39. tibial plafond (pilon) fractures

Detailed lecture on tibial pilon (plafond) fractures.

1. Tibial Plafond Tibial Plafond
FracturesFractures
(Pilon (Pilon
Fractures)Fractures)
Muhammad Abdelghani

2. Historical PerspectiveHistorical Perspective
The term ‘tibial pilon’ was first
used by Destot in 1911,
likening the pilon to a pestle.

3. DefinitionDefinition
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.

4. Are isolated fractures of the posterior Are isolated fractures of the posterior
malleolus considered pilon fractures?malleolus considered pilon fractures?
Yes
Isolated fractures of the
posterior malleolus
(Volkmann triangle) account
for 5% of tibial pilon
fractures.

5. AnatomyAnatomy
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.

6. EpidemiologyEpidemiology
Pilon fractures account for 7%-10% of all tibia Pilon fractures account for 7%-10% of all tibia
fractures.fractures.
Most pilon fractures are a result of Most pilon fractures are a result of high-energyhigh-energy
mechanismsmechanisms. .
Thus, concomitant injuries are common and should Thus, concomitant injuries are common and should
be ruled out.be ruled out.
Most common in men 30-40 years old.Most common in men 30-40 years old.

7. Mechanism of injuryMechanism of injury
Fracture pattern is dictated
by position of foot and
talus at time of impact:
Plantar flexion injury:Plantar flexion injury:
posterior lip fragment. posterior lip fragment.
Neutral ankle:Neutral ankle: anterior and anterior and
posterior fragments. posterior fragments.
Dorsiflexion injury:Dorsiflexion injury: anterior anterior
lip fragment.   lip fragment.  

8. Mechanism of InjuryMechanism of Injury
Axial compression: fall from a heightAxial compression: fall from a height
The force is axially directed through the talus The force is axially directed through the talus
into the tibial plafond, causing impaction of into the tibial plafond, causing impaction of
the articular surface.the articular surface.
It may be associated with significant comminution. It may be associated with significant comminution.
If the fibula remains intact, the ankle is forced If the fibula remains intact, the ankle is forced
into varus with impaction of the medial into varus with impaction of the medial
plafond. plafond.
Plantar flexion or dorsiflexion of the ankle at Plantar flexion or dorsiflexion of the ankle at
the time of injury results in primarily posterior the time of injury results in primarily posterior
or anterior plafond injury, respectively.or anterior plafond injury, respectively.

9. Mechanism of InjuryMechanism of Injury
Shear: skiing accidentShear: skiing accident
Mechanism is primarily torsion Mechanism is primarily torsion
combined with a varus or valgus combined with a varus or valgus
stress. stress.
It produces 2 or more large It produces 2 or more large
fragments and minimal articular fragments and minimal articular
comminution. comminution.
There is usually an associated There is usually an associated
fibula fracture, which is usually fibula fracture, which is usually
transverse or short oblique.transverse or short oblique.

10. Mechanism of InjuryMechanism of Injury
Combined compression and shearCombined compression and shear
These fracture patterns These fracture patterns
demonstrate components of both demonstrate components of both
compressioncompression and and shearshear. .
The vector of these 2 forces The vector of these 2 forces
determines the fracture pattern.determines the fracture pattern.

11. Clinical PresentationClinical Presentation
Patients typically present Patients typically present nonambulatorynonambulatory with with
variablevariable gross deformitygross deformity of the involved distal of the involved distal
leg.leg.

12. Clinical EvaluationClinical Evaluation
Full trauma evaluation and surveyFull trauma evaluation and survey may be may be
necessary.necessary.
Most pilon fractures are associated with high-energy Most pilon fractures are associated with high-energy
trauma.trauma.
Assessment of Assessment of neurovascular statusneurovascular status
Evaluation of any Evaluation of any associated injuriesassociated injuries..

13. Clinical EvaluationClinical Evaluation
SwellingSwelling::
Often massive and rapidOften massive and rapid
Necessitates serial Necessitates serial
neurovascular neurovascular
examinations as well as examinations as well as
assessment of skin assessment of skin
integrity, necrosis, and integrity, necrosis, and
fracture blisters.fracture blisters.
Soft tissue injury including
oedema, contusion and blisters
associated with pilon fractures

14. Clinical EvaluationClinical Evaluation
Meticulous Meticulous assessment of soft tissue damageassessment of soft tissue damage
Significant damage occurs to the thin soft Significant damage occurs to the thin soft
tissue envelope surrounding the distal tibia as tissue envelope surrounding the distal tibia as
the forces of impact are dissipated. the forces of impact are dissipated.

