pilon ankle fractures · 2020. 9. 5. · farc, inc., trauma atlas© suite # 5901 wlbanks drive,...

FARC, Inc., Trauma Atlas© Suite # 5901 Wlbanks Drive, Norcross, GA. USA30092-1141 Tel: 770-448-0769 www.PodiatryPrep.com

PILON ANKLE FRACTURES[FARC Trauma Atlas from PodiatryPrep™]

Dr. Maurice A. Perry; MS

Maurice A. Perry, D.P.M., M.S.Chairman, Department of Podiatric Surgery

Northridge Hospital Medical Center

TRAUMA OF THE ANKLE AND LEG

TRAUMA SYMPOSIUM

TRAUMA OF THE ANKLE AND LEG

INJURIES OF THE ANKLE

• Ankle Fractures• Syndesmosis Separations• Vertical Compression Fractures


• Ankle Fractures3 Types

A) Malleolar

B) Bimalleolar

C) Trimalleolar


Syndesmosis Separations

Diastasis between the tibia and fibula isunstable and must be repaired


• Ankle FracturesClassification

Lauge - Hansen

Weber - AO

LAUGE HANSEN

Based on position of foot during injuryFirst word – position of foot

Second word – direction of deforming force, movement of the

foot or talus

Predicts injury

LAUGE HANSEN• Based on position of foot during injury

• Predicts injury

SUPINATION ADDUCTION I II

PRONATION ABDUCTION I II III

SUPINATION EXTERNAL ROTATION I II III IV

PRONATION EXTERNAL ROTATION I II III IV

WEBER - AO• Based on level of fracture on the fibula

• Provides consistent classification among Doctors

TYPE A below the syndesmosis

TYPE B at the level of the syndesmosis

TYPE C above the level of the syndesmosis

WEB

ER-A

O

FRACTURES

• CLOSED

skin intact no compromise of dermis

• OPEN ( Compound Fracture)

skin broken open allowing possibility

of bone contamination and infection.

CLOSED FRACTURE

Skin intact no compromise of dermis

COMPOUND FRACTURE

Skin broken open allowing possibility ofbone contamination and infection.

Infectious spread

COMPOUND FRACTURE

Infection is the major complication tobe avoided and can be related directlyto the type of wound

COMPOUND FRACTURE

Gustilo and Anderson wound classification

Type II - > 1cm w/o extensive tissue damage

Type III - having extensive soft tissue damage,including muscles, skin, and neurovascularstructures, with severe contamination

Type I - wound less than 1 cm long and clean

Gustilo and Anderson wound classification

In their review of open fractures in which immediate fixationwas achieved Chapman and Mahoney noted the infectionrate in

Type I wounds 2%

Type II wounds 8%

Type III wounds 29%.

This is significant because immediate internal fixationof ankles with type I wounds can be performed withoutan infection rate greater than that seen in closedfractures.

Type II

COMPOUND FRACTURE

Type III – (High velocity injuries, Farm injuries)

a. Adequate soft tissue coverage of bone

b. Extensive soft tissue loss with periosteal strippingand bone exposure, severe cominution

c. Arterial injury requiring microvascular repair,regardless of soft tissue coverage

Type III A

Type III C

Type III C

Neurovascular Bundle

Type III C

Ankle Fractures

3 TypesA) Malleolar

B) Bimalleolar

C) Trimalleolar

Single Malleolar Fractures

• Medial Malleolar

• Lateral Malleolar (Fibular Fracture)

• Posterior Malleolar (Posterior Tibial Lip)

• Undisplaced stable fractures can begin weightbearing in a short-leg walking cast for 6 weeks

• Other unstable injuries should be placed in along-leg cast with the knee flexed 15 degrees

• Displaced > 2mm requires closed reduction orOpen Reduction with Internal Fixation



• Appreciate effects of minor displacements onthe congruity of the ankle mortise

• A 1-mm lateral shift of the talus reduces thecontact area of the ankle joint by 42%

• Up to 2 mm of displacement of the malleoliand 1 to 2 degrees of talar tilt seem to becompatible with a satisfactory result

• Unstable• Requires ORIF• If closed reduced, requires long leg cast• Difficult to reduce without a buttress for

stabilization, often reduction is loss withoutpatient’s knowledge.

Bimalleolar Fractures

• Talus faithfully follows the lateralmalleolus

• Anatomic reduction of the lateralmalleolus is crucial in bimalleolarfractures

Bimalleolar Fractures

• Same as bimalleolar fracture-dislocation plus fractures ofthe posterior lip of the tibia

Trimalleolar Fractures

• Posterior Fragment less than 25%Treat the same as a bimalleolar Fx, nofixation of posterior fragment

• Posterior Fragment greater than 25%Must reduce fragment anatomically andfixate with lag screw.

