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Case Presentation

: pilon fracture


: 2006. 7. 22.
:
: 20113120

PK admission note
; O
; 358796
/ ; F / 36
admission date ;
1 :2006.5.20.
2 :2006.6.08

1. Chief complication
Right ankle pain (onset : 2006.05.20.)

2. Present illness
passenger TA C/C . ER
admission.
3. Past medical history
DM/HTN/TB/Hepatitis(-/-/-/-)

4. Physical examination
1) Vital sign ; stable
2) Rt ankle : External wound (+) : supf. abrasion 1cm
on calcaneous tuberosity 2cm area
Tenderness (+) & Swelling (+) : on whole ankle area
Ecchymosis (-)
Distal sensory, motor, contraction : intact
ROM - limitation due to pain

5. Initial Lab & X-ray


1) CBC & WBC diff. :
WBC 10.7810/L (diff. N-segment 56.9%, lymphocyte 34.1%) RBC 4.54106/L, Hb 13.6g/dl, Hct
43.1%
2) PT 11.7 sec
PT 0.98 INR
aPTT 30.2 sec
3) Urinalysis : non-specific
4)X-ray : comminuted fx line distal tibia Rt.
comminuted fx line lat. malleolus ankle Rt

6. ECG

normal sinus rhythm

7. Impression
#1. pilon fx distal tibia Rt.
#2. fx lat. malleolus ankle Rt.
8. Plan
DP>#1. CT for fx site
#2. bone scan
TP>#1.consider temp External fixation
change to plate with screw
#2.antibiotics
#3.Rt. leg elevation
#4.sensory, motor, circulation check

Pre OP note
bullae(+)-> dressing with flazile gauze
ECG : normal sinus rhythm

Brief op note
(06. 05. 23)
under spinal anesthesia
pre-op diagnosis : pilon fx ankle Rt.
(Ruedi allogower class III)
post-op diagnosis : same as above
op name : CRIF monofixation
operator : prof.
assists : R4 , R3 ,int
postop H-vac was inserted

postop compression dressing was done & LLS applied

Progression note
POD #1. (2006.5.24)
hyposthesia(+) 1st web space
big toe dorsiflexion : grade 4
->splint release for peroneal n

postop X-ray check after 1mm release


-> slightly reduced on tibia AP

wound : nondried for bullae


no interval change
distal sensory : hypothesia on ist web dorsum
motor : big toe dorsiflexion grade 4
circulation : intact

POD #4. (2006.5.27)


wound clear
billae : mildly wet

POD # 7. (2006.5.30)
bone scan checked
: hot uptake Rt. distal tibio fibular area
wound : wet
bullae : dry
distal sensory : intact
motor : intact
circulation : intact

further evaluation .

PK admission note
2 :2006.6.08
1. Chief complication
for post OP care

2. Present illness
passenger TA ER admission.
06. 05.23 pilon fx ankle Rt imp temporary monofixation OP
further evaluation post op care .
3. Past medical history
DM/HTN/TB/Hepatitis(-/-/-/-)

4. Physical examination
1) Vital sign ; stable
2) Rt ankle : status post monofixation

bullae (+) on ant joint area-> wet


Tenderness (+) & Swelling (+)
OP wound : clear
Distal sensory: paresthesia (+) on dorsum foot Rt.
motor: big toe dorsiflexion grade 5
circulation : intact
5. Initial Lab & X-ray
1) CBC & WBC diff. :
WBC 7.1610/L (diff. N-segment 63.9%, lymphocyte 22.5%) RBC 3.88106/L, Hb 12.0g/dl, Hct
36.3%
2)X-ray : no interval change
6. ECG
normal sinus rhythm

7. Impression
#1. pilon fx ankle Rt. (Ruedi allogower class III) s/p monofixation
8. Plan
#1. pain control
#2. antibiotics
#3. keep splint
#4. consider ORIF

Progression note
HD #4. (2006.6.11)

wound : clear
bullae(+): wet
distal sensory, motor, circulation
: no interval change
bullae healing OP delay .

