39. tibial plafond (pilon) fractures

$Page 1: 39. tibial plafond (pilon) fractures$
Tibial Tibial Plafond Plafond

FracturesFractures(Pilon (Pilon

Fractures)Fractures)Muhammad Abdelghani

Historical PerspectiveHistorical Perspective

The term ‘tibial pilon’ was first used by Destot in 1911, likening the pilon to a pestle.

DefinitionDefinition

All fractures of the tibia involving the distal articular surface should be classified as pilon fractures, except for medial or lateral malleolar fractures and trimalleolar fractures where the posterior malleolar fracture involves < 1/3 of the articular surface.

Are isolated fractures of the Are isolated fractures of the posterior malleolus posterior malleolus

considered pilon fractures?considered pilon fractures?Yes

Isolated fractures of the posterior malleolus (Volkmann triangle) account for 5% of tibial pilon fractures.

AnatomyAnatomy

Tibial pilon = the distal end of the tibia including the articular surface.

Proximal limit of tibial pilon: 8-10 cm from the ankle articular surface.

EpidemiologyEpidemiology

Pilon fractures account for 7%-10% Pilon fractures account for 7%-10% of all tibia fractures.of all tibia fractures.

Most pilon fractures are a result of Most pilon fractures are a result of high-energyhigh-energy mechanismsmechanisms. . Thus, concomitant injuries are common Thus, concomitant injuries are common

and should be ruled out.and should be ruled out. Most common in men 30-40 years Most common in men 30-40 years

old.old.

Mechanism of injuryMechanism of injury

Fracture pattern is dictated by position of foot and talus at time of impact: Plantar flexion injury:Plantar flexion injury:

posterior lip fragment. posterior lip fragment. Neutral ankle:Neutral ankle: anterior anterior

and posterior and posterior fragments. fragments.

Dorsiflexion injury:Dorsiflexion injury: anterior lip fragment. anterior lip fragment.

Mechanism of InjuryMechanism of InjuryAxial compression: fall from Axial compression: fall from

a heighta height The force is axially directed through The force is axially directed through

the talus into the tibial plafond, the talus into the tibial plafond, causing impaction of the articular causing impaction of the articular surface.surface. It may be associated with significant It may be associated with significant

comminution. comminution. If the fibula remains intact, the ankle is If the fibula remains intact, the ankle is

forced into varus with impaction of the forced into varus with impaction of the medial plafond. medial plafond.

Plantar flexion or dorsiflexion of the Plantar flexion or dorsiflexion of the ankle at the time of injury results in ankle at the time of injury results in primarily posterior or anterior plafond primarily posterior or anterior plafond injury, respectively.injury, respectively.

Mechanism of Mechanism of InjuryInjury

Shear: skiing accidentShear: skiing accident Mechanism is primarily Mechanism is primarily

torsion combined with a torsion combined with a varus or valgus stress. varus or valgus stress.

It produces 2 or more large It produces 2 or more large fragments and minimal fragments and minimal articular comminution. articular comminution.

There is usually an There is usually an associated fibula fracture, associated fibula fracture, which is usually transverse which is usually transverse or short oblique.or short oblique.

Mechanism of InjuryMechanism of Injury Combined compression and Combined compression and

shearshear These fracture patterns These fracture patterns

demonstrate components of demonstrate components of both both compressioncompression and and shearshear. . The vector of these 2 forces The vector of these 2 forces

determines the fracture determines the fracture pattern.pattern.

Clinical PresentationClinical Presentation

Patients typically present Patients typically present nonambulatorynonambulatory with with variablevariable gross gross deformitydeformity of the involved distal leg. of the involved distal leg.

Clinical EvaluationClinical Evaluation

Full trauma evaluation and surveyFull trauma evaluation and survey may be necessary.may be necessary. Most pilon fractures are associated with Most pilon fractures are associated with

high-energy trauma.high-energy trauma. Assessment of Assessment of neurovascular statusneurovascular status Evaluation of any Evaluation of any associated associated

injuriesinjuries..


SwellingSwelling:: Often massive and Often massive and

rapidrapid Necessitates serial Necessitates serial

neurovascular neurovascular examinations as well examinations as well as assessment of skin as assessment of skin integrity, necrosis, integrity, necrosis, and fracture blisters.and fracture blisters. Soft tissue injury

including oedema, contusion and blisters associated with pilon fractures


Meticulous Meticulous assessment of soft assessment of soft tissue damagetissue damage Significant damage occurs to the Significant damage occurs to the

thin soft tissue envelope thin soft tissue envelope surrounding the distal tibia as the surrounding the distal tibia as the forces of impact are dissipated. forces of impact are dissipated.

