Published on January 24, 2014
Tibial P ond laf Fractures (Pilon Fr act ur es) Muhammad Abdelghani
Historical Perspective The term ‘tibial pilon’ was first used by Destot in 1911, likening the pilon to a pestle.
Definition All fractures of the tibia involving the distal articular surface should be classified as pilon fractures, except for medial or lateral malleolar fractures and trimalleolar fractures where the posterior malleolar fracture involves < 1 /3 of the articular surface.
Are isolated fractures of the posterior malleolus considered pilon fractures? Yes Isolated fractures of the posterior malleolus (Volkmann triangle) account for 5% of tibial pilon fractures.
Anatomy Tibial pilon = the distal end of the tibia including the articular surface. Proximal limit of tibial pilon: 8-10 cm from the ankle articular surface.
Epidemiology Pilon fractures account for 7%-10% of all tibia fractures. Most pilon fractures are a result of high-energy mechanisms. Thus, concomitant injuries are common and should be ruled out. Most common in men 30-40 years old.
Mechanism of injury Fracture pattern is dictated by position of foot and talus at time of impact: Plantar flexion injury: posterior lip fragment. Neutral ankle: anterior and posterior fragments. Dorsiflexion injury: anterior lip fragment.
Mechanism of Injury Axial compression: fall from a height The force is axially directed through the talus into the tibial plafond, causing impaction of the articular surface. It may be associated with significant comminution. If the fibula remains intact, the ankle is forced into varus with impaction of the medial plafond. Plantar flexion or dorsiflexion of the ankle at the time of injury results in primarily posterior or anterior plafond injury, respectively.
Mechanism of Injury Shear: skiing accident Mechanism is primarily torsion combined with a varus or valgus stress. It produces 2 or more large fragments and minimal articular comminution. There is usually an associated fibula fracture, which is usually transverse or short oblique.
Mechanism of Injury Combined compression and shear These fracture patterns demonstrate components of both compression and shear. The vector of these 2 forces determines the fracture pattern.
Clinical Presentation Patients typically present nonambulatory with variable gross deformity of the involved distal leg.
Clinical Evaluation Full trauma evaluation and survey may be necessary. Most pilon fractures are associated with high-energy trauma. Assessment of neurovascular status Evaluation of any associated injuries.
Clinical Evaluation Swelling: Often massive and rapid Necessitates serial neurovascular examinations as well as assessment of skin integrity, necrosis, and fracture blisters. Soft tissue injury including oedema, contusion and blisters associated with pilon fractures
Clinical Evaluation Meticulous assessment of soft tissue damage Significant damage occurs to the thin soft tissue envelope surrounding the distal tibia as the forces of impact are dissipated.
Plain Radiography It is essential to have plain films centered on the ankle as well as films of the entire tibia.
Plain Radiography Ankle films AP, lateral, and mortise views Delineate articular incongruity and fragmentation.
Plain Radiography Tibial films Necessary to fully evaluate the metaphyseal and diaphyseal extent. Proximal injuries may easily be overlooked.
Plain Radiography Traction X-Ray Traction and ligamentotaxis often pull the displaced fragments back into position, allowing for a better definition and understanding of the fracture pattern.
Radiographic Evaluation Computed tomography (CT) Used as an adjunct to plain films. Shows details often not readily available on most plain films. Acts as guide to the articular injury for fracture orientation, fragment location, and amount of comminution or impaction. Aids in surgical decision making.
Radiographic Evaluation The 3 classic articular components of pilon fracture (Axial CT): 1. Anterolateral (Chaput fragment) 2. 3. Medial Posterolateral (Volkmann fragment) These fragments vary in their size and amount of comminution
Radiographic Evaluation Radiographs of the contralateral side may be useful as a template for preoperative planning.
Radiographic Evaluation The 3 important anatomical zones to be considered in the decision-making and prognosis: 1. 2. 3. Articular surface Metaphysis Fibula
Associated Inuries Because of their high-energy nature, these fractures can be expected to have specific associated injuries, e.g.: Calcaneus fractures Tibial plateau fractures Pelvis fractures Vertebral fractures
Classification Rüedi & Allgöwer Commonly used today Based on the severity of comminution and the displacement of the articular surface.