Trimalleolar Fractures

Posterior Fragment

greater than 25%must reduce fragmentanatomically and fixatewith lag screw.

• Syndesmosis separations that are unstableshould be stabilized

• With fibular fractures above a syndesmosisseparation, some surgeons elect to treatonly the syndesmosis separation

• Fully threaded, 4.5-mm cortical screws arebest because they avoid over reduction ofthe syndesmosis


• the ankle should be held at neutraldorsiflexion when inserting the screw

• must avoid over tightening the syndesmosis• removal of the syndesmosis screw by 8 to

12 weeks after injury is usually indicated.

• the use of bioresorbable screws fortibiofibular syndesmosis fixation obviate theneed for late screw removal


Wide medial gutter

Syndesmosis separation

Bioresorbable screw

Hyperdorsiflexion ofthe ankle producesa vertical shearfracture of theanterior tibialplafond

Vertical Compression Fractures

2 Types

Tibial Plafond Fracture

Tibial Pilon FractureHigh Energy vs. Low Energy

Tibial Plafond Fractures

A comminuted fracture of the ankle isusually caused by vertical loading thatproduces compression of the cancellousbone above the tibial plafond

Tibial Pilon Fractures

When the fracture involves themetaphysis and distal shaft, it is knownas a pilon (French for “rammer” or“hammer”) fracture

Vertical Compression Fractures

3 Types

I. Undisplaced

II. Joint Incongruity

III. Comminuted with articular displacementand crushing of cancellous bone

PlafondC

lassification

PilonC

lassification


Because the degree of comminution andthe poor condition of the soft tissues,may make internal fixation impossible


The surgeon must weigh the goals ofsurgery against such risks as increasedsoft tissue trauma from multiple incisionsand the adverse effects of prolongedsurgery

Tibial Pilon Fractures

Avoid ORIF of complex intraarticular Fxs

Complication rates are high, necessitatingfurther reconstructive surgery

Soft tissue technique must be atraumaticand meticulous.


Soft Tissue TechniqueAn anterior incision between the anteriortibial and extensor hallucis longus tendons


Soft Tissue TechniqueFlaps are developed at the level of theperiosteum,

Flaps are developed at the level of theperiosteum,


Soft Tissue Technique

The periosteum must be left attached to theanterior fragment, which can easily beopened like a book

Tibial Plafond

Talar Dome


Soft Tissue TechniqueAvoid entering the sheath of the anteriortibial tendon

Tibialis Anterior Tendon in sheath

Fixation Devices

• Large Fragment Screws

• Buttress Plates – DCP, Cloverleaf, Spoon

• EBI External Tibial Fixator

• ILIZAROV Thin Wire Ring Fixators

Large Fragment Screws

Screws

Buttress Plates - Cloverleaf

Surfaces aligned. Buttress platesused. Fibular length restored

Type III Pilon Fracture

Buttress Plates - Cloverleaf

EBI External Tibial Fixator

ILIZAROV Type Thin Wire Ring Fixators

Emergency Treatment

Excessive swelling can so compromise thetreatment of even minor ankle sprains thatpatients should all have their lowerextremities elevated higher than their heartwhile undergoing initial evaluation andtreatment.

Emergency Treatment

A soft compression dressing andradiolucent long-leg splint should beapplied before radiographic examination.

Emergency Treatment

Grossly distorted ankles with severe skindistortion should be reduced immediately inthe emergency room to avoid skin necrosisand to eliminate tension on theneurovascular structures

CRITERIA FOR TREATMENT

For best functional results in thetreatment of Plafond / Pilon fracturesthe following four criteria must befilled.

CRITERIA FOR TREATMENT

1. Dislocations and fractures should bereduced as soon as possible.

2. All joint surfaces must be preciselyreconstituted

3. Reduction of the fracture must bemaintained during healing

4. Motion of joints should be instituted asearly as possible

Case Presentation

Low Energy Type 2 Plafond

Case Presentation

High Energy Type 3 Pilon

33 y/o Window washerFalls 4 storiesType III High EnergyX-Fix w/ screws

Post-op day 3

Pressure on skin

1 month following splitthickness Skin Graft

Reconstruction / Salvage

Loss of bone with collapse and deformity

Malunion, resulting from closed treatment

Severe arthritis

The Sequelae of fractures can result inthree major problems:

Reconstruction / Salvage

• Fusions

• Osteotomies

• Soft tissue releases

or a combination of these procedure

Reconstruction is performed by a varietyof techniques, including:

SO NEXT TIME: THINK FIXATOR !

The End

FARC, Inc., Trauma Atlas© Suite # 5901 Wilbanks Drive,Norcross, GA. USA Tel 770-448-0769 www.PodiatryPrep.com

Maurice A. Perry; DPM, MSThank You

pilon ankle fractures · 2020. 9. 5. · farc, inc., trauma atlas© suite # 5901 wlbanks drive,...

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