15. Plain RadiographyPlain Radiography
It is essential to have plain
films centered on the ankle as
well as films of the entire tibia.

16. Plain RadiographyPlain Radiography
Ankle films
APAP, , laterallateral, and , and mortisemortise views views
Delineate articular incongruity and
fragmentation.

17. Plain RadiographyPlain Radiography
Tibial films
Necessary to fully evaluate the metaphyseal
and diaphyseal extent.
Proximal injuries may easily be overlooked.

18. Plain RadiographyPlain 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.

19. Radiographic EvaluationRadiographic 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.

20. Radiographic EvaluationRadiographic Evaluation
The 3 classic articular
components of pilon
fracture (Axial CT):
1.Anterolateral (Chaput
fragment)
2.Medial
3.Posterolateral (Volkmann
fragment)
These fragments vary in
their size and amount of
comminution

21. Radiographic EvaluationRadiographic Evaluation
Radiographs of the contralateral sideRadiographs of the contralateral side may may
be useful as a template for preoperative be useful as a template for preoperative
planning.planning.

22. Radiographic EvaluationRadiographic Evaluation
The 3 important anatomical
zones to be considered in the
decision-making and
prognosis:
1.Articular surface
2.Metaphysis
3.Fibula

23. Associated InuriesAssociated Inuries
Because of their high-energy nature, these Because of their high-energy nature, these
fractures can be expected to have specific fractures can be expected to have specific
associated injuries, e.g.: associated injuries, e.g.:
Calcaneus fracturesCalcaneus fractures
Tibial plateau fracturesTibial plateau fractures
Pelvis fracturesPelvis fractures
Vertebral fracturesVertebral fractures

24. ClassificationClassification
Rüedi & AllgöwerRüedi & Allgöwer
Commonly used today
Based on the severity of comminution and on the severity of comminution and
the displacement of the articular surface.the displacement of the articular surface.

25. ClassificationClassification
Rüedi & AllgöwerRüedi & Allgöwer
Type I:Type I: Nondisplaced Nondisplaced
cleavage fracture of the cleavage fracture of the
ankle jointankle joint
Type II:Type II: Displaced Displaced
fracture with minimal fracture with minimal
impaction or impaction or
comminutioncomminution
Type III:Type III: Displaced Displaced
fracture with significant fracture with significant
articular comminution & articular comminution &
metaphyseal impactionmetaphyseal impaction

26. ClassificationClassification
Rüedi & AllgöwerRüedi & 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.Prognosis correlates with increasing grade.

27. ClassificationClassification
MastMast
Combination of the Lauge-Hansen classification of Combination of the Lauge-Hansen classification of
ankle fractures and the Ruedi-Allgöwer classification.ankle fractures and the Ruedi-Allgöwer classification.
Type A:Type A: Malleolar fractures with significant posterior lip Malleolar fractures with significant posterior lip
involvement (Lauge-Hansen SER IV injury)involvement (Lauge-Hansen SER IV injury)
Type B:Type B: Spiral fractures of the distal tibia with extension into Spiral fractures of the distal tibia with extension into
the articular surfacethe articular surface
Type C:Type C: “ “Central impaction injuries” as a result of talar Central impaction injuries” as a result of talar
impaction, either with or without fibula fracture; impaction, either with or without fibula fracture;
subtypes 1, 2, and 3 correspond to the Ruedi-Allgöwer classificationsubtypes 1, 2, and 3 correspond to the Ruedi-Allgöwer classification

28. ClassificationClassification
AO/OTAAO/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.

29. ClassificationClassification
AO/OTAAO/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.

30. TreatmentTreatment
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.

31. TreatmentTreatment
Factors dictating treatment strategy:Factors dictating treatment strategy:
Patient Patient ageage & & functional statusfunctional status
Severity of injurySeverity of injury to bone, cartilage, and soft tissue to bone, cartilage, and soft tissue
envelopeenvelope
Degree of comminution and osteoporosisDegree of comminution and osteoporosis
Capabilities of the surgeonCapabilities of the surgeon

32. TreatmentTreatment
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

33. TreatmentTreatment
Strategies for an optimal outcome:
Anatomical reconstruction of the joint
Restoration of tibial alignment
Stabilization of the fracture to facilitate union

34. TreatmentTreatment
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.

35. TreatmentTreatment
Non-operativeNon-operative
Long leg cast for 6 weeks followed by fracture Long leg cast for 6 weeks followed by fracture
brace and ROM exercises or early ROM brace and ROM exercises or early ROM
exercises.exercises.
Indications:Indications:
Nondisplaced fracture pattern Nondisplaced fracture pattern
Severely debilitated patientSeverely debilitated patient
Manipulation of displaced fractures is unlikely to Manipulation of displaced fractures is unlikely to
result in reduction of intraarticular fragments.result in reduction of intraarticular fragments.