Classification Rüedi & Allgöwer Type I: Nondisplaced cleavage fracture of the ankle joint Type II: Displaced fracture with minimal impaction or comminution Type III: Displaced fracture with significant articular comminution & metaphyseal impaction
Classification Rüedi & Allgöwer Ovadia and Beals added types IV and V to include fractures that extend into the metaphyseal and diaphyseal regions with more severe comminution, which is characteristic of many high-energy injuries Prognosis correlates with increasing grade.
Classification Mast Combination of the Lauge-Hansen classification of ankle fractures and the Ruedi-Allgöwer classification. Type A: Malleolar fractures with significant posterior lip involvement (Lauge-Hansen SER IV injury) Type B: Spiral fractures of the distal tibia with extension into the articular surface Type C: “Central impaction injuries” as a result of talar impaction, either with or without fibula fracture; subtypes 1, 2, and 3 correspond to the Ruedi-Allgöwer classification
Classification AO/OTA An even more comprehensive classification. Includes subdivisions based on amount of comminution. Very useful for research as it permits a more exact description of the injury, allowing better comparisons between studies.
Classification AO/OTA Three main subgroups: Extra-articular (43-A) Partial articular (43-B) Complete articular (43-C) These are further divided into subgroups depending on the comminution. Most type B fractures have traumatic torsion mechanisms, while the C-type usually have high energy compression mechanisms.
Treatment Treatment challenges: Difficulties in anatomical reduction of the articular surface Instability may occur due to ligamentous and soft tissue injury Numerous soft-tissue complications may be encountered during treatment open surgery is associated with poor wound healing, restoration of the anatomy is difficult and delayed union and infection are common.
Treatment Factors dictating treatment strategy: Patient age & functional status Severity of injury to bone, cartilage, and soft tissue envelope Degree of comminution and osteoporosis Capabilities of the surgeon
Treatment Possible treatment methods: Conservative treatment with cast Open reduction and internal fixation (as described by Riiedi and Allgower) Combination of different types of external fixators with or without internal fixation
Treatment Strategies for an optimal outcome: Anatomical reconstruction of the joint Restoration of tibial alignment Stabilization of the fracture to facilitate union
Treatment Understanding of the anatomy of the fracture should allow the development of improved operative techniques and outcomes. Proper length and rotation are critical, as are preserving and maximizing ankle and subtalar motion. Even when these goals are met, there is no guarantee that patients will have an acceptable result.
Treatment Non-operative Long leg cast for 6 weeks followed by fracture brace and ROM exercises or early ROM exercises. Indications: Nondisplaced fracture pattern Severely debilitated patient Manipulation of displaced fractures is unlikely to result in reduction of intraarticular fragments.
Treatment Non-operative Disadvantages: Loss of reduction: common Inability to monitor soft tissue status and swelling
Treatment Operative Displaced pilon fractures are usually treated surgically. Helfet (1994) was the first to propose a twostage protocol for this type of fracture: First stage: Temporary external fixation, to restore length, alignment and rotation of the limb + ORIF of a fibular fracture, if present, if the soft tissue allows. Second stage: Definitive surgery, when the soft tissues have recovered sufficiently to limit the likelihood of complications.
Decision making flowchart
Treatment Operative TIMING OF SURGERY Proper timing of treatment is required to minimize soft-tissue complications. Interventions must respect the underlying tissue and the amount of surgery that the soft-tissue envelope can tolerate. Staged procedures are therefore often required to reduce complications and maximize functional results.
Treatment Operative TIMING OF SURGERY Staged protocols have been shown to be effective in preventing complications related to soft tissue. Immediate or early intervention (within 12-18 h of injury) is usually limited to stabilization of the fibula with a plate, using transarticular external fixation to keep the extremity out to length and to obtain a preliminary reduction by ligamentotaxis. Definitive reconstruction can be performed at a later date.
