5. What is Pilon Fracture?
• Pilon is a French word for pestle ( also
known as Plafond Fracture ) .
• It is intraarticular
fracture of the
distal end of the
tibia , involving the
disruption of the
distal tibial
weight-bearing
articular surface .
• It is different from ankle fractures .
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• In most cases, both bones are broken .
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6. EPIDEMIOLOGY
• Account for approximately 5-7% of all tibia
fractures.
• But less than 1% of all lower-extremity
fractures .
• More commonly at average age of 35 to 40
years old. rare in children and elderly.
• Commonly in men than women (3:1)
• Because of the energy required to cause
this type of fracture, 25% to 50% of patients
have additional injuries that require
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treatment.
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7. Mechanism
Pilon fractures are most often caused by axial
loading (high-energy impacts or combination),
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 )
such as : Ski accident .
- Leads to ( less degree of disruption of articular surface )
Often affects both bones of the lower leg.
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9. E
V
A
L
U
A
T
I
O
N
Clinical presentation
• Signs and symptoms
include an inability to bear weight , marked
pain , marked swelling , and evidence of soft
tissue injury and deformity ( out of place ) .
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10. E
V
A
L
U
A
T
I
O
N
Physical examination
• Neurovascular examination
include distal pulses , capillary refill ,
motor and sensory examination .
• Soft tissue
- Closed fractures : classified using the
method of Tscherne
- Opened fractures : classified using the
method of Gustilo .
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13. CLASSIFICATIONS
Association for Osteosynthesis/Orthopedic
trauma association (AO/OTA) Classification
Has good interobserver and intraobserver
agreement at the type level .
Reudi and Allgower Classification
Has good interobserver and intraobserver
agreement at the group level
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(the most important ).
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14. C
L
A
S
S
I
F
I
C
A
T
I
O
N
S
Reudi and Allgower Classification
Type I
Fracture involving
minimal displacement
Type II
Significant
displacement of the
joint surface
Type III
Impaction and
comminution of the
articular surface
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16. ASSOCIATED INJURIES
• Other skeletal injuries
• Soft tissue injuries
- open fractures
- closed fractures
• Neurovascular injuries
• Other body parts injuries
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17. T
R
E
A
T
M
E
N
T
TREATMENT and RATIONAl
Treatment goals
Treatment options
Bony considerations
soft tissue considerations
Timing of surgery
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18. T
R
E
A
T
M
E
N
T
Treatment goals
- Anatomical restoration of distal tibial articular surface .
- Early ankle range of motion.
Treatment options
Non-surgical
( to manage
non-displaced fractures)
Cast and Splints
Surgical
( To manage displaced
fractures )
Modern methods :
(ORIF) and external
fixation with or without
limited internal fixation
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19. T
R
E
A
T
M
E
N
T
Bony considerations
Fibula
Tibia
- Comminution
- Lower energy : (ORIF)
- High energy + large
number of small
articulations :
external fixation with or
without limited internal fixation
- Diaphyseal extention
Typically epi and
meta of fracture is
heal more rapid .
ORIF with plate and
scrow
Remember the most
important is restore
Tibia
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20. T
R
E
A
T
M
E
N
T
soft tissue considerations
Low-energy injuries :
By ORIF
High-energy injuries :
By external fixation with
or without limited
internal fixation
Timing of surgery
Depend on soft tissue affection .
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22. ANATOMICAL
CONSEDARATIONS AND
SURGICAL TECHNIQUES
• ORIF
• External fixation
- Unilateral
- ilizarvo ( consists of fine wire “ 1.8mm” for
interfragmentary fixation ) .
- hybird ( ring with wire distally )
• Soft tissue
• Ligamentotaxis
When traction is applied across the ankle joint , the
intraarticular fragments may be reduced by pull of the
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capsule and ligamentous structures .
23. COMPLICATIONS
Sever complications following ORIF of tibial fractures
range from 10-55% and some can lead to amputation
•
•
•
•
•
•
•
•
Soft tissue slough.
Infections .
Neurovascular injuries.
Bone healing problems
( Mal-alignment, Mal-union and Non-union ) .
Painful plates and screws.
Decreased ankle joint range of motion.
Chronic edema .
Posttraumatic arthritis .
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25. REFERENCES
- Review of Orthopaedic
Trauma by Mark R.Brinker , M.D.
- AAOS
- Medescape
(press on the title )
(press on the title )
- UpToDate
(press on the title )
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Pilon is a French word for pestle, an instrument used for crushing or pounding. In many pilon fractures, the bones of the ankle joint are crushed due to the high-energy impact causing the injury. Pilon fractures may be considered high-energy ankle fractures.
Pilon fractures affect the bottom of the shinbone (tibia) at the ankle joint. In most cases, both bones in the lower leg, the tibia and fibula, are broken near the ankle.
Any neurovascular injury must be documented at the time of presentation.Compartment syndrome is a risk in acute injuries; therefore, frequent evaluations are necessary. A systematic and complete evaluation is necessary because other injuries (eg, to the spine or other extremities) may have occurred after a fall from height.
The Oestern and Tscherne classification for open fractures uses wound size, level of contamination, and fracture pattern to grade open fractures, and is as follows:
Grade I - Open fractures with a small puncture wound without skin contusion, negligible bacterial contamination, and a low-energy fracture pattern
Grade II - Open injuries with small skin and soft-tissue contusions, moderate contamination, and variable fracture patterns
Grade III - Open fractures with heavy contamination, extensive soft-tissue damage, and, often, associated arterial or neural injuries
Grade IV - Open fractures with incomplete or complete amputations
The Gustilo classification can also be used for open fractures and is as follows:
Grade 1 - Skin lesion smaller than 1 cm; clean, simple bone fracture with minimal comminution
Grade 2 - Skin lesion larger than 1 cm, no extensive soft-tissue damage, minimal crushing, moderate comminution and contamination
Grade 3 - Extensive skin damage with muscle and neurovascular involvement, high-speed injury, comminution of the fracture, instabilityGrade 3a - Extensive laceration of soft tissues with bone fragments covered, usually high-speed traumas with severe comminution or segmental fractures
Grade 3b - Extensive lesion of soft tissues with periosteal stripping, contamination, and severe comminution due to high-speed traumas; usually requires replacement of exposed bone with a local or free flap as a cover
Grade 3c - Exposed fracture with arterial damage that requires repair
To fully evaluate the fracture, your doctor may recommend an x-ray (left), a CAT scan (center), or a three-dimensional CAT scan (right).
The AO/OTA classification (part of a comprehensive classification of long-bone fractures and tibia, numbered 43) is as follows:
Type A: These fractures are extra-articular and subcategorized as simple (A1), comminuted (A2), or severely comminuted (A3).
Type B: These fractures involve only a portion of the articular surface and a single column. Subcategories include pure split (B1), split with depression (B2), and depression with multiple fragments (B3).
Type C: These fractures involve the whole of the articular surface. Type C fractures may be categorized as a simple split in the articular surface and the metaphysis (C1), an articular split that is simple with a metaphysis split that is multifragmentary (C2), or a fracture with multiple fragments of the articular surface and the metaphysis (C3).
