Pilon Fracture

Jinnasit hongtrakul
11/1/61
Introduction to tibial pilon fracture
• The term ‘tibial pilon’ was first used by Destot in 1911,
• French language pilon means pestle.
• Plafond, meaning “ceiling”
Tibial pilon fracture
• 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.
Mechanisms of Injury for Tibial
Pilon Fractures
Mechanisms of Injury for Tibial
Pilon Fractures
• Distal tibial articular surface
• Metaphyseal comminution
• Joint impaction
• Disruption of the ankle mortise
• Severe soft tissue injuries
Clinical Presentation and evaluation
• Clinical Presentation Patients typically present non-ambulatory with
variable gross deformity of the involved distal leg.
• Swelling  Often massive and rapid
• Assessment of soft tissue damage
• Assessment neurovascular
Clinical Presentation and evaluation
• Assessment associated injury
• Because of their high-energy nature, these fractures can be expected to have
specific associated injuries
• Calcaneus fractures
• Tibial plateau fractures
• Pelvis fractures
• Vertebral fractures
 Blister
Clear fluid-filled blister

Blood-filled blister
• Deeper and worser
• Free of epidermal cells
• Slow re-epithelialization
• Increasing rate of infection,
scarring, delayed definite surgery

Avoid making incision through a blood-filled blister bed

Radiographic Evaluation
• Ankle AP, lateral and mortise views
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. Medial malleolar
• 3. Posterolateral (Volkmann fragment)
• These fragments vary in their size and
amount of comminution
Ruedi - Allgower Classification

• 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
AO/OTA Fracture Classification
AO/OTA Fracture Classification
• More comprehensive & higher interobserver reliability

A3

B3

C3
Tibial Pilon Fracture Surgical Anatomy
Four-column Classification
Tibial Pilon Fracture Surgical Anatomy
Tibial Pilon Fracture treatment option
• Nonoperative Treatment of Tibial Pilon Fractures
• Operative Treatment of Tibial Pilon Fractures
Nonoperative Treatment of Tibial Pilon
Fractures
• 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 intra-
articular fragments.
• Disadvantages:
• Loss of reduction: common
• Inability to monitor soft tissue status and swelling
Operative Treatment of Tibial Pilon Fractures
Goal of management of pilon fracture
• 1. Reconstruction of the correct fibular length
• 2. Reconstruction of the tibial articular surface
• 3. Autologous bone grafting at metapyseal defect
• 4. Buttress plating of medial tibia
 Two Staged Protocols
Low soft tissue complication rate
Low infection rate
Time for careful pre-op. planning
Early Late
• Spanned external fixation • Definitive articular
• +/- Fibular fixation reconstruction
• +/- Limited ORIF of • Remove fixator
diaphyseal extension • Bone grafting
• CT scan + Pre-op. planning
• Allow soft tissue stabilization
Two Stage Protocol (Stage I)
• Stage 1: Fibular Open Reduction and Internal Fixation and Spanning
Tibiotalar Spanning External Fixation.
Two Stage Protocol (Stage I)
Two Stage Protocol (Stage I)
Fibular Alignment Controls Talus
Fibular Alignment Controls Talus
“traveling traction”
 Two Stage Protocol (Stage I)
• The limb is placed into a well-padded splint and a CT scan of the distal tibia
and fbula is then obtained to allow for the preoperative planning of the
defnitive tibial fxation.
• Final tibial reduction and fxation is usually performed 7 to 21 days
after this initial stage and only after soft tissue recovery has
occurred1
Surgical Time
• Resolution of edema
“Wrinkle” sign
• Resolution of
ecchymosis over the
intended surgical site
• Re-epithelialized of Avoid 2-7 days
fracture blisters
• Healing of open
fracture wounds
• No infection
Two Stage Protocol (Stage II)
• Stage 2: Defnitive Tibial Pilon Fracture Open Reduction
and Internal Fixation
• restorationof the articular surface along with stable internal fxation
that allows early motion is felt to be the most important predictor of
a satisfactory outcome
Two Stage Protocol (Stage II)
• preoperative Planning for Defnitive Tibial Pilon Fracture
Open Reduction and Internal Fixation.
• (1) a complete review and assessment of the postspanned CT scan
• (2) the initial injury radiographs to determine the optimum location for
implants to stabilize the metadiaphysis
• (3) a clinical assessment of the soft tissue envelope to determine areas that
are optimal or suboptimal for surgical incisions and implants.
Two Stage Protocol (Stage II)
• C-type injury patterns commonly demonstrate three main
fracture segments
• the anterolateral (Chaput) fragment
• the posterior (Volkmann) fragment
• the medial malleolar fragment
• Each of these fragments typically remains attached to the
anterior tibiofbular ligament, the posterior tibiofbular ligament,
and the deltoid ligament, respectively.
 Surgical Approaches
• Standard approaches
 Medial, anteromedial, posteromedial
 Lateral, anterolateral, posterolateral
• Minimal invasive approach

