Fractures of the Tibial Plafond

Dan HorwitzGeisinger

Objectives

n Define pilon fracturesn Classify pilon fracturesn Discuss treatment protocols

n Staged managementn Definitive options – focus on ORIF

n Highlight complications

Definitions

Articular injury Usually axial load injury

Frequently high energy Can be low energy or rotational

Soft tissue injury

No Returns or Second Chances NO Returns or Second Chances

HandleWith Care

Caution! Open carefully, intra-articular fracture inside

47 c

Not An Ankle Fracture!

Ankle fracture Low energy Rotational Minimal comminution Possibility of articular involvement�Posterior malleolus�Large medial malleolus

Relatively little soft tissue injury

Epidemiology

Reasonably Rare 1% of all lower extremity injuries 10% of all tibia fractures

Bilateral up to 8% Open in 10 – 50% Compartment syndrome 0 -5% Other fractures 27 – 50%

AO/OTA fracture classification

A3

B3

C3

Soft Tissue Evaulation

History of Treatment

Immediate Immediate ORIFORIF

External External FixatorsFixators

Staged Staged ReconstructionReconstruction

What Do We Do Now?

Staged Protocols

Sirkin, 1999• 56 Pilons• Immediate fibular ORIF

with ankle spanning external fixation

• Average 12.7 - 14 days to ORIF• 1.8% wound dehiscence• 3.6% infection

Patterson, 1999• 22 C3 Pilons• Average 24 days to ORIF• 73% Anatomical reductions

• No Infections

Staged Protocol

Early• Trans-articular

external fixation• Fix fibula…????• Allow soft tissue

stabilization

Late• Definitive

Articular reconstruction

• Remove fixator

Pilon Fractures Staged Fixation

Initial ex-fix +/- ORIF fibula

Definitive Fixation

WhatWhatHappens?Happens?

Soft Tissue Soft Tissue ImprovesImproves

Partial HealingPartial Healing

Poor Timing

Poor OutcomePoor Outcome

Soft tissue must be ready for surgical insult

GuaranteesWagner, Unfallchir, 1986 Mast, CORR 1988Trumble, JOT 1992 Wyrsch, JBJS 1996Helfet, CORR 1994

Stage 1 Goals

• Restoration of skeletal length and alignment

• Span joint and allow soft tissues to stabilize

• Distraction across ankle joint

Stage 2 Goals• Avoid complications• Anatomic restoration

of joint• Stable fixation to

allow motion• Healed anatomically

aligned limb

Stage 2 Goals• Multiple methods

• Ex-fix (definitive)• Hybrid fixation• ORIF

Stage 2 Goals -Strategy

• Multiple Incision Options• Based on soft

tissues• Articular Involvement• Multiple small

(percutaneous)

Articular Injury• 3 Major Fragments

Anterolateral Articular (Chaput)

Medial Malleolus

Posterior Articular (Volkmann’s)

AnteromedialStage 2 Goals -Strategy

Anterolateral

Stage 2 Goals -Strategy

AnteriorStage 2 Goals -Strategy

Anterior “workhorse incision”Stage 2 Goals -Strategy

What about the “7cm” Rule ?• Multiple smaller

approaches• Posterolateral fibular

approach and fixation• Anterolateral approach

for articular surface and metadiaphyseal fixation with submuscular plate

• Percutaneous medial buttress plate

• Begin with Posterolateral Fragment

• Fix posteromedial to posterolateral

• Reduce central impaction• Reduce Medial and

Anterolateral fragments• Provisional wire fixation• Lag Screw Fixation• Fix articular block to

diaphysis

Stage 2 Goals -Strategy

n Always fix the fibula first…???n Always fix the fibula…?n When do you graft..??

n When you need it for structural support or if you have stripped ST more than you want and are worried about biology

Post-op Protocol• Immobilization until sutures out (2-4 wks)

• Cam walker until able to keep foot at neutral

• NWB for 10-12 weeks

Outcomes• Patients get better for up to 2.4

years (perception)–Ankle scores improve with time

• Increase arthritis with time–Radiographic

Marsh, JBJS 2003

Outcomes• Negative long term impact on

function• Limitation in recreation

–Running (27/31)• Half change jobs

Marsh, JBJS 2003

CASE

21 yo male fall while rock climbing

Closed injury

Case

n32 yo male in MVAnClosed isolated injury

Case

nI don’t like this one….

Outcomes• 50% don’t return to work• Significant impact on overall

function• Bad injuries

Pollack, JBJS 2003

•

Salvage?

PILONn More complex…n Simplistic approach – Willie Sutton rulen VERY systematic approach – back to front

or medial to lateraln Choose the best implant – sometimes

smaller is bettern Never never never hesitate to span and

wait…rare exception has early ORIF

Summary

• Difficult fractures• No single

treatment method• Staged protocol• Patience

Summary

• Biological exposure & fixation

• Anatomic restoration of the articular surface

• Rigid fixation to allow early motion