You are in: eMedicine Specialties > Orthopedic Surgery > FOOT AND ANKLE Pilon FracturesArticle Last Updated: Jun 19, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Vinod K Panchbhavi, MD, Assistant Professor of Orthopedics, Department of Orthopedics and Rehabilitation, University of Texas Medical Branch Vinod K Panchbhavi is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, British Medical Association, British Orthopaedic Association, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, and Texas Orthopaedic Association Editors: James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St. Luke's Hospital, Jacksonville, Florida; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: tibial plafond fracture, pylon fracture, distal tibial fracture, explosion fractures of the distal tibia, axial compression fractures of the distal tibia, tibia, ankle, distal tibia, ankle joint INTRODUCTIONSection 2 of 12
  Pilon fractures in the distal tibia result from axial forces that can range from low to high energy and produce a spectrum of articular and metaphyseal injuries. These can be challenging to manage, especially when associated with significant soft-tissue injury. Although a variety of options are available to treat these fractures, timing of definitive surgery is crucial with respect to the condition of the soft tissues. Despite the advances that have been made in managing these fractures, new developments in the field continue to lead to better outcomes. History of the ProcedurePilon is a French word for pestle, an instrument used for crushing or pounding.1 The first recorded use of the term pilon in the orthopedic literature is in 1911, by Étienne Destot.2 In 1959, Jergesen stated that open reduction and stabilization of severe tibial pilon fractures is impossible. The treatment of pilon fractures has evolved over the last century. Conservative management gave way to surgical intervention when implants became available, but poor outcomes led to a return to cast immobilization or limited internal fixation of the fibula only. However, outcomes after nonoperative treatment continue to be poor. In the early 1960s, the Association for Osteosynthesis/Orthopaedic Trauma Association (AO/OTA) developed general guidelines for the treatment of intra-articular distal tibial fractures, which led to open reduction and anatomic and rigid internal fixation. Good outcomes were reported when these principles were used for low-energy injuries (eg, those from skiing accidents). However, when the same principles were used to fix high-energy injuries (eg, from motor vehicle accidents), the outcomes were poor, mainly because of soft-tissue complications. Over the years, the importance of soft tissues and the differences between low- and high-impact energy injuries have become better understood. This has led to the development of newer treatment concepts, which continue to evolve, along with an availability of more advanced surgical options, such as minimally invasive internal fixation implants.3, 4, 5 ProblemPilon fractures involve the dome of the distal tibial articular surface and extend into the adjacent metaphysis. The fibula may or may not be intact (see Images 1-6). FrequencyPilon fractures account for approximately 7% of tibial fractures. EtiologyPilon fractures occur when the talus is driven vertically into the tibial plafond. The cortical bone shatters; the softer metaphyseal bone can also be affected. PathophysiologyDepending on the mechanism, a wide variety of injuries can occur. At one end of the spectrum are low-energy injuries that follow activities such as skiing and result in minimal soft-tissue injury. The fracture fragments are fewer, may have a spiral orientation, and are relatively minimally displaced. At the other end of the spectrum are high-energy injuries such as a fall from height or a high-speed motor vehicle accident. Such a mechanism can produce significant comminution with multiple displaced fracture fragments and, importantly, a contused or crushed soft-tissue envelope, which could also be breached and open to external contamination through wounds. The fibula is usually fractured in high-energy injuries. A variable amount of damage can occur to the articular cartilage of the tibia, which can be scuffed, bruised, or fragmented. In severe cases, the weight-bearing central dome can be fragmented. The fragments, which can be tiny (approximately 2-3 mm3), are completely broken off and are driven up into the metaphysis of the tibia by the impact. Damage to the talar articular surface can also occur. ClinicalPatients involved in high-energy trauma should be treated according to advanced trauma life-support guidelines because they may have associated life- or limb-threatening injuries. History Obtain a history of any allergies, intake of medications, past medical history (eg, diabetes mellitus, peripheral vascular or naturopathic disease), and events leading to the injury. An understanding of the mechanism of injury may lead to an indication of the forces involved. Also, knowledge of any history of previous trauma in either limb is helpful during restoration. Clinical presentation varies depending on the severity of the injury and the duration from the time of the injury. Soft tissues swell rapidly, and tissue tension can produce enormous blisters. The underlying bony fragments may be significantly displaced, threatening the viability of the overlying soft-tissue envelope. Crushing, degloving, bruising, and hematomas can further compromise soft tissues (see Image 7). The Oestern and Tscherne classification of soft-tissue injury in closed fractures is as follows:
