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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 ligament)
  • Associated conditions
    • 75% have associated fibula fractures
  • Prognosis
    • parameters that correlate with a poor clinical outcome and inability to return to work
      • 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
 

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Technique Guides (2)
Questions (11)

(OBQ13.135) A 34-old-male was involved in a high speed MVC. He sustained an injury to his right leg as seen in Figures A and B. He was treated initially with external fixation for 11 days before his soft-tissues would permit definitive open internal fixation. After removing the external fixator and plating the fibula, what would be next step in the operative plan for reduction and fixation of this injury? Review Topic

QID:4770
FIGURES:
1

Application of an anterolateral pre-contoured plate with distal locking screws to the tibia

5%

(173/3199)

2

Anatomical reduction and stabilization of the tibial articular surface

86%

(2744/3199)

3

Application of a medial pre-contoured plate with distal non-locking screws to the tibia

4%

(113/3199)

4

Anatomical reduction and stabilization of the tibial metaphyseal segment

4%

(121/3199)

5

Proximal screw insertion with non-locking screws to distract the metaphyseal fracture comminution

1%

(37/3199)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Figures A and B show an AO/OTA Type C Pilon fracture with metaphyseal comminution and intra-articular involvement of the tibia. There is an associated fibula fracture. The next step in the operative treatment of this injury, after removal of external fixation, would be anatomical reduction and stabilization of the articular surface.

The first step in the treatment of pilon fractures involves anatomical reduction and stabilization of the articular surface. This can be accomplished with pointed reduction clamps, K-wires, lag screws, or any combination of these. Plate fixation and reduction of the metaphyseal comminution should occur after the joint surface has been re-established. Simple fibular fractures can be plated before fixation of the tibia. Comminuted fibular fractures are usually better reconstructed after the tibia has been repaired, so that the tibia and talus can be used as a guide for positioning of the lateral malleolus.

Sirkin et al. reviewed the protocol for treatment of complex pilon fractures. They showed that the severity of soft-tissue injury will dictate the timing of fixation and choice of implant. To avoid wound healing problems, it is generally accepted that two or more stages of repair should be used.

Figure A, B and C show a high energy fracture to the distal tibia.

Incorrect Answers:
Answer 1, 3: Plate preparation and insertion should be considered after reduction and stabilization of the articular fracture fragments. The use of medial and anterolateral locking plates are appropriate for fixation of this fracture. Longer implants improve load distribution and stability.
Answer 4: The metaphyseal segment of this fracture does not require anatomical reduction. Basic fixation principles for metaphyseal comminution would include, re-establishing tibia length, rotation and angulation at the fracture site. Reduction of the metaphysis should occur after reduction of the articular surface.
Answer 5: The final step in metaphyseal reduction is usually achieved by securing the proximal end of the plate to the tibial shaft. A kick-stand screw can be placed in the most proximal hole to increase the working length of the plate. This can be placed percutaneously if desired.


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(SBQ12TR.30) A 55-year-old female presents to the emergency room after falling off her balcony. She sustained the isolated, closed injury shown in Figures A and B. She is otherwise healthy, but routinely smokes 30 cigarettes per day. What would be the most appropriate sequence of treatment steps for definitive management of this injury? Review Topic

QID:3945
FIGURES:
1

Closed reduction and splinting followed by delayed casting

0%

(7/3754)

2

Immediate open reduction internal fixation

1%

(45/3754)

3

Closed reduction and splinting, CT scan, and immediate open reduction internal fixation

2%

(77/3754)

4

Closed reduction and splinting, CT scan, external fixation, delayed open reduction internal fixation

12%

(438/3754)

5

Closed reduction and splinting, external fixation, CT scan, delayed open reduction internal fixation

84%

(3167/3754)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Figures A and B show radiographs of a comminuted AO/OTA C3 fracture of the distal tibia. The most appropriate steps in the management of this patients injury would include: Closed reduction and splinting, external fixation, CT scan, and delayed open reduction internal fixation in this sequence.

Infection and wound healing problems are common with comminuted distal tibia fractures due to an increased incidence of soft-tissue complications associated with the operative management. Patients with a history of diabetes and smoking are at further risk. To decrease the risk of complications in this patient, a two-staged, delayed open reduction internal fixation technique is the best option for the treatment of severe pilon fractures.

Patterson et al. reviewed 23 consecutive patients with comminuted distal tibia fractures. They showed 0% infections or wound-healing problems in their patient population treated with a two-staged protocol. Their protocol involved fibula fixation with an intramedullary implant and application of a medial external fixator to to regain length and restore anatomic alignment. Re-evaluation of the limb occurred ten to fourteen days later for definitive fixation.