Plain RadiographyPlain Radiography

It is essential to have plain films centered on the ankle as well as films of the entire tibia.


Ankle films APAP, , laterallateral, and , and mortisemortise views views Delineate articular incongruity and

fragmentation.


Tibial films Necessary to fully evaluate the

metaphyseal and diaphyseal extent.

Proximal injuries may easily be overlooked.


Traction X-Ray Traction and ligamentotaxis often

pull the displaced fragments back into position, allowing for a better definition and understanding of the fracture pattern.

Radiographic EvaluationRadiographic Evaluation Computed tomography (CT)

Used as an adjunct to plain films. Shows details often not readily available

on most plain films. Acts as guide to the articular injury for

fracture orientation, fragment location, and amount of comminution or impaction.

Aids in surgical decision making.

Radiographic EvaluationRadiographic Evaluation The 3 classic articular

components of pilon fracture (Axial CT):

1. Anterolateral (Chaput fragment)

2. Medial3. Posterolateral

(Volkmann fragment) These fragments vary

in their size and amount of comminution

Radiographic EvaluationRadiographic Evaluation

Radiographs of the contralateral Radiographs of the contralateral sideside may be useful as a template may be useful as a template for preoperative planning.for preoperative planning.

Radiographic EvaluationRadiographic Evaluation

The 3 important anatomical zones to be considered in the decision-making and prognosis:

1. Articular surface 2. Metaphysis3. Fibula

Associated InuriesAssociated Inuries

Because of their high-energy Because of their high-energy nature, these fractures can be nature, these fractures can be expected to have specific expected to have specific associated injuries, e.g.: associated injuries, e.g.: Calcaneus fracturesCalcaneus fractures Tibial plateau fracturesTibial plateau fractures Pelvis fracturesPelvis fractures Vertebral fracturesVertebral fractures

ClassificationClassification Rüedi & AllgöwerRüedi & Allgöwer

Commonly used today Based on the severity of on the severity of

comminution and the comminution and the displacement of the articular displacement of the articular surface.surface.


Type I:Type I: Nondisplaced Nondisplaced cleavage fracture of cleavage fracture of the ankle jointthe ankle joint

Type II:Type II: Displaced Displaced fracture with minimal fracture with minimal impaction or impaction or comminutioncomminution

Type III:Type III: Displaced Displaced fracture with fracture with significant articular significant articular comminution & comminution & metaphyseal metaphyseal impactionimpaction


Ovadia and Beals added types IV and V to include fractures that extend into the metaphyseal and diaphyseal regions with more severe comminution, which is characteristic of many high-energy injuries

Prognosis correlates with increasing Prognosis correlates with increasing grade.grade.

ClassificationClassification MastMast

Combination of the Lauge-Hansen Combination of the Lauge-Hansen classification of ankle fractures and the Ruedi-classification of ankle fractures and the Ruedi-Allgöwer classification.Allgöwer classification. Type A:Type A: Malleolar fractures with significant Malleolar fractures with significant

posterior lip involvement (Lauge-Hansen SER IV posterior lip involvement (Lauge-Hansen SER IV injury)injury)

Type B:Type B: Spiral fractures of the distal tibia with Spiral fractures of the distal tibia with extension into the articular surfaceextension into the articular surface

Type C:Type C: “ “Central impaction injuries” as a result of Central impaction injuries” as a result of talar impaction, either with or without fibula talar impaction, either with or without fibula fracture; fracture;

subtypes 1, 2, and 3 correspond to the Ruedi-Allgöwer subtypes 1, 2, and 3 correspond to the Ruedi-Allgöwer classificationclassification

ClassificationClassification AO/OTAAO/OTA

An even more comprehensive classification.

Includes subdivisions based on amount of comminution.

Very useful for research as it permits a more exact description of the injury, allowing better comparisons between studies.

ClassificationClassification AO/OTAAO/OTA

Three main subgroups: Extra-articular (43-A) Partial articular (43-B) Complete articular (43-C)

These are further divided into subgroups depending on the comminution.

Most type B fractures have traumatic torsion mechanisms, while the C-type usually have high energy compression mechanisms.

