Case Presentation
: pilon fracture
: 2006. 7. 22. : : 20113120
PK admission note
; O ; 358796/ ; F / 36admission date ; 1:2006.5.20.2:2006.6.081.
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 examination1) Vital sign ; stable2) Rt ankle :
External wound (+) : supf. abrasion 1cm on calcaneous tuberosity
2cm area Tenderness (+) & Swelling (+) : on whole ankle
areaEcchymosis (-)Distal sensory, motor, contraction : intactROM -
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 secPT 0.98 INR aPTT 30.2 sec3)
Urinalysis : non-specific4)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. PlanDP>#1. CT for fx site#2. bone scan
TP>#1.consider temp External fixationchange to plate with
screw#2.antibiotics#3.Rt. leg elevation#4.sensory, motor,
circulation check
Pre OP notebullae(+)-> dressing with flazile gauzeECG :
normal sinus rhythm
Brief op note(06. 05. 23)under spinal anesthesiapre-op diagnosis
: pilon fx ankle Rt.(Ruedi allogower class III)post-op diagnosis :
same as aboveop name : CRIF monofixation operator : prof. assists :
R4, R3,int postop H-vac was insertedpostop compression dressing was
done & LLS applied
Progression notePOD #1. (2006.5.24)hyposthesia(+) 1st web
spacebig toe dorsiflexion : grade 4->splint release for peroneal
n postop X-ray check after 1mm release-> slightly reduced on
tibia AP
wound : nondried for bullaeno interval change distal sensory :
hypothesia on ist web dorsummotor : big toe dorsiflexion grade
4circulation : intact
POD #4. (2006.5.27)wound clearbillae : mildly wet
POD # 7. (2006.5.30)bone scan checked: hot uptake Rt. distal
tibio fibular area wound : wet bullae : dry distal sensory :
intactmotor : intactcirculation : intact
further evaluation .
PK admission note
2:2006.6.081. 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 examination1) Vital sign ; stable2) Rt ankle :
status post monofixation bullae (+) on ant joint area-> wet
Tenderness (+) & Swelling (+) OP wound : clearDistal sensory:
paresthesia (+) on dorsum foot Rt. motor: big toe dorsiflexion
grade 5circulation : intact5. 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
change6. ECG normal sinus rhythm
7. Impression#1. pilon fx ankle Rt. (Ruedi allogower class III)
s/p monofixation8. Plan#1. pain control#2. antibiotics#3. keep
splint#4. consider ORIF
Progression noteHD #4. (2006.6.11)
wound : clearbullae(+): wet distal sensory, motor, circulation:
no interval changebullae healing OP delay .
HD #7. (2006.6.14)
wound : clearbullae(+): wet improved distal sensory, motor,
circulation: no interval change
Brief op note(06. 06. 17)under spinal anesthesiapre-op diagnosis
: pilon fx ankle Rt. s/p monofixation(Ruedi allogower class
III)post-op diagnosis : same as aboveop name :1) ORIF with 1/3
tubulr plate(8 holes) for ankle2) ORIF with DMT plate
(7-holes)allogenous B.G & K-wire * 2 & monofixationoperator
: prof. assists : R4, R3, intern postop S-drain tube was
insertedpostop compression dressing was done & Long Leg Splint
applied
post op X-rayOff duty note06.07.08imp: pilon fx ankle Rt. s/p
monofixation(Ruedi allogower class III)->06.05.23 CREF with
monofixation06.06.19 ORIF with 1/3 tubulr plate(8 holes) for
ankleORIF with DMT plate (7-holes)allogenous B.G & K-wire * 2
& monofixation
splint off ambulation antibiotics leukopenia-> anti stoptoxic
erythema, tinea pedis f/up
POD #4 (06. 07.17)f/up X-ray check - no interval changepin site
clear ECR/CRP 6/0.3WBC 4220 (n- seg 60%)AST/ALT (113/138): liver
sono : normalBrief op note(06. 07. 20)under IV anesthesiapre-op
diagnosis : pilon fx ankle Rt. s/p monofixation(Ruedi allogower
class III)post-op diagnosis : same as aboveop name : External
fixation removaloperator : 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
tibiaw/ or w/o concomitant fibular frx;- subdivided as discussed
into subgroups A-C depending on degree of displacement of
articularsurface & presence or absence of comminution and/or
impaction;- type A:- minimal or no anterior tibial cortical
communition, > 2 large tibial articular fragments, andusually 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 fibulausually 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
largefragment 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 ofjoint
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
adjustmentis necessary, temporarily held w/ K wires until w/
subsequent application of dynamiccompression 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, reconstructionof the joint
surface is assoc w/ producing a metaphyseal defect in the
transitional bonebetween 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 anoblique
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)
andif 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 allowsthe 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 fracturesegments
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). .
, , .