HD #7. (2006.6.14)

wound : clear
bullae(+): wet improved
distal sensory, motor, circulation
: no interval change

Brief op note
(06. 06. 17)
under spinal anesthesia
pre-op diagnosis : pilon fx ankle Rt. s/p monofixation
(Ruedi allogower class III)
post-op diagnosis : same as above
op name :1) ORIF with 1/3 tubulr plate(8 holes) for ankle
2) ORIF with DMT plate (7-holes)
allogenous B.G & K-wire * 2 & monofixation
operator : prof.
assists : R4 , R3 , intern
postop S-drain tube was inserted
postop compression dressing was done & Long Leg Splint applied

post op X-ray

Off duty note

06.07.08
imp: pilon fx ankle Rt. s/p monofixation
(Ruedi allogower class III)
->06.05.23 CREF with monofixation
06.06.19 ORIF with 1/3 tubulr plate(8 holes) for ankle
ORIF with DMT plate (7-holes)
allogenous B.G & K-wire * 2 & monofixation

splint off ambulation


antibiotics leukopenia-> anti stop
toxic erythema, tinea pedis f/up

POD #4 (06. 07.17)


f/up X-ray check - no interval change
pin site clear
ECR/CRP 6/0.3
WBC 4220 (n- seg 60%)
AST/ALT (113/138): liver sono : normal

Brief op note
(06. 07. 20)
under IV anesthesia
pre-op diagnosis : pilon fx ankle Rt. s/p monofixation
(Ruedi allogower class III)
post-op diagnosis : same as above
op name : External fixation removal
operator : prof.
assists : int.

post OP X-ray

Review of disease

1. :

1)Classification: (Ruedi-Allgower):
- type I: Pilon Frx
- malleolar frx w/ significant axial load at time of injury & therefore large posterior plafond fragments;
- type II: Pilon Frx
- spiral extension frx;

- type III: Pilon Frx


- type III frxs are central compression injuries w/ impaction of talus into distal tibia
w/ or w/o concomitant fibular frx;
- subdivided as discussed into subgroups A-C depending on degree of displacement of articular
surface & presence or absence of comminution and/or impaction;
- type A:
- minimal or no anterior tibial cortical communition, > 2 large tibial articular fragments, and
usually a fibular fracture of transverse or short oblique at the level of the plafond (or ankle joint);
- type B:
- results from severe axial compression force, causing distal tibial bony impaction and comminution;

Type I: Pilon Frx

--------------------------------------------------------------------------------

- Discussion:
- articular fracture without significant displacement;
- malleolar fractures with large plafond fragments;
- these fragments are usually posterior;
- posteroinferior tibiofibular ligament & deep transverse ligament are attached to the fragment;
- first reduce & fix fibula;
- may usually be accomplished w/ lag screw & neutralization plate;
- because of the intact state of ligamentous connection to posterior fragment, reduction of fibula
usually restores length relationship of posterior plafond fragment;
- distal tibia is exposed;
- large posterior fragment needs to be identified;
- large pointed reduction forceps are placed from anterior to posterior, holding the large
fragment firmly reduced;
- fixation should include lag screw placed from posteromedial to posterolateral or posterior;
- medial malleolar fragment is reduced & fixed w/ lag screw or tension band;
Type II Pilon Frx

--------------------------------------------------------------------------------

- Discussion:

- comprises articular frx w/ articular incongruity but minimal comminution;


- frx extend into the joint distally from a spiral frx of distal tibia
- ankle mortise must be evaluated carefully to determine if fibular frx in question is part of
joint injury or merely frx assoc w/ tibial shaft frx;
- proximal frxs are reduced & fixed with lag screws;
- articular reduction is fixed either definitively w/ lag screws initially or, if further adjustment
is necessary, temporarily held w/ K wires until w/ subsequent application of dynamic
compression plate, contoured to fit the medial aspect of the tibia;

