21 Pilon Fracture Student 2024.pdf

Pilon Fractures Sean T. Grambart DPM FACFAS Assistant Dean of Clinical Affairs College of Podiatric Medicine and Surgery Objectives Identify the anatomy of the ankle and how it relates to pilon fractures. Demonstrate knowledge of mechanisms of injury and classification schemes for p...

Pilon Fractures Sean T. Grambart DPM FACFAS Assistant Dean of Clinical Affairs College of Podiatric Medicine and Surgery Objectives Identify the anatomy of the ankle and how it relates to pilon fractures. Demonstrate knowledge of mechanisms of injury and classification schemes for pilon fractures. Demonstrate knowledge of conservative and surgical treatment of pilon fractures. 2 Historical Perspective The term “pilon” was introduced by Destot in 1911 Refers to a pestle, which is a club- shaped tool Suggest that the talus acts as a hammer, or pestle 3  aka. Tibial Plafond Fracture What is a Pilon All intra-articular fractures of the tibial plafond EXCEPT: Fracture?? Medial malleolar fractures Lateral malleolar fractures Trimalleolar fractures where the posterior fracture is less than 1/3 of the articular surface 4 Anatomy SOFT TISSUE! SOFT TISSUE! SOFT TISSUE! Distal tibia is a “subcutaneous” bone Grossly displaced fractures can lead to soft-tissue necrosis 5 Mechanism of Injury Rotational or Axial Loading Forces Significantly different Fracture patterns Soft tissue damage Associated injuries Prognosis Associated fibular fractures are common to both injury mechanisms 6  Mechanism of Injury Torsion (Rotational) Low-energy trauma Spiral in nature with little comminution Articular injury is composed of mildly or moderately displaced large articular fragments with minimal chondral impaction or disruption Less soft tissue injury (swelling) Open wounds with significant devitalization are not common Prognosis is more favorable 7  Mechanism of Injury Axial Compression High-energy trauma Marked articular damage with articular debris Metaphyseal comminution, wide displacement, chondral impaction, and articular Bad soft tissue envelope Ultimate fracture pattern depends on Direction and rate of application of the force Position of the foot at the time of loading Worse prognosis 8 Mechanism of Injury – Foot Position Böhler et al, in Technik der knochenbruchbehandelung. Vienna:Aufi Maudrich;1951 9 Physical Exam Soft tissue envelope is of critical importance Degree of swelling Severity of contusions Presence of abrasions, blisters, open wounds, and compartmental syndrome Don’t forget about the other stuff!!!!! 10 Imaging – Xray/CT 11 Imaging – Xray/OR/CT 12 Ruedi and Allgower Classification Type I: Non-displaced fractures Type II: Displaced fractures with loss of articular congruency Type III: Displaced and severely comminuted fractures with impaction 13 AO Classification Extra-articular 43A Partial Intra-articular 43B Completely Intra-articular 43C Degree of Comminution 1,2,3 14 CT Evaluation Axial Compression 3 Main Fracture Fragments Medial fragment Anterior or Anterior-lateral fragment Posterior or Posterior lateral fragment 15 Non-Operative Treatment Nonoperative management of displaced intra-articular fractures of the tibial plafond are extremely limited Reserved for those fractures that are truly nondisplaced Patients that have a significant or absolute contraindication to surgical management 16 Operative Treatment External fixation Open reduction and internal fixation Minimally invasive plate fixation Medullary nailing Arthrodesis Combination of the above 17 Principles of Pilon Fracture Fixation Restoration of anatomic fibular length Anatomic restoration of the distal tibial articular surface Bone grafting of metaphyseal defects Stable fixation of the fracture with buttress plating 18 What Dictates Operative Treatment? Low-energy rotational injury without soft-tissue compromise Safe to immobilize the extremity in a splint Plan for an early primary ORIF 19 Rotational 20 Staged Procedure 21 Staged Procedure Two-Staged Delayed Open Reduction and Internal Fixation of Severe Pilon Fractures. Patterson, Michael; Cole, J Journal of Orthopaedic Trauma. 13(2):85-91, February 1999. 2 22 Staged Procedure A Staged Protocol for Soft Tissue Management in the Treatment of Complex Pilon Fractures. Sirkin, Michael; Sanders, Roy; DiPasquale, Thomas; Herscovici, Dolfi Journal of Orthopaedic Trauma. 13(2):78-84, February 1999. 5 23 First Stage Stabilization of the soft tissue envelope Urgent surgical procedure as soon as the patient’s general condition permits The key components of this stage include Anticipation of all skin incisions Debridement of any open wounds 4-compartment fasciotomy if required ORIF of the fibular fracture if present Reduction and temporary spanning external fixation of the tibial plafond fracture 24 Why is Fixation of the Fibula Key? Accurate fibular length, alignment and rotation indirectly reduces the majority of tibial deformity Anatomic reduction of the fibula facilitates indirect reduction of the associated anterior (Chaput) and posterior (Volkmann) tibial articular fragments via the anterior and posterior distal tibiofibular syndesmotic ligaments Fibular reduction usually neutralizes the tendency for valgus angulation and/or lateral translation of the talus and associated tibial pilon fracture fragments 25 Application of the External Fixator Provides stability as the soft tissue calms down Goal Talus lined up on the lateral and AP view Distraction 26 Stage 2: Definitive Surgical Management Restoration of the articular surface along with stable fixation allows early motion Meticulous attention to preoperative planning Soft tissue handling Appropriate timing of intervention 27 Reduction and Fixation Reduction of the articular portion is the most critical aspect Sequence Posterolateral fragment is often the starting point Volkmann’s fragment is frequently accomplished with anatomic reduction and stabilization of the fibula fracture Reduce the posterior aspect of the medial malleolar fragment to the Volkmann fragment Central comminution is then disimpacted and reduced to the posterior plafond (bone grafting) The medial malleolar fragment is secured using the medial shoulder chondral interdigitations Reduction of the anterolateral (Chaput) fragment 28 Surgical Approaches Anterior-Medial Anterior-Lateral Posterior-Lateral Posterior Medial Anterior 29 Anterior-Medial Approach 30 Anterior-Medial Approach 31 Anterior Medial 32 Anterior-Medial Approach 33 Anterior-Medial Approach 34 Anterior Lateral Approach 35 Anterior Lateral Approach 36 Posterior-Lateral 37 Anterior 38 Anterior 39 Anterior 40 Posterior-Medial 41  Well-padded plaster splint with the foot in neutral position Post-Op Splinting with the foot in neutral is continued until the sutures are removed at the 2–3 week mark Cautious physical therapy program consisting of active, active-assisted, and passive range of motion CAM boot can be removed at nighttime and resting Weight-bearing is typically delayed for approximately 12 weeks Patient begins partial progressive weight- bearing in a removable boot Edema may be substantial 42 Primary Arthrodesis 43 Primary Arthrodesis 44 Primary Arthrodesis 45 Outcomes Outcomes following high-energy pilon fractures are usually poor when compared with functional outcome scores Midterm outcomes of pilon fractures managed with either ORIF or external fixation, with or without limited ORIF. Patient scores in the SF-36 General Health Questionnaire were significantly lower than age-matched controls 43% of previously working patients were unemployed after suffering the injury Pollak et al. J Bone Joint Surg [Am] 2003 Clinical results usually deteriorate with time, and the incidence of post-traumatic arthritis significantly increases over time Chen et al. Arch Orthop Trauma Surg 2007 46 Thank You! 47