Tibial Pilon Fracture Flashcards
Explain Tibial Pilon Fracture
AKA plafond fracture.
Severe injury affecting the distal tibia.
Mechanism of injury
High-energy axial loads as the tibial plafond is injured by the talus punching up into it
RTCs
Fall from a height
Why are pilon fractures serious and complicated?
Characterised by articular impaction
Severe comminution
Soft tissue injury
They are complex injuries and often require specialist imput
Clinical features
History of trauma
Severe ankle pain and inability to weight-bear
Examination findings
Obvious ankle deformity
Significant swelling and bruising
Skin blistering can occur as well.
Important to look for evidence of open fracture and for compartment syndrome.
Peripheral pulses and peripheral nerve examination should be carried out as well.
What nerves should be tested?
Superficial peroneal
Deep peroneal
Tibial nerves
Classifications
Ruedi and Allgower classification
Explain Ruedi and Allgower classification
Used to describe the severity of pilon fractures
Type I - Undisplaced intraarticular fracture
Type II - Displaced intraarticular fracture
Type III - Comminuted or impacted fracture
Dx
Look for other injuries from high-energy mechanism like spine, pelvis, femure, tibial plateau or tibial shaft.
Investigations
ATLS guidelines followed from major trauma.
Urgent bloods + Coag and G&S
If there is a pathological cause suspected serum Ca2+ and myeloma screen might be warranted.
Imaging done in pilon fracture
Plain X-ray with AP, lateral and mortise views.
Full length views of the tibia and knee are also required to exclude any fracture higher up.
CT is required for further anatomical assessment and pre-operative planning.
Initial management
Realignment of the limb and application of a below-knee backslab
After this a repeated neurovascular assessment should be done and new X-ray.
The limb must be elevated and monitored for compartment syndrome and patient should be kept nil by mouth with IV fluids in preparation for surgery.
Indications for non-operative management.
Simple undisplaced pilon fractures (which are very rare).
Loss of reduction and subsequent malunion is common if this approach is chosen.
Explain surgical management.
Staged approach is often preferred especially if there is significant soft tissue swelling.
Temporary spanning external fixators -> Definity fixation by ORIF 7-14 days later once the soft tissues have had opportunity to heal.
When definitive fixation takes place it is best performed under traction like provided by external fixators.
Complications
Compartment syndrome
Wound infection or dehiscence
Delayed or non-union
Post-traumatic OA