Traumatic wounds can vary from a puncture wound, which is usually either medial or lateral, to large injuries with extensive loss of soft tissue. The Oestern and Tscherne classification for open fractures uses wound size, level of contamination, and fracture pattern to grade open fractures, and is as follows:
The Gustilo classification can also be used for open fractures and is as follows:
Any neurovascular injury must be documented at the time of presentation. Compartment syndrome is a risk in acute injuries; therefore, frequent evaluations are necessary. A systematic and complete evaluation is necessary because other injuries (eg, to the spine or other extremities) may have occurred after a fall from height. Clinical types Based on the mechanism of injury and damage to soft tissue and bone, pilon fractures can be divided into 2 broad categories as follows:
Related Medscape topic: INDICATIONSSection 3 of 12
Indications for surgery include the following:
RELEVANT ANATOMYSection 4 of 12
The distal tibia and fibula, along with the ligaments and capsule, help to form the ankle mortise. Any disruption of length, axis, or rotation of the fibula or the tibia can result in an incongruent ankle joint. The lateral aspect of the distal tibia forms a triangular notch, which is where the fibula articulates. The interosseous and the anterior and posterior tibiofibular ligaments bind these bones together. The ligaments often avulse fragments from the tibia, such as the anterolateral fragment termed the Chaput fragment and the posterior malleolar fragment termed the Wagstaffe fragment. The blood supply in the distal leg is provided by branches that arise from the posterior tibial, peroneal, and dorsalis pedis arteries. The great saphenous vein travels along with the saphenous nerve anterior to the medial malleolus. The small saphenous vein passes posterior to the lateral malleolus. Disruption of the venous system can lead to subsequent chronic venous stasis. CONTRAINDICATIONSSection 5 of 12
The presence of soft-tissue swelling and/or blisters, peripheral vascular disease, and/or wound infection are contraindications for extensive surgery such as open reduction and internal fixation. External fixation with use of a hybrid frame or a cast can be used in such situations. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyPain relief is necessary. Antibiotic prophylaxis is used for open fractures and for internal fixation. Conservative treatment may be indicated in undisplaced fractures, which can be managed with cast immobilization. Surgical therapyPrehospital care Prehospital care depends on other associated injuries, but if an isolated lower limb fracture is suspected, the following steps are important:
Emergency department care
Consultations
Timing of surgery
Stabilization of fracture Definitive surgery to restore the fragments and stabilize the fracture is delayed to allow soft tissues to recover from the traumatic injury. Adding surgical insult to already injured or compromised soft tissues leads to a higher incidence of wound complications and poor outcomes; therefore, surgical intervention is staged.9, 10, 11
Related Medscape topics: Preoperative detailsConsent is essential and includes a fully informed discussion to explain the nature of the injury; the options, risks, and benefits; the need for bone grafting; the likely rehabilitation plan; the potential for amputation, either acutely or in the future; and the prognosis. Careful and detailed planning of the procedure, based on findings from radiography and CT scanning, is necessary to anticipate any difficulties and save time. Determine (1) the sequence and strategy to reduce and stabilize the fragments, and (2) the choice of implants and alternatives. The surgery is performed on a radiolucent table with a fluoroscope and portable radiograph machine available. Antibiotic prophylaxis is administered at the time of anesthesia induction. Intraoperative detailsPositioning The surgery is performed with the patient placed supine with a bump under the ipsilateral hip; this allows access to both sides of the ankle. The opposite leg heel is elevated to relieve pressure on the calf and prevent deep vein thrombosis. All bony prominences are padded. A thigh tourniquet placed after elevation helps achieve exsanguination for a bloodless field. In addition to the extremity, the iliac crest area should be prepared and draped in a sterile fashion in case a bone graft is required. Approach The surgical approach depends on the fracture pattern, the method of stabilization, and the implant choice. Essentially, the aim is to restore the tibial articular surface and stabilize the articular block to the metaphysis in an anatomic alignment. Restoration of fibular length may aid in this process.13 Percutaneous or minimally invasive fixation The articular fragments can be reduced by closed