Review Question - QID 219526

This 35-year-old sustained a complex, comminuted pilon fracture which was complicated by a tendoachilles contracture. Lack of dorsiflexion above neutral that does not resolve with knee flexion is indicative of a tendoachilles contracture (Answer 1).

Tibial plafond (“pilon”) fractures are high-energy fractures ranging from simple to complex. Due to the high energy nature, pilon fractures are often fraught with complications including infection, wound complications, nonunion, and malunion. Loss of mobility/range of motion, while not strictly considered a complication, is common following these injuries and can require additional treatments to restore mobility from stretching and physical therapy to surgical releases. The Silfverskiold test, which differentiates gastrocnemius versus tendoachilles contracture, is commonly employed in instances of limited ankle dorsiflexion. Deficiencies in ankle dorsiflexion only when the knee is in extension suggest gastrocnemius contracture (Answer 3), while lack of dorsiflexion with the knee flexed and extended suggests tendoachilles contracture (Answer 1).

Barske et al. reviewed isolated gastrocnemius contractures and the entity's impact on foot and ankle pathology. The authors note gastrocnemius stretching must be trialed before considering release, which could involve the Baumann, Strayer, or Vulpius techniques. They note the application of this procedure can be done in a variety of pathologies, including plantar fasciitis, Achilles tendinopathy, metatarsalgia, and persistent plantar foot ulceration. The authors conclude the gastrocnemius release, regardless of technique, is reliable at improving pain and range of motion, however functional improvement remains less clear.

Cychosz et al. performed a systematic review of 18 articles examining the efficacy of gastrocnemius recession for adults in Achilles tendinopathy, midfoot-forefoot overload syndrome, and diabetic foot ulcers. The authors found fair results with gastrocnemius recession for mid- and forefoot overload syndrome, but the evidence was insufficient to support the procedure's use for diabetic foot ulcers and those with Achilles tendinopathy.

Figures 1 & 2 demonstrate AP and lateral radiographs of a severely comminuted pilon fracture.

Incorrect Answers:
Answer 2: These findings represent a relatively normal finding for a patient without contracture.
Answer 3: This finding would be representative of a gastrocnemius contracture.
Answer 4: 5 degree subtalar arc of motion suggests subtalar arthritis, which would be best treated with an isolated subtalar fusion
Answer 5: 25-degree subtalar arc of motion is a normal range of motion for the subtalar joint.