Fracture of distal 3rd of the tibia involving tibial plafond

1. PILON FRACTURES
Dr. Anshul Sethi
PG student
Dept of orthopaedics

2. What is
Pilon fracture?
• All the fractures of the distal tibia involving
the distal articular surface should be classified
as pilon fractures
except medial, lateral & tri-malleolar fractures where the
posterior malleolus is< 13 of the articular surface
If isolated fracture of the posterior malleolus which is more
than 1/3 of articular surface should also called as pilon
fracture.

3. ANATOMY
• TIBIAL PILON: Distal end
of Tibia including
articular surface
• Proximal limit of tibial
pilon ; 8 to 10 cm from
the tibial articular
surface
EXCLUDING BI-MALLEOLAR
&TRIMALLEOLAR fractures

4. EPIDIOMOLOGY
• Accounts for approximately 5-7% of all tibial fractures
• Accounts for <1% of all lower extremity fractures
• Average age ;35-40 years rare in children and elderly
• Common in men than women; (3:1)
• High energy fractures 25 to 50% of the patients have
additional injuries

5. MECHANISM
• Pilon fractures are most often caused by axial
loading (high energy impacts)
• such as fall from height
• motor vehicle accident
-leads to high degree of disruption of articular surface and soft tissue
affection
• It may be caused by shear loading (rotational or lower
energy impacts)
Leads to less degree of disruption of articular surface

6. EVALUATION OF PILON FRACTURES
1. Presentation of patient
2. Physical examination
3. Imaging

7. Clinical Presentation
• Immediate and severe pain
• Swelling
• Bruising
• Tenderness

8. • Inability to bear weight on lower limb
• Angular deformity

9. EXAMINATION
• Sign of vascular injury
• Swelling
• Fracture blister
• Soft tissue crushing
• Compartment syndrome

11. IMAGING
• ROUTINE X RAYS –
1. Anterio-posterior
2. Lateral
3. Mortise view
Ct scan – to know the fracture pattern and intra-
articular involvement.

12. CT Scan
• Extent of articular involvement
• Orientation of fracture
• Extent of comminution or
impaction of fracture
• Surgical decision making

13. The classic articular components of pilon
fractures
• Anterolateral(chauput fragment)
• Medial fragment bearing medial
malleolus
• Posterior malleolus
• Die punch fragment

14. Classification

15. AOOTA CLASSIFICATION
• Three main subgroups
A) Extrarticular(4,3-A)
B) Partial articular(4,3-B)
C) Intra aricular(4,3-C)
• These fractures are further divided in to sub-groups
depending upon the comminution
• Most of B- type fractures are torsional injuries
and
C-type of fractures are high energy compressive injuries

18. Associated injuries
• Because of their high energy nature, these
fractures can be expected to have specific
associated injuries like
1. Calcaneal fractures
2. Tibial pleatue fractures
3. Pelvic fractures
4. Vertebrae fractures

19. MANAGEMENT
•

20. • Surgical treatment of tibia pilon fractures is challenging
because of articular comminution, metaphyseal bone loss
and serious soft tissue injury.
• Management of this injury must include articular surface and
metaphysis reconstruction as well as treatment of injured soft
tissue envelope.
• Timing of surgery is crucial in pilon fractures because of
extensive soft tissue damage.
• Main target of treatment is preserving the function of the
ankle

21. Goals of surgical treatment
1. To obtain anatomical articular alignment
2. Restore axial alignment
3. Achieve joint stability
4. Regain pain-free and functional mobility
5. Avoiding INFECTIONS

22. Treatment challenges
• Difficult to get anatomical restoration of joint
• Instability of ankle -ligament and soft tissue
injuries
• High soft tissue complication
• Open surgery –high incidence of poor wound
healing,infection,delayed union and non-union

23. Three important anatomical zones to
be considered in the decision
making treatment and prognosis
• Articular surface
• Metaphysis
• Fibula

24. Treatement options
• NON -SURGICAL • SURGICAL

25. Non-surgical
• Undisplaced fracture and debilitated patients
A1,B1 and C1
Long leg cast for 6 weeks fallowed by brace and ROM excercises
Disadvantages;
• Loss of reduction
• Inability to monitor soft tissue status in the cast

26. Surgical
• Factors determining the surgical treatment
• BONY FACTORS
• SOFT TISSUE FACTORS

27. Types of surgical treatment
• 1. ORIF, Open Reduction Internal ‘‘rigid’’ Fixation
• 2 External Fixation with minimal osteosynthesis
• 3 Closed Reduction Internal ‘‘biological’’ Fixation.
(MIPPO Technique)
• 4. Intramedullary nailing
• 5.Two stage protocol

28. • 1. ORIF, Open Reduction Internal ‘‘rigid’’
Fixation
Reudi & Allower …… type 1
AOOTA………………………. A1,A2
type C-Fractures not advocated

32. Closed Reduction Internal ‘‘biological’’ Fixation (MIPPO Technique)
• Ruedi &Allgower type 1&2
• AOOTA a1 b1 & c1

33. Pre op Post op

35. .4 Intramedullary nailing
YES –A1,A2,& C1, C2

36. TWO STAGE PROTOCAL
• All B3 and C type 0f
AO/OTA
• Ruedi & Allgower type 3

37. First step
• 1. Fix the # fibula(90%)
through postero lateral
approach to regain the
correct length of the tibia
and facilitate three
dimensional view of the
fracture
• 2.External fixator-
• a)Ankle Spanning
b) Non spanning - illizarov
-hybrid

42. Second stage
• After 10-14 days average(10
days)
• Remove the Ex Fix
• Through antero lateral incision
• Articular reduction & fixation
with pre countered plate and
screws
• Additional antero medial
incision may require to fix
MM or large medial fragment
• Two incision required-
maintain not<6-7 cm between
two incision

44. Open Pilon Fracture
• Usually –C fractures
meticulous debridment+Ex Fix
soft tissue cover(plastic surgery)
delayed definitive ORIF

45. Complications
1. Wound dehiscence / Skin necrosis
2. Malunion
3. Delayed / Non Union
4. Post-traumatic Arthritis

46. THANK YOU