techniques or through minimally invasive methods using Kirschner wires (K-wires) to "joystick" them into position. Once they are aligned, cannulated screws can be inserted under fluoroscopic guidance. This percutaneous technique, as described by Syed and Panchbhavi, can be used in minimally displaced fractures.14 An arthroscope may also be used to visualize that reduction is satisfactory. If a satisfactory reduction of the articular surface is obtained, the articular block can be stabilized to the metaphysis and held in acceptable anatomic alignment using external fixation. However, this method of percutaneous reduction and stabilization is not suitable for fractures with significant comminution or die-punched articular fragments; this would require open reduction (see Images 7-17). Open approach The location and number of incisions for an open approach is best decided based on the fracture pattern. However, most often, an anteromedial incision overlying the distal tibia just lateral to the tibial crest and following the tibialis anterior tendon provides adequate exposure for open reduction of the tibial articular fragments. Do not create skin flaps, but dissect down to the bone, staying medial to the tibialis anterior and in the fracture plane. This incision is similar to the incision used in total ankle replacement, and, if reasonable restoration of the ankle is achieved and the ankle becomes arthritic at some point in the future, ankle replacement remains an option. Similarly, just as in total ankle replacement, avoid any tension on the skin. Place 1-2 deep retractors to open up the deep soft tissue for visualization, but, very importantly, ensure the retractors do not rest against or apply tension to the skin. Reduction of fracture fragments The anterior lateral and medial fracture fragments are held apart to visualize the impacted central fragments and the posterior fragment. Sometimes, the posterior fragment must be derotated in the sagittal plane and held temporarily with K-wires. If any central fragments are impacted, they need to be disimpacted, and the resulting cavity in the metaphysis is grafted with bone using an autogenous graft. This can be augmented with synthetic substances such as calcium sulfate, which will set fast and provide some immediate stability for the screw fixation. Then, the anterolateral fragment and medial fragment are restored and held temporarily with K-wires. Internal fixation Cannulated screws over washers can be inserted in the appropriate direction in a lag-screw fashion using fluoroscopic guidance in different planes to assess proper placement across fracture planes and into intact bone. Once adequate reduction of the articular block is achieved, it is stabilized to the metaphysis. Stability of both the medial and lateral columns is important to prevent a varus or valgus deformity. Also important is stability in the sagittal plane. Often, comminution is present in the anterior cortex of the distal tibial metaphysis and at the junction of the metaphysis and diaphysis. Collapse of the anterior column can result in recurvatum deformity. Internal fixation, external fixation, or both can be used to provide stability to the medial, lateral, anterior, and posterior columns of the tibia.15, 16 The choice of fixation depends on the condition of the soft tissues and the experience of the surgeon.17 For internal fixation, a low-profile contoured plate can be introduced over the medial aspect of the tibia through the existing exposure and advanced percutaneously proximally into the metaphysis, thus limiting the soft-tissue stripping over the bone and limiting soft-tissue injury (see Images 18-26). A smaller anterolateral tibial plate may also be necessary to reduce and hold the anterolateral column out to length. Locking contoured plates have threads within the screw holes that engage heads of screws to create a fixed-angle construct that improves fixation in osteopenic bone and multifragment fractures. They also have a broader distal end, providing more than a single hole along the width of the plate and thus providing additional purchase in the shorter distal cancellous metaphyseal fragment. An external fixator can also be used to stabilize and align the reconstructed articular block to the metaphysis. The fixator may span the ankle joint and incorporate the foot to give additional stability to the reconstruction, but this limits ankle movement. A nonspanning fixator allows for early range of motion and cartilage nutrition, and it limits arthrofibrosis. A variety of external fixator frames are available, but a hybrid fixator is commonly used.18, 19 The wires used should be inserted carefully so as not to damage any tendons or neurovascular structures.20 Usually, one wire is passed through the articular block from posterolateral to anteromedial, starting just anterior to the fibula or through the fibula if the fibula is not plated. To avoid injury to peroneal tendons and the sural nerve, it should not be started posterior to the fibula. A second wire is passed in a posteromedial-to-anterolateral direction, starting in the posteromedial aspect of the tibia anterior to the neurovascular bundle. The wires are placed parallel to and approximately 20 mm proximal to the