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Figure A
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Figure B
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Figure C
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Figure D
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Figure E
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This 67-year-old man sustained a right ankle injury secondary to rotational and impaction (axial) forces to the tibial plafond which often results in the so-called posterior pilon fracture (as seen in Figure B) that straddles the gap between rotational ankle fractures and those caused by axial loading. Tibial plafond (pilon) fractures are common injuries and a byproduct of high-energy mechanisms. As such, there is often a large degree of bony comminution and impaction secondary to significant axial forces. However, pilon fractures can vary in appearance, particularly when rotational elements are introduced into the mechanism of injury. Because of this, pilon injuries can resemble the more benign-appearing rotational ankle fractures. One subset of fractures is dubbed as "posterior pilon" fractures, this subset of fractures can possess large posterior malleolus fragments and/or posteromedial comminution, as represented by the double-density sign on AP and/or oblique ankle radiographs. Because of the degree of impaction and intra-articular destruction, ORIF is required to restore articular congruity and ultimately allow for appropriate articulation of the talus within the plafond.Weber performed a retrospective review examining fracture characteristics and one-year outcomes in ten patients with ankle fractures exhibiting the double-density sign. The author noted high rates of articular impaction at the posteromedial corner of the plafond, which was reconstructed during surgery and resulted in excellent function at one year. Ultimately, the author concludes that the presence of the double-density sign should alert the physician to the presence of posteromedial comminution and tailor treatment accordingly.Amorosa et al. reported on 15 posterior pilon fracture patients using novel posteromedial and/or posterolateral approaches to the ankle. The authors reported high rates of anatomic reduction (73%) with satisfactory function scores at an average of 32-month follow-up. The authors concluded the utilization of these approaches provides direct visualization of the plafond, allowing for adequate reconstruction. Figure B represents a "posterior pilon" fracture as illustrated by the large posterior malleolus fracture and double-density sign signifying posteromedial comminution. Illustration A highlights the double density sign seen in Figure B, with the red arrow representing the intact anteromedial cortex, while the yellow arrow represents the posteromedial malleolar fragment/comminution. Illustrations B and C represent axial and coronal CT imaging, respectively, of the pilon fracture in question, exhibiting the degree of comminution often seen in these types of injuries.Incorrect Answers:Answer 1: Figure A demonstrates a pronation-external rotation type bimalleolar ankle fracture, due to the transverse medial malleolus fracture and spiral lateral malleolus fracture above the level of the syndesmosis.Answer 3: Figure C represents a pronation-abduction type trimalleolar ankle fracture, due to the transverse medial malleolar fracture and comminuted lateral malleolus fracture above the level of the syndesmosis in addition to the posterior malleolus fracture.Answer 4: Figure D represents a medial subtalar dislocation, which occurs with a plantarflexed foot with forceful inversion.Answer 5: Figure E demonstrates a supination-external rotation type bimalleolar ankle fracture, due to the transverse medial malleolar fracture and spiral lateral malleolus fracture at the level of the syndesmosis.
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