TreatmentTreatment

Treatment challenges: Difficulties in anatomical reduction of

the articular surface Instability may occur due to

ligamentous and soft tissue injury Numerous soft-tissue complications

may be encountered during treatment open surgery is associated with poor

wound healing, restoration of the anatomy is difficult and delayed union and infection are common.

TreatmentTreatment

Factors dictating treatment Factors dictating treatment strategy:strategy: Patient Patient ageage & & functional statusfunctional status Severity of injurySeverity of injury to bone, cartilage, and to bone, cartilage, and

soft tissue envelopesoft tissue envelope Degree of comminution and Degree of comminution and

osteoporosisosteoporosis Capabilities of the surgeonCapabilities of the surgeon

TreatmentTreatment

Possible treatment methods: Conservative treatment with cast Open reduction and internal

fixation (as described by Riiedi and Allgower)

Combination of different types of external fixators with or without internal fixation

TreatmentTreatment

Strategies for an optimal outcome: Anatomical reconstruction of the

joint Restoration of tibial alignment Stabilization of the fracture to

facilitate union

TreatmentTreatment

Understanding of the anatomy of the fracture should allow the development of improved operative techniques and outcomes.

Proper length and rotation are critical, as are preserving and maximizing ankle and subtalar motion.

Even when these goals are met, there is no guarantee that patients will have an acceptable result.

TreatmentTreatmentNon-operativeNon-operative

Long leg cast for 6 weeks followed by Long leg cast for 6 weeks followed by fracture brace and ROM exercises or fracture brace and ROM exercises or early ROM exercises.early ROM exercises.

Indications:Indications: Nondisplaced fracture pattern Nondisplaced fracture pattern Severely debilitated patientSeverely debilitated patient

Manipulation of displaced fractures is Manipulation of displaced fractures is unlikely to result in reduction of unlikely to result in reduction of intraarticular fragments.intraarticular fragments.

TreatmentTreatmentNon-operativeNon-operative

Disadvantages:Disadvantages: Loss of reduction:Loss of reduction: common common Inability to monitor soft tissue Inability to monitor soft tissue

status and swellingstatus and swelling

TreatmentTreatmentOperativeOperative

Displaced pilon fractures are usually Displaced pilon fractures are usually treated surgically.treated surgically.

Helfet (1994) was the first to propose a two-stage protocol for this type of fracture: First stage: Temporary external fixation, to

restore length, alignment and rotation of the limb + ORIF of a fibular fracture, if present, if the soft tissue allows.

Second stage: Definitive surgery, when the soft tissues have recovered sufficiently to limit the likelihood of complications.

Decision making flowchart


TIMING OF SURGERYTIMING OF SURGERY Proper timing of treatment is required

to minimize soft-tissue complications. Interventions must respect the

underlying tissue and the amount of surgery that the soft-tissue envelope can tolerate.

Staged procedures are therefore often required to reduce complications and maximize functional results.


TIMING OF SURGERYTIMING OF SURGERY Staged protocols have been shown to be

effective in preventing complications related to soft tissue. Immediate or early intervention (within 12-

18 h of injury) is usually limited to stabilization of the fibula with a plate, using transarticular external fixation to keep the extremity out to length and to obtain a preliminary reduction by ligamentotaxis.

Definitive reconstruction can be performed at a later date.


SKELETAL TRACTIONSKELETAL TRACTION If more than a few hours have elapsed between

the injury and the evaluation, the soft-tissue swelling will be too great to allow for immediate ORIF.

In this situation, skeletal traction (using a calcaneal pin or an external fixator) should be used to prevent skeletal shortening while awaiting for soft-tissue recovery (which may take days or weeks).

Indirect reduction with traction helps to realign the fracture surfaces, which makes subsequent internal fixation easier to accomplish.


SKELETAL TRACTIONSKELETAL TRACTION

Placement of the external fixator creates a more optimal environment for soft-tissue healing.

It is necessary to wait for the reepithelialization of each blister locally and assess the status of the skin until the wrinkle sign of the skin is positive.

Associated fibula fractures may undergo ORIF at the time of fixator application.


DEFINITIVE RECONSTRUCTIONDEFINITIVE RECONSTRUCTION Definitive reconstruction through open

approaches should be delayed until soft-tissue swelling has decreased, as the tissues are tenuous and cannot withstand surgical trauma.

Surgery should be delayed for at least 10 days to allow wrinkles to return, blisters to re-epithelialize, and wounds to heal.

In some cases delaying the procedure for up to 4 weeks may be required to allow soft-tissue swelling to subside.