Anteromedial Anterolateral

Medial
Lateral

Posterolateral
Posteromedial
Surgical Approaches
 Which surgical approach?

• Location and Anteromedial

displacement of
Anterolateral
major fragments
• Local soft tissue
condition
Posteromedial

Posterolateral
Surgical Approaches  modified anteromedial
Surgical Approaches  anterolateral
 Surgical Incision

• Skin bridge “7 cm” Rule ?

• Recent prospective study
 At least 2 skin incisions
averaging 5.9 cm in 42 patients
with 46 pilon fractures
 Low soft tissue complications

Howard JL, J Orthop Trauma (2008)

Liporace FA, J Orthop Trauma (2012)
Surgical Technique for Defnitive Tibial Pilon
Fracture Open Reduction and Internal Fixation.
• Reduction, and stabilization of the posterolateral (Volkmann) fragment. Via
the posterior tibiofibular ligament
• An accurate fibular reduction begins the tibial reduction by indirectly
reducing the posterolateral Volkmann fragment relative to the proximal
tibia
• reduction of the posterolateral fragment is performed via an anterior
exposure, or directly using a posterolateral exposure
• The reduction sequence commonly involves reducing the posterior aspect
of the medial malleolar fragment to the posterolateral fragment.
• The medial malleolar fragment is secured using the medial shoulder
chondral interdigitations, followed by reduction of the anterolateral
(Chaput) fragment.
• An anatomic reduction of the proximal metadiaphyseal component
essentially converts the C-type tibial pilon fracture into a partial articular
(B-type) injury
 Reduction techniques
More important than “direct“ or “indirect“, ORIF or MIS
is the gentle care for the soft tissues without force
or any additional damage.

Tools for reduction

• Pointed reduction clamp
• Distractor
• Push-pull technique
• K-wire cage push

• Femoral distractor
pull
• Combinations…
 Reduction & Fixation Strategies

• Secure articular segment

• Connect articular block to

diaphysis
 Fixation Techniques
• Low- profile pre-contoured plate

Cloverleaf plate
 Locking Plate is Necessary?
Indications
• Osteoporotic bone
• Extensive metaphyseal
comminution
• Metaphyseal bone loss
• Small articular fragments
• Convention plate can’t be
used due to local soft tissue
condition.
Two Stage Protocol (Stage II)
Postoperative Care for Tibial Pilon Fracture
Open Reduction and Internal Fixation.
• The injured limb is placed into a well-padded plaster splint with the
foot in neutral position.
• Pain is controlled with patient controlled anesthesia devices.
Peripheral nerve blocks, including peripheral nerve catheters, are
commonly used during the first 24 to 48 hours.
• The wound is typically examined approximately 4 to 5 days
postoperatively
• The limb is subsequently splinted in a neutral position until the
sutures are removed at 2 to 3 weeks.
Postoperative Care for Tibial Pilon Fracture
Open Reduction and Internal Fixation.
• Supervised physical therapy program consisting of active, active-
assisted, and passive range of motion of the ankle, subtalar, and
metatarsophalangeal joints is then initiated.
• To avoid equinus contracture, a removable nighttime and resting
splint is recommended
• Partial progressive weight bearing in a removable boot is initiated
approximately 12 weeks after defnitive surgery
Outcomes of Tibial Pilon Fracture Open Reduction
and Internal Fixation.
Complication
• Superficial Wound infection
• Deep Wound Complications
• Osteomyelitis
• Nonunion
• Posttraumatic Arthritis
THANK YOU