Review article
Pilon Fractures: Assessment and Treatment

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Anatomy

The relatively thick-walled cortical bone of the tibial diaphysis flares distally at the transition of the diaphysis to metaphysis. The cortex is much thinner here and the metaphysis is filled with trabecular bone. The anteromedial surface of the distal metaphysis is concave with a radius of curvature of approximately 20 cm and internally rotated 25° with respect to the posterior tibia.21 This torsion is more extreme proximally than distally and is more pronounced anteriorly than posteriorly.

Mechanism of Injury

Fractures of the tibial plafond are believed to result from either axial compression or torsion of the leg. Fractures resulting from axial compression are often the result of high-energy trauma and often have several displaced articular fragments, comminution of the metaphyseal bone, and soft tissue injury. In these types of injuries, it is common that the fibula is also fractured. These injuries commonly occur when individuals fall from a height, are involved in a motor vehicle crash, or

Fracture Classification

Effective fracture classification schemes improve communication among treating physicians, provide insight into injury prognosis, and help guide treatment. The classification proposed by Rüedi and Allgöwer29, 30, 31 30 years ago is still widely used today. This classification system separates the fractures into three types depending upon the amount of articular fracture displacement. Type A fractures are simple cleavage type fractures with little or no articular displacement, type B fractures

Operative Indications

The primary indications for surgical intervention of fractures of the tibial plafond are articular fracture fragment displacement of more than 2 mm, joint instability resulting from the fracture, unacceptable axial alignment of the limb, and an open fracture. The presence of a vascular injury necessitating repair to maintain viability of the foot is also an indication for operative stabilization of the fracture. The benefits of operative stabilization include anatomic reconstruction of the

Treatment Options

There are several treatment options for tibial plafond fractures that include hybrid external fixation, limited internal fixation with external fixation, percutaneous plating (generally reserved for extra-articular fractures or these with minimal intra-articular involvement), and external fixation. The method where temporary external fixation is performed and followed by formal ORIF is gaining in popularity.26, 42

Hybrid external fixation of pilon fractures has been advocated recently.1, 10, 36,

Summary

The treatment of high-energy intra-articular fractures of the tibial plafond involves many potential complications. A protocol, which includes immediate ORIF of the fractured fibula and the application of a spanning external fixator followed by delayed ORIF of the tibia, has been developed. This protocol recognizes the importance of the surrounding soft tissues and is based on sound principles and thorough clinical experience. This protocol allows the soft tissues to recover before definitive

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References (46)

  • RJ Brumback et al.

    Fractures of the tibial plafond: Evolving treatment concepts for the pilon fracture

    Orthop Clin North Am

    (1995)
  • JO Anglen

    Early outcome of hybrid external fixation for fracture of the distal tibia

    J Orthop Trauma

    (1999)
  • GC Babis et al.

    Results of surgical treatment of tibial plafond fractures

    Clin Orthop

    (1997)
  • R Barbieri et al.

    Hybrid external fixation in the treatment of tibial plafond fractures

    Clin Orthop

    (1996)
  • SK Bonar et al.

    Unilateral external fixation for severe pilon fractures

    Foot Ankle

    (1993)
  • RB Bourne et al.

    Intra-articular fractures of the distal tibia: The pilon fracture

    J Trauma

    (1983)
  • HN Burwell et al.

    The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement

    J Bone Joint Surg

    (1965)
  • E Destot

    Traumatismes du pied et rayons x malleoles, astragale, calcaneum, avant-pied

  • DR Dirschl et al.

    A critical assessment of factors influencing reliability in the classification of fractures using fractures of the tibial plafond as a model

    J Orthop Trauma

    (1997)
  • RF Gaudinez et al.

    Hybrid external fixation in tibial plafond fractures

    Clin Orthop

    (1996)
  • CP Giordano et al.

    Fracture blisters

    Clin Orthop

    (1994)
  • CP Giordano et al.

    Fracture blister formation: A laboratory study

    Clin Podiat Med Surg

    (1995)
  • CP Giordano et al.

    Treatment of fracture blisters: A perspective study of 53 cases

    J Orthop Trauma

    (1994)
  • RB Gustilo et al.

    Prevention of infection in the treatment of 1025 open fractures of long bones

    J Bone Joint Surg

    (1976)
  • DL Helfet et al.

    Intra-articular “pilon” fracture of the tibia

    Clin Orthop

    (1994)
  • F Jergeson

    Open reduction of fractures and dislocations of the ankle

    Am J Surg

    (1959)
  • JF Kellam et al.

    Fractures of the distal tibial metaphysis with intra-articular extension: The distal tibial explosion fracture

    J Trauma

    (1979)
  • IRE Leach

    A means of stabilizing comminuted distal tibial fractures

    J Trauma

    (1964)
  • V Leone et al.

    The management of soft tissue in pilon fractures

    Clin Orthop

    (1993)
  • JL Marsh et al.

    Use of an articulated external fixator for fractures of the tibial plafond

    J Bone Joint Surg

    (1995)
  • JP Mast et al.

    Reduction with Plates

  • M McFerran et al.

    Complications encountered in the treatment of pilon fractures

    J Orthop Trauma

    (1992)
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