DECISION MAKINGDECISION MAKING

What kind of incision should be made, medial or lateral?

Which implant will maintain the reduction the best?

Should an external fixator be used? Should it be placed temporarily or

used for definitive treatment? Should treatment be staged or done all

at once?


GOALSGOALS

Maintenance of fibula length and Maintenance of fibula length and stability.stability.

Restoration of tibial articular Restoration of tibial articular surface.surface.

Bone grafting of metaphyseal Bone grafting of metaphyseal defects.defects.

Buttressing of the distal tibia.Buttressing of the distal tibia.

The 4 traditional principles of reconstruction


SURGICAL TACTICSURGICAL TACTIC Articular fracture reduction can be Articular fracture reduction can be

achieved percutaneously or through achieved percutaneously or through small limited approaches assisted by a small limited approaches assisted by a variety of reduction forceps, with variety of reduction forceps, with fluoroscopy to judge fracture reduction.fluoroscopy to judge fracture reduction.

The metaphyseal fracture can be The metaphyseal fracture can be stabilized either with plates or with a stabilized either with plates or with a non-spanning or spanning external non-spanning or spanning external fixator.fixator.

Bone graftingBone grafting of metaphyseal defects of metaphyseal defects

Limited Open ReductionLimited Open Reduction


SURGICAL TACTICSURGICAL TACTIC

Internal fixation:Internal fixation: Like in all articular fractures,

ORIF is the most reliable way to obtain an anatomic reduction of the articular surface.

However, this option should be carefully weighted against: Soft-tissue condition (vascularity may

be affected by surgical approach if too early)

comminution and number of fragments.



Internal fixation:Internal fixation: After soft-tissue recovery, a limited open

reduction and stabilization of the articular component is done with screws alone or with screws and a small buttress plate.

Location of incisions and steps of reduction are based on the preoperative plan.

Soft-tissue dissection should be minimized and fragments should remain attached to the periosteum and the joint capsule.



Internal fixation:Internal fixation:

The first step is the fixation of the fibula, to regain the correct length of the tibia and to facilitate the three-dimensional orientation and reduction of the fracture.


SURGICAL TACTICSURGICAL TACTICInternal fixation:Internal fixation: Several surgical approaches to the tibia have

been described for the treatment of these fractures.

Whatever the surgical route chosen, the surgical approach should be centred on the larger bone fragment and care taken not to traumatize the skin with aggressive surgical technique.

An arthrotomy is essential for the accurate reduction of articular fragments.

Keep a maximum of 2 mm of incongruity of the articular surface.

The distance between the two incisions should not

be less than 6-7 cm

Anteromedial approach

Anterolateral approach

Posterolateral approach, allowing access to the fibula


SURGICAL TACTICSURGICAL TACTICInternal fixation:Internal fixation: The articular surface generally is reassembled from

lateral to medial and from posterior to anterior. The anterolateral portion of the tubercle of Chaput

usually is still attached to the anterior syndesmotic ligaments and is brought down into position at the time of fibular reduction.

The anterolateral corner of this reduced fragment can be used as a guide for the restoration of tibial length.

Any posterolateral or posterior fragments then are reduced to the anterolateral fragment.

The remaining fragments, including any central depressed fragments, then are realigned.



Internal fixation:Internal fixation: When necessary, the split medial

malleolar fragment can be retracted posteriorly to allow for better visualization of the articular reduction.

Temporary fixation is obtained with K-wires, and the reduction is confirmed radiographically.



Internal fixation:Internal fixation: Bone-grafting of any structurally

deficient areas in the cortical or cancellous bone of the metaphysis then should be done.



Internal fixation:Internal fixation: When plate fixation is planned, an

anterior or anteromedial buttress plate is used, depending on the fracture configuration.

Large spoon and T-plates no longer are recommended (too bulky and can compromise the overlying soft tissues).

Spoon plate as an anterior buttress plate. This plate should never be used; rather, a lower profile implant as one may use in the distal radius should be used


SURGICAL TACTICSURGICAL TACTICInternal fixation:Internal fixation: A 3.5-mm cloverleaf plate has a much

smaller profile than the large-fragment-system plates but still has adequate strength to maintain reduction and can be bent and contoured relatively easily for positioning on the tibia.

Cannulated screws can be placed independent of the plate, either through the wound or percutaneously, to secure isolated fragments.

The importance of meticulous care of the soft tissues, including a tension-free closure, cannot be overemphasized.