Type III: Pilon Frx

--------------------------------------------------------------------------------

- Discussion:
- severe articular comminution and articular impaction frx;
- reduce fibula then perform plate & lag screw fixation;
- restores length of fractured distal tibia:
- reduce articular surface
- carried out & maintained by temporarily stabilizing it with K wires;
- because of impaction of joint surface upward into metaphyseal cancellous bone, reconstruction
of the joint surface is assoc w/ producing a metaphyseal defect in the transitional bone
between joint & shaft;
- this must be filled in with a cancellous bone graft;
- buttress plate:
- addresses comminution in medial metaphyseal cortical bone,
- function of this plate is to provide support to this weakened area and prevents varus deformity;

~~~~~~~~~~~~~
Tibial Plafond Fracture
(w/ assistance and narration by Dr Kyle Dickson MD)

- Discussion:
- term pilon (hammer) fracture was introduced to describe these compression injuries by Destot in 1911;
- frx components:
- combination of ankle frx & distal tibial metaphyseal frx, usually w/ intra articular comminution;
- frx of medial malleolus;
- frx of anterior margin of tibia;
- transverse frx of posterior tibial surface;
- 20-25% of these will be open;

- mechanism of injury:
- vertical loading drives talus into distal tibia;
- position of foot & rate of loading affect injury pattern;
- it is important to distinguish between low energy frx (from skiing) vs high energy frx (as from MVA);
- plantar flexion: posterior articular damage;
- dorsiflexion: anterior articular damage;
- fibular frx:
- if fibula is frxed, then force involved is usually valgus shear w/ severe injury to the lateral aspect of the
joint;
- fibula intact: (25% of injuries);
- pilon frx w/o assoc frx of fibula occur in approx 15 % of cases;
- w/ compression injuries fibula may remain intact, which never happens w/ shearing type injury;
- w/ intact fibula, ankle is often driven into varus w/ severe impaction of the medial part of the tibial
plafond;

- associated injuries: (30% will have ipsilateral injuries and 5-10% will have bilateral injuries;)
- compartment syndrome
- compression frx of vertebral column, particularly L1;
- contralateral fractures of: os calcis, tibial plateau, pelvis, or acetabulum (verticle shear injuries):
- outomes:
- with operative treatment, high energy pilon fractures will take 4 months on average to heal;
- 75% of patients who do not develop wound complications may expect a good result;
- subsequent arthrodesis rate may be as high as 10%;

--------------------------------------------------------------------------------

- Exam:
- soft tissue: note presence of swelling and any fracture blisters;
- perform an Allen test using a pulse oximeter for the foot vasculature (pulse ox is placed on the toe);
- note function of posterior tibial pulse while the dorsalis pedis pulse is occluded and vice versa;
- ideally, the pulse ox should demonstrate normal mp3e forms even w/ occlusion of either vessel;
- reference: The management of the soft tissues in pilon fractures.

see the fat cat

-------------------------------------------------------------------------------- Radiographs:

- consider taking a traction x-rays of extremity to help judge effects of ligamentotaxis on displaced
articular fragments;
- note whether fibula is intact or fractured;
- w/ comminuted fibular fracture it is important to bring fibula out to length (talo-crural angle)
- w/ fibula intact, carefully evalute the syndesmosis;

- classification: and degree of articular comminution;


- type I: pilon frx
- type II: pilon frx
- type III: pilon frx

- type A:
- minimal or no anterior tibial cortical communition, two or more large tibial articular fragments, and
usually an
oblique or transverse fibular fracture at the level of the plafond (or ankle joint);
- type B:

- results from severe axial compression force, causing distal tibial bony impaction and comminution;
- CT scan: helps plan surgical fixation of articular fragments;

-------------------------------------------------------------------------------- Surgical Treatment:


- controversies:
- surgical timing and staged reconstruction;
- plate vs ex fix;
- role of bone grafting;
- role for primary ankle arthrodesis;
- initial treatment and timing of surgery:
- surgical technique:
- reduction of fibula;