Treatment Operative SKELETAL TRACTION If more than a few hours have elapsed between the injury and the evaluation, the soft-tissue swelling will be too great to allow for immediate ORIF. In this situation, skeletal traction (using a calcaneal pin or an external fixator) should be used to prevent skeletal shortening while awaiting for soft-tissue recovery (which may take days or weeks). Indirect reduction with traction helps to realign the fracture surfaces, which makes subsequent internal fixation easier to accomplish.
Treatment Operative SKELETAL TRACTION Placement of the external fixator creates a more optimal environment for soft-tissue healing. It is necessary to wait for the reepithelialization of each blister locally and assess the status of the skin until the wrinkle sign of the skin is positive. Associated fibula fractures may undergo ORIF at the time of fixator application.
Treatment Operative DEFINITIVE RECONSTRUCTION Definitive reconstruction through open approaches should be delayed until soft-tissue swelling has decreased, as the tissues are tenuous and cannot withstand surgical trauma. Surgery should be delayed for at least 10 days to allow wrinkles to return, blisters to re-epithelialize, and wounds to heal. In some cases delaying the procedure for up to 4 weeks may be required to allow soft-tissue swelling to subside.
Treatment Operative DECISION MAKING What kind of incision should be made, medial or lateral? Which implant will maintain the reduction the best? Should an external fixator be used? Should it be placed temporarily or used for definitive treatment? Should treatment be staged or done all at once?
Treatment Operative GOALS Maintenance of fibula length and stability. Restoration of tibial articular surface. Bone grafting of metaphyseal defects. Buttressing of the distal tibia.
The 4 traditional principles of reconstruction
Treatment Operative SURGICAL TACTIC Articular fracture reduction can be achieved percutaneously or through small limited approaches assisted by a variety of reduction forceps, with fluoroscopy to judge fracture reduction. The metaphyseal fracture can be stabilized either with plates or with a non-spanning or spanning external fixator. Bone grafting of metaphyseal defects
Limited Open Reduction
Treatment Operative SURGICAL TACTIC Internal fixation: Like in all articular fractures, ORIF is the most reliable way to obtain an anatomic reduction of the articular surface. However, this option should be carefully weighted against: Soft-tissue condition (vascularity may be affected by surgical approach if too early) comminution and number of fragments.
Treatment Operative SURGICAL TACTIC Internal fixation: After soft-tissue recovery, a limited open reduction and stabilization of the articular component is done with screws alone or with screws and a small buttress plate. Location of incisions and steps of reduction are based on the preoperative plan. Soft-tissue dissection should be minimized and fragments should remain attached to the periosteum and the joint capsule.
Treatment Operative SURGICAL TACTIC Internal fixation: The first step is the fixation of the fibula, to regain the correct length of the tibia and to facilitate the threedimensional orientation and reduction of the fracture.
Treatment Operative SURGICAL TACTIC Internal fixation: Several surgical approaches to the tibia have been described for the treatment of these fractures. Whatever the surgical route chosen, the surgical approach should be centred on the larger bone fragment and care taken not to traumatize the skin with aggressive surgical technique. An arthrotomy is essential for the accurate reduction of articular fragments. Keep a maximum of 2 mm of incongruity of the articular surface.
The distance between the two incisions should not be less than 6-7 cm
Posterolateral approach, allowing access to the fibula
Treatment Operative SURGICAL TACTIC Internal fixation: The articular surface generally is reassembled from lateral to medial and from posterior to anterior. The anterolateral portion of the tubercle of Chaput usually is still attached to the anterior syndesmotic ligaments and is brought down into position at the time of fibular reduction. The anterolateral corner of this reduced fragment can be used as a guide for the restoration of tibial length. Any posterolateral or posterior fragments then are reduced to the anterolateral fragment. The remaining fragments, including any central depressed fragments, then are realigned.