Sirkin et al. retrospectively reviewed 40 closed and 82 open pilon fractures (AO types 43A-C) that were treated with staged surgical management (avg. time from ext. fix. to formal reconstruction was 14 days (range 4 to 31) They reported 17% post-operative wound complication in the closed group and 11% post-operative wound complication in the open group (Gustilo Type I-III). They suggest the technique was successful in both closed and open pilon fractures.

Illustration A shows open reduction internal fixation of the above injury.

Incorrect Answers:
Answer 1: Universally, nonoperative treatment of OTA/AO C3 fractures has led to poor outcomes.
Answer 2,3: Although Ruedi and Allgower (1969) were the first to report successful results with primary open reduction and internal fixation of low-energy fracture patterns, few studies have achieved good results with low soft-tissue complications.
Answer 4: CT scan is most appropriate after frame application. This will allow for distraction and indirect reduction of the fragments to better characterize the fracture pattern for pre-operative planning.

ILLUSTRATIONS:

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(OBQ12.161) A 46-year-old male falls 15 feet from a ladder while working. He presents with the radiographs shown in Figures A and B. The injury is closed, and soft tissues are intact upon arrival. Which of the following treatment regimens has been shown to decrease wound complications in the definitive management of these injuries? Review Topic

QID:4521
FIGURES:
1

Immediate definitive fixation of the tibia, and nonoperative treatment of the fibula

1%

(43/4360)

2

Immediate plate fixation of the fibula and placement of a ankle-spanning external fixation device, followed by delayed reconstruction of the tibia

82%

(3561/4360)

3

Placement of a temporary splint, elevation, and definitive fixation 1 week from injury

7%

(310/4360)

4

Immediate definitive fixation of the tibia and fibula

2%

(81/4360)

5

Immediate placement of a spanning Ilizarov fixator with limited internal fixation of the distal tibia and fibula

8%

(340/4360)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Studies have shown that a staged treatment protocol consisting of immediate fixation of the fibula with placement of an ankle-spanning external fixation device followed by delayed reconstruction of the tibia results in minimal surgical wound complications.

Historically, high rates of infection have been associated with open reduction and internal fixation of pilon fractures due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation of the tibia can then be performed semi-electively with only minimal wound problems.

Sirkin et al performed a study to determine whether open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol (defined in the above paragraph) resulted in improved surgical wound complications. In their cohort of 29 patients with closed pilon injuries treated in this manner, all wounds healed, and none exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively.

Patterson et al evaluated the use of a two-staged technique for the treatment of 21 consecutive patients with 22 C3 pilon fractures. All patients underwent immediate fibular fixation and placement of a medial spanning external fixator. After, on average, twenty-four days, patients underwent removal of the external fixator and formal open reduction and internal fixation of the pilon fractures. There were no infections or soft tissue complications.

Figure A and Figure B demonstrate orthogonal views of a high-energy intra-articular distal tibia fracture.

Incorrect Answers:
1,3,5: These treatment regimens have not been shown in the trauma literature to be associated with decreased wound complications in the fixation of complex pilon fractures.


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(OBQ12.199) A 52-year-old carpenter falls off of a balcony while at work and sustains the injury shown in Figure A. The patient's BMI is 52 and he smokes 2 packs of cigarettes per day; a clinical photograph of the limb is shown in Figure B. What is the most appropriate next step in management? Review Topic

QID:4559
FIGURES:
1

Short leg splint placement and transition to short leg cast at 2 weeks

0%

(9/3055)

2

Closed reduction and spanning external fixation of the ankle

92%

(2798/3055)

3

Open reduction and internal fixation of the fibula and tibia

4%

(119/3055)

4

Open reduction and internal fixation of the fibula with Blair arthrodesis of the ankle

1%

(31/3055)

5

Open reduction and internal fixation of the tibia and articulating external fixation of the ankle

3%

(89/3055)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Closed reduction with spanning external fixation of the ankle is the most appropriate next step in management with planned definitive tibia ORIF when soft tissue swelling allows. Fixation of the fibula at the time of external fixation has been well-described but is a controversial subject.

Pilon fracture treatment with a staged procedure is performed with initial restoration of length and tibial external fixation. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation of the tibia can then be performed semi-electively with only minimal wound problems.

Sirkin et al performed a Level 4 retrospective review of open reduction and internal fixation of intra-articular pilon fractures using a staged treatment protocol. The protocol consisted of ORIF of the fibula and application of an external fixator spanning the ankle joint within twenty-four hours. Patients then underwent formal open reconstruction of the articular surface by plating when soft tissue swelling had subsided at around the 2 week mark. This protocol resulted in improved surgical wound complications. In their cohort of 29 patients with closed pilon injuries treated in this manner, all wounds healed, and none exhibited wound dehiscence or full-thickness tissue necrosis requiring secondary soft tissue coverage postoperatively.

Illustration A shows an external fixator used for initial stabilization of a pilon fracture.

