Pilon fracture

Fracture of distal 3rd of the tibia involving tibial plafond

1. PILON FRACTURES Dr. Anshul Sethi PG student Dept of orthopaedics

2. What is Pilon fracture ? All the fractures of the distal tibia involving the distal articular surface should be classified as pilon fractures except medial, lateral & tri-malleolar fractures where the posterior malleolus is< 1\3 of the articular surface If isolated fracture of the posterior malleolus which is more than 1/3 of articular surface should also called as pilon fracture.

3. ANATOMY TIBIAL PILON: Distal end of Tibia including articular surface Proximal limit of tibial pilon ; 8 to 10 cm from the tibial articular surface EXCLUDING BI-MALLEOLAR &TRIMALLEOLAR fractures

4. EPIDIOMOLOGY Accounts for approximately 5-7% of all tibial fractures Accounts for <1% of all lower extremity fractures Average age ;35-40 years rare in children and elderly Common in men than women; (3:1) High energy fractures 25 to 50% of the patients have additional injuries

5. MECHANISM Pilon fractures are most often caused by axial loading (high energy impacts) such as fall from height motor vehicle accident - leads to high degree of disruption of articular surface and soft tissue affection It may be caused by shear loading (rotational or lower energy impacts) Leads to less degree of disruption of articular surface

6. EVALUATION OF PILON FRACTURES Presentation of patient Physical examination Imaging

7. Clinical Presentation Immediate and severe pain Swelling Bruising Tenderness

8. Inability to bear weight on lower limb Angular deformity

9. EXAMINATION Sign of vascular injury Swelling Fracture blister Soft tissue crushing Compartment syndrome

10. IMAGING ROUTINE X RAYS – Anterio -posterior Lateral Mortise view Ct scan – to know the fracture pattern and intra-articular involvement.

11. CT Scan Extent of articular involvement Orientation of fracture Extent of comminution or impaction of fracture Surgical decision making

12. The classic articular components of pilon fractures Anterolateral ( chauput fragment) Medial fragment bearing medial malleolus Posterior malleolus Die punch fragment

13. Classification

14. AO\OTA CLASSIFICATION Three main subgroups A) Extrarticular (4,3-A) B) Partial articular (4,3-B) C) Intra aricular (4,3-C ) These fractures are further divided in to sub-groups depending upon the comminution Most of B- type fractures are torsional injuries and C-type of fractures are high energy compressive injuries

15. Associated injuries Because of their high energy nature, these fractures can be expected to have specific associated injuries like Calcaneal fractures Tibial pleatue fractures Pelvic fractures Vertebrae fractures

16. MANAGEMENT

17. Surgical treatment of tibia pilon fractures is challenging because of articular comminution, metaphyseal bone loss and serious soft tissue injury. Management of this injury must include articular surface and metaphysis reconstruction as well as treatment of injured soft tissue envelope. Timing of surgery is crucial in pilon fractures because of extensive soft tissue damage . Main target of treatment is preserving the function of the ankle

18. Goals of surgical treatment To obtain anatomical articular alignment Restore axial alignment Achieve joint stability Regain pain-free and functional mobility Avoiding INFECTIONS

19. Treatment challenges Difficult to get anatomical restoration of joint Instability of ankle -ligament and soft tissue injuries High soft tissue complication Open surgery –high incidence of poor wound healing,infection,delayed union and non-union

20. Three important anatomical zones to be considered in the decision making treatment and prognosis Articular surface Metaphysis Fibula

21. Treatement options NON -SURGICAL SURGICAL

22. Non-surgical Undisplaced fracture and debilitated patients A1,B1 and C1 Long leg cast for 6 weeks fallowed by brace and ROM excercises Disadvantages ; Loss of reduction Inability to monitor soft tissue status in the cast

23. Surgical Factors determining the surgical treatment BONY FACTORS SOFT TISSUE FACTORS

24. Types of surgical treatment 1 . ORIF , Open Reduction Internal ‘‘rigid’’ Fixation 2 External Fixation with minimal osteosynthesis 3 Closed Reduction Internal ‘‘biological’’ Fixation. (MIPPO Technique) 4. Intramedullary nailing 5.Two stage protocol

25. 1 . ORIF, Open Reduction Internal ‘‘rigid’’ Fixation Reudi & Allower …… type 1 AO\OTA………………………. A1, A2 type C-Fractures not advocated

26. Closed Reduction Internal ‘‘biological’’ Fixation (MIPPO Technique) Ruedi & Allgower type 1&2 AO\OTA a1 b1 & c1

27. Pre op Post op

28. .4 Intramedullary nailing YES –A1,A2,& C1, C2

29. TWO STAGE PROTOCAL All B3 and C type 0f AO/OTA Ruedi & Allgower type 3

30. First step 1. Fix the # fibula(90%) through postero lateral approach to regain the correct length of the tibia and facilitate three dimensional view of the fracture 2 .External fixator- a)Ankle Spanning b) Non spanning - illizarov -hybrid

31. Second stage After 10-14 days average(10 days) Remove the Ex Fix Through antero lateral incision Articular reduction & fixation with pre countered plate and screws Additional antero medial incision may require to fix MM or large medial fragment Two incision required- maintain not<6-7 cm between two incision

32. Open Pilon Fracture Usually –C fractures meticulous debridment+Ex Fix soft tissue cover(plastic surgery) delayed definitive ORIF

33. Complications Wound dehiscence / Skin necrosis Malunion Delayed / Non Union Post-traumatic Arthritis

34. THANK YOU