Treatment Operative SURGICAL TACTIC Internal fixation: When necessary, the split medial malleolar fragment can be retracted posteriorly to allow for better visualization of the articular reduction. Temporary fixation is obtained with K-wires, and the reduction is confirmed radiographically.
Treatment Operative SURGICAL TACTIC Internal fixation: Bone-grafting of any structurally deficient areas in the cortical or cancellous bone of the metaphysis then should be done.
Treatment Operative SURGICAL TACTIC Internal fixation: When plate fixation is planned, an anterior or anteromedial buttress plate is used, depending on the fracture configuration. Large spoon and T-plates no longer are recommended (too bulky and can compromise the overlying soft tissues).
Spoon plate as an anterior buttress plate. This plate should never be used; rather, a lower profile implant as one may use in the distal radius should be used
Treatment Operative SURGICAL TACTIC Internal fixation: A 3.5-mm cloverleaf plate has a much smaller profile than the large-fragment-system plates but still has adequate strength to maintain reduction and can be bent and contoured relatively easily for positioning on the tibia. Cannulated screws can be placed independent of the plate, either through the wound or percutaneously, to secure isolated fragments. The importance of meticulous care of the soft tissues, including a tension-free closure, cannot be overemphasized.
Treatment Operative SURGICAL TACTIC Techniques to minimize plating complications: Surgical delay until definitive surgical treatment using initial spanning external fixation for high energy injuries Use small, low-profile implants Avoid incisions over the anteromedial tibia Use indirect reduction techniques to minimize soft tissue stripping Use percutaneous techniques for plate insertion
Treatment Operative SURGICAL TACTIC External Fixation as Definitive Treatment: This has been of interest in recent years, particularly for its benefits with respect to minimal interference with the soft tissue. External fixators can be either unilateral or circular, they may span or not the ankle joint and may permit or not its motion. Portable traction
Treatment Operative SURGICAL TACTIC External Fixation as Definitive Treatment: The principle of treatment with an external fixator is through ligamentotaxis. While most fixators are constructed to provide a tibiotalar-calcaneal bridge, circular fixators allow a tibial-only assembly. This can allow early ankle mobilization and, depending on the size and orientation of the wires, a juxtaepiphyseal assembly and partial control over the comminution of the fragments, which may be assembled under arthroscopic control.
Tibial Safe Zones
Treatment Operative SURGICAL TACTIC External Fixation as Definitive Treatment: The assembly of the external fixator should not jeopardize the attainment of an eventual coverage flap. The pins of the fixator should not be placed along the course of a possible incision site for future surgical treatment. The assembly of the external fixator should, as with internal fixation, be preceded by the fibular synthesis, where necessary and if the soft tissue allows, in order to restore the correct length. Circular frame (LiMA) external fixation of a pilon fracture
Treatment Operative SURGICAL TACTIC Articulating vs non-articualting spanning external fixation: Nonarticulating (rigid) external fixation: most commonly used. Theoretically allows no ankle motion. Articulating external fixation: Allows motion in the sagittal plane, thus preventing ankle varus and shortening. Application is limited, but theoretically it results in improved chondral lubrication and nutrition owing to ankle motion, and it may be used when soft tissue integrity is the primary indication for external fixation.
Treatment Operative SURGICAL TACTIC Hybrid external fixation: A type of nonspanning external fixator. Fracture reduction is enhanced using thin wires ± olives to restore articular surface and maintain bony stability. Especially useful when internal fixation of any kind is contraindicated.
Treatment Operative SURGICAL TACTIC Hybrid external fixation: With severe soft-tissue injuries or open fractures, a hybrid ring fixator for the tibia may be used in combination with standard plating of the fibula. As definitive treatment, this technique is only suitable for simple articular fractures, which can be reduced anatomically by indirect reduction techniques and fixed by percutaneous lag screws. In complex fractures an anatomical and stable reconstruction of the articular bloc usually requires ORIF.
Treatment Operative SURGICAL TACTIC If an external fixator is used, weight-bearing should be delayed until there is radiographic evidence of bone healing.
