Review Question - QID 4559

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