Review Question - QID 3811

This patient has sustained a pilon fracture, with severe comminution and impaction at the articular surface.

The correct sequence of management includes (1) immediate splinting, (2) application of an external fixator, (3) restoration of length alignment and rotation with temporizing external fixation, (4) computed tomography, followed by (5) definitive fixation once soft tissues are amenable.

Tornetta and Gorup analyzed the use of preoperative CT scans in comparison to radiographs in preparation for fixing pilon fractures. The authors noted increased recognition of intra-articular fragments, comminution and noted a high percentage of operative planning changes following CT analysis. Furthermore, the authors recommended CT scans AFTER external fixation, for even better fragment characterization.

Marsh et al. in their instructional course lecture provide tips and tricks in successful management of pilon fractures. One of the highlighted points include staged, delayed treatment of pilon fractures via spanning external fixator as well as highlighting the importance of obtaining the CT after restoring length and alignment.

Figure A exhibits a radiograph of a comminuted, impacted, shortened pilon fracture.

Incorrect answers:
Answer 1: With such a short, impacted fracture, external fixation as a temporizing measure is recommended to help calm the soft tissue envelope.
Answer 2: Closed treatment is not accepted in this type of fracture, due to the high incidence of arthritis and malunion.
Answer 3: CT scan should be obtained AFTER external fixation, not before.
Answer 5: This high-energy injury likely has severe soft tissue injury, which is not amenable to acute fixation.