36. TreatmentTreatment
Non-operativeNon-operative
Disadvantages:Disadvantages:
Loss of reduction:Loss of reduction: common common
Inability to monitor soft tissue status and Inability to monitor soft tissue status and
swellingswelling

37. TreatmentTreatment
OperativeOperative
Displaced pilon fractures are usually treated Displaced pilon fractures are usually treated
surgically.surgically.
Helfet (1994) was the first to propose a two-
stage 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.

38. Decision making flowchart

39. TreatmentTreatment
OperativeOperative
TIMING OF SURGERYTIMING 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.

40. TreatmentTreatment
OperativeOperative
TIMING OF SURGERYTIMING 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.

41. TreatmentTreatment
OperativeOperative
SKELETAL TRACTIONSKELETAL 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.

42. TreatmentTreatment
OperativeOperative
SKELETAL TRACTIONSKELETAL 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.

43. TreatmentTreatment
OperativeOperative
DEFINITIVE RECONSTRUCTIONDEFINITIVE 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.

44. TreatmentTreatment
OperativeOperative
DECISION MAKINGDECISION 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?

45. TreatmentTreatment
OperativeOperative
GOALSGOALS
Maintenance of fibula length and stability.Maintenance of fibula length and stability.
Restoration of tibial articular surface.Restoration of tibial articular surface.
Bone grafting of metaphyseal defects.Bone grafting of metaphyseal defects.
Buttressing of the distal tibia.Buttressing of the distal tibia.

46. The 4 traditional principles of reconstruction

47. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Articular fracture reduction can be achieved Articular fracture reduction can be achieved
percutaneously or through small limited percutaneously or through small limited
approaches assisted by a variety of reduction approaches assisted by a variety of reduction
forceps, with fluoroscopy to judge fracture forceps, with fluoroscopy to judge fracture
reduction.reduction.
The metaphyseal fracture can be stabilized either The metaphyseal fracture can be stabilized either
with plates or with a non-spanning or spanning with plates or with a non-spanning or spanning
external fixator.external fixator.
Bone graftingBone grafting of metaphyseal defects of metaphyseal defects

48. Limited Open ReductionLimited Open Reduction

49. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation: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.

50. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation: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.

51. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation:Internal fixation:
The first step is the fixation of the
fibula, to regain the correct length of
the tibia and to facilitate the three-
dimensional orientation and reduction
of the fracture.

52. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation: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.

53. The distance between the
two incisions should not
be less than 6-7 cm

54. Anteromedial approach

55. Anterolateral approach

56. Posterolateral approach, allowing access to the
fibula

57. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation: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.

58. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation: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.

59. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation:Internal fixation:
Bone-grafting of any structurally deficient areas
in the cortical or cancellous bone of the
metaphysis then should be done.

60. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation: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).

61. 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

62. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Internal fixation: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.

66. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Techniques to minimize plating Techniques to minimize plating
complications:complications:
Surgical delaySurgical delay until definitive surgical treatment using until definitive surgical treatment using
initial initial spanning external fixationspanning external fixation for high energy for high energy
injuriesinjuries
Use Use small, low-profile implantssmall, low-profile implants
Avoid incisions over the anteromedial tibiaAvoid incisions over the anteromedial tibia
Use Use indirect reduction techniquesindirect reduction techniques to minimize soft to minimize soft
tissue strippingtissue stripping
Use Use percutaneous techniquespercutaneous techniques for plate insertion for plate insertion

67. MIPO
MIPO

68. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
External Fixation as Definitive External Fixation as Definitive
Treatment: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

69. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
External Fixation as Definitive External Fixation as Definitive
Treatment: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 juxta-
epiphyseal assembly and partial control
over the comminution of the fragments,
which may be assembled under
arthroscopic control.