Incorrect Answers:
Answer 1: Nonoperative management is not indicated in displaced pilon fractures.
Answer 3 & 5: Immediate ORIF of the tibia plafond fracture has a higher incidence of wound complications.
Answer 4: Blair fusion of the ankle is not indicated in pilon fractures

ILLUSTRATIONS:

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(OBQ11.103) Which of the following statements is true regarding brake travel time after surgical treatment of complex lower extremity trauma? Review Topic

QID:3526
1

Brake travel time is significantly increased until 6 weeks after patient begins weight bearing

74%

(1708/2298)

2

Return of normal brake travel time takes longer after long bone fracture compared to articular fractures

1%

(25/2298)

3

Normal brake travel time correlates with improved short musculoskeletal functional assessment scores

6%

(139/2298)

4

Brake travel time is significantly reduced until 8 weeks after patient begins weight bearing

16%

(366/2298)

5

Brake travel time returns to normal when weight bearing begins

2%

(51/2298)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Brake travel time (BTT) has been shown to be significantly increased until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity.

Egol et al used a computerized driving simulator to compare BTT in three groups of patients; 1)control group, 2)long bone lower extremity fracture group, 3)lower extremity articular fracture group. They concluded that BTT was significantly increased until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity, and that short musculoskeletal functional assessment scores improved with respect to function and other indexes, but did not correlate with improvement in BTT.

An earlier study by Egol et al looked at total brake time as it related to distance traveled by the automobile before braking at 6, 9, and 12 weeks after operative fixation of a right ankle fracture. When compared with controls, braking time was shown to return to normal by 9 weeks post-operatively, and no significant association was found between the functional scores and this normalization.

Giddins et al provide a review of the literature, the law and the views of the major motor insurers related to driving after injury or operations.


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(OBQ08.182) A 34-year-old male sustains the closed injury seen in Figure A as a result of a high-speed motor vehicle collision. What is the most appropriate next step in treatment? Review Topic

QID:568
FIGURES:
1

Open reduction and internal fixation

4%

(77/1755)

2

Spanning external fixation

94%

(1649/1755)

3

Percutaneous internal fixation

0%

(4/1755)

4

Closed reduction and cast placement

1%

(18/1755)

5

Ankle arthrodesis

0%

(4/1755)

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PREFERRED RESPONSE 2

The radiograph shows a comminuted pilon fracture, which is associated with high-energy trauma and significant soft tissue injury. The tested concept here is the importance of avoiding definitive reduction and fixation of this high-energy injury, which has been shown to be associated with an increased risk of wound complications and deep infections (as compared to staged treatment with usage of a spanning external fixator).

Patterson et al. reviewed 23 consecutive patients with comminuted distal tibia fractures. They showed 0% infections or wound-healing problems in their patient population treated with a two-staged protocol. Their protocol involved fibula fixation with an intramedullary implant and application of a medial external fixator to to regain length and restore anatomic alignment. Re-evaluation of the limb occurred ten to fourteen days later for definitive fixation.

Sirkin et al. retrospectively reviewed 40 closed and 17 open pilon fractures (AO types 43A-C) that were treated with staged surgical management (avg. time from ext. fix. to formal reconstruction was 14 days (range 4 to 31) They reported 17% post-operative wound complication in the closed group and 11% post-operative wound complication in the open group (Gustilo Type I-III). They suggest the technique was successful in both closed and open pilon fractures.


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(OBQ06.8) A 33-year-old male sustains the injury shown in Figure A. He is initially treated with a spanning external fixator followed by definitive open reduction internal fixation of the tibia and fibula. His wounds healed without infection or other complications. Two years following surgery, which of the following parameters will most likely predict a poor clinical outcome and inability to return to work? Review Topic

QID:19
FIGURES:
1

Joint line restoration

36%

(161/448)

2

Degree of fracture displacement

9%

(39/448)

3

Time before definitive ORIF

2%

(9/448)

4

Open fracture

8%

(34/448)

5

Lower level of education

45%

(203/448)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Lower level of education is the parameter that correlated most closely with a poor clinical outcome and inability to return to work.

To determine what fracture- and patient-specific variables affect outcome, Williams et al evaluated 29 patients with 32 tibial plafond fractures at a minimum of 2 years from the time of injury. Outcome was assessed by four independent measures: a radiographic arthrosis score, a subjective ankle score, the Short Form-36 (SF-36), and the patient’s ability to return to work. The four outcome measures did not correlate with each other. Radiographic arthrosis was predicted best by severity of injury and accuracy of reduction. However, these variables did not show any significant relationship to the clinical ankle score, the SF-36, or return to work. These outcome measures were more influenced by patient-specific socioeconomic factors. Higher ankle scores were seen in patients with college degrees and lower scores were seen in patients with a work-related injury. The ability to return to work was affected by the patient’s level of education.

