Tibial Pilon Fractures

Pilon = french for Pestle

Mechanism of Injury

• Axial loading drives talus into distal tibia
• Position of foot & rate of loading affect injury pattern
• Associated injuries
  • fibula fracture (15%)
  • compartment syndrome
  • lumbar compression fracture (esp L1)
  • contralateral fracture – calcaneus, tibia, pelvis or acetabulum

Clinical presentation

• pay close attention to soft tissues
  • fracture blisters, skin wounds, tenting of skin, vascular compromise
• detailed neurologic exam
• look for associated injuries

Classification of distal tibial fractures

AO Classification

A – extra-articular (metaphyseal fracture) A1 – metaphyseal simple A2 – metaphyseal wedge A3 – metaphyseal complex

B – partial articular fracture B1 – pure split fracture B2 – split-depression fracture B3 – comminuted depression fracture

C – complete articular fracture C1 – articular simple, metaphyseal simple C2 – articular simple, metaphyseal complex C3 – articular complex

Reudi Classification

Type	Description
1	Undisplaced
2	Displaced Simple
3	Displaced Complex

Treatment

• Depends on soft tissues
  • open fractures require I & D
  • grade 3 open fractures
    • temporary ex fix & late reconstruction of articular surface
    • may require plastic surgery – usu free flap in this location
• Surgical options
  • ORIF
    • Timing
      • immediate
        • before significant swelling
      • delayed
        • to allow soft tissues to heal
    • Fibula
      • fix fibula fracture if present
      • usually small fragment LCDCP for ↑ stability & brings fracture out to length
    • Tibia
      • minimal stripping of comminuted fragments & careful soft tissue handling
      • choices
        • locking vs nonlocking
        • large fragement vs small fragment
        • anterolateral vs medial
    • Complications
      • risk of infection & wound slough
  • External fixator
    • Temporary spanning External Fixateur
      • from tibia to calcaneus to hold soft tissues out to length & maintain reduction
      • half pins in tibia
      • steinman pin through calcaneus
      • half pins in base 1st MT
    • Definitive Ring Fixator
      • mini-open reduction of articular surfaces using K-wires & small fragment screws
      • ORIF of fibula fracture
      • fine wires at level of articular surface (at least 2) & half pins in tibia

Outcomes

• with operative treatment, high energy pilon fractures will take about 4 months to heal
• 75% may expect good result (if no wound complications)
• arthrodesis rate up to 10%