ankle joint. Olive wires can be used to aid compression across fracture planes or to hold alignment. A ring is attached to the proximal aspect of these wires. Two 5-mm half pins are inserted in the tibia proximal to the fracture in a sagittal plane. Carbon fiber rods link the half pins to the ring, and the attachments are tightened after reduction of any malalignment, which is checked using fluoroscopy and confirmed with plain radiography. Fibular fracture fixation is also important. It may be used to restore the length of the lateral column of the tibia indirectly via ligament taxis on the Chaput fragment anterolaterally and the Wagstaffe fragment posteriorly. It also provides additional strength to the entire reconstruction, especially if some screws are directed into the tibia and through the fibular plate. It helps to prevent valgus deformity.21 The incision to fix the fibula should be positioned slightly posterior to the lateral aspect in order to maximize the width of the skin bridge between this incision and the one on the tibia. Problems can arise with the fibular plating. A straight or noncontoured plate can push the tibial articular fragment medially and can resist reduction. Anatomic restoration of length, contour, and axial rotation of the fibula can be challenging in cases of severe comminution and/or segmentation of the fibula. Restoration of fibular length is difficult without plating the fibula. However, when an external fixator is used in such a way that it incorporates and distracts the talus, it can indirectly restore fibular length by applying traction on the fibula through the intact talofibular ligaments. Also, some overall symmetrical shortening of both the tibia and fibula is acceptable. In fact, shortening is preferred if restoration of the leg length by just a few centimeters means a more extensive surgery with devitalization of fracture fragments. Wound closure Meticulous soft-tissue handling is important throughout the surgery. The anterior joint capsule is closed, but the anterior tibial fascia is left open to prevent postoperative compartment syndrome. Skin should be closed under no tension. The tibial wound is closed first. The preferred technique is an Allgöwer modification of the Donati stitch using nylon or Prolene suture and with the knots on the lateral flap of the tibial wound. If necessary, the fibular wound can be left open and closed after a few days. Sterile dressings are used to cover incisions and wounds, but the pin sites for a frame are left open. A well-padded, below-knee, posterior splint reinforced with 2 side splints is applied with the ankle held at 90°. Postoperative details
Related eMedicine topic: Follow-upPin-site care requires daily irrigation and regular removal of any crust to prevent pin-site infection. The incision sites are inspected at 1 week, and sutures are removed when incisions have healed, in approximately 2 weeks. The temporary splint is changed to a cast at this stage. Depending on the stability and type of fixation, ankle range-of-motion exercises are started as soon as feasible. Fracture alignment and healing are checked with serial radiography. Weight bearing is not commenced until plain radiography demonstrates evidence of bony healing. In patients with preexisting peripheral neuropathy, such as patients with diabetes mellitus for more than 10 years, prolonged protection in a removable cast or a boot is necessary to prevent late displacement, refracture, or both. COMPLICATIONSSection 8 of 12
The rate of severe complications following open reduction and internal fixation of tibial plafond fractures ranges from 10-55%; some can lead to amputation.8, 22 Soft-tissue complications include the following:
Bony complications include the following:
Implant-related complications include the following:
Related eMedicine topics: OUTCOME AND PROGNOSISSection 9 of 12
The outcome varies depending on the following factors:
Low-impact pilon fractures have better outcomes than high-impact pilon fractures. In general, good outcomes can be expected in approximately 60-80% of patients.22, 23, 24, 25 Many patients continue to improve for many years after the injury. The severity of the injury and the quality of the articular reduction frequently correlate with the development of arthrosis, but radiographic signs of arthrosis have only a weak correlation with clinical outcome26. Ankle fusions may be required in approximately 3-27% of patients with posttraumatic arthritis. Nonunion in the distal tibia can be treated with a fibula-pro-tibia plating and bone grafting procedure, as described by DeOrio and Ware.27 Ankle replacement is an option in selected individuals. FUTURE AND CONTROVERSIESSection 10 of 12
Minimally invasive plating techniques have been introduced in the past few years, and these help to minimize soft-tissue trauma and periosteal stripping. Use of a CT C-arm intraoperatively may increase the accuracy of articular reduction. Arthroscopy may be used intraoperatively to aid visualization of the reduction.28, 29 Plating of the fibula is controversial (see Fibular plating in the Treatment, Intraoperative details section, above). MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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