70. Tibial Tibial
Safe Safe
ZonesZones

72. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
External Fixation as Definitive External Fixation as Definitive
Treatment: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

74. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Articulating vs non-articualting spanning external fixation:Articulating vs non-articualting spanning external fixation:
Nonarticulating (rigid) external fixation:Nonarticulating (rigid) external fixation:
most commonly used.most commonly used.
Theoretically allows no ankle motion. Theoretically allows no ankle motion.
Articulating external fixation:Articulating external fixation:
Allows motion in the sagittal plane, thus preventing ankle varus Allows motion in the sagittal plane, thus preventing ankle varus
and shortening.and shortening.
Application is limited, but theoretically it results in improved Application is limited, but theoretically it results in improved
chondral lubrication and nutrition owing to ankle motion, and it chondral lubrication and nutrition owing to ankle motion, and it
may be used when soft tissue integrity is the primary indication may be used when soft tissue integrity is the primary indication
for external fixation.for external fixation.

75. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Hybrid external fixation:Hybrid external fixation:
A type of nonspanning external fixator. A type of nonspanning external fixator.
Fracture reduction is enhanced using Fracture reduction is enhanced using
thin wires ± olives to restore articular thin wires ± olives to restore articular
surface and maintain bony stability. surface and maintain bony stability.
Especially useful when internal fixation Especially useful when internal fixation
of any kind is contraindicated. of any kind is contraindicated.

76. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Hybrid external fixation: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. .

77. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
If an external fixator is used, weight-bearing
should be delayed until there is radiographic
evidence of bone healing.

78. TreatmentTreatment
OperativeOperative
SURGICAL TACTICSURGICAL TACTIC
Arthrodesis: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.

79. TreatmentTreatment
OperativeOperative
Open Pilon FracturesOpen 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.

80. TreatmentTreatment
OperativeOperative
Open Pilon FracturesOpen 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.

81. TreatmentTreatment
OperativeOperative
Open Pilon FracturesOpen 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.

82. Post-operative ManagementPost-operative Management
Initial Initial splintingsplinting in neutral dorsiflexion with careful in neutral dorsiflexion with careful
monitoring of soft tissues.monitoring of soft tissues.
Early ankle and foot motionEarly ankle and foot motion when wounds and when wounds and
fixation allow.fixation allow.
Non-weight bearingNon-weight bearing for 12-16 weeks, then for 12-16 weeks, then
progression to full weight bearingprogression to full weight bearing once there is once there is
radiographic evidence of healing.radiographic evidence of healing.

83. Main pitfalls and the resulting complications in
operated pilon fractures

84. ComplicationsComplications
Pilon fractures, especially those caused by high-
energy 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.

85. ComplicationsComplications
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

86. ComplicationsComplications
Soft tissue slough, necrosis, and hematoma:Soft tissue slough, necrosis, and hematoma: result result
from initial trauma plus improper handling of soft tissues. 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.

87. ComplicationsComplications
Nonunion:Nonunion: Results from significant comminution Results from significant comminution
and bone loss, as well as hypovascularity and and bone loss, as well as hypovascularity and
infection. infection.
Incidence:Incidence: 5%, regardless of treatment method. 5%, regardless of treatment method.

88. ComplicationsComplications
Malunion:Malunion: Common with non-anatomic reduction, Common with non-anatomic reduction,
inadequate buttressing followed by collapse, or inadequate buttressing followed by collapse, or
premature weight bearing. premature weight bearing.
Incidence: up to 25% with use of external fixation.
Stabilization of the anterolateral fragment and bone-
grafting 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.

89. ComplicationsComplications
Infection:Infection: Associated with open injuries and soft Associated with open injuries and soft
tissue devitalization. tissue devitalization.
Highest incidence with early surgery under unfavorable Highest incidence with early surgery under unfavorable
soft tissue conditions. soft tissue conditions.
Late infectious complications may manifest as Late infectious complications may manifest as
osteomyelitis, malunion, or nonunion.osteomyelitis, malunion, or nonunion.

90. ComplicationsComplications
Posttraumatic arthrosis: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.

91. ComplicationsComplications
Tibial shortening:Tibial shortening: Caused by fracture comminution, Caused by fracture comminution,
metaphyseal impaction, or initial failure to restore metaphyseal impaction, or initial failure to restore
length by fibula fixation.length by fibula fixation.

92. ComplicationsComplications
Decreased ankle ROM:Decreased ankle ROM: Patients usually average Patients usually average
<10°of dorsiflexion and <30°of plantar flexion.<10°of dorsiflexion and <30°of plantar flexion.

93. ReferncesRefernces
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.