Pilon fracture

A PIlon fracture is a burst fracture of distal tibial articular surface.

They are terrible injuries, excellent results are rare.

Radiological reduction of joint correlates with radiological arthritis but does not absolutely correlate with clinical outcome. The injury to the cartilage is one of the rate limiting steps.

Although technically it may be possible to reduce the joint surface and absolutely fix fragments, extensive dissection and severe soft tissue injury predisposes to wound complications and infection..

Ideally absolute anatomical reduction with stable fixation allowing early movement and rehabilitation should be aspired to. BUT AVOID COMPLICATIONS

Imaging

Plain radiographs are useful to make the diagnosis but are not sufficient to fully delineate the injury and plan treatment.

For severe injuries it is best to "Span and then scan"

Apply an external fixator and pull the Tibia out to length, provisionaly reducing the fracture as best as possible.

This is then followed by a CT scan.

Treatment

Initial treatment is directed at stabilising the soft tissues. Apply an external fixator to allow the soft tissues to settle. Reduce the fracture as best possible and try maintain length of tibia and fibula.

Definitive treatment is planned depending on the fracture pattern but more importantly considering what the soft tissues will tolerate in terms of further surgical insult and wound healing.

External fixation

May be temporary or definitive treatment.

Reduction of the joint correlates with radiological arthritis but does not absolutely correlate with outcome.

Infection is disastrous. External fixation may start of as temporary treatment but become definitive treatment if soft tissues never improve to state of allowing for internal fixation.

Several external fixator configurations:

Hybrid external fixation, good if you are good with it

Unilateral external fixators

See Approaches for external fixation of distal tibia

Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO)

If the external fixator has put the fracture in a good position, fixation may be augmented with Limited open reduction and internal fixation (LORIF) once the fracture pattern and planes have been identified on the post ex fix CT. Using percutaneously placed screws and or plates.

Adapt your approach and fixation according to fracture pattern.

3 D CT scans are very useful to fully appreciate the anatomy of the injury.

Consider performing an opening medial malleolar osteotomy to visualize the articular surface, if the soft tissues will allow for it.

References

The Surgeon - Journal of The Royal Colleges of Surgeons of Edinburgh and Ireland

April 2003 Volume 01 Number 2

The early management of severe tibial pilon fractures using a temporary ring fixator
B.J. Mockford, L. Ogonda, D. Warnock. R.J. Barr and C. Andrews

Percutaneous pin placement in the medial calcaneus: is anywhere safe?

Casey D, McConnell T, Parekh S, Tornetta P 3rd. J Orthop Trauma. 2002 Jan;16(1):26-9.