Introduction

Also known as pilon fractures

Epidemiology
incidence
account for <10% of lower extremity injuries
incidence increasing as survival rates after motor vehicle collisions increase
demographics
average patient age is 35-40 years
more common in males than females
Pathophysiology
mechanism
high energy axial load (motor vehicle accidents, falls from height)
pathoanatomy
often characterized by
articular impaction and comminution
metaphyseal bone comminution
soft tissue injury (open or Tscherne II/III closed fractures)
associated musculoskeletal injuries
3 fragments typical with intact ankle ligaments
medial malleolar (deltoid ligament)
posterolateral/Volkmann fragment (posterior inferior tibiofibular
ligament)
anterolateral/Chaput fragment (anterior inferior tibiofibular ligam
Associated conditions
75% have associated fibula fractures
Prognosis
parameters that correlate with a poor clinical outcome and inability to return to wor
lower level of education
pre-existing medical comorbidities
male sex
work-related injuries
lower income levels
Anatomy

Osteology
tibia
distal tibia forms an inferior quadrilateral
surface and pyramid-shaped medial malleolus
articulates with the talus and fibula laterally
via the fibula notch
Vascular anatomy
anterior tibial artery
first branch of popliteal artery
passes between 2 heads of tibialis
posterior and interosseous membrane (IOM)
lies anterior to IOM between tibialis anterior
and EHL
terminates as dorsalis pedis artery
posterior tibial artery
continues in deep posterior compartment of
leg
courses obliquely to pass behind medial
malleolus
terminates by dividing into medial and
lateral plantar arteries
peroneal artery
main branch takes off 2.5 cm distal to
popliteal fossa
continues in deep posterior compartment
between tibialis posterior and FHL
terminates as calcaneal branches
Nerves
tibial nerve (L4-S3)
crosses over popliteus from the popliteal
fossa and splits 2 heads of gastrocnemius
passes deep to soleus coursing to the
posterior aspect of the medial malleolus
terminates as medial and lateral plantar
nerves
muscular branches supply posterior leg
(superficial and deep posterior compartments)
common peroneal nerve (L4-S2)
winds around neck of fibula and runs deep
to peroneus longus
divides into superficial and deep peroneal
nerves
superficial peroneal nerve
courses along border between lateral and
anterior compartments of leg
supplies muscular branches to peroneus
longus and brevis (lateral compartment)
terminates as medial dorsal and
intermediate dorsal cutaneous nerves
deep peroneal nerve
courses along anterior surface of IOM
supplies musculature of anterior

compartment and sensation to first web space

saphenous nerve (L3-L4)
continuation of femoral nerve of the thigh
becomes subcutaneous on medial aspect
of knee between sartorius and gracilis
supplies sensation to medial aspect of leg
and foot
sural nerve (S1-S2)
formed by cutaneous branches of tibial
(medial sural cutaneous) and common peroneal (lateral sural
cutaneous) nerves
lies on lateral aspect of leg and foot

Classification

AO/OTA Classification
43-A
Extra-articular
43-B
Partial articular
43-C
Complete articular
Each category is further subdivided based on amount and
degree of comminution
Ruedi and Allgower Classification
Type I Nondisplaced
Type II Simple displacement with incongruous
joint
Type III Comminuted articular surface
Each category is further subdivided based on amount and
degree of comminution

Presentation
Symptoms
ankle pain, inability to bear weight, deformity
Physical exam
inspection
examine soft tissue integrity
swelling, abrasions, ecchymosis,
fracture blisters, open wounds
examine for associated musculoskeletal
injuries
ROM & stability
examine stability and alignment of the
ankle joint
neurovascular
check DP and PT pulses
look for neurologic compromise
check for signs of compartment syndrome
Imaging
Radiographs
recommended views
AP, lateral, mortise views of ankle
full-length tibia/fibula and foot x-rays
performed for fracture extension
CT scan
delineate articular involvement
surgical planning
most useful after ligamentotaxis is provided by a
spanning external fixator
Treatment
Nonoperative
immobilization
indications
stable fracture patterns without
articular surface displacement
critically ill or nonambulatory patients
significant risk of skin problems
(diabetes, vascular disease, neuropathy)
technique

long leg cast for 6 weeks followed by

fracture brace and ROM exercises
alternative treatment is with early
ROM
outcomes
intra-articular fragments are unlikely
to reduce with manipulation of displaced fractures
loss of reduction is common
inability to monitor soft tissue injuries
is a major disadvantage
Operative
temporizing spanning external fixation across
ankle joint
indications
acute management
provides stabilization to allow
for soft tissue healing
fractures with significant joint
depression or displacement
leave until swelling resolves
(generally 10-14 days)
ORIF
indications
definitive fixation for majority of pilon
fractures
limited or definitive ORIF can be
performed acutely with low complications in certain situations
outcomes
ability to drive
brake travel time returns to
normal 6 weeks after weight bearing
external fixation alone
indications
may be indicated in select cases
intramedullary nailing with percutaneous
screw fixation
alternative to ORIF for fractures with simple
intra-articular component (AO/OTA 43 C1/C2)
Techniques
External fixation
fixation
joint-spanning articulated vs. nonspanning
hybrid ring
none have been shown to be
superior with respect to ankle stiffness
2 tibial shaft half pins connected to hindfoot
half pins or calcaneal transfixation pin
with hybrid fixators, thin wires may be
placed within joint capsule or within zone of injury
soft tissues

maintain soft tissue attachments of

fragments
Chaput fragment - anterior inferior
tibiofibular ligament
pros
decreased incidence of wound
complications and deep infections compared to ORIF
can combine with limited percutaneous
fixation using lag screws
cons
pin and wire tract infections
loss of ankle motion
injury to neurovascular structures
anatomic articular reconstruction may not
be possible, especially with central depression
ORIF (AO technique)
approach
use of multiple small incisions that can
include
direct anterior approach to ankle
anterolateral approach to ankle
useful with fractures impacted
in valgus or with an intact fibula
puts the deep peroneal
nerve at risk during exposure and dissection in the anterior
compartment
superficial peroneal nerve at
risk during superficial dissection in the lateral compartment
anteromedial approach to ankle
medial approach
posteromedial approach
posterolateral approach
lateral approach
must respect soft tissues (generally >7 cm
skin bridge with full thickness skin flaps)
goals
anatomic reduction of articular surface
restore length
reconstruct metaphyseal shell
bone graft
reattach metaphysis to diaphysis
steps
reduce and instrument fibula to establish
lateral column length (if needed)
reduce articular surface
reattach articular block to metaphysis and
shaft
fixation
may be augmented with external fixation
(with or without limited ORIF)

can use anterolateral, anterior,

anteromedial, medial, or posterior plating techniques for the
tibia
location of plates/screws are fracture
and soft-tissue dependent
ORIF of fibula if needed
can be with intramedullary screw/wire
or plate/screw construct
pros
direct anatomic reduction
rigid fixation
early motion of ankle
clinical improvement may occur for up to 2
years
cons
high incidence of soft tissue complications
and infection without staged ORIF
Complications
Wound slough (10%)
free flap for postoperative wound breakdown
Dehiscence (9-30%)
wait for soft tissue edema to subside before ORIF
(1-2 weeks)
Infection (5-15%)
Varus malunion
Nonunion
usually at metaphyseal junction
treat with bone grafting and plate fixation
more common with hybrid fixation
Posttraumatic arthritis
most commonly begins 1-2 years postinjury
arthrodesis is not commonly required until many
years later
Chondrolysis
Stiffness