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Pilon Fractures: Advances inSurgical Management

Abstract

Pilon fractures are challenging to manage because of the

complexity of the injury pattern and the risk of significant

complications. Variables such as fracture pattern, soft-tissue injury,

and preexisting patient factors can lead to unpredictable outcomes.

Avoiding complications associated with the soft-tissue envelope is

paramount to optimizing outcomes. In persons with soft-tissue

compromise, the use of temporary external fixation and staged

management is helpful in reducing further injury and complications.

Evidence in support of new surgical approaches and minimally

invasive techniques is incomplete. Soft-tissue management, suchas negative-pressure dressings, may be helpful in preventing

complications.

Surgical management of pilon

fractures is technically demand-

ing and requires thoughtful plan-

ning. Fracture patterns are complex

and carry the risk of major complica-

tions. Outcomes are unpredictable

because of fracture characteristics

(ie, impaction, comminution, articu-

lar cartilage damage, residual joint

incongruity), the risk of soft-tissue

complications, and preinjury patient

factors.

Pilon fractures are caused by high-

and low-energy mechanisms.1 Axial

compression injuries typically are the

result of higher-energy injuries, with

resultant metaphyseal comminution,

multiple displaced articular frag-

ments, and significant soft-tissue in-jury. Torsional injuries are typically

low energy and spiral in nature, with

decreased comminution and less se-

vere soft-tissue injury. The soft-tissue

injury associated with pilon fractures

generally reflects the amount of en-

ergy absorbed at the time of injury

and directly reflects the mechanism

of injury.

Preoperative planning, staged de-

finitive management, and biologi-

cally friendly surgical techniques are

critical to prevent complications and

increase the likelihood of success. In

particular, limiting and/or delaying

surgical trauma is often valuable in

protecting the soft-tissue envelope.2-4

Surgical advances include soft-tissue

management, locked plating, mini-

mally invasive plating, and external

fixation.

Preoperative Planning

Complete clinical and radiographic

evaluation of the patient is necessary

to determine surgical timing, ap-

proach, and technique. A thoroughmedical history identifies patient fac-

tors associated with increased risk of 

soft-tissue complications, poor frac-

ture healing, and fixation failure.

These factors include malnutrition,

alcoholism, diabetes mellitus and

associated neuropathy, peripheral

vascular disease, tobacco use, and

osteoporosis. Systematic physical ex-

Brett D. Crist, MD

Michael Khazzam, MD

Yvonne M. Murtha, MD

Gregory J. Della Rocca, MD

From the Department of

Orthopaedic Surgery, University ofMissouri, Columbia, MO (Dr. Crist

and Dr. Della Rocca), the University

of Texas-Southwestern, Dallas, TX

(Dr. Khazzam), and the University of

Kansas School of Medicine–Wichita,

Wichita, KS (Dr. Murtha).

Dr. Crist or an immediate family

member has stock or stock options

held in Amedica; has received

research or institutional support from

Medtronic, NovaLign, Synthes, and

Wound Care Technologies; and

serves as a board member, owner,

officer, or committee member of the

Orthopaedic Trauma Association.Dr. Della Rocca or an immediate

family member has stock or stock

options held in Amedica; has

received research or institutional

support from Synthes, Kinetic

Concepts, Smith & Nephew, Stryker,

and Wound Care Technologies; and

serves as a board member, owner,

officer, or committee member of the

Orthopaedic Trauma Association

and the American Academy of

Orthopaedic Surgeons. Neither of

the following authors nor any

immediate family member has

received anything of value from orowns stock in a commercial

company or institution related

directly or indirectly to the subject of

this article: Dr. Khazzam and

Dr. Murtha.

J Am Acad Orthop Surg  2011;19:

612-622

Copyright 2011 by the American

Academy of Orthopaedic Surgeons.

Review Article

612   Journal of the American Academy of Orthopaedic Surgeons

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amination identifies associated inju-

ries involving the ipsilateral foot and

knee, pelvis, contralateral lower ex-tremity, and spine. In addition, it is

critical to evaluate the neurovascular

status and soft-tissue envelope (ie,

presence or absence of an open frac-

ture wound, fracture blisters, ecchy-

mosis, edema) of the involved lower

extremity. In the patient with a

closed fracture, early recognition of 

impending skin compromise and ur-

gent fracture reduction avoids the

risks of conversion to an open frac-

ture and a compromised surgical ap-

proach.

Radiographic assessment is a pri-

mary indicator for determining surgi-

cal technique and approach. Stan-

dard ankle radiographs (Figure 1)

and full-length radiographs of the

tibia and fibula are required to iden-

tify fracture extension as well as ipsi-

lateral tibial and fibular fractures.5

CT is useful to identify the extent of 

articular involvement and determine

the most appropriate surgical ap-proach and fixation strategy.6,7 CT

has been shown to add information

in 82% of patients and change the

surgical plan in 64%.6

Topliss et al6 analyzed 126 pilon

fractures using plain radiography

and CT to determine fixation rec-

ommendations based on fracture

pattern. The six major articular frag-

ments identified were anterior, poste-

rior, medial, anterolateral, postero-

lateral, and die-punch. The fracturelines were plotted radially, and two

main fracture groups were identified:

coronal and sagittal. Coronal frac-

tures occurred in older patients with

low-energy injuries and demon-

strated valgus angulation. Sagittal

fractures occurred in younger pa-

tients with high-energy injuries and

demonstrated varus angulation. Ob-

taining a CT scan after initial ankle-

spanning external fixation improvesfracture fragment visualization sec-

ondary to ligamentotaxis (Figure 1).

CT following initial external fixation

is used to plan the definitive surgical

approach, determine the need for

bone grafting, and identify which im-

plants are necessary to complete the

fixation.

The overlay tracing method can be

helpful in surgical planning.7 A pre-

operative tracing is made of the in-

jured side, using the uninjured sideas a template. This surgical tactic

specifies patient positioning, equip-

ment needs, fracture reduction and

fixation strategy, and indications for

postoperative care (Figure 2). Digital

radiographs are commonplace, and

new digital templating systems are

available.

In the patient with pilon fracture, ligamentotaxis provided by initial ankle-spanning external fixation with or withoutfibular open reduction and internal fixation allows for appropriate preoperative planning of definitive management.Mortise radiographs demonstrating pilon fracture in a right ankle before (A) and after temporary external fixation (B).C,  Postoperative axial CT scan demonstrating the typical AO/OTA type C3 comminution pattern. A = anterolateralfragment, B = medial fragment, C = posterolateral fragment

Figure 1

Brett D. Crist, MD, et al

October 2011, Vol 19, No 10   613