Pilon Fractures

Question 1

What are the 6 major articular fragments in Pilon Fx?

Answer 1

1. anterior
2. posterior
3. medial
4. anterolateral
5. posterolateral
6. Die-punch

• when plotted radially, there are two patterns: coronal fractures in OLD patients (valgus) and sagittal fractures in YOUNG patients with high-energy injuries (varus)

Question 2

goals of surgical management of pilon’s are:

Answer 2

• reconstruct the articular surface
• restore the mechanical axis
• get stable fixation and early ankle ROM

Question 3

4 classic technical pearls from Reudi and Allgower:

Answer 3

1. reduce and stabilize the fibula with restored length, correct valgus deformity in the distal tibia, reduce the anterolateral (chaput) and reduce the posterior (volkmann) fragment through ligamentotaxis
2. restore the tibial articular surface
3. autologous bone grafting of metaphyseal defects to support the articular surface, preventing collapse and stimulating fracture healing
4. buttress plate the medial tibia to prevent varus angulation and neutralize rotation

Question 4

What is the optimal surgical timing for Pilon injuries:

Answer 4

immediate ORIF has skin complications up to 100% (literature from the 80s and 90s)

Question 5

What is the optimal timing of fibular fixation

Answer 5

• controversial
• many perform it at the time of external fixation to gain length and alignment of tibia
• but if NOT anatomic, may impede subsequent tibial reduction
• plating fibula acutely does not alter the rate of tibial malunion or nonunion, but DOES increase the risk of wound complications related to the fibular wound

Question 6

What is the classic approach for tibial pilon injuries?

Answer 6

anteromedial approach

• associated with difficulty in visualizing the lateral Chaput fragment
• implant prominence
• wound breakdown over the anteromedial tibia

Question 7

Advantages of anterolateral approach:

Answer 7

• extensile
• allows access to the entire articular surface
• superficial and deep peroneal nerves at risk
• anterior tibial artery and vein at risk

Question 8

minimal necessary skin bridge?

Answer 8

5-7cm

Question 9

what is the interval for posteromedial approach to the ankle?

Answer 9

FDL and FHL

- the posterior tibial artery and vein and nerve are taken posteriorly with the FHL

Question 10

The indications for locked plating include:

Answer 10

• osteoporotic bone
• extensive metaphyseal comminution
• small articular fragments

Question 11

advantages of MIPO techniques?

Answer 11

• low infection rates
• good healing rates
• low skin complication rates

Question 12

high energy pilon fractures are characterized by:

Answer 12

sagittal plane fractures and varus deformities

Question 13

how often does CT scan alter surgical tactic for pilon fractures?

Answer 13

64% (tornetta)

Question 14

which fractures should not be widely opened, and fracture fragments not handled?

Answer 14

AO 43-C injuries with complex comminution have high soft tissue complication rate if dissected extensively

Question 15

why would not fixing the fibula be advantageous in pilon fractures?

Answer 15

allows option to shorten the tibia, improving bony contact in the metaphysis where there are frequently bone defects and prone to delayed healing