Pollak et al performed a retrospective cohort analysis of pilon fractures. Patient, injury, and treatment characteristics were recorded. The primary outcomes that were measured included general health, walking ability, limitation of range of motion, pain, and stair-climbing ability. A secondary outcome measure was employment status. Multivariate analyses revealed that presence of two or more comorbidities, being married, having an annual personal income of less than $25,000, not having attained a high-school diploma, and having been treated with external fixation with or without limited internal fixation were significantly related to poorer results as reflected by at least two of the five primary outcome measures.


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(OBQ05.93) A 32-year-old man sustains a pilon fracture which is treated initially with a spanning external fixator, as shown in figure A. He is now 3 weeks from injury and skin swelling has subsided significantly. What is the most appropriate definitive treatment? Review Topic

QID:979
FIGURES:
1

open reduction internal fixation of the fibula only

1%

(9/884)

2

open reduction internal fixation of the tibia and fibula

98%

(864/884)

3

removal of external fixator and conversion to a walking cast

0%

(4/884)

4

dynamization of the external fixator

0%

(2/884)

5

tibio-talar arthrodesis

0%

(2/884)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

External fixation is a temporizing treatment that allows the soft tissues to return to normal while maintaining your overall alignment. A fibular plate can help keep the length. Final treatment involves restoration of the tibial plafond articular surface which can only be done with ORIF +/- bone grafting. There is no role for primary arthrodesis in this young patient.


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(OBQ05.157) In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures? Review Topic

QID:1043
1

Interosseous ligament

1%

(23/1697)

2

Anterior inferior tibiofibular ligament

80%

(1366/1697)

3

Posterior inferior tibiofibular ligament

13%

(224/1697)

4

Deltoid ligament

3%

(43/1697)

5

Tibiotalar ligament

2%

(30/1697)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament.

ILLUSTRATIONS:

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(OBQ04.73) A 35-year-old male laborer falls off a ladder and sustains the injury shown in Figures A and B. He has a 2 cm laceration over the medial ankle with exposed bone and a normal neurovascular exam. What is the recommended initial treatment? Review Topic

QID:1178
FIGURES:
1

Immediate open reduction and internal fixation

1%

(19/1809)

2

Closed reduction and casting

0%

(6/1809)

3

Irrigation and debridement and external fixation

96%

(1741/1809)

4

Irrigation and debridement and splinting

2%

(36/1809)

5

Amputation

0%

(2/1809)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Severe pilon fractures are generally the result of high energy trauma leading to bony comminution of the articular and metaphyseal bone. They are usually associated with significant soft tissue injury which prevents immediate definitive open reduction and internal fixation. In this situation, due to the soft tissue injury and open fracture, initial treatment should consist of irrigation and debridement and stabilization with external fixation. Definitive management such as open reduction and internal fixation is performed once the soft tissue swelling has improved and there is no evidence of infection. Sirkin et al published their results of a staged protocol for complex pilon injuries. Their data suggests the historically high rates of infection associated with ORIF of pilon fractures are likely due to attempts at immediate fixation through swollen, compromised soft tissues.


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(OBQ04.216) A 45-year-old male laborer falls off a 15 foot retaining wall 6 hours ago and sustains an open fracture shown in Figures A through C. He has a normal neurovascular exam. Coronal and sagittal CT scan images are shown in Figures D and E. What is the MOST appropriate next step in management in addition to operative irrigation and debridement? Review Topic

QID:1321
FIGURES:
1

ORIF with standard plating of the tibia and fibula

0%

(2/436)

2

ORIF with locked plating of the tibia and fibula

3%

(11/436)

3

ORIF with standard plating of the tibia and fibula and immediate bone grafting of tibia defect

2%

(8/436)

4

External fixation of the tibia, ORIF of the fibula with standard plating, and immediate bone grafting of tibia defect

10%

(42/436)

5

External fixation of the tibia

85%

(371/436)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

External fixation of the tibia is the MOST appropriate initial treatment. Some surgeons prefer to defer the fibular fixation until definitive ORIF of the pilon but the common theme is that pilon fractures are treated with external fixation and staged ORIF. If bone grafting of the tibia is necessary it would be performed during the staged ORIF of the tibia.

Sirkin et al reports Level 4 evidence of a staged protocol of immediate (within twenty-four hours) open reduction and internal fixation of the fibula, using a one-third tubular or 3.5-mm DC plate and application of an external fixator spanning the ankle joint. They followed both open and closed pilon fractures that were treated with external fixation until the soft tissue swelling resolved and then underwent ORIF. There was less than an 11% rate of major wound complication or infection in both groups. Their conclusions suggested the historically high rates of wound complication and infection associated with ORIF of pilon fractures are likely due to attempts at immediate fixation through swollen, compromised soft tissues.


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