- some authors will avoid ORIF of the fibula in these injuries if there is excessive fibular comminution (ie
poor chance of good fixation) and
if there is excessive varus of the articular surface (ORIF would accentuate the varus);
- note that the fibular incision often must be placed posteriorly indorder to accomodate an adequate skin
bridge for the tibial incision;
- in some cases, the fibula can be anatomically reduced along with application of external fixator which
allows
the fracture to be brought out to length and which allows the talus to be centered under the tibia;
- then 7-21 days later, the medial column and articular surface can be restored once the soft tissues have
healed;
- exposure of tibial articular surface:
- restoration of tibial articular surface:
- fixation of metaphysis to diaphysis:
- uniplanar external fixation
- circular wire fixators
- theoretically, there is some danger of osteomyelitis in having transfixation wires pass through the
fracture
segments since the incidence of pin tract infections in pilon fractures may be as high as 55%;
- other complications with circular wire fixators include ankle stiffness, swelling, RSD, and ankle tendon
injury;

- ref: Treatment of displaced pylon fractures with circular external fixators of Ilizarov.
K. Aktuglu MD et al. Foot and Ankle International. Vol 19. No 4. Apr 1998. p 208.
- external fixation - foot inclusion;
- cancellous bone grafting of metaphyseal defect:
- wound closure:

***

--------------------------------------------------------------------------------

- Complications:
- wound complications and infection:
- w/ tranditional early ORIF of the tibial articular surface the occurrance of wound slough and infection
has ranged from 10 to 50%;
- some authors feel that this complication can be minimized by delayed ORIF (once the swelling has
diminished);
- 37% deep infection rate in tibial plafond Redi III (Teeny, Clin Orthop 1993);
- unplanned surgery for complications (Wyrsch, JBJS 1996)
- 55% for ORIF
- 18% for external fixation and limited ORIF

:Duke Orthopaedics presents Wheeless' Textbook of Orthopaedics


2 Pilon
Treatment of Tibial Pilon Fractures with Two-Staged Delayed Open Reduction and Internal Fixation
( Journal of the Korean Orthopaedic Association )
2005 40 2 p.188 ~ p.194
(Sohn HM )
(Lee JY) , (Ha SH) , (Choi SM )
/Hong-Moon Sohn
/Jun-Young Lee
/Sang-Ho Ha
/Sung-Min Choi


Department of Orthopaedic Surgery, College of Medicine, Chosun University, Gwangju, Korea
: pilon 2
.

: 2002 1 2003 7 pilon 2


1 11 . 1
28.5 (, 14-34). Burwell Charnley
, Mast Teipner
, .

: 10 17 (, 14-20) 1
. 8 (73%), 2 (18%), 1 (9%)
7 (64%), 3 (27%), 1 (9%).

: 2 pilon
.

Purpose: To evaluate the short-term results of two-staged delayed open reduction and internal fixation in
tibial pilon fractures with severe soft tissue damages.

Materials and Methods: Eleven patients, who underwent two-staged delayed open reduction and internal
fixation for tibial pilon fractures between January 2002 and July 2003, were followed for more than one
year. The mean interval time between first stage and second stage of the procedures was 28.5 days
(range, 14-34 days). Radiographs were graded by the criteria of Burwell and Charnley and ankle functions
were graded by the criteria of Mast and Teipner. Ankle function, union time and postoperative
complications were also analysed.

Results: Average union time was 17 weeks (range, 14-20 weeks) in ten of the eleven fractures, but there
was one fracture resulting in soft tissue complication and infected nonunion. At the lastest follow-up,
review of the radiographic results showed that eight fracture (73%) achieved an anatomic reduction, two
(18%) achieved a fair reduction, and one (9%) achieved a poor reduction. And clinical functional
assessment showed that there were seven (64%) good results, three (27%) fair results, and one (9%) poor
result.

Conclusion: Two-staged delayed open reduction and internal fixation technique is an excellent option for
the treatment of tibial pilon fractures with severe soft tissue injuries.

Treatment of Articular Fracture of the Distal Tibia (Pilon Fracture) with Limited Open Reduction and
External Fixator
( Journal of the Korean Society Fractures )
2000 13 2 p.272 ~ p.280
(Hui Taek Kim )
(Moon Bok Song )
/
/
:
.
: K-
1 15 .
Ruedi Allgowerd ( 3 , 7 5 ),
Ovadia Beals , , .
: 12 , 3 , 1 , 9 ,
3 , 2 , 5 , 8 , 2
. 6.5 (5-11 ).

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