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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)
        • when compared to no instrumentation of the fibula no difference in alignment or reduction but higher rates of fibular hardware removal 
      • 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
    • chondrocyte cell death at fracture margins is a contributing factor 
  • Chondrolysis
  • Stiffness
 

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