Treatment Operative SURGICAL TACTIC Arthrodesis: Seldom performed acutely. Reserved only for severe articular comminution which is not otherwise reconstructable Best done after fracture comminution has consolidated and soft tissues have recovered. Generally performed as a salvage procedure after other treatments have failed and posttraumatic arthritis has ensued.
Treatment Operative Open Pilon Fractures Open pilon fractures present an additional challenge. Like all open fractures, they require emergency debridement, irrigation, and stabilization. The typical wound associated with an open pilon fracture is a transverse distal anteromedial laceration. The proximal skin flap is contused, and use of the usual anteromedial incision may compromise its blood supply.
Treatment Operative Open Pilon Fractures Steps in treating open pilon fractures: Apply an external fixator Obtain indirect reduction Stabilize the fibula Perform the reconstruction of the articular surface through the open wound with use of cannulated screws for stabilization. This technique has been found to be less traumatic to the already injured soft tissues than the traditional extensile exposure.
Treatment Operative Open Pilon Fractures Cancellous bone-grafting and even internal fixation can, if necessary, be delayed until 4-6 weeks later, when the soft tissues have stabilized and the risk of soft-tissue slough and infection is reduced.
Post-operative Management Initial splinting in neutral dorsiflexion with careful monitoring of soft tissues. Early ankle and foot motion when wounds and fixation allow. Non-weight bearing for 12-16 weeks, then progression to full weight bearing once there is radiographic evidence of healing.
Main pitfalls and the resulting complications in operated pilon fractures
Complications Pilon fractures, especially those caused by highenergy trauma, have been associated with a high rate of complications. Even when accurate reduction is obtained, predictably excellent outcomes are not always achieved, and less than anatomic reduction can lead to satisfactory outcomes.
Complications Early postoperative problems: Skin necrosis Superficial and deep infection Loss of fixation. Complications with fracture healing: Delayed union or non-union of the metaphyseal-diaphyseal junction Varus or valgus malunion of the distal part of the tibia Non-anatomical reduction or postoperative loss of reduction of articular surface
Complications Soft tissue slough, necrosis, and hematoma: result from initial trauma plus improper handling of soft tissues. Avoid excessive stripping Avoid skin closure under tension Secondary closure, skin grafts, or muscle flaps may be required for adequate closure. Prevalence of postoperative skin and wound problems decreased substantially with use of the technique of indirect reduction with external fixation and reconstruction of the articular surface with small plates or screws, or both.
Complications Nonunion: Results from significant comminution and bone loss, as well as hypovascularity and infection. Incidence: 5%, regardless of treatment method.
Complications Malunion: Common with non-anatomic reduction, inadequate buttressing followed by collapse, or premature weight bearing. Incidence: up to 25% with use of external fixation. Stabilization of the anterolateral fragment and bonegrafting of the lateral border of the distal part of the tibia promote union and reduce the prevalence of both valgus malunion and non-union of this fracture.
Complications Infection: Associated with open injuries and soft tissue devitalization. Highest incidence with early surgery under unfavorable soft tissue conditions. Late infectious complications may manifest as osteomyelitis, malunion, or nonunion.
Complications Posttraumatic arthrosis: Results from damage of articular cartilage at the time of injury Also associated with fractures in which a congruous articular surface was not restored or maintained. Primary ankle arthrodesis is rarely indicated because the long-term outcome is not easy to predict. Although some patients may need an ankle arthrodesis because of symptomatic osteoarthrosis, others do fairly well despite radiographic signs of post-traumatic osteoarthrosis.
Complications Tibial shortening: Caused by fracture comminution, metaphyseal impaction, or initial failure to restore length by fibula fixation.
Complications Decreased ankle ROM: Patients usually average <10°of dorsiflexion and <30°of plantar flexion.
Refernces Sirkin MS: Plating of Tibial Pilon Fractures. Am J Orthop. 2007;36(12 suppl):13-17. Topliss CJ, Jackson M, Atkins RM: Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg [Br] 2005;87-B:692-7.
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