographs may look okay, however it can be misleading. The joint usually has three fragments attached to ligaments. Because the ligaments are intact, the fragments can be pulled by the external fixator, which is called ligamentotaxis. The three fragments are medial malleolus (attached to the deltoid ligament) or anterolateral fragment (Chaput fragment attached to the anterior inferior tibiofibular ligament). In children, this fragment is called Tillaux fracture. If the fracture involves avulsion of the fibula, it is called Wagstaffe fracture, as rarely seen in some ankle fractures. The third fragment is the Volkmann Fragment (posterolateral fragment attached to the posterior inferior tibiofibular ligament). When the fibula is intact, the lateral collateral ligament of the ankle may rupture (fibula is intact in 20% of the cases). The break travel time returns to normal 6 weeks after initiation of weight-bearing. In ankle fractures, it returns to normal 9 weeks after fixations (post-operatively). The goal of anatomic reduction and stabilization of the articular surface. You may start with fixation of the fibula with a plate or with a screw (in some cases the screw is better because it is minimally invasive). The fibular plate may add stability to the external fixator of the tibia, especially if there is a defect or comminution of the metaphysis of the tibia. Plating of the fibula adjunct to external fixation of the tibia. When there is a metaphyseal defect of the tibia, plating of the fibula can enhance the stiffness of the external fixator. Axial loading is 2.2 times stiffer with plated fibula. There is no significant difference in torsional force. Approaches are many and it varies between limited approach and extensile approach.


 

Try to protect the superficial peroneal nerve. With dual incisions approach, make sure that the distance between the incisions is no less than 7 cm. this is controversial. Everybody agrees that staged ORIF is the best. Arthritis occurs in about 50% of cases and increases with time. Arthrodesis is rare. Usually after 2 years, most of the patients return to work despite having some pain. Significant disability in physical function was noted even with successful treatment in 36- item short form survey (SF-36). In Pilon fractures, SF-36 scale is lower than in patients with pelvic fractures, multiple trauma, and AIDS. Patient socioeconomic factors are predictive of the clinical outcome, and the outcome really did not correlate with reduction of the fracture or with the arthritis. Improvement in function and pain may take up to 2 years and eventually about 10%-15% may need arthrodesis. For a pilon fracture with fracture of the tibial shaft: do fixation of the articular surface (usually percutaneously) then do fixation of the tibial shaft, usually with IM rodding. Put external fixator calcaneal pins or talar pins. I usually put the calcaneal pin from the medial side of the ankle. Be aware of the location of the neurovascular structures.


Error in placement or the direction of the calcaneal pin can interfere with the neurovascular bundle. Avoid the bulge area. Application of the calcaneal traction pin is done at the posteromedial site. There is a ¾ distance between the palpable tip of the medial malleolus and the heel. The calcaneal transfixation pin is inserted in a transverse direction. It is better to keep the pins away from the area of future incisions. Pin insertion should be medial to lateral, anterodistal to anterior colliculus. Placement should be in 10 degrees anterocephalad direction. These three principles in Pilon fractures are great principles: anatomical reduction, stable internal fixation, and early range of motion. Achieving these three principles in every case of pilon fracture may not be possible.

Author
Nabil Ebraheim, MD

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