Techniques to minimize plating Techniques to minimize plating complications:complications: Surgical delaySurgical delay until definitive surgical until definitive surgical

treatment using initial treatment using initial spanning external spanning external fixationfixation for high energy injuries for high energy injuries

Use Use small, low-profile implantssmall, low-profile implants Avoid incisions over the anteromedial tibiaAvoid incisions over the anteromedial tibia Use Use indirect reduction techniquesindirect reduction techniques to to

minimize soft tissue strippingminimize soft tissue stripping Use Use percutaneous techniquespercutaneous techniques for plate for plate

insertioninsertion

MIPO

MIPO



External Fixation as External Fixation as Definitive Treatment:Definitive Treatment:

This has been of interest in recent years, particularly for its benefits with respect to minimal interference with the soft tissue.

External fixators can be either unilateral or circular, they may span or not the ankle joint and may permit or not its motion.

Portable traction


SURGICAL TACTICSURGICAL TACTICExternal Fixation as Definitive External Fixation as Definitive

Treatment:Treatment: The principle of treatment with an

external fixator is through ligamentotaxis.

While most fixators are constructed to provide a tibiotalar-calcaneal bridge, circular fixators allow a tibial-only assembly.

This can allow early ankle mobilization and, depending on the size and orientation of the wires, a juxta-epiphyseal assembly and partial control over the comminution of the fragments, which may be assembled under arthroscopic control.

TibiaTibial l

Safe Safe ZoneZone

ss



SURGICAL TACTICSURGICAL TACTICExternal Fixation as External Fixation as

Definitive Treatment:Definitive Treatment: The assembly of the external

fixator should not jeopardize the attainment of an eventual coverage flap.

The pins of the fixator should not be placed along the course of a possible incision site for future surgical treatment.

The assembly of the external fixator should, as with internal fixation, be preceded by the fibular synthesis, where necessary and if the soft tissue allows, in order to restore the correct length.

Circular frame (LiMA) external fixation of a pilon fracture



SURGICAL TACTICSURGICAL TACTICArticulating vs non-articualting spanning Articulating vs non-articualting spanning

external fixation:external fixation: Nonarticulating (rigid) external fixation:Nonarticulating (rigid) external fixation:

most commonly used.most commonly used. Theoretically allows no ankle motion. Theoretically allows no ankle motion.

Articulating external fixation:Articulating external fixation: Allows motion in the sagittal plane, thus preventing Allows motion in the sagittal plane, thus preventing

ankle varus and shortening.ankle varus and shortening. Application is limited, but theoretically it results in Application is limited, but theoretically it results in

improved chondral lubrication and nutrition owing to improved chondral lubrication and nutrition owing to ankle motion, and it may be used when soft tissue ankle motion, and it may be used when soft tissue integrity is the primary indication for external integrity is the primary indication for external fixation.fixation.



Hybrid external fixation:Hybrid external fixation: A type of nonspanning external A type of nonspanning external

fixator. fixator. Fracture reduction is enhanced Fracture reduction is enhanced

using thin wires ± olives to using thin wires ± olives to restore articular surface and restore articular surface and maintain bony stability. maintain bony stability.

Especially useful when internal Especially useful when internal fixation of any kind is fixation of any kind is contraindicated. contraindicated.


SURGICAL TACTICSURGICAL TACTICHybrid external fixation:Hybrid external fixation: With severe soft-tissue injuries or open

fractures, a hybrid ring fixator for the tibia may be used in combination with standard plating of the fibula.

As definitive treatment, this technique is only suitable for simple articular fractures, which can be reduced anatomically by indirect reduction techniques and fixed by percutaneous lag screws.

In complex fractures an anatomical and stable reconstruction of the articular bloc usually requires ORIF. .



If an external fixator is used, weight-bearing should be delayed until there is radiographic evidence of bone healing.



Arthrodesis:Arthrodesis: Seldom performed acutely. Reserved only for severe articular

comminution which is not otherwise reconstructable

Best done after fracture comminution has consolidated and soft tissues have recovered.

Generally performed as a salvage procedure after other treatments have failed and posttraumatic arthritis has ensued.


Open Pilon FracturesOpen Pilon Fractures Open pilon fractures present an

additional challenge. Like all open fractures, they require

emergency debridement, irrigation, and stabilization.

The typical wound associated with an open pilon fracture is a transverse distal anteromedial laceration.

The proximal skin flap is contused, and use of the usual anteromedial incision may compromise its blood supply.


Open Pilon FracturesOpen Pilon Fractures Steps in treating open pilon fractures:

Apply an external fixator Obtain indirect reduction Stabilize the fibula Perform the reconstruction of the articular

surface through the open wound with use of cannulated screws for stabilization.

This technique has been found to be less traumatic to the already injured soft tissues than the traditional extensile exposure.


Open Pilon FracturesOpen Pilon Fractures Cancellous bone-grafting and even

internal fixation can, if necessary, be delayed until 4-6 weeks later, when the soft tissues have stabilized and the risk of soft-tissue slough and infection is reduced.

Post-operative Post-operative ManagementManagement

Initial Initial splintingsplinting in neutral dorsiflexion in neutral dorsiflexion with careful monitoring of soft tissues.with careful monitoring of soft tissues.

Early ankle and foot motionEarly ankle and foot motion when when wounds and fixation allow.wounds and fixation allow.

Non-weight bearingNon-weight bearing for 12-16 weeks, for 12-16 weeks, then then progression to full weight progression to full weight bearingbearing once there is radiographic once there is radiographic evidence of healing.evidence of healing.

Main pitfalls and the resulting complications in operated pilon

fractures

ComplicationsComplications

Pilon fractures, especially those caused by high-energy trauma, have been associated with a high rate of complications.

Even when accurate reduction is obtained, predictably excellent outcomes are not always achieved, and less than anatomic reduction can lead to satisfactory outcomes.


Early postoperative problems: Skin necrosis Superficial and

deep infection Loss of fixation.

Complications with fracture healing: Delayed union or non-

union of the metaphyseal-diaphyseal junction

Varus or valgus malunion of the distal part of the tibia

Non-anatomical reduction or postoperative loss of reduction of articular surface


Soft tissue slough, necrosis, and Soft tissue slough, necrosis, and hematoma:hematoma: result from initial trauma plus result from initial trauma plus improper handling of soft tissues. improper handling of soft tissues. Avoid excessive stripping Avoid skin closure under tension Secondary closure, skin grafts, or muscle flaps

may be required for adequate closure. Prevalence of postoperative skin and wound

problems decreased substantially with use of the technique of indirect reduction with external fixation and reconstruction of the articular surface with small plates or screws, or both.


Nonunion:Nonunion: Results from significant Results from significant comminution and bone loss, as well as comminution and bone loss, as well as hypovascularity and infection. hypovascularity and infection. Incidence:Incidence: 5%, regardless of treatment 5%, regardless of treatment

method.method.


Malunion:Malunion: Common with non-anatomic Common with non-anatomic reduction, inadequate buttressing reduction, inadequate buttressing followed by collapse, or premature followed by collapse, or premature weight bearing. weight bearing. Incidence: up to 25% with use of external

fixation. Stabilization of the anterolateral fragment

and bone-grafting of the lateral border of the distal part of the tibia promote union and reduce the prevalence of both valgus malunion and non-union of this fracture.


Infection:Infection: Associated with open Associated with open injuries and soft tissue devitalization. injuries and soft tissue devitalization. Highest incidence with early surgery Highest incidence with early surgery

under unfavorable soft tissue conditions. under unfavorable soft tissue conditions. Late infectious complications may Late infectious complications may

manifest as osteomyelitis, malunion, or manifest as osteomyelitis, malunion, or nonunion.nonunion.


Posttraumatic arthrosis:Posttraumatic arthrosis: Results from damage of articular cartilage at the

time of injury Also associated with fractures in which a

congruous articular surface was not restored or maintained.

Primary ankle arthrodesis is rarely indicated because the long-term outcome is not easy to predict.

Although some patients may need an ankle arthrodesis because of symptomatic osteoarthrosis, others do fairly well despite radiographic signs of post-traumatic osteoarthrosis.


Tibial shortening:Tibial shortening: Caused by fracture Caused by fracture comminution, metaphyseal impaction, comminution, metaphyseal impaction, or initial failure to restore length by or initial failure to restore length by fibula fixation.fibula fixation.


Decreased ankle ROM:Decreased ankle ROM: Patients Patients usually average <10°of dorsiflexion usually average <10°of dorsiflexion and <30°of plantar flexion.and <30°of plantar flexion.

ReferncesRefernces

Sirkin MS: Plating of Tibial Pilon Fractures. Am J Orthop. 2007;36(12 suppl):13-17.

Topliss CJ, Jackson M, Atkins RM: Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg [Br] 2005;87-B:692-7.


39. tibial plafond (pilon) fractures

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